Contending with My FB Friends

Social media can be rather toxic, giving the full extent of humanity verbal access to you with no restraint on being abusive with no adverse consequences beyond being blocked.  Medical care also brings us into the full realm of humanity, mostly delightful people but a few for whom the most enticing response might be Undoctor.  But they rarely arrive in the hospital bed or the exam room as your perceived equal, keeping a cap on the abusiveness. But unlike patients who have no obligation to me beyond making an appointment, keeping it, and paying the fee but unchallenged acceptance provided their problem falls within my skill.  Social media is a more equal relationship but a more manageable one.  First, I am not required to show up.  Sermo has been dispatched for cause for some time.  After a few misgivings I might have been premature at not wanting to have trolls as my medical colleagues, any urge to reconnect has long since passed.  Twitter gives me access to some of the finest minds and most influential individuals around.  At that level it is not interactive at all.  At least my Congressional delegation sends a computerized thank you note when I comment on an issue, and usually my representative's position on the issue of concern to me.  Over the years, though, I've received my share of personal responses including my wording in their response.  It is really a forum for me to make a statement, though never to make a difference.  I cannot block anyone from hostility to my comments though I'm generally too much of a peasant in a forum where who you are matters more than what you think.

Facebook remains my media of choice, even to quasi-addiction in the absence of formal limitations on my frequency of access.  I know all the people designated friends personally.  I've largely stopped commenting on organizational sites where loons cannot be regulated away.  Most of my cohort comes from high school.  Ironically, few of us were close friends at the time but the exchange of comments has been respectful.  Each of us have developed over those 50 years certain proficiencies and certain predictabilites of response.  I never Unfriended anyone who I knew personally and only unfollow the occasional nudnik who posts ever ten minutes while awake or somebody who bypasses analysis to toss out a slogan.  But for the most part, my high school educated us well.

The situation with police misconduct leaves me a little at odds with my friends.  We vote the same.  We have different experiences.  My medical career has required mostly favorable interaction with constables who keep my hospital secure, officers who identify people on the street as needing medical care, prison guards who maintain a three way banter between me and the fellow handcuffed to the bed rail.  We agree that targeting Black folks for harshness is unprofessional at best, sometimes criminal or lethal at worst.  We analyze the best solution differently.  Hang the wrongdoers just doesn't change the culture.  

Medicine changed its culture in my professional lifetime.  I could not think of people more demeaning of the patient public than officers of the AMA and regional medical societies, who in many ways opposed physician accountability early in my career.  The state societies had to divest themselves of a unification requirement with a more haughty AMA just to maintain their own membership.  And we got accountability big time, but not objectionable accountability.  It came in the form of performance enhancement but without fear of reprisal which too often undermines that goal.  We have guidelines for many conditions with compliance of analyzed best practices by physicians.  Licensure requires some attention to making medical care safer through risk management.  Some of us find analysis of Big Data and institutional reporting requirements objectionable, though nobody objects to the improvement in care these efforts create.

Calls for police defunding or other punitive responses undermine public safety, not enhance it.  I already met hundreds of honorable officers as patients or in the workplace.  Some of the brutality that makes the cell phone camera exposees may very well be successful implementation of their training.  You don't fix that by any measure other than changing the training, establishing best practices, confidential peer reviews, CME appropriate to policing, and public image enhancement because you accomplished things worthy of public image enhancement.

My FB friends are probably no more outraged by events than me.  They are considerably less analytical than me and most experienced physicians in addressing it.  We've been there ourselves and succeeded but it took a generation.

New Trick for the Old Dog

My subscription to the NEJM remains in force and I schedule two articles a week, even into retirement.  Often the Case of the Week attracts me the most since it challenges my skills.  I can usually get the differential reasonably close but some of the lab testing has passed me by, even in my own specialty where I recently fumbled with a presentation of Monogenic Diabetes.  I knew the forms and the genetic identification but did not know how to correlate phenotype genetic results.  More importantly, I did not know that the tests come as a commercial panel and that it is cost effective to order it, something that I avoided doing in my Medicaid and uninsured population, asking those patients to have their affected child tested for financial reasons.

Recently, they had a case of SIADH which I recognized easily and could get a reasonable differential diagnosis.  The case included treatment with saline and desmopressin together.  I thought a rare lapse in editing, expecting tolvaptan, but later it appeared again.  So I looked it up.  Apparently the vaptans have gotten too expensive.  Since saline of the right concentration and right amount will correct hyponatremia, the barrier has been the safety of overcorrecting.  Apparently desmopressin, while counterintuitive when ADH is already excessive, provides the protection against too rapid a rise in sodium with adverse neurological demyelination.  Good to know my curiosity and inclination to challenge what seems suspicious has not been seriously impaired by retirement.

Eerily Quiet

Periodically I donate platelets, being CMV negative.  My previous donation occurred right before the coronavirus.  I delayed the followup a little, partly due to Passover which would keep me out of the post-donation snack canteen and partly because I wasn't feeling my best.  But achiness stabilized, diet resumed at baseline and I made the next donation.

Our regional donation center sits across the street from the Christiana campus of the Christiana Care Health System, the state's largest single employer.  Around the corner lies the regional megamall which predates the medical complex by quite a few years and across lies Delaware Park, a venerable racetrack with more recently added casino.  A smaller shopping center is also across the street and the main branch of the community college has a campus at the highway exit that people take to reach the medical complex.  Typically at 8AM, a lot of traffic accumulates, though not this time.  Surrounding hotels have been ordered closed by the Governor except for a few people involved in the nearby medical care.  The medical complex itself has active employees but also a lot of inactivated employees.  Retail has all but disappeared. At the racetrack, the horses need to be fed, the slot machines don't.  Our mini-metropolis looked virtually abandoned.

Inside the donor center, only modest adaptations were made.  Everyone, staff and donors, wore protective face coverings but social distancing is not realistic when nurses need to take blood pressures, measure hemoglobins, insert IV access and tend to machines.  The post-donation canteen still operated fairly normally. 

The number of donors seemed a little less than usual for an early midweek morning, maybe a little younger crowd now that these time slots are not currently prime work hours.  They are participating in an experiment to harvest post-convalescent Coronavirus plasma for transfusion to critically infected patients but it was not possible for a casual visitor to identify those donors.  Mostly business as usual, fewer people and a new video system to keep the donors from getting too disengaged while they bleed out. 

I leave my cell phone in the car during donations.  When I returned, I opened email to find a note from a friend who departed for NY a few months ago to take a job as radiologist.  I just assumed as a center of coronavirus pandemic he would be inundated with chest images to report.  He noted that it really did not play out that way.  There were coronavirus related images but not excessive.  Offsetting that was a drastic decline in other imaging as most non-urgent care has gone into hibernation.  Financially, that's a net loss for his department and a reduction in assignments for him personally. 

Coronavirus has stressed medical capacity at its peak, though more selectively than I would have imagined.  Those working can be overworked but everyone else lives amid suspended activities.

Suspending Burnout

As I read comments from active physicians immersed in Coronavirus care, Burnout has virtually disappeared from the conversation.  Physical exhaustion occurs and there are skirmishes with the management, though less so.  People have found meaning in what they do.  The EHR with its irritations has become secondary.  Hierarchies seem to have flattened.  Meetings have been cancelled.  In some settings those pesky middlemen have been furloughed.

It would be interesting to administer those Maslach Burnout Inventory profiles to see if a change of focus changes the score.  Viktor Frankl's belief that finding life's meaning as the ultimate satisfaction may express itself that way.

Pink Slips

As people and institutions adapt to coronavirus disruptions, hospitals cannot be displaced as essential points of care.  Yet not everyone within a hospital building or network really contributes to immediate care or to planning essential for restoring normalcy.  A report came to my inbox announcing layoffs at a number of regional centers, with the one from which I retired appearing at the top of the list.  There may be no greater demonstration of institutional values than selecting who plays and who warms the bench.  The ICU people and the hospitalists have to stay.  I presume residents do as well, though electives other than Infectious Disease or Radiology may need to be reconsidered.  My own position as endocrinologist would be useful to surgeons, hospital teams and the like, though maybe expendable to bill payers as the hospital has plodded along in my absence without replacement.  Since residents are now needed both for labor and education, I would expect the director of the residency program who herds this collection of cats to remain on payroll.

How badly do we need dieticians?  Well, diabetes and heart disease patients occupy beds as they did before.  Sanitation crew?  We have the same amount of floor space.  Those people who maintain statistics to report Meaningful Use?  We could have argued whether this blight on medicine should even exist.  As office encounters give way to remote visits, the folks who take weights and blood pressure might be expendable, though they often take the intake history as well and may be the only people on site who know how to troubleshoot the malevolent EHR when it impedes medical care.  And there is always a layer of management that impedes medical care.  They should be more recognizable in that capacity.  Nobody wants to impede medical care right now.  Layoffs for them, though not permanent.  It is a chance to really think about the value of what the many contributors do.  Whether it adds to the learning curve of how to best provide medical care to the public without padding the bill with non-contributory payroll remains to be seen.

Resident Reappears

Some residents are just more memorable than others.  There is a barely definable bell of knowledge, insight, and social grace that lumps most into this big ball.  A progression from novice to experienced occurs, the certificates get signed and onward they move to their next destination.  A few remain colleagues, some fill military or visa obligations, a few appear in print later on.

An article by a former resident, one of the most unique, came my way.  Nicest fellow, the type you would do anything to help advance.  And it took quite a lot.  He did not finish our program but transferred to a different specialty which now puts him face to face with the difficulties of the corona pandemic.  I remember most how appreciative he was of any assistance he received from faculty and other residents.  He remains appreciative for the people who assist him at the front lines of coronavirus.

There is no better gratification than learning that a former resident has been trained in the best way possible. 

Changing the Medical Conversation

Dealing with Covid-19 has been a stress on medical providers.  Retirees like me are dormant, and maybe even regret not being in the fray.  It has changed the conversation of medicine for the better, though.  We'll start with Provider.  The Flexner Report, not yet fully of Blessed Memory, purged practitioners of lesser training and instituted licensing and credentialing.  Physicians often resent parity with other practitioners for understandable reasons.  But with stresses on caring for high volumes of sick patients, a willingness to work and threshold of skill rises in importance.  Doctors get the most attention but good medical care also depends on nurses, technicians, housekeepers with their disinfectants and secretaries to direct patients to the right place and assure their appointments.  They are at personal risk and often have young families.  In a crisis we are all providers with a much flattened hierarchy.

As a reader of social media, medical and otherwise, the conversation in the charting rooms and doctors' lounges no longer focuses on the devaluation of physicians.  Those reviled dysfunctional EHR's have not gone away.  Eventually somebody will get back to our metrics and RBVU's.  But for now we are focused on good outcomes for patients.  Not just the doctors but the managers.  We are all rowing our canoes in the right direction.  Professional antagonism, even animosity sometimes, no longer appears in the physician restricted or public postings.  As we watch TV, we wish there was a Gong to get the President off the podium so we can hear from the learned doctor instead.  People have better priorities from this health stressor, both in public and in private.

Like most calamities other than the extinction of the dinosaurs, Covid-19 will one day pass from the forefront to fond anecdotes and ultimately to the history books.  It remains to be determined if the professional nobility of thought and expression will remain.  But for now we can admire those doing their best to mitigate our crisis and take comfort in knowing that our loftiest doctors can rise in stature above all others.