Flying home from the first HIMSS Patient Engagement summit, I finished Atul Gawande’s book, Being Mortal. I found myself aggregating my thoughts on the conference and the book. They both highlighted how slowly medicine embraces change as we struggle to put patients at the center of the healthcare stage. My reflections revealed that as far as I’ve come, I’m still not there in many interactions with patients. It’s still difficult for me to be more than “Dr. Informative”, which is Dr. Gawande’s accurate portrayal of physicians who are uncomfortable with medicine’s previous paternalism but unsure how to unravel the patient’s goals. During the conference patient panel, Kym Martin, a patient experience expert and four-time cancer survivor, commented that health is not just about the disease process. Physicians, indeed healthcare as a system, must consider a holistic picture that includes financial status, relationships, family support, work issues, etc. Present provider and hospital goals seem to concentrate efforts on what what we, the system, identify as the patients’ goals. Those “should bes” in our eyes are often not the reality of a patient’s existence if all circumstances are taken into account. Dr. Gawande struggles to remember to ask the following of his patients: “What is your understanding of the situation and its outcome? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?” And while his book is concentrated on end of life decisions, isn’t this true for all our patient interactions? Then at 10,000 feet over Chicago it occurred to me–wait, this was what I was taught a million years ago in Family Practice residency–to understand the patient and all that individual has to deal with, not just the disease AND to guide that person through the tangle of the healthcare system. Now if someone will just tell me how to do that in the seven minutes I have with them…by
Surrounded by this talent, about five years ago I began to draw, hoping to do it well enough that my sketches would be recognizable in my journals, especially with travel. It’s been a slow painful journey but recently I began Sketchbook Skool, online classes founded by Danny Gregory, an artist I’ve admired for years. The first class began with an intimidating assignment – draw with a pen. The purpose of the exercise is learning to “live with the line”. Multiple times in the last six weeks I began a drawing and wanted nothing more than to tear it out of the book, get rid of the line and start the sketch over. But I had to persevere and since it was an assignment I kept working with it. Amazingly, as I continued with the drawing it would take shape and become something I really liked. My mistakes were not only livable, many times they were my favorite drawings when finished.
There are corollaries to be made in healthcare–perseverance for example, of which most family practice doctors need a healthy dose of every day. But the acceptance of imperfection, is that even safe in medicine? How do you accept, even more, celebrate the difficulties of practicing medicine today, especially in primary care? With drawing it’s a matter of going beyond ignoring the line–it’s using it to “bend” the reality of a picture, thereby creating something that resembles the object but is different, still recognizable but different. The corollary in my practice is helping patients become participants by using tools like social media, whiteboards and smart phone apps. But I’m an apprentice artist compared to the DaVincis of medical care: The DPC movement with physicians like Dr. Robert Lamberts, and models like Turntable Health are “bending” healthcare practice to create better care for patients, and in the doing, taking physician practice to a point where it once again feels like Art.
My children are no strangers of death. They understand the cycle of life and have said goodbye to pets, mourned with their friends who have lost parents and grandparents. My youngest stood by one of her closest friends who lost her younger brother unexpectedly of a heart problem. My girls have know acquaintances who suicided or died in accidents but tonight is the worst. My daughter calls me, sobbing “They found his body”–a friendship forged in high school at the Governor’s Scholars program, a young man–handsome, intelligent, gone missing two days before. A hate crime. My daughter is 2300 miles away. I cannot hold her. I can only cry with her from the distance, feel her pain and wonder how and why this happens.
Tonight I try to calm the vitriol that rises in my own throat, knowing that is not the answer but is of the same poison that killed this young man.
But it is hard.
Many years ago, a wise family practice mentor said to me “One of the nice things about being a physician for many years is that my patients have grown old with me. Unfortunately that means I am losing more of them.” Those words came back to me recently after the loss of my third male patient in six months, all close to my age. Two of them, avoidable deaths but work and inflammation came before healthy habits and lifestyle changes. The third was from a quick and devastating disease that was not avoidable.
The wife of the third man came in for a visit yesterday. We talked a little bit about his disease and its quick progression. She talked about the usual things–their 30 year marriage, children, hopes for grandkids. I told her that I would miss him after our many year patient-doctor relationship. I hesitated, then shared with her that it had been a rough year with patient losses and that he was one of three men that died much too young–at 70 he had been the oldest. She looked at me and said “then you feel the void.”
Obviously, not the same way that she does, but indeed, I feel the void.by
As I look to the end of my sixth decade, time is more precious than ever. Having a mother, maternal uncle and maternal grandmother with late onset dementias forces the realization that not only is my time limited on this earth, but my intellect as well. How can I squeeze the most out of the moments? Like most physicians, in addition to my career in medicine there are life enhancing avocations I enjoy such as perfecting my French language skills and improving my sketch art that has joyfully crept into my journals. To those ends I listen to Johan, the creator of Français Authentique and began an online course with Sketchbook Skool. Understanding that exercise is the single most important way to ward off memory loss, time must be found to keep moving. Important relationships are built and remain strong with convivial meals and moments together.
Age forces the recognition that time is the true currency of our lives. When people waste it for you, it is frustrating and angst producing. One of the underlying tragedies of physicians’ daily lives, especially in primary care, is the theft of our time, stolen away by the health care system. We entered medicine expecting to spend our lives caring for patients by spending time with them and researching best practices, not being glorified data-entry clerks and insurance company proxies. The amount of time that governmental regulations, employers, compliance directed mandates, insurance company prior authorizations and administrator volume expectations take from us is demoralizing. I want that time back to spend with my patients, my family, and myself.
After more than two years of listening to the innovative suggestions of individuals who care about creative disruption in medicine, I firmly believe that this time theft can only be stopped when our patients come first–before profits, shareholders, meetings, EHRs, or any other thing on the long list of healthcare “needs” that may serve but should not be served. When patient needs are met, so will my own.
It’s a Monday. Drinking my coffee and in my email is the weekly update from mdwebpro.com. There is a new listing on one of the MD rating sites. I groan inwardly. By working hard to maintain patient-physician partnerships it’s easy to fall into the trap of believing it’s possible to please everyone. When staying abreast of new developments in one’s profession and practicing evidence-based medicine where it is appropriate, one thinks the bases are covered. Staying on time in order to avoid wasting my patients’ time is a priority. Encouraging patients to use exercise and dietary changes to control and reduce the development of life-threatening illnesses isn’t what every patient wants to hear though. And let’s face it, I am human. Sometimes when I see patients, it’s with exhaustion. Sometimes it’s necessary for me to get to a meeting or go home in time to take care of something. None-the-less I try very hard not to allow my impatience to show in the exam room, that’s unprofessional. But this morning there is the knowledge that patients generally don’t post online reviews unless they are unhappy gnawing in my brain. Sometimes I ask patients to review us, but I haven’t done that recently. Indeed the review is terrible. I recognize the name of the individual who posted it and am somewhat surprised. They’ve been a patient for 10 years. It is a sad commentary on our medical relationship that after knowing someone for 10 years there isn’t enough of a comfort level to bring concerns to me instead of writing it in public. I look at the interaction in the EHR. Nothing jumps out at me, it was not a day I was rushed, there was discussion about an unexpected medication cost. What am I missing? How did the interaction go badly and I missed it? My office manager will reach out to the patient and ask questions. Hopefully this will improve our care (the staff was rude too, according to the review, so that may have set the stage for my failure).
Intellectually I know that the great majority of my patients are satisfied with my care (we’ve done a variety of surveys that tell me that). As written above, it’s important to me to deliver competent care that includes partnering with patients to ensure that their questions and needs are addressed. I think I’m doing the best that is humanly possible and recognize that the human element ensures that I will sometimes fail—despite knowing all this my sleep will be interrupted tonight.
And I guess that’s OK. That’s how we improve our skills.by
Sleepily perusing a blog post I read, “Think about when you’ve been happiest in your life”. The post was about finding happiness and hit close to home as I’ve struggled with how busy my life has become and wondered how satisfied I am in it.
When I am most frenetic and busy, it is not when I’m most happy. As an introvert who has to spend time alone to recharge, I often come home spent. Because of that, I don’t exercise like I should. Intellectually I understand that if I exercised more, my energy levels would recharge better.
Between the morning coffee and my thoughts, my brain awakens and uses the moment as a stepping stone to consider: “what do you want with the last third of your life, what is it that makes you most satisfied?”
Ultimately the question becomes, how does one craft life to increase those moments that give you real joy. After 58 years on this earth I should be able to do that, shouldn’t I?by