Checking for a Pulse

I originally set up a website with the idea of having a place for my poetry and a place for my medical practice. I thought patients could contact me on the medical side as a way around my offices' very dysfunctional phone system ($20.000 for a new system which we cannot afford). Due to privacy laws it turns out that this site does not comply with necessary security to meet HIPAA standards. The office computer software supplier promised one that will comply almost two years ago and we are still waiting. So, THE LEGAL DISCLAIMER: this site is not private. For my patients: do not leave anything of a personal or private nature. Do not leave requests for anything urgent as I may not be getting to it daily. I plan to see how this evolves but thought I could start with a few musings on the state of medicine and medical care in the United States. Since both are looking sickly at the moment, when my website designer asked me for a title "Checking for a Pulse" was the first thing that came into my head. When you find an unconscious person you check for a pulse--call me cynical but it does seem appropriate.

I tell people that I am a dinosaur and the tar is up to my chin. I have been practicing medicine since I finished my formal training in 1983. I believe that to do it right, I will always be "practicing", trying to do it a little better by repetition, studying and learning from each encounter. My patients have taught me a lot and I am grateful to them for that and for the privilege of being their doctor. I like taking care of office visits, hospital and nursing home rounds and house calls. I may grumble over lost sleep in the middle of the night and it does get harder as I age, but there is still a little satisfaction in figuring out a puzzling set of problems and getting someone through the night. I still find it amazing to walk up to one of my patients in a gurney in the ER with blood pressure and heart beat tracing on a screen over their head, put my hand on their arm and watch their heart rate slow and their blood pressure start coming down just because I showed up. (No this doesn't happen that often but it does pretty reliably with a few of my folks. And I still find it wondrous.) I think I am doing what I was meant to be doing.

I started in college as a chemistry major saying repeatedly "I am really glad I am not one of those pre-med students. They work way too hard!" I kept saying it as I floundered around getting more worried because chemistry was almost right but not entirely--some excitement was missing. A summer job as a receptionist in an ER after my sophomore year did light a little fire of possibility and got me looking at medical school. My first year was the hardest loneliest time in most of my life but by the time I got to my clinical years -- dealing with patients -- I was in love. I was scared and spent a lot of time thinking that any moment someone was going to catch on that I was not smart enough to be there and throw me out. There have been times when I wished that they had but mostly I am glad to be where I am in my profession.

That being said, I will also tell you that I would not advise medicine to any young person asking me today about becoming a doctor. It will break your heart. There are a lot of easier ways to both make a living and to help people. Among the doctors and nurses I work with almost daily someone says "This system is broken". I could rant for hours about the stupidities: endless piles of paperwork, rules that pay for weeks in the hospital for an illness that is treated by a few dollars of medication, people afraid of hospitals as places of infection and errors, people faced with choosing between food or medication, insurance companies "managing"care out of existence.

Health care used to be about a sick person and a doctor or nurse trying to help them heal. Now it is about a system of bureaucracies, insurance companies, pharmaceutical companies, regulations, formularies, licenses and money. Ever one of us a cog in the vast grinding machine and all of us are being ground down into a fine dust of "healthcare consumers", "healthcare providers" and "healthcare payors". (I once received a Christmas greeting letter from a home care agency addressed "Dear Referral Source"). I think it may be too late to go back to being people again, but I think if we don't start there no grand plan to save us all will ever work.

I don't have many easy solutions but I have some pretty clear ideas about where things went wrong and what some of the problems are. It is not about greedy insurance executives or evil malprctice lawyers vs noble doctors either. Every player in this drama: doctors, nurses, patients, administrators, insurance companies, drug companies and politicians contributes to the problems. Modern medicine is capable of some nearly miraculous things but somewhere along the way possibility became the standard and everyone wants nothing less than miracles daily. But miracles are expensive and in a time of limited resources we as a society are not budgeting well. Doctors are supposed to advocate for their patients. I am not sure who advocates for society. I am hoping that the upcoming election will start some meaningful discussion on expectations and possibilities.

I would be happy to just take care of my patients--some of them people who have been with me since I was an intern -- and not worry about which medicine will be covered by the formulary and how many forms I will have to fill out to get it and whether I should code up a notch for the extra time I spent writing down each medicine so they won't get mixed up and whether that will flag me in some computer as an outlier and trigger an audit requiring me to send in copies of all of my chart notes for the last five years then wait for six months to receive payment and will it be enough to pay my rent this month and do this every fifteen minutes twenty times a day. (Yes it really is like that.) There are moments of transcendence when someone who has been in pain for months says "I slept last night and nothing hurt" or when it is not bad news or when it was cancer five years ago and they are cancer-free today because I did the right things then. I only need a little of that to go on a long time treading slowly through the tarpit.

This is a long beginning and much pouring out of soul. Where I go from here? Don't know, but for whomever reads this--thanks for listening.