Wednesday, March 30, 2016


I don't know anyone in medicine who's particularly happy with their career choice. (Okay, maybe the locums neurosurgeon who gets paid five figures per day to sit in a call room and say things like, "Yeah, that's pretty complex, and since I'm not really familiar with the surgical team here you'll better send that along to a referral center." What a deal.) However, nobody will tell you this. It's true that we may have occasional flashes of genuine delight or emotional reward, but most of physicians just gut it out, showing up for work each day, wading through the teeming masses, deferring work as much as we can (translated as "Go to the ER") and wondering why we're not working at a tire store putting tires on cars, because no one is unhappy when they have new tires; or stacking bottles at Liquor Kingdom, because nobody's unhappy when they leave there, either.

It's sad we feel this way because the actual practice of medicine is the easy part. Especially within the vast breadth of issues that come before the ER, there are only so many ways to do things and only so many ways things can go. It's actually very black and white. You're sick or you're not. You're alive or you're dead. You can't be "kind of sick" or "sort of alive." (And you most certainly cannot have fibromyalgia, because it doesn't exist.). Age, race, culture, gender identity, and a host of other characteristics don't change that basic biological equation. There's really not a lot of "gray zone," although that admission puts any number of academics, me in a past life included, out of business.

The Internet is rife with stories about why physicians don't like their careers, and I could list the common themes as well as anyone; administrative hassles, government mandates, insurance nightmares, falling reimbursements, crushing student debt, long hours. (The one they won't list...because it goes against the social narrative that everything is someone else's that physicians and patients themselves are often part of the problem.). While some of the articles I see are understanding of the physician's plight, most are of the "arrogant doctor deserve everything they get, whiney bastards" ilk. So when people ask me about my enjoyment of medicine...or lack thereof...I struggle with the best way to explain it.

After years of trying to come up with a politically correct solution, I now think that perhaps I don't actually have to explain it. Maybe what I have to do is turn the question into a riddle and let people figure it out for themselves.

In Room 1 is an elderly man with chest pain. In Room 2 is a child with a snotty nose. Room 3 holds a young woman who took an ambulance ride to the ER for a toothache (yes, it happens, and it happens a lot). Who do you see first?

It's an obvious decision, right? The person with chest pain might be having a heart attack. The kid with the snotty nose is just that. So you go and see the chest pain patient, ask careful questions and perform a focused yet detailed exam, take a moment to form your differential diagnosis, place judicious orders into the computer based on your assessment, and document your thoughts into the electronic medical record while the encounter is fresh in your mind.

Meanwhile, the wait time for the kid goes up, and the parents (if there are two parents) become frustrated because they've taken time off work, or away from sleep, or had to pay a babysitter to bring the child to the ER, or brought the other three kids because they couldn't find a babysitter and are now crawling all over the exam rom. Before you even address the issue at hand you're apologizing for delays, and it takes you extra time to not only calm them down, but also to explain how you care for a kid with a snotty nose, because in medicine, as well as in society, we've indoctrinated new parents into learned helplessness. So what could be a ought to be a five minute encounter becomes twenty, which prolongs your patient throughput times. And if you've tried to provide care without a plethora of labs and x-rays, all of such would prolong patient care times, you've decreased your potential reimbursement.

Maybe you can juggle two things at once. Maybe you can have someone quickly show you the EKG from Room 1 to make sure it's not a flaming heart attack, ask one or two questions of the nurse to get the show rolling, and let them start doing things according to a preset protocol whether the protocol is relevant or not. Meanwhile, you duck into Room 2 and get through the kid as fast as you can. It;s an easy case, there's nothing to do for it, and so what if you've not really had a discussion wth the parents? The kid is fine, and time saved. Then you can backtrack to Room 1 and figure out what's really been going on all the time, rolling your eyes at all the lab and x-rays that have been ordered when it turns out the patient's chest pain only happens on Tuesdays. At some point you go back and document both cases in the EMR, noting once again, as you've done before, that it takes exactly the same amount of time to document the care of a kid with a snotty nose or an adult with potentially life-threatening chest pain.

Here's a choice: Maybe you go see the toothache first. It's the quickest to be seen, it'll involve a minimum of charting and paperwork, and since there's no dentist in the ER and you personally don't pull, drill, or fill, it's a matter of a couple of prescriptions and an admonition to go see the dentist. Your average patient throughput time will certainly go down. You might even get a good patient satisfaction score. But if you do that, don't you just reward behaviors that abuse the EMS system and the entire rationale for the Emergency Department? And surely someone will call you back to Room 1 if the chest pain patient turns sour.

Now take this scenario and recognize that in most busy ER's in this country, your average ER physician is responsible for up to twelve patients at a time. And that the toothache (and maybe even the snotty nose), being a non-emergent condition, has probably been seen by a Physician Assistant or Nurse Practitioner, to be replaced on the doctor's agenda by something like abdominal pain, vomiting, vaginal bleeding, migraine headache, fever, possible injuries from a motor while accident or a fall in a nursing home, overdose, psychiatric crisis, or chronic pain, all scenarios in which it's incumbent upon the physician to do something to make sure there's no actual emergency, but not do too much to take up too much time or generate an excessive bill. All the while navigating family dynamics, patient expectations, social needs, clinical disposition, and appropriate pain management with the inevitable negotiations that accompany them all.

(As an aside, our ER has started giving out cards that list the Patient Advocate's phone number as part of our discharge paperwork. Not a bad idea, I suppose; if people have questions about their care, or their bill, they ought to have someone to call. But when you read the card it says to contact the Patient Advocate if you have "concerns" about your care. Nothing there about compliments. Which lets you know exactly where the Patient Advocate, as well as Administration, stands in reference to doctors and nurses. Words matter.)

It's an extreme example, of course, but it serves to illustrate the point that emergency medical staff (and, to a lesser degree, all health care providers) are working under a set of inherently contradictory mandates that are plain to everyone involved in patient care but are absolutely invisible to those in the corporate suite: The belief that you can, with no changes in resources and increasing patient loads, have faster greeting times, faster turnaround times, higher billings, and higher patient satisfaction, all at the same time. (Quality of care is an afterthought, and if there's a problem it's time to come down on the physician, for the hospital is not in the practice of medicine and it's simply not right to recognize any pressures or mandates the hospital might put upon the physician as contributing to any errors that might be made.)

I've had good bosses and bad bosses, but just like you can pull some valuable lessons out of a bad relationship (which is why I like sushi and know what an eyelash curler is), my worst boss did teach me something that I still think holds true. (Personally, I think he was an idiot, so I assume he got it from somewhere else and was able to read it off an index card.) It's that in health care:

(Access) x (Quality ) = Cost

Working through this equation, recognizing that access is a "people" number, quality is whatever we happen to define it as at the moment, and that cost is not always counted in dollars but can be counter in time or lost opportunities, it's clear that the paradigm that all things are simultaneously possible is fatally flawed.

Let's say that the number of patient being seen ("access") is flat, and improved patient satisfaction is our measure of quality. We know that time spent with the patient is the prime determinant of patient satisfaction. Patients want to move through the system, but they don't want to feel part of an assembly line. So using the equation, increasing patient satisfaction necessarily increases throughput times. We also know that another determinant of patient satisfaction has to do with the amount of care provided in terms of testing and prescriptions. If that's our measure, then costs in dollars rise.

If we want to decrease costs, ether as dollars or time, something else has to go. Each provider needs to see less patients (decreasing the access number) or patient satisfaction must fall. This is true even if we use (heaven forbid) true quality of care as defined by clinical metrics as our outcome goal. It's health care stoichiometry. It needs to balance.

I don't know the right answer, other than I don't think there is one. I would say that good clinical care is the optimal outcome, but within policy and administrative circles that is clearly no longer the case and that horse has long ago left the barn. There can, in fact, be no right answer when your goals are at odds with one another. What I'm hoping is that someday someone far above my pay grade will actually admit, in a nod to Spandau Ballet, that they know this much is true. But I have no confidence that this will occur before even more physicians and nurses, exhausted and burned out, become mere wage earners trapped in their jobs rather than the caring and compassionate professionals most of us wanted to be.

No, there's no right answer, at least not one that I, as an individual physician doing patient care, will ever be privy to. The Administrator du Jour, or the Administration du Four-Year Term, will decide what the right answer is for now, and undoubtedly one component of the answer will be that the providers are just not doing things right. Policies will be written, institutions will undergo "culture change" and "rebranding," metrics will be compiled, and a couple of months later we'll be back where we've started, with administration spending great whopping gobs of cash and rewarding themselves for non-existent accomplishments and providers feeling once again disheartened and disillusioned. No matter how many times you rearrange the deck chairs on the Titanic, the ship still goes down. And while those on the top decks are offered first place in the lifeboats, those in steerage...your doctors and nurses...are locked behind iron grates below decks and left to drown.

Friday, March 25, 2016

Bar Mitzvahs and Bomb Shelters

Being a parent is truly the greatest thing ever. I love my kid like nobody’s business, and I suspect most parents feel the same way. It’s true that The Teen drives me nuts in more ways than I can count (and I’m certain he would say the same about his father), but the real frustration is in seeing your faults repeating themselves in your child. He and I were talking about that the other day, one of those pre-dawn chats you have when you come home early on a night shift and inadvertently wake up the kid, when he’s not sleepy enough to tune you out but no so awake that he heads straight for his computer. We talked about the things he does to get in his own way, and I talked about mine. It seems like laziness…or at least the ability to be easily distracted into things that are not productive…is one of my unfortunate legacies.

As I get older, I find I’m much more comfortable with confession and admitting my faults. Maybe this is the insight and wisdom that comes with age; more likely, it’s finding excuses for not being all I could have been, shrugging off lost opportunities based on based on bad habits I can’t break the same way the patient with end-stage lung disease says they can’t give up smoking…and since they’re at the end, why bother now? But I think it’s true that I could have done a lot more in life if I didn’t get lazy.

Here’s an actual example of what I mean, ripped from the pages of my life just this past week. When I get home after work, I should be working out so I don’t wheeze after going up two flights of steps, or so dedicated to the frustrated writer inside of me that I would be willing to scribe on a TV tray like Stephen King used to do before Carrie. What I actually do is eat either two bowls of Apple Jacks or, if I’m feeling adventurous, make French toast. Then I watch an “on-demand” episode of The First 48, yelling at the screen the whole time (“Nail that perp! Nail his a__ to the ____ing wall!), then hit the channel guide and realize that I can’t stay awake long enough to watch “The Big Valley” on MyTV. I then retire to bed with my iPad in hand and find that I’m looking up The Big Valley, then Miss Barabra Stanwyck, then Richard Long, then Nanny and the Professor, then back to Barbara Stanwyck again, then off to Double Indemnity, then Fred MacMurray, then My Three Sons, off to Tina Cole, to the Four King Cousins (four You Tube videos as well, loads of hairspray everywhere), then the King Family, next the King Family Specials on PBS, then Mr. Rogers, and finishing up with searches for Joe Negri. Robert Trow, Francois Clemons, and Betty Aberlin. Then I’m not tired anymore so I play an hour of Fishdom. And by now it’s too late to take a melatonin to get to sleep, because I’ll wake up with a hangover, and I’ve totally missed the episode of The Big Valley that I couldn’t stay awake for three hours before.

(Incidentally, if you’ve not seen “The Bitter Tea of General Yen,” a 1933 film with Barbara Stanwyck and Nils Asther, it’s well worth a look. Obscure now, but daring themes for the time. And don’t get the new Fishdom game, “Dive Deep.” I hate in-app purchases to get to the next level. Just tell me how much to pay for the game and let me play.)

So as I’m talking to The Teen about those things in life that get in our way, I mention to him that while he has unquestionably inherited my wit, charm, good looks, and above all modesty, he’s also got my tendency to be distracted and lazy. As I’ve noted before in these pages, he wants to be the next Roger Ebert, and he unquestionably has the talent to do so. But I’m trying to explain to him that this means you learn to work on a deadline, not just when the flash of literary inspiration hits you. He, of course, rightly points out that I’m just as bad. So he and I have worked out a deal. We will require each other to blog at least once a week. If he doesn’t come through, I get to choose a costume that he must wear throughout the four days of GenCon, the largest gaming convention in the world. (I’m thinking Fluttershy of My Little Pony). If I don’t…well, he’s trying to think up an appropriate penalty because, as he says, “You have no shame.” No, I don’t, not where embarrassing my kid’s concerned. It’s a Dad thing.

Brendan’s entry this week is a review of 10 Cloverfield Lane. (It’s brilliant. Please take a look at The But as Brendan is a true movie buff, able to place films in context with genres and styles, when I see a movie my mind usually does what it does with my iPad before I go to sleep, wandering from topic to topic with no particular focus in mind. So my thoughts on the movie generally center around the fact that the lead character (played marvelously by John Goodman) is named Howard, which is my name as well, a point The Teen continually reinforces with veiled suggestions that perhaps I should build a bomb shelter in the backyard.

(For the record, I have no intention of building a bomb shelter in the backyard. This is not because I have great faith, as does every pageant contestant since Eve duked it out with Lilith, in world peace. It is because I’m certain that one of my fellow doctor friends whom I know has a guest room in his house will take my in, and that his home has enough tinfoil lining the walls to stop them from reading our thoughts and enough weaponry to keep us all alive throughout the Zombie apocalypse and then some.)

Howard’s not a great name. Never has been, but at least I know how I wound up with it. It wasn’t a deliberate act on my parent’s part to keep me in comic books and dateless until my early 20’s (I did that to myself.) It’s a Fiddler on the Roof kind of thing. In Jewish tradition, you usually try to hand down part of a name of the most recently deceased relative, which in English usually translates to using the first letter of the first name. So when my great-grandfather Harry Burgheim married a woman named Hennie, and they had a son named Harold, the die was cast. My Mom was a Harriet, I wound up a Howard, and my brother is another Harold. And two generations hence, when we’re gone, another crowd will wind up with “H” names and wonder why their parents hate them, too.

Just as Christians often get confirmation names, we also have Jewish names. You usually get this at a bris or a naming ceremony as an infant, which is why no liberal Jew has any idea what their Hebrew name really is. These are also usually passed down from deceased relatives, but not quite as literally. For example, your name could be Bob (and mine is Bob every time I got to someplace that asks for my name on an order, because I’m tired of telling people how to spell “Howard”), and your late great-grandfather’s name could be Fred, but if his Hebrew name was Yitzchak yours likely will be too.

As I’ve mentioned, nobody really knows their Hebrew name unless it’s the same as their actual name (think the ultra-orthodox in New York, where I understand the name Pinchas, with a guttural “ch”, really get the ladies going). This came to be a problem several weeks ago at my nephew Thomas’ bar mitzvah. Before I go any further, I need to say that Thomas did a magnificent job, even though somehow in his speech he forgot to thank his best uncle on the planet for his support from afar, which may or may not manifest itself in an acute deficit of Channukah presents this year. But I digress.

During the ceremony, different members of the family are called to the bimah (the stage in front of the sanctuary) to recite blessings over the Torah before it is read. You get called up to do the blessings by your Hebrew name, which was a problem because neither Brendan nor I knew our Hebrew names. Fortunately, Judiasm is nothing if not a creative religion (we came up with that whole monotheism thing), so we were assigned Hebrew names by the enterprising rabbi of the Joliet Jewish Congregation. I became Avigdor ben Yussel (“ben” means “son of,” and my Dad’s name, Joseph, does translate into Yussel), and Brendan morphed into Efron ben Avigdor. It could have been worse. My Uncle Steve got the alliterative Schmuel Yuel ben Matisyahu, and my nephew Thomas wound up with Tovia Fivesh Meir ben Shoshana, which sounds like…well, I don’t know, but probably something that doesn’t go down well on Tinder.

I didn’t particularly like these names. So I wrote my sister, who was actually in charge of the festivities (she’s a Jewish woman; did you really think anyone else would run the show?), that I wanted a different Jewish name. I wanted mine to be Moshe Dayan, and I thought Brendan’s might be Harpo Marx. I was told that changes this year were not an option, but that I might be able to make a case for next year at my niece Lauren’s ceremony. I’m still holding out for Moshe Dayan, and I have an eye patch ready to go. But I think Brendan may opt for something from Yu-Gi-Oh or Pokemon (Charizard ben Charmander, I choose you! Gutteral “ch”s all around.)

(Incidentally, this rabbi was great. Had a wonderful speaking voice, moved the service along…which matters when you’re the child of parents who always went to the early services on Erev Yom Kippur and Rosh Hashonah because they knew the rabbi had to get up to speed to be able to clear the house for the late show…and was really a lot of fun. He would ask us to “kiss the torah” with the edge of our prayer shawls in the voice of Sebastian the Crab from The Little Mermaid. This made me laugh out loud, much to the dismay of an old man who shushed me from under his rainbow-striped tallit that looked like something on the box of Lucky Charms.  This rabbi also plays dodge ball:  "I never get to throw things at the kids in the synagogue."

Oh, and in the Sibling Rivalry Department, I should mention that while my brother screwed up his blessings, I got mine right. I did so well, in fact, that another little old guy came up to me at the reception afterwards and wanted to know if I was a member of a synagogue. When I told him I lived out of town, he engaged in that well-known game of Jewish Geography, noting that he had second cousins in Kansas City and did I know them? He also wanted to make sure that I was going to take The Dental Empress to Israel. For her part, The Empress was a trooper the whole weekend, especially when confronted with a bowl of chicken liver…“Try it first and I’ll then I’ll tell you,” was my Mom’s response to her inquiry about its’ nature…and she was very understanding when Dad said she was welcome in any of our pictures, but I’d better not do something to lose her because he was tired of cutting the heads of my ex-wives out of family photos. This is the same father who has given his blessing to this relationship, as opposed to my priors, because, “this one comes with a house and a job.”)

It also turns out, unbeknownst to the family in advance, that if you’re over 13 and called to the bimah to perform the religious duties of an adult Jewish male, it counts as a bar mitzvah of sorts, a recognition that through your participation you’re accepting the obligations of an adult Jewish man. So in addition to the bar mitzvah we thought we were attending, there were four additional “drive-by” bar mitzvahs that morning between myself, my brother, my Dad, and The Teen. Which was pretty cool considering that we didn’t have to go to Hebrew school, we got to read transliterations of our blessings, and we got to sponge off someone else’s reception.

But back to 10 Cloverfield Lane. Bottom line: It’s got a Howard in it. He’s a creepy survivalist with a bomb shelter and tub of acid in the backward. Howard is a crappy name. It’s mine, too, which means for the foreseeable future I’m going to hear an endless stream of 10 Cloverfield Lane jokes. But at least I used to be Dan Conner, Geln Allen Walken, Walter Sobchak, and King Ralph, and at least one of them is Jewish. Could be worse. And as I’ve said, I won’t be building a bomb shelter in the backyard. I’m just lazy.