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Good in the Balance


Good in the Balance

I am normal.

OK, aside from that llama thing.

I have good days and bad.  Some days I am content, connected, focused, and motivated.  On those days I enjoy my job, I enjoy the people I’m with, I am willing to be inconvenienced by interruptions.

On other days…not so much.  I wake up grumpy and (despite multiple cups of coffee) continue it through the day.  I keep score of all the ways in which life has conspired to make the day difficult.  Too many red lights.  Too windy.  Clearly terrible things going on.  I am not patient with people, and am distracted by little things.

Like I said: I am normal.  I do my best to not let these things stand in the way of the care I give, and I try to hide my emotions from my patients.  It’s a necessary part of the job.  But there are still days I’m better at it than others.



The Mission

It's a big job, but it's sure a lot easier when I have my nurses and my patients rooting for me and helping me achieve this goal.  Really.  I cannot express just how much better life is in this practice than it was in my old one.  From what I've heard, things are just getting worse in that world.

It's my mission to help pave a road to a better way.  I am grateful to have not only nurses on my side, but patients joining in this mission.





I think there is something in us that makes us want to make heroes.  This is part of the attraction of sport and other entertainment.  We want to see people doing things that are amazing, superhuman, and heroic.  As a child, I imagined me hitting the home run in the bottom of the 9th inning, or hitting the basket with no time left on the clock.  I imagined the adulation and praise of my skill from the adoring masses.  I dreamed of being a hero.


Occam's Razor Burn


Occam's Razor Burn

As a clinician, I fantasize about being the heroic detective who notices those obscure facts that others would miss, coming up with the life saving  diagnosis when all others had failed.  This, unfortunately, is not how it usually works when dealing with real human patients, and my desire to find a single diagnosis to explain what is going on can actually distract me from finding the answers my patients need.


Doctors aren't Healers


Doctors aren't Healers

I've heard many doctors refer to themselves as "healers," as if we have some special power to bring about healing in our patients.  This idea confers some sort of a higher status and originates, to some, from a "higher calling" to a more noble life.  Again, this is a logical step, in that we have opportunities on a regular basis to help and even save the lives of people.  It's natural to believe that somehow the healing power comes from our touch, or even from our knowledge.

It doesn't.  I am not a healer.  


Target Demographic


Target Demographic

He seemed a bit grumpy when he came into the office.  I am used to the picture: male in his early to mid-forties, with wife by his side leading him into the office to "finally get taken care of" by the doctor.  Usually the woman has a disgusted expression on her face as he looks like a boy forced to spend his afternoon in a fabric store with his mother.  My office is the last place he wants to be.



The Broken System - #4: Who Am I Working For?

I was recently posed with the question: "who do you work for?"

Since I am self-employed (as part of a partnership), the easy answer would be to say I work for myself.  That is not, however, what was meant by the question (and it would make a dull blog post if it was); the intent of the question was this: for whose interest am I most working for?  Who am I trying to please?  Who is my boss?

My answer?  I have many bosses:

  • My patients
  • The insurance companies
  • My patients' employers
  • Our business
  • The government
  • Oprah

So who really is my boss?

We all, in the end, work for Oprah.  That's a given.  I won't add any more to that as it is self-evident.

Being a primary care doctor, I would like to say that I work for my patients.  I would like to say that the only thing that matters is the health and happiness of the people in my care; but that would not be true.  I fight to keep this focus in my office,  but sadly it's still not the reality I live.  The reality I live is that of a planet being torn out of its orbit by larger, more powerful celestial bodies, all trying to make themselves the center of my universe.

Who is my boss?

Insurance Companies?

They certainly write a big chunk of my paycheck, commanding an increasing amount of my time.  I have contracts with insurance companies, agreeing to what they pay.  I follow rules of insurance companies to get the patients the care they need and what the insurers dictate, (which are sometimes at odds).  Insurance companies have more access to patient records than patients do, or at least they have easier access.  Insurance companies can decide if they will pay me or not, while the patient doesn't have that option.

Clearly, the pull of the insurers' gravity is stronger than that of the patient.  Clearly my patients are not my real boss.


But who writes the check for the insurance companies?  Employers do.  Employers dictate just how strict of rules the insurance companies will keep me under.  When they choose an insurance plan for their employees, employers dictate how much I can charge at each visit, what services I offer will be covered, what payment structure I will receive (capitated, fee-for-service, or high-deductible).  Much of what I can or cannot do is dependent on this decision.

If you asked employers, however, they would tell you that they are "at the mercy" of the insurance companies.  Despite the fact that the employer is writing a check to the insurer, the relationship is hardly one of control on the part of the employer.  As owner of a my own business I can attest to the one-sided nature of my relationship with my employees' insurance carrier.

Are my patients' employers my boss?  No, it's not really close.  Insurance carriers win that contest with ease.

Our Practice?

So what about my business?  Is my practice my boss?  Since I am a part-owner of my business, it is not quite as clear as it would be for physicians employed by a practice or hospital.  But the reality is the same in many ways.  My practice decides what contracts we will accept or reject.  It tells me if I am seeing enough patients, dictating how much time I am spending on each patient.  The practice pays for the medical record system, tells me when I can have time off and, in extreme cases, could fire me.  I certainly feel like a factory worker at times, punching in at the start of a long day with a conveyor belt of patients coming in so I can make money for "the man."

But who am I fooling?  Our practice is also totally dependent on insurers, going to great lengths to make what I do come out in a format that will please insurers enough to pay us.  Our practice could go broke should the government go through with its threatened cut to Medicare reimbursement.  We are a service industry, totally at the mercy of our "customers," or "clients."  Our business is but a pass-through vehicle for me to be paid by insurers and a front to let me see patients.

I work at my practice, but not for my practice.  My practice is not my boss.

The Government?

A significant percentage of my patients are either Medicare or Medicaid, so a large chunk of my paycheck comes from the government.  Many of the contracts I get from private insurers are based on a percentage of Medicare's rates, so the government is a very powerful force in determining what I get paid.  In addition, while I can opt out of any insurance plan if I don't like the rates, and have the option of negotiating a better rate, dropping out of government contracts is much, much harder.  There is also no chance for negotiation; I either take what they offer or don't have their patients.

In addition:

  • The government set up our procedure-driven model of care that has so favored the specialist over primary care.
  • They pay for enormous hospital bills but not (up until very recently) for me to prevent those enormous hospital bills.
  • The government sets the rules for documentation - those rules that force me to put so much meaningless information into the record that I can't find the useful information I need.
  • The government says that I can't send many kinds or e-prescriptions, even though doing so would be more secure and less prone to abuse.
  • The government sets malpractice laws that favor the accuser and so makes my nurses quick to send people to the ER unnecessarily and makes me increase my test-ordering and documentation to avoid litigation.
  • The government doesn't just tell me to get on electronic medical records (which I had already done), but gives me a large number of hoops I must jump through to prove that I am using them "meaningfully."
  • The government promises to make those rules more invasive and onerous as time progresses.
  • The government is supposed to regulate the insurance carriers, drug companies, and device manufacturers, many of whom are making huge profits during a time of economic crisis.  They "regulate" the drug industry, letting companies gouge with generic drugs, set prices inordinately high, and advertise directly to patients information that tricks them into believing things that aren't proven or that are patently false.
  • The government does nothing while more and more people outside the doctor-patient relationship plunge onto the system and plunder it for what they can get.

In short, the government stands watch while the health care system crashes and burns, the end result of which is that my patients are able to afford less and less care and I am too busy dealing with pleasing the system to give them the attention they deserve.

So who am I working for?  The one for whom the system is designed, the patient, is not just competing for my attention but is on the periphery looking in while I deal with these other entities.  The patient waits for an hour while I see extra patients and document profusely.  The patient can't afford prescriptions I write because the cost of drugs is too high or the drugs are denied due to insurance formularies.  The patient is afraid of me making a diagnosis for fear of losing their insurance.  The patient pays more and gets less.  I work harder and get less.

Who am I working for?  Far too many people who are making it far too hard to do my job.

I wonder what care would look like if I actually did work for my patients?  What would real care, not care that is torn apart by competing gravitational forces, be?  What would the chart look like?  How long would the visits last?  How much would the visit cost, and how much would drugs cost?

What would care look like if the patient was really who I was working for?

I'll ask Oprah the next time I get a chance.




The Good Things in Medicine - #1: The Exam Room

I said I would do it and I will follow through with it: I am going to talk about good things about my job.  I must confess, however, that finding 53 of them might be difficult at this moment, as I am overwhelmed with the craziness and stupidity of the system.  I must also confess that I can't find a whole lot of good things to say about our system.  I fight the system and it's foibles all day long, and try to practice good medicine despite the way I am forced to do it; so finding good stuff about the structure of our payment system will be difficult, if not impossible.  Maybe it's just me and my current mindset.  I hope so.  Unfortunately, it is how good the good is that makes the bad all the worse.  The fact that the system itself stands in the way of the good in medicine makes the system all the more broken. Anyhow, I do have things that I really, really like about medicine.  I've got to have them, as I could not deal with these negatives if I didn't have a reason to stay that was at least as strong as my reason to leave.  It's like the nucleus of an atom: we know that the forces holding the protons together is strong, because they repellant force of two positively charged particles is very strong.  There must be a stronger force keeping them together.  Likewise, I am drawn to medicine in a very strong way, and nothing draws me back more than the exam room.

No, I am not talking about the table that is too high for my old people to climb on, out-of-date magazines, or the smell of rubbing alcohol.  I am talking about the interchange I get to have every day with people.  To me, the exam room encounter is medicine.  It is the Holy of Holies, the sacred part of a secular system.  The practice of medicine can be boiled down to a single thing: the interchange between a person with a need and a person who tries to meet that need.  While this is actually the description of all commerce and much of human interaction, it is the nature of the interchange and needs that make it so special to me.  Here are the things that make this encounter so unique and so (in my mind) sacred:

A. It is Personal

The patient does not need an object or a luxury item.  They don't want to be entertained.  The thing the patients need is themselves.  They want to live and to be healthy.  They want to have a good life and to be out of pain.  Our possessions are not what define us, but to a large degree, our bodies do.  We are what is confined in that package of flesh.  Our time on earth is defined by what that body does, and how long it does it.  So, to come asking for care for our bodies is intimately personal - a fact unfortunately forgotten by many in health care.

B.  It is Private

The door to the exam room is closed and I am committed to keeping what goes on in the room closed off to others.  The more that I can assure the patient that their privacy is safe, the more they will expose their needs to me.  We humans don't like to share our needs with many people, as it exposes our weakness and vulnerability.  We also feel that we are intruding on others' lives when we ask them for help.  So, actually asking for help is only possible when done in a situation of great trust.

The fact that people can be asked to get naked in the exam room is evidence to the degree of vulnerability they are exposing to me.  The nakedness extends to the emotional realm, as boundaries that are expected on the outside are not present behind the closed door.

C.  It is Relational

The thing that is so sacred about the exam room to me is not the fact that it's private or personal, however; it is that I am asked to be with them in that vulnerable moment and hear the weaknesses.  The relationship is physical: I listen to what they say, look at what they are, and feel their bodies with my hands.  It is mental: I listen to them, think about them, and help them decide what to do.  It is emotional: I hear their sadness, fear, and relief; I feel emotion as I hear their emotions; I try to help, heal, or comfort them.  This is the sacred, as it is human relations stripped to the core, free from most of the pretense and facades that are there in nearly every other place.

D. It is Meaningful

I take great comfort in the fact that what I do has meaning.  When other parts of my life are difficult, I find refuge in the opportunity I have every day.  When I am feeling sad or anxious about other things, feeling insecure in my relationships or in my future, or regretting my decisions, I heal myself in the exam room.  It's not that I see that my life is good compared to my patients - that's no comfort at all - it's that I get to do and to give to other people; and while I can lose relationships and material things, nobody can take away the good I have done.

It's really an honor to be a part of the exam room encounter every day.  It does take its toll on my emotions, and it is a convenient escape when I'm avoiding other areas of my life, but I know it's where I need to be.  I am glad that I am a doctor.  I really lucked into the profession I chose, as I didn't know most of the good things before I enrolled in medical school.  It's good for me to remember this good, as I can get lost in the struggles and troubles that the other part of my job brings.  Our system needs to do everything it can to enable more real exam room encounters, and remind health care providers that they do more than just work at their jobs; they heal.




One of the main things driving  me back to blogging is madness.  While I can’t be sure that I am not overcome by madness, it is not my own of madness I am referring to.  Well, no, I am mad, but not mad in the way that I hear Elvis whispering in my ear or think that the squirrels are evil robots put there by aliens to spy on us.  The squirrel theory may be true (evidence does strongly support it), but it’s not that kind of madness I am talking about.

I am angry at the madness of our system.

I am angry when patients come to me after a two week hospitalization and I have no records or even an idea that they were hospitalized.  I am angry when I have to rely on my patients to find out what happened at the specialist, the emergency room, or in the hospital.  I am angry at all of the money that is being wasted on useless and sometimes harmful care and is done because nobody knows what is going on with patients.  I am angry when my life is spent chasing around ever-changing drug formularies and drug “shortages.” I am angry when my patients have to wait for a three-hour visit with a specialist who I recommended, only to have their complaints ignored and their questions unanswered.

I am angry about the political game of chicken that is regularly played by congress with Medicare reimbursement.  I am angry that it is far more lucrative to document than it is to care for patients.  I am angry at all the time I spend more time every day dealing with rules and regulations I don't understand than I do deciding what's best for people's health.  I am angry that electronic record systems pay more attention to "meaningful use" certification than they do to making their systems be useful in a meaningful way.

I am angry at doctors who prescribe narcotics like candy and then send me their patients when the DEA investigates.  I am angry at patients who try to fool me into prescribing drugs they are not taking, but selling.  I am angry that there are no psychiatrists available and so I am forced to perform amateur psychiatry on them in a 15-minute visit.  I am angry that my patients assume their doctors know their medical history when they don't, and that doctors assume the patient knows their medical history when they don't.

If any other business operated like health care, it would go out of business and the people who ran the business would go to jail.  I am serious.  People are gouged by our system and are given terrible care in return.  More and more I am seeing why people no longer trust the medical community and are turning to alternatives.  If our system is treating them poorly, they find someone who will do otherwise. I can't blame them.

And guess what, folks; it's an election year!  Prepare for more madness.  Prepare for politicians who prey on the fear of the elderly by telling them the other party wants to kill them.  Prepare for simplistic, head in the sand solutions to the problem that avoid the real problem because doing so would lose votes.  Prepare for promises of bigger, better programs that will fix our bloated system.  Prepare for complete madness transformed by political spin to look like rational policy.

Yes, there is a lot of madness to be had.  Everyone can have their fill.  The fire hose of madness is waiting to knock over whoever stands in its spray.

All of this makes me sad.  I am sad because I sit in the room every day with people who are pummeled by this madness.  I am sad because the madness hurts people I am trying to help. I am sad because I know of things I could do to decrease the madness for my patients, but would be rewarded with a decreased salary.  I am sad because I have to choose between making a living for my family and giving the best care possible.  I can't have both.

People need to know how dysfunctional our system is, not on a political or sociological level, but in the reality of the exam room.  This madness is making the most committed doctors have second thoughts about their profession.  I didn't go into medicine to learn to "play the game."  We all deserve better than this.

Don't worry; I don't intend for this blog to be a whining rant.  I wouldn't have come back to blogging just to complain about problems without giving hope.  There is hope, but few people see it.  Perhaps the biggest tragedy is that many if not most of our problems do have real solutions.  I want to beat the drum of sanity.  I want to bypass the spin and rhetoric, the editors and publishers with agendas, and tell you what I see here.  At some point the little boy needs to speak up about the emperor's nakedness.  There are others saying it, but the voice needs to be loud enough to be heard over the societal cacophony.

Maybe once we do that, we can get that squirrel problem under control.