Thursday, April 28, 2011


My poem "Dyspnea" appears in the latest issue of The Pharos

Monday, April 25, 2011

They've Got It All Wrong

I mean...they've got it all wrong.

Health reform....the silly alphabetical soup...ACO, PCMH, PQRI.

These things don't mean quality. Not even close. They don't mean economical. They are not about giving good care, or even about being cost effective. They are just that....a bunch of letters. Standing for obscure, unproven concepts being passed off by academics, politicians, medical societies. It's about political expediency. Ask any practicing physician. And were killing primary care.

Because what I do is not about community health. It is not about how many of my patients A1c's are below 7 or how many of my hypertensives meet certain "goals". That's all good...but it's not how I save lives, or how I cut down on hospitalizations, or how I provide economical care. I do that a different way. I use my years of training, experience, intuition, deep knowledge of my patients, and understanding of medicine to hash out a plan that sometimes works. I strive to:

-quickly separate the various causes of both common and uncommon symptoms. I try to be king of the differential diagnosis. Defining whether the 50 year old with chest pain has coronary disease, gerd, anxiety or a pulmonary embolism. Primary care is uniquely situated better then any specialty to do this because we have the broadest knowledge base and experience.

-manage chronic illnesses and titrate medications sometimes on a daily basis. Diabetes, Chf, Copd...the patients often have specialists but unless they want to speak to a nurse practitioner they call me for day to day management.

-Have end of life discussions. Every day. Over and over. When the cards are on the table the oncologist, or cardiologist, or pulmonologist have disappeared. I am the the one left talking about hospice.

And when it works...I save lives, keep people out of the hospital, and allow them to die in peace.

But now there is the collective. Soon we (not I) will be an ACO. We will be a PCMH. Swallowed into a large group and no independence. Tethered to quality indicators that mean nothing to actual patient care. Incentivized to think less about people as individuals and more about groups. Patients will be shuttled from provider to provider to meet some type of quality goal about physician availability. The paperwork will expand..and expand...and expand. And I will expend...expend more energy thinking about everything but clinical care.

Businessmen will siphon off profits to meet the needs of the whole...expensive administrative salaries. Expensive facilities to have to feed the have to feed the mri have to feed our specialists.

You see ACO doesn't equal ethical. The majority of hospitals and medical groups are not going to become one because its the right thing to do.....they are adapting to meet the market. The market changes and they adapt. But these are businesses...they need to make money.

They will use us...just as the government is going to use as. We will help them sell their wares.

Good old primary care is going to save the day. But not the primary care that was proven in all those studies to cut down on the cost of care and lead to better outcomes. No...we've created a new shiny primary care. All sorts of new bells and whistles. Nothing like that old and patient...primary care thing.

The death knell is sounding.

Adapt and become a shadow of what we used to be....

Or stubbornly maintain...

And be eaten alive.

Tuesday, April 12, 2011

Today....I felt like a doctor

I felt like a doctor today as I awoke from a restless night on call. My shoulders and neck hurt as I arched out of the bed and toward the shower. The rest of the house was asleep and the streets were dark. I gently placed my pager and telephone on top of the toilet as I disrobed to get in the shower. The face of the pager showing 5 messages. I had cleared it the night before laying down for sleep.

I felt like a doctor today as I raced through traffic on the expressway. My pager beeping incessantly as I adjusted my blue tooth and answered phone calls. It has been so long since I could drive to work without being interrupted. I briefly caught a look at myself in the rear view mirror. My eyes tired and my head balding.

I felt like a doctor today as I dashed up the hospital stairs. My long gray coat bumping against my knees and my stethoscope almost falling out of the deep pockets. The secretaries at the nursing stations nod as I pass by. "Good morning doctor!". As if there was no place they would rather be at six in the morning.

I felt like a doctor today. Entering the quiet room. The sun starting to peak through the hospital windows. My patent's last sunrise. His eyes rolled back and breathing long drawn out breaths with uncomfortable pauses in between.

I felt like a doctor as I stood at his side. My stethoscope useless. My knowledge impotent. And waited sadly for death from an uncertain disease.

I felt like a doctor today....helpless

Because in medical school no ever taught me that every battle is lost in the end...

You just hope for a few small victories to keep you going...

From time to time

Sunday, April 10, 2011