Do the Right Thing

It’s a fine line that we walk as physicians. 

I went into medicine because I wanted to learn about the craft, become proficient at healing disease and easing suffering, and because I genuinely liked getting to know more about my patients and hearing their stories. These reasons for going into medicine as a career and staying in medicine as a vocation have not changed significantly through the last three decades. 

The problem we are faced with pretty often nowadays is this: the demands that patients (and through them insurance companies, pharmaceutical companies, families, and other third parties) make are often at odds with what we were taught to do. I’ll give you a few examples. 

Patients will come to me and ask for a specific diagnosis. Why? Because sometimes their insurance will not pay for a less severe diagnosis (an adjustment disorder versus a major depression, for example), they do not want to be perceived as being in treatment for an alcohol or other substance abuse problem (no matter how valid it is), or they need to be seen as having a particular problem because their attorney told them that it “would look good” for their disability case or other lawsuit. 

Patients will come to me asking, or sometimes outright demanding, that I prescribe a particular drug for them. Telling them that I do not presribe narcotic pain medications in a mental health clinic is easy enough. When they ask for benzodiazepines like Xanax, Ativan, Valium, Librium or Klonopin, the area might be grayer. Some patients might benefit from those drugs or even need to be on them long term, but they are the exceptions nowadays. “If you won’t given them to me, then I’ll just go to Dr. Jones down the street!” they exclaim, thinking that this is somehow a threat to me. Or, “I know that you give them to Ms. X from across town. Why won’t you prescribe them for me too?” 

Direct to consumer advertising on television has not made this any easier, since patients will come in asking to be prescribed powerful antipsychotics for insomnia or pain medication for panic attacks. What they are asking for often makes little sense clinically, but of course since they saw it on television it must be true and I should get out the RX pad. 

Some patients come in demanding a particular kind of treatment that they think makes the most sense for them. Aunt Sara may have told them to ask for it, since of course she took Psychology 101 in college and has the power of the Google search behind that vast amount of training, or they have read about it in Vanity Fair, or a friend of a friend of a friend had the particular treatment years ago and it worked for them. Some will want long term therapy when it makes little sense to drag things out for years when weeks or perhaps months will address the problems at hand. Some will want outpatient treatment when it is quite clear that they need to be admitted to the hospital. Others, already on an inpatient unit, will want to stay there for weeks, when the right thing clinically is to discharge them to an outpatient clinic. Some will ask for “counseling” when it is imperative that they enter drug rehab for a heroin problem that they do not want to acknowledge.  

Some patients want a specific kind of relationship, that is, they would like to consider the doctor their special friend, not their physician. Others like to consider themselves the medical, diagnostic and therapeutic equal of their physician, since they can and do research everything online, sometimes in real time on a smartphone while they are sitting in the exam or consulting room! Some of course want a clinical relationship to move to a friendship and then perhaps an even more intimate relationship, which is never appropriate in my opinion. I was taught, once a patient, always a patient, and I still subscribe to that maxim today. 

It is hard to do the right thing, in medicine and in life.

So what is a conscientious and well-trained and compassionate doctor to do?

Establish a professional doctor-patient relationship first, before doing anything to treat any malady. This means seeing the patient, getting a thorough history, doing an examination as indicated, establishing a diagnosis and coming up with a treatment plan. No shooting from the hip, sidewalk consulting and doing something for a friend. These will come back to bite you. Although some would not agree with me, I have not made a practice of treating my own family over the years either. If my children were ill, I figured a well-trained, trusted pediatrician was a much better option than a slightly frazzled, worried parent who happened to also be a doctor. 

As far as medication treatment goes, I have always been very conservative. If a mother is pushing for a three year old child to be put on stimulants for “ADHD”, I will balk. If a woman pregnant in her first trimester is pushing for Xanax to help her deal with the marital conflict with her husband because of the pregnancy, I will recommend counseling, not benzodiazepines. If someone who is not psychotic is having trouble sleeping, I will be much more likely to give them a two week course of a sleeping pill than put them on the small dose of a major antipsychotic that they heard about on television. What you’re treating, and not treating, is important. Efficacy and potential side effects are important. 

It is very important to tailor the treatment to the illness diagnosed, the symptoms that are being targeted and the outcome that is expected. 

Lastly, as alluded to above, the relationship between doctor and patient must be held to the highest standard of all. It should be professional, respectful, and collegial. We are partners, but by definition we are not equals in the process. You know yourself better than anyone in the world. You have information that you must impart, and I have decades of experience and learning and training that I must share with you in order to help you get better. 

If we are honest and work together, treatment happens, illness is managed, and patients recover. 

It is only then that it is much easier to do the right thing. 

Disorderly Conduct

My friend Jordan Grumet wrote yesterday about a house call, a visit on someone else’s turf, as he put it. Read this short but poignant post, The Home Visit, here. 

This post stirred something in me, as Jordan’s posts often do, especially in light of my own recent thinking about the new year and what it means to me and how my life is run. As I have recently written, at this time of the year I think about putting things in boxes, into their proper places, just as his cancer patient had her home arranged just so, everything in its place. I pride myself on keeping a tightly orchestrated to do or reminder list, following it, organizing it by date or priority, and not letting things fall between the cracks. Everything in its place. Everything with its appointed timeframe and due date and project goals mapped out for me. This usually works pretty well. I feel comfortable with my work load, how it flows, and my ability to get things done. 

However, I practice medicine, and a type of medicine that can be very unpredictable just by its very nature and the type of illnesses I see and deal with every day. Just when I think that I have my schedule mapped out for the day, a code blue is called as a teen is having a seizure out front on the bench in the freezing cold. I excuse my self hastily from the present appointment and patient in my office, walk briskly towards the front of the building, and deal with whatever I find when I get there. When the paramedics and ambulance arrive and the child is safely loaded up for transport to the local hospital emergency room, I go back to my appointment, shifting gears quickly as my pulse comes back down to normal range. 

I carefully orchestrate my schedule for the first month of the year, coordinating two jobs that usually mesh together tolerably well, filling up each patient slot for the next six to eight weeks ahead. There is little room for error, few slots for extra duties, and very little wiggle room in general. Funny thing, that, because my third grandchild is due in the next forty eight hours, and I don’t think he or she will care much about what my schedule looks like on Tuesday or Wednesday or whenever the delivery date turns out to be. I will juggle and reschedule and make time for the trip to be with my family because that is most important to me. I will make it all work somehow. 

I will do my best this year to advise my patients on the best treatments available for their presenting complaints, utilizing the available evidence base and my own experience and crafting the best treatment plan I can for each patient who asks for my help. The problem with this is that mental illness is insidious, chronic, and debilitating. It affects mood, judgment and impulse control. No matter how diligent I am, no matter how good the plan is, sometimes it will fail. Like Jordan’s patient with cancer who decided not to have surgery or chemo or other “disorderly” treatments, my patients will decide to stop their oral medications, not come in regularly for their injections, forget to get blood drawn for lab work, and decide not to attend AA meetings after all. 

Medicine, again by its very nature, has a certain amount of built-in entropy. We schedule and plan and scheme against it, but to no avail. Sometimes things just don’t go our way. We doctors are trained to diagnose and fix things, to problem solve and make decisions and move logically from one problem to the next to the next. When this happens, we feel smart and happy and powerful and in control. When it doesn’t, we get irritable and angry and depressed and then we are not at the top of our game. 

Like Jordan, even if things don’t go exactly my way, I would still rather they are clean, crisp and orderly. The patient with schizophrenia may not live as long a life as I wish he would live, since he does not take care of his diabetes, he drinks too much and he goes off his medications every few months. The patient with bipolar disorder will get manic at intervals and spend too much money, end up in jail, or take a cross-country trip that has family and friends worried sick about her. These things will happen. 

I will still see them when they come back, get them back on track with a reasonable treatment plan, write the prescriptions for medications that should help them, and schedule them to come back to see me the next time, wanting to believe that this orderly way of doing things will keep the disorderly conduct of illness and infirmity at bay for just a little longer. 

In this new year, I hope that Dr. Grumet and I, and all of our colleagues, are successful at doing just that. 

Shake It Up Baby, Twist and Shout

Time For Change

So, my friend Dr. Rob Lamberts and I decided to take a couple of hours last night to have a beer, eat some good seafood, and talk about the state of his new practice and healthcare in the United States in general.

Now, I obviously won’t talk about the confidential aspects of his new venture, nor the boring details of what we think about the state of American medicine, insurance reimbursement or traditional medical office structure and function. You may read some of his musings at The Health Care Blog and at Musings of a Distractible Mind. I will, however, tell you that we agreed on at least one thing during our wide-ranging discussion.

It’s going to take a powerful disruptive force to change how healthcare is provided in America. 

@doc_rob is one of the handful of people that I know who is stepping out on a limb, a limb that he is quite sure should not support the weight of his new ideas. He is setting up a new kind of practice that focuses on keeping patients well, not on treating them after they are already very sick. Can you imagine?

I started my training in American medicine in 1979, what seems like a millennium ago now. Like all doctors of my age, I was trained to look at medical illness as a problem to be solved. We learned to ask the right questions, lay on hands to examine, order tests as needed, come up with a differential diagnosis, further refine it as more information came in, make a more definitive diagnosis, and then act by treating the patient. We always saw the patient as sick. After all, if they were not sick, they would not be coming to us. We were taught to be highly skilled healers. In order to perform as a healer, one needs a steady stream of really sick people who need you.

A highly trained physician needs a practice full of really healthy patients like a fish needs a bicycle.

Rob is taking the idea of traditional medical office practice and standing it on its head. He is setting up a scenario where he can teach patients how to be healthy. How to stay well. How NOT to need him.

It’s very hard for me to communicate to you how extremely radical this notion is. It scares the hell out of the establishment, who, at least for now, hold all the cards. The powers that be hold the keys to the hallowed halls, the big diagnostic machines, the pharmacies full of expensive pills, and most of all, the power to decide what is and is not reimbursable and even worthy of payment.

If radicals like Dr. Rob are successful, and I have to tell you I think they eventually will be, American medicine will never be the same.

For a psychiatrist who sees patients who have both emotional and physical illnesses, this is an intriguing model. What if we were able to take the time to proactively look at families who are at risk for depression, bipolar disorder, schizophrenia AND the medical illnesses such as diabetes mellitus, coronary heart disease and hypertension that go with them? What if we could involve a dietician, a social worker, a diabetes educator, and other professionals at the front end for preventative care, instead of waiting for the first episode of diabetic ketoacidosis or the first time someone is homeless to intervene. How wonderfully radical would that be?

It would mean focusing on the needs of the patient, and it would mean trying to keep the patient well, not the medical establishment.

I will go to work today, as I do most every day. I have thirteen patients on my schedule today, a lot for a psychiatrist in a busy mental health center clinic. All of them will come in and tell me how very sick they are, how much they need the pills that they take and how they need to see me and their counselor more and more and more to be able to function at even a minimal level in the world. This is exactly what they have been trained to do. This is exactly what I have been trained to do.

Wouldn’t it be nice to live in a medical world where my success, and the success and health of my patients, was measured by how well they were and how little they needed me?

Radicalism.

Heresy.

Disruption.

It’s beautiful thing.

Sacrament and Talisman

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Medicine, it can be argued, is a religion.

It has its pantheon of stars, including the likes of Hippocrates of medical oath fame and Sir William Osler (“Listen to the patient, he is telling you the diagnosis.”).

It has its temples of worship, huge gleaming buildings of glass and steel and stone where monks and sisters minister daily and priests offer up sacrifices to appease the gods of death and disease. The Holy of Holies lies deep within the superstructure, or its practitioners would have you believe. It is a sterile sanctum, green, with stainless steel instruments and bright lights that illuminate and facilitate cleansing. Life is lost and regained there. Legends are born there.

It has its liturgy and its order of worship, time honored and beloved by many. Written and passed down through generations of physicians, it is followed with little deviation. Changing it takes a collective will.

It has its sacred books. Passages of handbooks and thick, expensive tomes and manuals are read, digested and committed to memory by thousands of novices and quoted verbatim by attendings.

Medicine as religion also has its sacraments, outward visible signs of something internal or not seen. It has its talismans, carried and worn lovingly by new and old practitioners alike, invoking the old gods of spell and chant and embracing the new gods of tablet and electron. What are some of these?

White coats confer authority and rank. Length of coat denotes length of training and experience. Pristine garments, while impressive, are not as indicative of prowess as those with fading blood stains and the dried bile of suffering and pain witnessed and now borne by the wearer.

A stethoscope worn around the neck is an unmistakable sign of a practitioner of the healing arts. It is a simple statement of knowledge gained, skills learned and the tacit authority given by society to touch, to listen, and to heal.

The simple pen, be it Mont Blanc or Bic, needle point or fountain pen nib, is mighty in the hands of a physician. With this instrument, the doctor can cure pneumonia, order the scan that will diagnose cancer, prep a patient for open heart surgery, or commit them involuntarily for mental health evaluation.

Beepers, smart phones, tablets and other gadgets are the new vehicles for communicating, learning and interacting in the Church of Modern Technology. Whereas a utility belt full of beepers was indicative of status and power in the medical world of old, bluetooth, WiFi and Google Glass carry us forward on an unstoppable wave of technological progress that threatens to engulf us and surgically excise our souls.

Medicine as religion is alive and well.

It has its practitioners, its priests, its temples.

It holds us up in times of trial. It supports us and separates us from dark doubt and ignorance and unexplainable disease.

At the same time, it threatens to become an autonomous beast, a scourge on the land, a metastatic malady so perfectly invasive, so exquisitely symbiotic that it will finally cause the death of the very thing it is trying to save.

That Old Black Magic

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I had seen them, of course, on television and even in real life before. I knew what they were, what they were for, who used them, where they showed up in the world. 

I never knew what was in them.

I never knew what they held, piled up in the main compartment, stuffed into little mesh compartments along the sides or way down in the bottom under other piles of stuff, forgotten and yellowing and crackling pieces of paper or boxes or maybe fine silver instruments. 

I bought my first one just before I did a physical diagnosis course in medical school. As a fledging doctor wannabe, I was now ready to figure out how to get my nose out of books and my hands on people, learning that wonderful skill of diagnostic touch.

Part of that involved the use of tools. Like the contractor’s low-riding leather belt or the bike messenger’s waxed canvas bag slung haphazardly over shoulder and trailing speeding bike and body through the downtown canyons of New York City, I needed something to both symbolize my profession as well as to perform the mundane task of getting my gear from one exam room or clinic to the other. 

It was small, compact, made of smooth leather, real leather her that smelled at first of outdoors and tanning and sunshine but years later of the mustiness of a profession going off the rails. At first, like me, its surface was perfect, uniformly colored and had no stains. Later, just before I disposed of it, in a sad fog of trying to hold on to my training and trying to embrace my middle age, it was musty and cracked and creaked a little every time I opened it. Like my old athlete’s knee, it could still perform its primary purpose, but its days of shiny public glory were long gone. 

My first black doctor’s bag held a stethoscope, a beauty that had a shiny silver bell and dual flexible rubber hoses and adjustable and changeable ear pieces. There was a tuning fork, hummmmmmmmm, that I loved to place on knee caps and wrists. There was an odd little medieval instrument used to check perception of noxious stimuli, its tiny silver wheel of razor sharp teeth looking more like a shrunken torture implement than a diagnostic tool. There was a reflex hammer, red-headed as any woodpecker, silver bladed and perfectly balanced. I had engraved my initials into the handle, GES, and I used it for almost thirty years. I think it probably still rests in a drawer in a crisis center examination room, where I left it, semi-purposefully, some months ago as I said goodbye to another position. There was a sphygmomanometer, yes, one of those things, that I learned to take blood pressures with. It was made of fine Corinthian leather or naugahyde or some such 1980s construct that evoked a sense of luxury in my young physician life at a time where having two nickels to rub together would have made me rich. 

My little black bag. 

The outward and visible sign of a life forever changed internally. A symbol of power, yes really, of the power to come into a house, reach in, lay on hands, diagnosis and heal. No, my friends, I am not being dramatic here. This bag, as did other props of my profession, helped to shape me, give me form and function, help me to be comfortable in public with the fact that I was now a doctor.

I had been given a charge. I had also lost some of my innocence forever. Each time something came out of that bag, each time I heard a sick heart or a blocked carotid or looked in vain for reflexes that no longer existed, I became more skilled but less pure. Less innocent. The leather on that bag aged and cracked and grew dull from being thrown about in the back seat of a car and from being jerked out into the rain.

Fast forward a few decades, friends, if you would bear with me, please. 

My last house call is long since behind me. I will never forget it.

My days of doing routine physical examinations and wearing long white coats are gone.

My days of doing a straightforward history and physical, a really, really good one, are gone.

Not because I can’t do those things. I still know where to put my hands. I still remember the lub dubs and the whooshes and what a tender liver versus a cirrhotic one feels like. 

My career path and the government and my patients’ preferences and insurance companies and I suppose the moon and stars have all weighed in and changed medicine forever. 

My black bag went from holding the wonder of hands-on medicine and Oslerian inquiry to ferrying boxes of medication samples to finally just being a repository of old needle caps and alcohol pads, still freshly sealed but never to be used to clean the earpieces of a Littmann again. 

I parted ways with my black bag a while back.

I tried to display it, keep it on a shelf, contemplate handing it down to my grandchildren. I even had a fantasy, oh, so brief and sweet and nostalgic, about using it again. For what, I did not know. The thought carried me through at least one day, then went the way of the tuning fork. 

Hummmmmmm.

When my granddaughter enters medical school one day hence, if she decides to, she will know of iPads and diagnostic scanners out of Star Trek and push button electronic treatment plans. 

Much like the first time she held that tiny plastic stethoscope to her chest and heard her own heartbeat for the first time that Christmas far away, she will scan my retina, flinging a colored holographic image into the air and saying, “See, Papa, see what we can do now?” 

I will talk to her and tell her stories of the old black magic.

She will tuck me in against the cold and tell me stories of the stars.