I Fought the Mall and the Mall Won

Let me make my position on the Mall of America patently clear:

I Hate It.

Yesterday, the Big E and his friend, who coincidentally shares the same name, dragged me to the Mall.  Their deep research into the topic had revealed that the MOA is a happening spot for Pokemon Go.

I kicked.  I screamed.  I whined.  I protested.  And eventually I said fine.  I’ll go with you for One Hour.  Seriously, it was like I’d suddenly produced a real live unicorn.  > Poof <

We parked in Georgia and walked into the Sears entrance.  Surely, the Mall can’t, in fact, be a hellmouth if it’s anchored in the northeast corner by Sears.

The Big Es were happy as Pikas in a Pokeball.  They wandered hither and yon, among the kiosks, through the massive indoor Nickelodeon Universe amusement park, around the potted palms.  They ran into a particularly wonderful situation outside of three consecutive cosmetics stores.  ”Mama!  We both caught a Blastoise!”  I’m not exactly sure what that means, but it’s good.

While they searched out mythical beings, I played my own game of Guess the Diagnosis.  Here’s what I saw:

1) many probable pre-diabetics and some actual diabetics

2) the diabetics/pre-diabetics were also likely hypertensive and dyslipidemic

3) polycystic ovarian syndrome in a couple young women

4) pregnancy – lots of it, like a whole epidemic

5) anorexia in one young man : (

6) sex trafficking – I didn’t see it, or didn’t realize I was seeing it, but there’s good reason I chaperoned The Big Es.

7) one definite hardcore smoker plus a handful of casual smokers

8) one definite methamphetamine addict

9) likely many prescription drug addicts – they’re harder to spot

10) a couple cases of osteoporosis

11) MANY broken ankles waiting to happen – what’s up with the Illogical Footwear Choices, ladies?

12) lots of nice, loving, normal human interaction – very refreshing indeed!  People were happy yesterday, and were treating their partners, kids, friends like we should all the time…

On the drive home, I reminisced about the Days of Yore when I’d go dancing at the MOA and my hair would reek of cigarettes for forty days.  Thank you to the authors of the Minnesota Clean Indoor Air Act.

My bottom line is if I have to be stuck in the Mall of America for an hour on one of the most glorious fall days ever, I’m glad I’m stuck with two boys who are only in it for the Pokemon.

Musical Moment


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Unapologetically Smart

I am a woman.  I am smart.

I’m using “smart” in the standard academic sense of the word, not to minimize other forms of intelligence (artistic, emotional, spatial-relational, etc.), but to limit the scope of this discussion.

Perhaps I made a few people uncomfortable by opening with those two lines.  Heck, I made myself uncomfortable.  Do I sound too braggadocious?  Should I back up my assertions with cold hard facts?  Is this the right way to make my point?

My parents expected that I would do my best work to the best of my ability.  Early on, I learned not to talk about doing well in school; my academic success was inversely correlated with Positive Reaction of Classmates.  ”You got an A?  I hate you!”  How many times did I hear that?  Being average is just that, being average, one of the majority.  Being above-average means drawing attention to yourself and attention, in the hierarchical pack mentality of 1970s public schoolchildren, was rarely good.

In elementary school I proved to be a good speller.  As my “reward,” the teacher removed me from class and sent me to the librarian to dissect word roots, his own personal linguistic passion, one that I did not share.  A good girl does as she is told.

The Junior High yearbook pictured a boy and a girl for each of several categories: Cutest Smile, Most Likely to Be a Moviestar, whatever.  Did we vote?  I think we voted.  Anyhow, I took it as a personal affront that “Most Likely To Succeed” seemed completely independent of academic performance.

In high school, I was insulated from teasing by surrounding myself with like minds.  Three of the five valedictorians came from my core group of HS friends.  Yes, I was one of them.  The valedictorians.  And I was mortified that people, like the entire student body, knew my GPA.

My high school dating experience was quite limited, fortunately.  I knew that boys didn’t like it when girls were too smart and I’m sure that I would’ve played dumber if I deemed it necessary for relational harmony.  So I’m glad I didn’t date much.  My end-of-HS boyfriend, another of the valedictorians, liked his girls smart, and immersed himself in friendships with girls who wanted to study and learn.

By the time college rolled around, I expected the competitive nasty teasing to be over and done with.  Not so much.  I continued to keep my academic situation to myself, even developing a script for when people asked, “What’d you get?”  Never trumpet your cerebral assets from the mountaintops.

I met my college boyfriend when he TA’d my computer programming class.  He seemed to enjoy that I presented him with a question/problem that he couldn’t answer, and I knew there might be some hope of a relationship working.  He married a super smart woman, whose line of work I can barely begin to comprehend, much less explain – something to do with genetics and the various factors that impact cell development, gene expression, and cellular death.

In my junior year at Oberlin, I received a letter from an organization about which I knew exactly nothing: Phi Beta Kappa.  They said I could mail them something like $50 and become a member.  I mentioned the letter to my parents as well as my hesitance to pay the fee and join their little club.  Mom and Dad said, Anne, this is ΦΒΚ.  You have to join.

Enter medical school.  Dating was, uh, interesting.  ”I’m in medical school” is completely different from saying “I’m in college.”  People have their own biases about medical school, medical students, doctors, and women doctors.  Even now, many folks who find out I’m a doctor are intimidated.  I found myself trying to reassure the last person to admit intimidation, saying, “Oh, I haven’t been in clinic in a long time,” as if the temporal remoteness of doctorly duties would somehow normalize me.

But back to dating.  Most of the men I dated felt threatened by me and my brain.  I say this because they engaged in frequent micro aggressions, to use a newer word for an ancient concept.  I was familiar with the little jabs, often masked as statements of fact or even compliments.  I’d heard similar sentiments on the playground years prior.  ”Of course you would know that because you’re going to be a doctor.”  Or “I only went to business school, not medical school.”

The most glaring example occurred when I was a third-year medical student.  I started dating a first-year resident.  I can’t remember what led up to it, but I basically said Isn’t it cool how the second half of the menstrual cycle is constant, like you can count backwards fourteen days from a woman’s period and, bam, that’s where she would ovulate.  So all the variability in the length of the menstrual cycle comes from the first half.  Awesome.

My boyfriend freaked out because he didn’t know this basic menstrual fact.  He didn’t know it and I did, a third-year med student and more importantly, his girlfriend.  My knowledge made him feel bad about himself.  I backpedalled – I just studied it, you know, so it’s fresh in my mind.  It’s okay.  I’m sure there’s a lot that you know (that I don’t know).

We didn’t last – thank goodness.  Maybe he needed to be with a woman who knew less than he did.  Lora Park (NY Univ at Buffalo) researches this phenomenon, that men want to be smarter than the women they date.

The field of medicine as a whole continues to be rife with sexism and misogyny, as evidenced in a recent Washington Post article.  How many times did people assume I was a nurse?  How many times did patients choose to call me by my first name, while referring to their male physicians as “Doctor”?  And there was that blatant proposition from the professional athlete after I had just finished his rectal exam in the ER.

Where am I going with this?  For many men, it’s deeply unsettling when a woman is smarter, faster, or better at something.  Insecure men often fall back into comforting patterns of objectification, sexism, and misogyny, instead of celebrating women’s strengths.  Regression to Mean.  As men contemplate a long-term committed monogamous relationship, let’s say a relationship lasting at least four years, they are freaked out by the idea that this woman might be smarter than they are.

The 2005 Access Hollywood video and Howard Stern tapes show Donald Trump being himself.  Anyone who is surprised hasn’t been paying attention.  Anyone deciding to disavow only now didn’t do their research.  In Trump’s mind, women are conquests, reduced to a compilation of body parts, either sexually desirable or disdained.  He believes he can take whatever and whoever he wants, without regard to pesky things like consent, legality, or morality.  And men who feel threatened by smart women love the camaraderie of “locker-room talk.”  A good old-fashioned session of misogyny will clear that insecurity right up.

In case you were wondering, #ImNotWithHim.

Here’s the deal: I want my president to be smarter than I am.  I want her (and I’m using “her” as the generic pronoun just for kicks, not as some commentary on Clinton’s candidential viability – I can make up words, right, ’cause I went to medical school), I want her to know more than I do about history, law, politics, Black Lives Matter, economics, conflict resolution, the Labor Movement, public education, communication, government, group dynamics, and activism to name just a few.  I want my president to be able to acknowledge when she is ignorant and continue her journey of lifelong learning.

There you have it.  I’ll see you at the polls and I’ll be voting for a candidate who is #SmarterThanIAm.

I’m all about action.  What can we do?  How can we do better?

1) Raise girls to be unapologetically smart.  This is different from being arrogantly smart or ungenerously smart.  Here’s a script we can teach our girls: “If you feel bad about yourself because of my accomplishments, that’s your problem, not mine.  Don’t attack who I am to feel better about yourself.”

2) Raise boys (and girls) to value smart girls.

3) Teach boys how to bond with each other intimately in ways that don’t denigrate girls and women.

4) Teach boys how to genuinely demonstrate affection, not by pulling hair, physical aggression, or teasing.  At the library, I recently witnessed a teenage boy throwing a girl around.  And he didn’t think he was being mean.  He probably thought he was telling her he liked her.

5) Speak up.  Speak up when you see that teenage boy throwing a girl around.  Speak up in the locker room when teammates start down the well-trod path of sexism and misogyny.  (Ace assures me that he hears reductive sexist banter in the hockey locker room all the time.)  Folks who do psychological work with children, teenagers, and adults, please chime in on suggested approaches.  I must confess, at the library I didn’t know what to do or say.

6) Give kids the vocabulary to admire each other.  ”I liked it when you read that poem in class.”  ”Wasn’t it awesome when Shanika went off on String Theory and Mr. X was like, dang.”

7) Vote for candidates who are smarter than you are.

8) Add to my list.

Musical Moment #1 evolves to

Musical Moment #2

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Minnesota Reportable Communicable Disease – the stuff we got in 2015

I did not watch the presidential debate last week.  Wild horses couldn’t drag me away from my most favorite publication from the Minnesota Department of Health:

The Annual Summary of Communicable Diseases Reported to the Minnesota Department of Health, 2015.

Folks, this is pleasure reading at its best, full of pestilence, suspense, and SEX.

I’ve culled this riveting report into a tiny list of takeaway messages.  For you.  From me. xoxo.

1) The numbers reflect reported cases, not the actual incidence of disease.  21,238 cases of Chlamydia were reported in 2015.  That’s like all of Golden Valley.  Or half of Edina.  As you may know, chlamydia can lurk around, relatively asymptomatic until it wreaks havoc.  So 21k is certainly a lowball number.  Plan accordingly.

2) Health disparities continue.  People of Color are disproportionately affected by HIV and AIDS, malaria, measles, chlamydia, carbapenem-resistant Enterobacteriaceae, gonorrhea, tuberculosis, and Hepatitis A, B, & C.  This is an opportunity for meaningful improvement!  Let’s get to work!

3) Many of the reported communicable diseases are vaccine preventable.  I will list them for you:

  • Haemophilus influenza (104 cases, 18 deaths)
  • Influenza, “The Flu” (1501 cases, 3 pediatric deaths)
  • Measles (2 cases)
  • Meningococcal Disease (7 cases)
  • Mumps (6 cases)
  • Pertussis, “Whooping Cough” (594 cases)
  • Rabies (No human cases!  Keep vaccinating your pets!)
  • Streptococcus pneumoniae Invasive Disease (534 cases, 56 deaths)
  • Varicella, “Chicken Pox” & “Shingles” (361 cases)
  • Viral Hepatitis A (21 cases)
  • Viral Hepatitis B (19 acute cases, 165 newly identified chronic cases)

4) Food prep is no joke.  Wash your hands.  Check internal temps.  Don’t eat raw meat.  Travel carefully and choose restaurants wisely.  (bloody diarrhea, bloody diarrhea, bloody diarrhea)

5) Tiny mosquitoes make big trouble.  West Nile Virus (9 cases), LaCrosse encephalitis (1 case), Western equine encephalitis, and Jamestown Canyon virus can all be transmitted by Minnesota mosquitoes.  My friend’s mother contracted West Nile Virus and is now wheelchair bound due to neurologic and cognitive impairment.  Chikungunya, dengue, malaria, and Zika are also transmitted by mosquitoes, but all Minnesota cases of these diseases were acquired internationally in warmer climes.

Here is some helpful information about DEET from the Environmental Protection Agency.

6) There is no need to travel internationally to acquire tick-borne illness.  Our very own Minnesota ticks can give you anaplasmosis (613 cases), Lyme disease (1176 cases), babesiosis (45 cases), Powassan virus, and ehrlichiosis.  There have also been rare Minnesota cases of tick-borne Tularemia and Rocky Mountain Spotted Fever.  Chester, our yellow labrador retriever, kindly collected 16 deer ticks in a 24-hour period in Otter Tail County.

Once again, here is some helpful information about DEET from the Environmental Protection Agency.

7) Let’s talk about sex.  The rates of chlamydia and gonorrhea in Minnesota are increasing, disproportionately impacting adolescents, young adults, and People of Color.  Syphilis is also on the rise, particularly among men who have sex with men.  Meanwhile, antibiotic resistance is (no shock) increasing.

The number of new Minnesota HIV diagnoses per year (228 cases in 2015) has remained relatively stable over the past ten years and continues to be associated with poverty and high population density (the Twin Cities).  Females and adolescents make up an increasing percentage of new HIV diagnoses.  According to the MDH, in 2014 Minnesota ranked 16th lowest HIV diagnosed infection rate at 7 cases per 100,000 people.  Louisiana had 36.6 cases per 100,000 people.  Coincidentally, Minnesota ranks 7th lowest for poverty, while Louisiana ranks 49th.

Start talking.  Silence = death.

8) I love public health.  Thank you to all the people who spend their lives trying to protect the rest of us.


You can read the full The Annual Summary of Communicable Diseases Reported to the Minnesota Department of Health, 2015 HERE.  I strongly recommend reading it with a bowl of popcorn and beverage of your choice.

Musical Moment



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Jacob Have We Loved

Dear Jacob:

They found your remains last week, buried just off a country road, scarcely thirty miles from your home.  That tiny remnant of hope, a single flickering candle, is now and forever extinguished.

You are dead.

The man who kidnapped you, raped you, killed you – can we even call him a man?  He is beyond evil, past the language that I understand.  I want him there, far away from what I know, far away from the comfortable familiarity of small-town Minnesota.

In his confession, he said that you asked, “What did I do wrong?”  Nothing.

You did nothing wrong.

You are light.  You are innocence.  You are truth.  You are beauty.  You are possibility.

I can’t read the rest of the confession or I will be haunted.  Your face stays with me, your smiling face.  I can conjure your image in my mind more easily than the faces of my cousins.  They are changing.  You are constant.

Forever young.

Please know that I hold your family in my heart.  Let me take a fraction of their pain, some small broken piece of the suffering they carry every day.  Help me teach my child strength and compassion, justice and peace, that he may be a gentle, healing presence while he walks this earth.

We love you, Jacob.  Rest easy now, rest in the arms of your community, and let us sing you to sleep.  You are one of us.  We will never forget you.


A Minnesota Mother

 Musical Moment

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The Beauty of a Handwritten Note

“I’m kind of old-school,” Dr. Seshat admits.  She’s a millennial doc, finishing her Internal Medicine residency around the year 2000.  Her practice straddles the old and the new.  During her training, Seshat documented with a pen in a paper chart.  She joined an independent group of primary care physicians in Florida.  “It’s kind of funny when you’re in it, you just don’t know.  I think we’re behind in a lot of ways.”

Several years ago, Dr. Seshat experienced two major changes with her practice.  1) A hospital gobbled up her group and suddenly she was one of 500 physicians.  2) Her clinic transitioned to an Electronic Health Record – not the one in use at the associated hospital.  Dr. Seshat’s clinic administrator said, “Scan the last three [chart] notes into the EHR,” as if any patient’s medical history could be summarized and transferred in three notes.  “I was never really a good dictater and I never dictated clinic notes.  Ever.  So even though we have Dragon [voice recognition software], which I’m trying to get better using, it wasn’t an easy transition.”

Seshat found the EHR to be completely inaccessible.  It’s not the way her brain works.  The group used one EHR for a couple years before switching to another.  EHR’s are like trying to make your way around a country where you don’t know the language and have limited resources (tech support).  At first, you’re lost.  As you wander around, you begin to recognize a few landmarks, maybe a restroom (the medication list), maybe a gas station (the past medical history).  If you’re lucky, you bump into someone who speaks your native tongue and can give you a few pointers (sharing dot phrases and exam templates).  Some docs have greater facility in the new territory.  Others are just trying to survive.

Now imagine being transported suddenly to a new country.  You have to start all over.

Dr. Seshat was drowning in documentation.  “I had to go part-time because I couldn’t do it with the documentation.”  She approached her clinic leader, armed with resources from the internet on how to present her request.  “I made this proposal for me to work part-time.  (No, no, it’s not done down here.)  I think the only reason they let me was I’d been there [in her particular clinic] so long.”  Seshat cut back to three work days per week.  “And at first it’s super great, but it turns out I just do a lot of work on the days I’m not there.”

The new EHR is less than optimal.  “There’s still a lot of box-checking,” Seshat says.  “I don’t even understand all the different score cards.  We have different quality goals because we merged with another group.  And there’s a Healthy Registries thing.  I don’t even really know how important it is that I’m trying to do these certain things.  With Counselling for BMI [Body Mass Index – a measure of obesity] I figured out it was fourteen clicks and two scrolls to enter in that I did the counselling, and that’s not even in my note!  And then it wasn’t even being counted [accurately] by Healthy Registries.”  She quit the rigamarole and decided to take a break from the fourteen clicks and two scrolls.

A prime example of the inefficient use of physician resources.

“I feel like I need to work at a frenzy, but I don’t.  And if I keep up with my notes I’m horribly behind with my patients.”  She completes her documentation at night, on vacation, on weekends.  “Like literally, we went to California and I spent the entire plane ride doing my notes.  I had to work the second day that we got there.”

Seshat’s greatest joy is “treating the same patients for such a long time.  Even though I’m not Family Medicine so I don’t see kids, I definitely have seen generations of the same family.  I really don’t see any new patients because I’ve been in practice so long.  The ones [patients] that don’t like me, they’re gone.  The relationship is the best part.”  Ironically, these long-standing relationships make it hard to stay on time.  “I can be much faster with someone else’s patients.”  No need to check in about the granddaughter headed off to college or the beloved geriatric pet parrot.

I ask Dr. Seshat what she would do for a micro change, at the level of her clinic practice.  “I really need a scribe.  I just feel like we’re always behind the times.  So I just assume sometime down the road there will be a scribe.”  We discuss a remote scribe service that charges $10/patient.  The physician wears a pair of special glasses so the scribe can “see” what’s going on.  “I just don’t see enough people to make it worth hiring someone.”

Dr. Seshat chose to preserve the doctor-patient relationship and her own sanity at the expense of her salary.  Her current compensation model is based on work RVUs [relative value units], a model that rewards quantity and not necessarily quality.  “So I just pretty much try to see as few people as possible so that I can have a normal life.”  Documenting for two days on vacation may not qualify as a “normal life.”  “I have really great patients,” she continues.  “My office set-up is good.  I feel like I shouldn’t complain.  It’s mostly the electronic piece, I guess.  It’s the worst.”

What change would Seshat like at a macro level?  “I guess better access at lower cost.”  I ask her to elaborate.  “If I want to send someone for a colonoscopy, I have to have them see GI [gastroenterology].”  Even to request a routine colonoscopy?  Yes!  “It’s a complete waste of time and money for the patient.”  When Seshat wants a patient to receive Zometa infusions for osteoporosis, she has to send them to rheumatology or oncology first.  I’m shocked by these revelations.  An unnecessary New Patient Consult costs money (for the patient and the insurance company) and generates money (for the specialist).  To demand that patients needing screening colonoscopy see a gastroenterologist first almost seems offensive, like a primary care doc can’t be trusted to make the call.  “I don’t know why.  I don’t know if it’s a culture of distrust or a culture of old-fashioned-ness.”

Access is a huge issue in Florida.  Seshat informs me that 44 counties in her state only have one insurer that accepts Obamacare patients.  ”And they didn’t expand Medicaid in Florida.”  Dr. Seshat echoes a familiar mental health refrain: “I feel like there are no psychiatrists.”  Disparities in access are further stretched by concierge medicine, where patients with financial means pay fees above and beyond insurance in order to join a concierge physician’s panel.  In essence, they pay for more immediate access to the doc of their choice.

We discuss the growing trend in the Northeast where physicians simply decline to accept insurance.  “They’ll give you something that you can try to get reimbursed on your own,” Seshat says.  Anyone who has ever disputed a denied insurance claim knows which patients are likely to wind up with a No-Insurance-Accepted physician.

Dr. Seshat’s longstanding relationships with patients are keeping her in the game.  For now.  “I want to quit my job but then part of me has that pride/guilt thing.  How could I not do this?  But I gotta do something.  I feel lucky that I can work three [long] days a week, I mean that’s huge.”

She’s spending Labor Day completing the documentation for 34 patient visits.  For the sake of accessible primary care in Florida, get that doctor a scribe!


Musical Moment

Seshat is the Egyptian goddess of writing and measurement.


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Vishnu, Protector of Humanity

“Some days I feel like I have the best job in the world.”  Dr. Vishnu works at an FQHC-designated clinic in California.  She calls me between the demands of work and parenting.  “We are invited into people’s intimate lives and it really is an honor.  I’m trying to hold that as the sacred trust that it is, in the midst of the uphill battle with the system as it is.”

I’m curious to learn her perspective.  FQHC-designated clinics qualify for government grants, malpractice insurance, and reimbursement for taking care of Medicaid patients, in exchange for caring for anyone who walks in the door.  Vishnu’s understanding is that her clinic is paid per patient visit, not for the number of problems you address or the specific tests you order.

This is very different from the production model of reimbursement and compensation previously described in this blog.  Vishnu has been there, done that.  She was perfectly willing to work hard.  Her one request was that she be allowed to put a few holds in her schedule, small blocks of time with no patients, so that she could adequately address the needs of complex patients and stay relatively on-time.  “Running behind isn’t respectful” of patients.  The health system where she worked declined to allow her any scheduling control.  She left.

Now Dr. Vishnu is on straight salary.  I’m wondering if maybe this is the answer to the escalating productivity expectations described by Dr. Apollo in my last post.  Nope.  When many health systems switched to twenty-minute appointments, Vishnu’s clinic followed suit.  “There’s no room in the system for phone calls, emergencies, getting lab information back to patients.  And now patients can electronic message you,” generating more requests demanding attention in an entirely rigid schedule.

“When do you do the preventive medicine, the holistic approach?  You either run late [with twenty-minute appointments], or you deal with one issue and then the patient has to come back.”

From an organizational perspective, bringing the patient back may have financial advantages.  Vishnu, on the other hand, is acutely aware of the logistics faced by many of her patients as they try to make it to even one appointment.  Arranging time off from work, child care, transportation.  Missing work might mean losing income or even losing their job.

“There’s this constant push to do more,” Vishnu continues.  “Every doctor that you’re seeing is doing their charts at home.”  For each clinic day, she generally has two hours of work left to do at home.  Or she’ll stay at work for an extra hour plus work through her lunch in an effort to complete her chart documentation.  “And that’s actually really, really good compared to most of my colleagues.”  Her colleagues routinely stay up till 1 am or get up at 5 am (before the kids awaken) to finish charting.  “Basically we have an army of health professionals who are sleep-deprived, having relationship issues, and who aren’t doing all the healthy lifestyle things we preach to people to do.”

“It’s such a farce,” she says of the every-twenty schedule.  Seeing the patient, making an assessment and plan for their conditions, documenting the visit in the electronic health record, entering all orders for tests and consults, and being ready for the next patient.  And still connecting on a deep interpersonal level in the doctor-patient relationship.  “Nobody can really do that.”

Dr. Vishnu is fluent in Spanish, an incredible asset for any clinic.  Imagine conducting a patient visit in Spanish and simultaneously trying to type in English into the computer.  The visit is twenty minutes.  Maybe you, the reader, have been handed an AVS (After Visit Summary) at the end of an appointment, with a list of your diagnoses as well as a short-term plan for your health.  There’s no easy way for Vishnu to generate a bilingual AVS unless she literally types everything twice.

“I don’t write in full-sentences,” Vishnu says.  She charts in sentence fragments and the charting short-cuts called “dot phrases.”  “The choice was be efficient or pay for it on the back end.  My goal every day is not to have to open my computer when I get home.  Bad weather can be a blessing because fewer patients come in and I can get caught up.”  Bad weather in California is a rare occurrence.

“It’s so demoralizing,” this leaching of work into family life.  “Not to have time with my partner, an hour or two doing charts on top of my long hours at clinic.”  Vishnu caught some heat from her boss who wanted to know why she wasn’t checking work emails and attending meetings on her day off.  She stood her ground.  Her colleagues cover each other for urgent matters on off-days.  “There is nothing that’s going to happen regarding my patients that I’m the only one smart enough to take care of.  We need to rely on each other more.  It’s this idea that we are these superheroes [who should simply deal with everything] – it wasn’t good for small-town docs years ago and it’s not good for us today.”

She talks of recent computer upgrades, where physicians were told, “’In your spare time you can play around with this.’  Imagine another profession where the tool you use is changed and you’re left to figure out how it works by yourself.”  Doc meetings (unpaid) often happen before work or during lunch.  “The ability to have any work/life balance is eroded away.”

I ask Vishnu what change she would make on a micro level.  “Other than removing my boss?”  We laugh and she goes on to describe a recent medical encounter.  Dr. Vishnu had taken her mother to see a specialist and noted the impressive array of support staff: two PAs, an MA, and a nurse enabled the doctor to be optimally efficient.  At Vishnu’s clinic, they ususally have an  MA for each provider and an LPN for ten doctors.  “The amount of stuff that could be done by somebody else but isn’t, due to budget, is incredible and highly inefficient.”  She might be able to make the twenty-minute appointment work if she were adequately supported.

The macro change is easy.  “I do not understand why we don’t have nationalized health care.  We spend so much money on administration.  I see so many people who have no insurance.  And half the time the people with insurance are as bad off as the people with no insurance.”  Vishnu recalls one of her patients, a 40-year-old with cancer.  Despite an alarming symptom, he put off seeing the doctor for three months so that his visit would go toward the next year’s deductible.  “People leave things until it’s too late,” when faced with the financial reality of their insurance deductibles.  Why should a resident of a “developed” nation have to choose between paying for her prescriptions or buying her groceries?  I shared this frustration when I worked in clinic.  I naïvely thought patients should be able to make their medical decisions based on my medical advice.

“I think we need to go back to the point that practicing medicine encompasses  knowledge and skills and a relationship,” Dr. Vishnu says.  “The relationship is paramount, the care team is paramount to promote health.  We don’t have systems in clinic or a society that supports that.  We are disease-focused.”  In Vishnu’s nationalized health plan Nirvana, each patient would have a baseline ninety-minute visit once a year, a preventive medicine and health assessment visit, where the physician and patient could sit down and discuss goals for health.  “It’d be me and Michelle Obama in a room together [with the patient] and I’d do the health things and she’d get ‘em moving.  And feed them kale.”

I ask Vishnu to describe her greatest joy as a physician.  She talks about the satisfaction of working with her patients to make healthy changes such as quitting smoking or beginning an exercise program.  “I also love seeing kids for well-child check-ups, healthy kids who are with competent parents.  Seeing a nine-month old for a healthy baby visit, assuming they have competent parents, can fix a pretty bad day.”

Vishnu recalls an episode from a few years ago.  She picked up her own child at daycare after work and was immediately called in to deliver a baby at the hospital.  “I was delivering this baby and the aunts of the patient were holding my son.”

Family medicine at its best.  People in community, taking the time to care for each other.


Musical Moment

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Vishnu is a Hindu God, the Protector of humanity.  He is generally depicted with four arms.  (I’m thinking extra arms could really enhance physician efficiency and improve work/life balance.)

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The Apollo Mission

I reconnected with Dr. Apollo (a pseudonym) after  my recent Oberlin College reunion.  I’m a doc, you’re a doc, let’s chat sometime.  He agrees to be interviewed after reading my blog post on physician burnout.  “Oh my gosh,” he says.  “This is exactly what we talk about!”  Scheduling the interview turns out to be a minor challenge.  Apollo and his wife have been trying to update their will for four years.  The night before we chat, Apollo spends the evening on the computer, finishing the electronic chart notes for his clinic patients.  Then he completes the twenty-five charts pending from earlier in the week.  He goes to bed at 6 am.

I send him a Facebook message that he reads at 1:27 am.  The next afternoon, I catch him in the car.  His wife’s driving.  For a guy who commonly gets three hours of sleep a night, he sounds pretty good.

Apollo loves medicine.  He was chief resident in Internal Medicine before pursuing a fellowship in Infectious Disease.  He wound up in a large health system in Ohio.  Germs rock his world.

Like Family Medicine and general Internal Medicine, Infectious Disease isn’t a procedure-driven specialty.  Dr. Apollo is paid for “production,” for the number of wRVUs (work Relative Value Units) generated in a day – or night.  The thinking specialties, Pediatrics and Internal and Family Medicine, pay far less than interventional or surgical specialties like Cardiology and Orthopedics.

The compensation system can’t even comprehend the complexity of the patients Apollo sees on a typical day.  Imagine the time it would take to communicate with an elderly Latino immigrant through an interpreter.  And by the way, the patient is deaf.  Add a sign-language interpreter.  What if I told you that the patient has multi-drug-resistant tuberculosis (add a boatload of protective gear) and is actively suicidal?

You have twenty minutes.  Good luck.

Life in the hospital is equally challenging.  About ten years ago, Apollo would make rounds on 6-8 patients per day, two of whom were new consults.  Now he rounds on 16-20 patients per day on top of 6-8 new Infectious Disease consults.  Weekends are grim with only one doc on service and an average census of 30 ID patients.  Apollo spoke up in defense of quality patient care.  This isn’t safe!  We need more docs!  Administration informed him that he could hire a moonlighter with his own money.

There was one day back in about 2002 when I was on my hospital week.  My census was 18, including folks in the ICU, pre- and post-operative consultations, newborns (some of whose parents requested neonatal circumcision – another topic, another time…), small-bowel obstructions, pretty much the routine spectrum of Family Medicine.  I cried that day.  I think I was standing at the nurses’ station.  Derica, one of my favorite nurses, did her best to reassure me.  It’s okay.  You’ll get through it.

Dr. Apollo is getting through it.  Sort of.  On top of caring for real-live patients, Apollo is also available via pager to whomever wants to chat.  This is a “service” that the specialists in the system provide, an unpaid service.  In procedure-driven specialties, the docs might see some procedural revenue.  In the thinking specialties, these “curbside consults” are a charitable contribution to the organization.

Let’s pretend I’m in clinic again, and I’m seeing a young man with newly-diagnosed HIV disease for his hospital follow-up.  I have questions about his medication regimen that require ID input.  In the olden days, I would ask my RN to please contact my favorite Infectious Disease doc’s office and try to get her on the line.  What would she get in return for being available to help me?  A new clinic patient.  And my undying loyalty and gratitude.  Maybe I could work her son into my schedule for his forgotten sports physical.  What goes around comes around.

Now, if I practiced in Apollo’s system, I would call a general number if I couldn’t find my MA, and request that an ID specialist call me back.  I’d ask Apollo to look at my patient’s x-rays and med list, and weigh in on a follow-up course.  I have no personal connection to Apollo.  He’ll never see my patient.  But his name is on the chart.  Welcome to liability risk with no benefit whatsoever.

On a recent Wednesday, Apollo tracked these “curbside consult” phone calls.  He spent four hours on the phone.  Unpaid.  What goes around comes back to the pocketbook of the CEO.

Ebola almost killed Dr. Apollo.  Three of his colleagues had recently left the department.  The new hire came from California and lacked familiarity with the facility, the staff, and the computers.  Ebola hit.  Who do you turn to when Ebola hits?  Your Infectious Disease specialists, duh.  In one week, Apollo pulled three all-nighters.  One day, he had eight hours of (unpaid) meetings and saw 18 patients in the hospital.

Apollo is burning out.  It’s a smoldering burn, gathering energy over the last several years.  His department continues to hemorrhage docs and the system continues to just not get it.  (Medical students and residents get it.  The applicant pool for Infectious Disease is in a three-year decline.)  Dr. Apollo took a stand last year, demanding compensation for the curbside consults, input into clinic support staff hiring, and more time with complex patients in his clinic schedule.

The organization basically said – Prove how much time you’re spending on the curbsides!  All the calls are recorded, and somewhere in the system that data is available.  Is it available to the docs appropriately asking for compensation?  No.  Clinic support staff decisions continue to be made without physician input.  In response to the need for more time with complex patients, an administrator said, “Fine.  You just can’t lose productivity.”  And suggested that Apollo add time slots earlier in the day and work through lunch.

“It feels like we have so little autonomy,” Dr. Apollo says.  On a recent day in clinic, a nurse asked Apollo to add a patient in to his schedule.  He said no, please put them in tomorrow’s schedule.  The patient was stuffed into his day anyhow.  “What did you do?” I ask.  “I just saw the patient,” he replies.  What else can he do?

Dr. Apollo recently attended a medical conference on physician burnout.  His pager went off so many times that he had to leave.  #irony

I ask Dr. Apollo about his greatest joy, if there is any joy left at all.  “I think probably it’s that there are certain patients that I do love taking care of.”  He enjoys the social justice aspect of infectious disease, particularly in regard to refugee populations.  “In the past month, every time I see a refugee, I thank them for coming to Ohio.  I say, ‘The state is so much better because you came here.’”

What recharges his batteries?  An appreciative patient.  A successful strategy to improve the efficiency of patient care.  Academic projects such as putting together a talk or a reading.

There’s no time.

The hamster wheel of productivity strips the organization of opportunities for creativity and innovation.

There’s not even room for creativity in a chart note.  The doc’s assessment winds up being a list of diagnoses instead of the thought process behind the list.  “Medicine is about storytelling.  We even comment on it it our notes!  ‘The patient is a poor historian.’  We value that!”

The story is lost.  And the therapeutic relationship suffers.  It’s “like a factory model of healthcare,” Apollo notes.  (His son concurs from the backseat.)  “I try to keep eye contact [with the patient while typing on the computer].  I can type fairly well without looking at the keyboard.”  Sometimes he glances down and finds a paragraph of gibberish.

Dr. Apollo is plotting his escape.  He’s researching other Internal Medicine fellowship options.  What time do docs leave clinic?  What’s the average number of patient visits in a day?  Would he be able to incorporate his love of infectious nasties?  Do the docs recognize their own children?  This is a bold and radical step for a middle-aged man, to take a drastic (but temporary) paycut for the promise of eventual sanity.

I ask what change he would make on a macro level, a BIG THING.  “Single-payer,” Apollo says immediately.  He cites a graph of the steadily increasing number of physicians over the past several decades, overlaid with the exponential increase in administrators.

If Dr. Apollo switches subspecialties, maybe he’ll have the time to help with the Revolution.

I ask where he hopes to wind up after completing yet another fellowship.  He’d consider staying in his current organization.  I’m shocked.  In spite of everything?  “The [redacted to prevent more physicians from flocking to this subspecialty] docs love it!  I don’t want to burn bridges.”  And he wouldn’t want to leave his home state.

Better the devil you know?

Dr. Apollo is convinced that necessary changes to the US healthcare system will be driven by patients.  I agree.  If patients understood the abusive system that gobbles down young idealistic medical students and spits out jaded, ulcer-riddled automatons, surely they would protest.  “If doctors advocate for themselves,” Apollo continues, “it’ll look self-serving.”

What then must we do?  I’m a patient.  You’re a patient.  Please.  Speak up!  Get on the phone.  Grab your computer.  Tell that CEO to stop killing your doctor or there will be no doctors left to kill.


Musical Moment

Apollo is the Greek god of healing.  And herding.  Convenient.

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Lend Me Your Eir

Over 13,000 people read my recent post on physician burnout.  Thank you.  Clearly, folks are interested in this topic.  Smart researchers are examining provider stress and burnout.  Readers mentioned several resources including Let My Doctor Practice and Physicians Working Together.  I’m not a researcher.  I’m not a practicing physician.  What can I contribute to the discussion?

When I was still a clinic doc, my greatest frustration was the electronic medical record.  We transitioned from transcription to the EMR during my clinic tenure.  I refused to develop my own “dot phrases” and “smart phrases,” generic chunks of documentation that could simply be dumped into anyone’s chart.  I was my own transcriptionist.  I listened to the patient’s story and translated it into a coherent SOAP (subjective, objective, assessment, plan) note.

A good SOAP note contains just the right number of words; It’s descriptive but not over-wrought.  You see into the patient’s mind, into her version of events.  You add details of the physical exam and then you make an assessment – This is what I’m thinking based on the data I’ve collected.  And here is the plan that I’ve made with input from my patient.

Medicine is storytelling.

For the next few weeks, I’ll tell the reverse stories, the backstories, the stories beneath the white coat.

I’ve already interviewed a family doc, an internist, and a medical spouse.  Anonymity is critical.  Squeaky wheels tend to be removed.  Anticipate that I might alter identifying data to protect those who speak the truth.

If you’d like to stay in the conversation, please sign up for my blog (below or up on the right-hand side).  You’ll get a confirming email RIGHT AWAY saying Thanks For Subscribing!  If you don’t see the confirmation, check your spam folder.

Eir is the Norse goddess of healing.  May she watch over this space.


Musical Moment

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Laying Down My Stethoscope

One of the Star Tribune’s leading articles 8/7/16 is “Doctors Battling Crisis of Burnout.”  The article talks about how many health care organizations are recognizing physician stress and burnout as an important issue and taking steps to help providers develop “resilience” in the face of stress.  Such steps include offering an exercise room at work, hosting dinners to discuss stress, and sending cleaners to doctors’ homes when the workload is particularly dense.

Pardon me while I try to prevent my brain from exploding.

People ask me at least weekly if I’m going back to work anytime soon.  After I completed residency, I signed a contract for ¾ time with one of the major healthcare organizations in the Twin Cities.  I had my own dedicated RN – this sounds possessive, but I assure you, I was hers, too.  Full-time status was considered to be 28 face-to-face hours with patients per week.  This doesn’t include the hours spent on phone calls, charting, paperwork, prescription refills, etc.

I worked one week out of every eight in the hospital, loving the interaction with our clinic’s patients and hospital specialists with whom I’d trained.  I took overnight call about three times a month, sometimes more.  Those nights were rough, often with little sleep and hours spent at the hospital.

I dictated my patient visits and handed the tape to our site transcriptionist.  The notes were filed in the chart in reverse chronological order.  The paper-bound story of a patient’s medical life.

When my son was born, we were up to 34 face-to-face hours as the expectation for full-time status.  Not including phone calls, charting, paperwork,, prescription refills, etc.  Benefits were dependent on your FTE (full time equivalent).  I was my own transcriptionist at that point.  We had transitioned, painfully, to an electronic medical record.  Physicians were encouraged to develop “dot phrases,” generic pre-fab chart note chunks, that could be plunked into anyone’s note and tweaked as necessary.  It’s like calling paint-by-number “art.”

We were paid on “production,” how much revenue we generated for the organization.  wRVUs is the technical term – “work Relative Value Units.”

RNs were a hot commodity by that time, sequestered into specialized roles like Coumadin management and phone triage.  Providers (we were mostly physicians with a couple nurse practitioners) worked with medical assistants, some of whom floated to different clinic sites.

So when the Big E was born, Ace and I each had non-coordinated, independent, overnight call schedules.  I asked for some time away from call with a concomitant decrease in pay.  The organization turfed the question back to my colleagues.  They declined.  I can understand it – if I didn’t take call and the organization offered no support, the burden fell upon my partners.

I gave my notice.  But the organization contractually required ninety days.  Eventually, the ninety years/days were up.  I wanted to continue working for the organization in urgent care sporadically but that meant I couldn’t cash in on the physician retention benefit plan.  I worked in urgent care twice and haven’t worked for money since.  We are fortunate.  We can make it on one income.

Last time I checked, “full-time” was considered to be 38 face-to-face hours per week.  That still doesn’t include phone calls, charting, paperwork, prescription refills, etc.  Part-time employment is not allowed unless you were “grandfathered” in.  Patient visits are scheduled at twenty minute intervals.  Yes, you’re expected to do a complete physical exam in twenty minutes on that 64-year-old three-pack-per-day hypertensive, dyslipidemic, diabetic who is transferring care from Florida and arrives with an oxygen tank and a wheelchair.  Providers work with whatever medical assistant is assigned to the patient care team for that day.

“When are you going back to clinic?” you ask.

After the revolution.

Physicians and mid-level providers are the way healthcare organizations make money.  VPs do not generate revenue.  Nurse managers do not generate revenue.  Presidents do not generate revenue.  When organizations find themselves in tough times financially, they whip the doctors. Work more!  See more patients!  Get us more money!

Pay-for-performance is a particularly devious form of torture.  Your pay is docked if your patients’ blood sugar control isn’t perfect or if their blood pressure isn’t within certain parameters.  Physicians are held personally responsible for patient outcomes.  On one level, of course this is appropriate.  Physicians must practice ethical, up-to-date medicine.  On another level, I can’t control whether my patients actually take their medication, follow my exercise advice, or smoke right before their appointment.

What would a revolution look like?

1) Medical scribes for all providers.  Physicians shouldn’t be typing their notes.  This is an unbelievable waste of the specialized knowledge of the sole income generators in a healthcare system.

2) Single-payer, universal healthcare system.  You can’t imagine the convoluted mess of human resources necessary to support our idiotic patchwork-payer system.

3) Allow part-time employment and build in support for life circumstances (illness, leave, surgery, birth, family emergency).

4) Reward thinking specialties (family medicine, internal medicine, pediatrics), not just procedure-driven specialties (gastroenterology, surgery, etc).

5) Make medical school free.  I graduated from med school in 1997 with $60,600 debt.  I paid most of it off during residency.  The average medical student today graduates with $170,000 in debt.  And we wonder why there is a shortage of primary care docs.

6) Study upper-level administrative pay and figure out a rational approach.

(7)As long as we’re having a revolution, let’s make it possible for a family to live on one average  income.)

8) Give some control back to docs.  If I want 45 minutes for a complete physical, let me have it.  I know I won’t be paid as much.  So be it.

9) Pay should depend upon quality and complexity of care as well as production.  But figure out the right ways to measure quality.

10) Off-load providers.  Providers should only be doing provider-level work.  This sounds arrogant to some, I realize.  Gee, the poor doctor didn’t want to room her own patient.  In terms of office efficiency, though, this is the only system that makes sense.  Develop protocols for refills, triage, rooming, updating chart info, etc, AND FOLLOW THEM.  PharmDs can do a lot of medication management for chronic disease.

There’s a lot more to the revolution.  And I have a headache.

In short, it’s great that more attention is being paid to physician burnout and stress.  However, the answers lie not in fixing the physicians, making them more “resilient,” but in fixing the healthcare system that’s burning them out.

PS (8/11/2016): Over 4500 people have read this post since Monday.

1) Thank you for caring about the health of healthcare.

2) I plan to continue with this topic for at least a couple weeks.  I generally post on Mondays.  If you want to stay in the conversation, please consider signing up for my blog (below or up on the right-hand side).  You’ll get a confirming email RIGHT AWAY saying Thanks For Subscribing!  If you don’t see the confirmation, check your spam folder.  Please.  (And here’s the next post.)

Musical Moment


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Heart, Broken

Rafa the Pomeranian turns eight in August.  When I accidentally acquired Rafa in the summer of 2011 (Happy Birthday to me!), Second Chance Animal Rescue thought he was about three.  I decided his birthday would be August 8, a date he shares with my friends, Jen and Rollin.


Cute, amirite? Doesn’t look like the type of dude who would gnaw off your arm.

Rafa is a pretty good dog.  He likes people.  He doesn’t bite children.  He barks like crazy at other dogs but he’s super cute and fuzzy so no one cares.  Much.  Rafa loves to sit on a pitcher’s mound of dirt, gazing at the neighbors’ back door, patiently waiting for their dogs to be released so he can BARK LIKE CRAZY and zip up and down along the fence line, talking about how he wants to rip them apart and munch on their lovely furry legs.

Rafa has always had a “slight” heart murmur.  Ace stole my stethoscope when I quit working in a clinic and we never bothered to listen to Rafa’s heart – don’t play doctor to your own kids and all that.  He (the dog) has always had a “slight” cough as well.  (Incidentally, Ace has a “slight” cough at the moment, too.)  Basically if you squeeze his chest he coughs.  We don’t squeeze his chest.

His cough worsened to the point that he was waking up at 5 am hacking.  5 am is not a good time for me.  The vet said Rafa’s murmur was louder and he wanted an xray.  The xray showed an enlarged heart that was probably compressing the trachea.  Our vet suggested a cardiac echo ($400).  I suggested a trial of medications (??$$).

I think Rafa is older than his stated age.  My guess is closer to 10 or 11.  The vet con-curs.

Ace and I bothered to listen to Rafa’s heart.  Generally, one hopes to hear a Lub and a Dub.  Rafa’s Lub and Dub are obscured by a WHOOSH.  Holy cow.

So here’s the theory: Rafa had a mildly leaky mitral valve.  The valve wore out over time and now he has significant mitral regurgitation, where the blood isn’t effectively pumped from one chamber to the next.  Inefficient pumping means more blood is pooling, stretching out the chambers of the heart.  And the enlarged heart mashes on his trachea and makes him cough.

I’m getting some good practice for old age, anyone’s old age, could be my parents, could be my husband.  Here is Rafa’s med list:

1)    Enalapril 2.5 mg per day

2)    Salix (human Lasix) 12.5 mg one or two tabs up to every six hours for symptoms of volume overload

3)    Dextromethorphan (plain, not with Guiafenesin) 13 mg as needed for cough

4)    Hydrocodone (?mg) ¼ tab (I accidentally gave him one tab for each of the first three nights – fortunately he kept breathing) up to every six hours

That was the initial list.  Then I decided to do a little research on the internet.  (Oooh, did you feel the vet roll his eyes?)  I found a lovely review of the research on the utility of Taurine and L-Carnitine supplementation in canines with cardiomyopathy.  And fish oil helps, too!IMG_2046

Off to Mastel’s Health Food Store.  The ladies at Mastel’s were extraordinarily helpful, showed me their pet supplement section, and assisted with finding appropriate preparations of Taurine, L-Carnitine, and fish oil.  If you have any supplement needs, I highly recommend this joint.

5) Add Taurine 500 mg once a day up to three times a day and

6) L-Carnitine 250 mg up to three times a day and

7) Carlson’s Fish Oil 2 mg daily

I called the vet and left a message about the supplements.  And I asked for antibiotics.  Basically, I want to leave no medicinal stone unturned.  I really don’t think my poor furbaby has kennel cough, but if he does, I wish to blast it to kingdom come with massive nuclear devices.

8) Add Clavamox (amoxicillin) 100 mg twice a day for seven days

Janna, my holistic vet friend in Wisconsin, suggested adding 9) Vitamin E and 10) Selenium as well.  I will eventually.


Step One – grind pills to powder


Step Two – add liquids

The morning routine consists of grinding everything but the fish oil and dextromethorphan with a mortar and pestle, dumping in the fish oil and DM, stirring the mess into a slurry, and adding half a teaspoon of unsalted peanut butter.


Step Three – mix in 1/2 tsp unsalted peanut butter


Step Four – Pomeranian narfs it up







Rafa loves it.

I’m not sure if he’s getting better.  He’s not as vigorous on our walks.  He still wakes up coughing each morning and coughs in fits throughout the day.  When I pick him up to snuggle him, I have to be extra special careful.

My dog is getting better medical care than many humans, even in the US.  I feel a bit sheepish/doggish about this fact, like I’m privileged.  I am privileged, privileged to enjoy the company of the World’s Largest Pomeranian, privileged to be in a position to try to help him enjoy good health.


Getting some love from Grampa.


The Big Pile. So far.

Please send a little love in Rafa’s direction.  He’s heart broken.                  And so am I.

Musical Moment

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