Transitioning Doctors

In the past year, as I've latched firmly onto Medicare, some asymptomatic numerical data has kept me more in touch with my personal physician than at any time since he served as one of my more distinguished Internal Medicine residents. He called the medicines correctly, and I've assisted him by taking them almost without fail, so numerical data obtained since the Covid-19 pandemic changed the medical care landscape has never been better. My prior quarterly assessment took place over the telephone, his taking my word for hypertensive data obtained mostly by my home kit. A second agent entered my daily pill container, the systolic BP's came down to desired levels, and I had no side effects of medication. Regional infection risks have abated enough for him to see me in the exam room.

As I waited my turn in his socially distanced waiting area, I seemed the sturdiest of the men there, no women waiting to be seen. People exited but I did not notice that none received a followup appointment, only a note from the secretary of a referral to the regional medical center.

My turn arrived, no complaints on my part. As he proceeded with the encounter, he noted that he and his partners opted to close their practice, accounting for the referral of the previous patients in lieu of followup scheduling. The reasons my doctor gave sounded very familiar, as I had done the same ten years earlier. A lease renewal with ruinous rent increase served as the terminal event. But a look around the waiting area told more. Charts, including mine, still came in bulky manila folders. He entered notes on a computer but could not afford to invest in fully electronic record keeping. Reporting data, billing, insurance, tracking hospitalizations which his group until recently had continued to follow in the hospital, and innumerable petty distractions from the more satisfying elements of being the doctor had claimed another four experienced clinicians, two late career, two mid-career . As much as I appreciated his expert guidance over many years, the time to transition had arrived.

He had inherited me from another outstanding resident who I helped train largely for geographic reasons. My office stood in the building next to his. I needed negligible medical care most of the time, some lipid management, a false alarm on a cardiac concern, allergic rhinitis before nasal steroids went OTC, and some annoying prostate symptoms with even more annoying orthostasis on the usual alpha blocker. He never seemed disappointed at tweaking the medically innocuous, unlike me who thrived on the complexity of lab work at the extremes. My blood pressure eventually needed attention and my appendix, of blessed memory, brought me to the OR after I retired, but medical care never reached complexity. An annual review with lab work became quarterly as medicine needed adjustment. I expected this to plod along indefinitely but the lure of a stable salary as part time hospitalist and part time internist for a thriving orthopedic practice replaced the burdens of independent practice management.

I had just retrieved my three month supply of medication from the pharmacy so there was no urgency to secure a replacement personal physician. As I exited the office the secretary handed me their closure letter, suggesting that followup care be arranged through the regional medical center, which had become something of a local monopoly, though a number of independent practices remained, often with concierge enrollment charges. I looked up the web site, which I expected to be the medical center's physician referral service. It was not. Rather it was an unselected list of staff physicians in Internal Medicine which numbered about 1000 individuals. Subspecialists, ICU physicians, hospitalists, education directors all aggregated with primary care physicians but excluded their whole family practice department which would add another few hundred people. The site had locations where the hospital operated satellite centers. I accessed those but none had a list of physicians assigned to those sites, let alone indication of FP or IM. Next option, called the physician referral phone number provided in my doctor's letter. I noted the site and asked her to give me a list of physicians at that site. She couldn't. This was not very helpful.

Next step, looking up a physician on their payroll who I know well, a contemporary, who I know works at one of the sites. Success. That site has seven physicians. I preferred on of the younger ones, somebody I don't know personally, and read the training bios. Interestingly, all five were women. I called the number which got answered on the 13th ring, though the person I finally reached could not have been more helpful. We reviewed the time frames for appointment, she asked when I would run out of medicine, and then we settled on a woman who seemed a contemporary of my own children who are also physicians. Mission accomplished, though I would have expected a dominant medical center to make the task of latching onto one of their employee physicians a little less troublesome than it seemed.

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.