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.

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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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Things Fall Apart

Entropy beckons.

All systems crave chaos.

Wrinkles.  Dementia.  Peeling paint.

Cleveland devolves, a frenzied orgy of hate.

Stone her!

Maggots in the flour.

Will the bread rise?  Will the bread rise?

Entropy makes his grand entrance, adorned with careless exclamation points.  We are the champions!  What face will he wear today?  Misogyny or Racism?  White Supremacy or Terrorism?

(Things fall apart.)

Feast on the flesh of a thousand immigrants!

Cockroaches scuttle across the parquet floor, seeking the comfort of corruption and decay.

Make America great again!

We speak.  We question.  We love.

And his tuxedo, sewn from the threads of ignorance and fear -

his tuxedo begins to fray.

Will the maggoty bread rise?

Light your candle!  Unravel the toxic cloak!  Lean your energy against the chaos.

Light your candle in this dark day.

Musical Moment

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Fresher Than

I met Mademoiselle in the fall of 1993.  We were sudden housemates at the rundown Phi Rho Sigma medical fraternity.  Please understand that Phi Rho wasn’t a frat in the Animal House sense of the word.  No goldfish, no hazing, no group activities.  There might’ve been a party, one, that I remember.

The frat had a cat for about two weeks, a mostly feral lad with a lackadaisical “owner” who fed him only occasionally.  In one of my Worst Decisions Ever, I captured Louie, stuffed him into a box (from which he escaped and rampaged about my Volvo 240 DL while I was attempting to drive), dragged him to my family’s vet, and got him a set of shots.  We ensconced him in the common room of one of the Phi Rho houses with a litter box, food, water, and occasional human interaction.  Louie the Free Range Cat was having none of it.  He pooped ALL OVER and at the end of a couple weeks we returned him to the wild to which he was accustomed.  But I digress.

I enrolled in the cult-like Summer Anatomy.  All of human anatomy, literally every single artery, vein, nerve, muscle, origin, insertion, organ jammed into two months.  Dr. Robertson, our esteemed professor, lectured entirely from memory.  My hair reeked of formalin and I couldn’t eat chicken for several months.

Prior to joining the fraternity, I lived above the Food Basket, a grocery store located about two blocks from the medical school.  I never actually lived there.  My friends helped me move my belongings up the rickety wooden fire escape.  Goldenrod, my 1970s hide-a-bed, nearly killed my friend Molly’s betrothed.

The entire apartment vibrated, dancing to the rhythm of the freezer units hung from my floor – the Food Basket ceiling.  I moved out.  Goldenrod played nice on the way to Phi Rho.  Summer Anatomy meant I lived alone for a couple months in the three-bedroom, second-floor apartment.  I got the best room.

Meela moved in at the start of the regular class schedule.  A woman of few words, she had a quietly wicked sense of humor.  I can still see the position of her hand as she’d adjust the frame of her glasses.  Meela practices emergency medicine in New Mexico.  I’m sure she’s perfect.  Absolutely unflappable.

Mademoiselle’s real name is Patience.  Her other real name is Ekuatinne.  Born in Minneapolis, raised in  Cameroon, and fluent in at least three languages, Patience returned to Minnesota at 17 and eventually landed at the U of MN Medical School.  She rounded out the inhabitants of our apartment, taking the glorified closet known as the third bedroom.  The three of us tied dishtowels around our waists and Mademoiselle attempted to teach me and Meela the basics of Cameroonian dance, with limited success.

Patience made a lasting impression, changed my life really, in the form of Moist Flushable Wipes.  I questioned her about the rectangular pack of something sitting on the back of the toilet and she schooled me on the many merits of the MFW.  I became an instant convert.  “Fresher than toilet tissue alone,” was the motto of Cottonelle brand Moist Flushable Wipes.


When Ace and I decided to join together in unruly matrimony, Moist Flushable Wipes came along as part of my dowry.  Apparently, MFWs are hard on the sewer system, hard on it to the point that cities are considering banning them.  Ace went into a tailspin when we got wind of the rumors.  I rushed to Costco and purchased a petite back inventory.  We plan to install our own wipe-munching system in our sewer line if necessary; we’d do just about anything to preserve our right to bear MFWs.  I sometimes wonder if Ace will be standing at my funeral, rhapsodizing in his introverted nonverbal way, about the Three Best Things that ever happened to him: The Big E, me, and Moist Flushable Wipes.


Musical Moment



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Disease Model of Systemic Racism

Chief Complaint: Stage IV Systemic Racism

History of Present Illness:

The USA is a North American Country with a 250+ year history of Institutionalized Racism.  Multiple prior exacerbations include: slavery, annihilation/dispossession/forced assimilation/reservation marginalization of native peoples, the Chinese Exclusion Act, internment camps during WWII, lynch mobs, assassinations, anti-miscegenation statutes, the Tuskegee Syphilis Experiment, segregation, destruction of the thriving African-American Rondo Community in Saint Paul by Interstate 94, for-profit prisons, and the corrupt political system.  (Please note, this is not an exhaustive list.)

The country presents today with a recent escalation in symptoms, manifesting in the shooting deaths of two black men by police officers.  Mr. Alton Sterling died in Baton Rouge, LA, on 7/5/16.  Mr. Philando Castile died in Falcon Heights, MN, during a routine traffic stop on 7/7/16.  The shootings triggered an autoimmune response, with a sniper attack on Dallas police officers, resulting in five deaths and numerous serious injuries.

These recent symptoms have caused significant widespread distress, with frank emotional trauma, copious anger, and serious economic and logistical interruption.  The US wonders if any new treatment modalities are available and also seeks immediate amelioration of pain.

Prior treatment attempts utilized forced de-segregation, affirmative action, the Black Panther movement, anti-discrimination laws, the Black Lives Matter movement, “need-blind” admissions, and internet campaigns.

Objective: Vital signs unstable with notable pressure buildup in various organ systems.  Areas of deeper skin pigmentation across the country continue to be associated with poverty, incarceration, and lack of educational and employment opportunity.  Brief focused physical exam demonstrates ongoing increased concentration of people in the region of the Governor’s Mansion on Summit Avenue in Minnesota, as well as smaller vigil-type clusters at the sites of recent shootings.  The overnight blockage of both directions of I-94 in Saint Paul on 7/9/16 has resolved.

Comprehensive imaging again reveals stage IV disease, with widespread metastasis via hematogenous and lymphatic spread to all major organ systems, including but not limited to: education, employment, housing, politics, nutrition, military, law enforcement, social services, prison system, and healthcare.


The United States presents with ongoing Malignant Stage IV Systemic Racism intercalated within all major organ systems in the country.  Today’s visit was prompted by a recent escalation in symptoms resulting in death, distress, and trauma.  The country seeks information about curative procedures, therapeutic trials, and pain relief options.


With Stage IV involvement, the patient will require an intensive multidisciplinary approach utilizing numerous specialists.  Curation is a lofty goal and perhaps unattainable.  However, hope is not lost as we know that even the placebo effect (If-You-Can’t-Say-Anything-Nice-Shut-Your-Trap) results in statistically significant improvement in symptoms.

Specific therapeutic suggestions include:

1)    Surgery:  We know from past treatment attempts that violent radical surgical approaches result in a high level of collateral damage.  We will instead proceed with tumor debulking, where pockets of Racism are identified publically and provided high-dose education and legal poultices when necessary.  Systematic dissection of all involved systems is necessary.  Anticipate the need for significant reforms in education, housing, law enforcement, the prison system, healthcare, and etc.

2)    Adjuvant Chemotherapy:  We will begin a therapeutic trial of the new chemo cocktail fICE (facilitated Interaction, Compassion, Empathy).  This combination works most potently at the cellular level, person-to-person.  Common side effects of this novel chemotherapy include new friendships, relief, joy, and heightened understanding.  During chemotherapy, people with less melanocytic activity are advised to close their mouths, open their ears, and bear witness.

3)    Radiation: Plan to utilize two different modalities including HDR brachytherapy and EBR therapy.  The specific radioactive energy type is LOVE, the most potent energy available at the time of this publication.  As we know from lab studies, Racist cells die in the presence of LOVE.

A)   High Dose Rate Brachytherapy: Love will be implanted directly into tumor-filled, Racist areas.  Dr. Martin Luther King Jr. experimented with the direct implantation of love, with good result.

B)   External Beam Radiation: We recommend full-body, daily, high-dose radiation with LOVE.  Contrary to other radiation agents, there is no limit to the total Gy dose of LOVE that can be delivered.  In fact, we continue to see an encouraging dose-response relationship even at extremely high doses.  No negative side effects have been reported in the literature.

4)    Close follow-up at regular intervals and prn to evaluate progress.


Musical Moment

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