Part of the Team

https://www.nejm.org/doi/full/10.1056/NEJMms1906654

This NEJM essay discusses transformation of medical culture.  It bridges a few realities as physicians go from independent professionals to employees who can be manipulated or leveraged.  Being one of them, supervised by decent people who were themselves supervised by people who I didn't know but I'd wonder a bit about, the top-down model has some real flaws.  While I was on the direct interface of the mission of patient care, I was never solicited for my experience.  I saw myself as part of the team, never a gadfly, but never enthusiastic.  I could be a loyal steward, but never an owner. Doctors follow the rules for the most part, both rules of mainstream patient care and rules of our employers.  We are very much a part of the culture of what is around us, but far less contributory than we should be.  Professional satisfaction is no longer a high priority in a medical culture.  The NEJM authors seem disturbingly content with that.

Those Journals Keep Coming

More than a year has elapsed since retiring.  My two state licenses remain active.  My professional liability policies do not so I have no interest in seeing patients.  Yet being a doctor is more than seeing patients.  Sometimes keeping the patients as inviolable top priority displaced other opportunities.  Now, no patients, but no research prospects, teaching, or committees either.  I am left with my knowledge and accumulated insight.  It can no be expanded for its own sake.

Currently I have two paid subscriptions, the New England Journal of Medicine and the Journal of Clinical Endocrinology & Metabolism.  The former comes weekly with a handful of articles.  I read all titles, abstracts of interest, and at least two articles ranging from core research to opinion.  I've largely stayed on track.  The JCEM arrives monthly.  It is bulky, fewer reviews, largely studies more appropriate to research groups doing similar investigation, but with clinical studies that are sometimes intriguing, more often pedantic.  It comes as part of my Endocrine Society membership.

Everything else is a freebie.  Mayo Clinic Proceedings, Cleveland Clinic Journal which is mostly topic reviews, JAMA Endocrinology, Lancet Endocrinology, and a couple of newspaper sized publications but glossier that have mostly news reports of current research or opinions of experts who seem to be interviewed by journalists.

All are available electronically but the only one I read that way is sometimes the NEJM. 

Clutter can get out of hand.  The ones I pay for stay for a year, the other journals three months, the newspaper sized publications the current and previous months.  They are recyclable.  I don't think I've ever retrieved one from the storage box to read it.  When I want to retrieve anything from the NEJM, I do it electronically. 

By now I know what I like to read, brief reviews, case of the week, and opinions on the experience of being a doctor.  For their own sake.

Intercepting the Asinine

My New England Journal of Medicine still arrives each week.  I pay for the subscription so I feel obligated to read two articles from it each week, roughly 100/yr, even in retirement.  They tend to be cases of the week or a review of something related to endocrinology, but I am as interested in the changes of how we practice, having lived through it.  One element that exploded during my final years as a clinician has been the number of directives and processes that differ from what an experienced physician would likely devise on his own.  Now, I may have gotten in on the ground floor of this, starting my post-residency career as a VA physician.  These guys didn't have the insight to allow me to receive a flu vaccine in my non-dominant shoulder.  One kabooby from the lab ordered, who didn't know what a patient looked like prior to autopsy, ordered that all the lab slips be placed in the chart without having been seen by the ordering doctor first, where they ended up in somewhat random order.  They used to transport World War I veterans 100 miles each way for their appointments, paying $700 dollars to the driver of a Ford Pinto that just squeaked by state inspection.  I had the transportation director price the cost  of a limo for the same trip.  For one-third of that, the old warrior could have travelled the breadth of New Jersey in style.  He would have to pay for what he took from the back seat bar, but if he drank too much, the VA would dry him out for free and hire the Pinto back to take him home.

On graduation to the university and private sectors, directives declined in number.  I am pretty hard pressed to come up with anything that matched the VA encounters.  Scheduling made sense.  Rules on charting were understandable.  We got our own parking spaces and as security became more important, ID tags enabled access to the places we needed to be to provide patient care.

And then came HITECH and the computer.  It all changed.  In an inner city area, it was common for patients not to keep appointments.  Any number of schemes were devised to either reduce the no-show rate or compensate for it, with scheduling bedlam when everyone came.  There was a directive to see everyone within seven days of discharge.  A schedule does not expand indefinitely, not everyone really needs to be seen sooner that three months by the consultant, and thinking about appropriate post-hospitalization is part of the competence that the residents are expected to acquire.  Meetings to discuss quality addressed non-problems to the neglect of what really needed more attention.

Intercepting the asinine seemed hopeless in this era of an expanded middle layer of managers charged with doing things that they don't really have the insight to do because they seemed like a good idea at the time.  Once there, they have a life of their own until the hospital is forced to reconsider by either legal allegations or loss of revenue.

It came as a welcome though unexpected surprise to learn that all elements of the inane did not have to become immortal.  A NEJM Sounding Board essay described an algorithm that can be computerized to identify and intercept the dysfunction, though not until it has become dysfunctional.

https://www.nejm.org/doi/full/10.1056/NEJMsb1900856

Based on importance, these mavens at NYU targeted processes that had no real basis but were intended to solve a problem.  If they didn't solve the problem, they were identified and sent back for rethinking.

Do we really need a computer algorithm for that or would a simple anonymous suggestion/complaint box suffice?  The big corporations probably addressed this decades ago.  A directive would come by or a customer would complain.  The VP's would hire people to address the concerns or deal with an external regulation.  Before you know it, you had people with significant salaries tweaking what would be better neglected.  Somewhere around the time of the 1992 election, they figured this out and pink slipped the capable high salaried people whose work wasn't worth doing.  Medicine has always lagged behind, which is why we are now being pummeled by insurers and product manufacturers.  They had their restructuring.  We have not.  If the algorithm really intercepts the many asinine processes imposed upon us, we might have a chance of catching up.

Psychiatric Stigma

Among my courses at the Osher Lifelong Learning Institute is a weekly discussion group where each of the dozen participants is assigned a topic one week per semester to lead a discussion.  Medical related topics crop up, and even non-medical subjects often benefit from the expertise or experience of the doctors in the room.  One lady, now retired like the rest of us, was raised amid severe psychiatric illness with a father displaying bizarre and often controlling, paranoid behavior and the next generation including a sibling with a less clear diagnosis but chronic personal and social instability.  She is a survivor who could have escaped through bitterness but took a path empathy which has served her well, though from the discussion, maybe less efficacious for the two patients than it could have been.

Endocrinologists like myself are the most frequently consulted specialists in a psychiatric unit where the nursing staff cannot avoid bedside glucose monitoring and occasional lithium generated thyroid, calcium and electrolyte dysfunction.  All this needs to be coordinated with the psychiatric needs, always usually severe enough to require hospitalization beyond the 72-hour form #302 involuntary diagnostic commitment allowed by the Commonwealth of Pennsylvania with a subsequent length of stay, sometimes voluntary, sometimes court approved, that far exceeds length of hospitalization on other medical units.  I never saw any families there when I did my consultations and periodic follow-up rounds, though undoubtedly the psychiatrists and social workers would regard the impact on family as a core part of their medical advice.  I was shielded, making the discussion from a family perspective an interesting revelation for me.  I also have a medical perspective, noting what could have been many lost opportunities to achieve a better result for her father, her brother, and her family.  And as happenstance would have it, a review of schizophrenia, with a brief section on non-medical psychosocial support, appeared in the New England Journal shortly thereafter.

https://www.nejm.org/doi/full/10.1056/NEJMra1808803

As the doctor in the room among the dozen discussants in the room, my focus immediately gravitated to the medical, with some resentment on her part.  Like it or not, as the NEJM review indicates, the fortunes of these people depend on how well the medicines are managed, both their therapeutic benefits and the undesired effect.  If you pick up one end of s stick, you pick the other one up as well.  The obligation of the physician is first to the one designated as ill.  The family becomes a form of collateral damage, something to be addressed though not necessarily by the medical expert.  As she noted in her presentation, the medical community was not a reliable source of empathy or family repair.  These patients can function surprisingly well at the workplace, as her father did with a perceptive supervisor who minimized the employee's tenuous social interactions, focusing on productivity at work.  He supported a family economically for an entire career but inevitably the household lacks the resources of a medical institution or a major corporation so disruption emerged.

People with bizarre affect, socially marginal behavior, or atypical appearance get noted.  They also get avoided, and as my OLLI classmate noted, the close family gets avoided as well.  That aspect has not done as well as modern medical care.  She is a survivor, though not unscathed.  Her father has passed away, late life divorce for her mother's safety.  His death, found alone and unresponsive, took its toll on her, probably more than on him.  A sibling drifts along, unstable socially, managed professionally by the medical and correction communities, but leaving the lingering impression on her that her brother was basically written off for lack of the employable skills that her father had acquired that secured a better level of protection for him, if not for the other family members.

While the treatment of schizophrenia has advanced and the chronic psychiatric hospitals that functioned more as a warehouse have waned, the people are still amid the public, identifiable as outliers and largely avoided by those who do not have a direct professional or family responsibility for their welfare.  Good medical care, as her discussion noted, does not fix that.