Nothing in Life is Free

Nothing in life is free.

In the midst of all the turmoil and excitement surrounding the newly passed Affordable Care Act, I believe we should not lose sight of the bigger picture: providing better healthcare at a lower cost for more people.  The idea of the Patient Centered Medical Home, although in its trial stages thus far, is what we should be focusing on as physicians and health care providers. 

Much has been said about our broken healthcare system.  A fantastic description of this can be found in the book “Fractured” by Ted Epperly, former president of the AAFP and director of the Family Medicine Residency of Idaho.  But the only way to dig into the problem is to change the focus from problem centered medical care to wellness centered care; that is, trying to keep patients out of the hospital and emergency rooms instead of the typical fee-for-service model most common in healthcare today. The focus of medicine needs to change.  We- meaning physicians, insurance companies, hospitals and even patients themselves- need to try to prevent illness and strive for wellness, not have our entire focus be on scrambling to keep diseases in check and deal with ineffective coordination of care.

So here is the part of the healthcare system that physicians are loathe to discuss- we are paid more if patients come back often.  There is no incentive, at least monetarily, to keep patients at home.  There is actually a DISincentive to do phone encounters- they are not reimbursable.  The ACA, in theory, will reward physicians and hospitals for quality medical outcomes and appropriate use of tests and services (Medicare Shared Savings) as opposed to quantity. All too often emergency rooms are flooded with patients in underserved areas who are there for lack of anywhere else to go, no primary care provider will take them without any insurance, and most cannot afford to pay out of pocket.  This is the reality we face today.   The ACA may not be perfect, but it is a good first step towards fixing the system.

The Patient Centered Medical Home should be what we strive for as physicians.  With this model, a team of healthcare providers can communicate and work together to prevent hospital readmissions and emergency room visits.  Although this new approach might have added cost up front, I believe in the end will save millions by decreasing readmissions and countless superfluous emergency room visits.  

Regardless of your political viewpoint, I believe as physicians we must not lose sight of our responsibility as role models and community leaders to care for our patients in the best way we can.  The Patient Centered Medical Home proposes to do just that.  Today’s ruling in the Supreme Court although not perfect in the eyes of some, but will help us take steps as a country to provide better healthcare at a lower cost for more people. 

Adventures of a Square Foot Garden

It's my first summer to fully enjoy our new home, my children, and to tackle some projects I've always wanted to do.  I was inspired by a post by Dr. John Halamka in his blog Life as a Healthcare CIO some months ago.  I was introduced to this blog by my husband who happens to be in the CIO/CMIO world as well.  Also, if Dr. Halamka, who is CIO of Harvard Medical School, as well as full professor and practicing emergency physician- among other things- has time to make a Square Foot Garden, then I would think I should as well.

Square Foot Gardening was popularized in 1981 by Mel Bartholomew, where a finite amount amount of land is used to strategically plant in order to maximize crops.  Since I've always wanted to have a garden, and I was going to try to make planter boxes by the side of the house.  After planning to do this for several months, I realized when it was June already, I had better either do it quickly or wait until next year.

So this is technically not the EXACT Square Foot Gardening, but I did put soil UP instead of digging down, and the width of the plot is about 1 1/2 feet, but I have extraordinarily long arms with which to reach quite long spans.  Occasionally the arm stature of an orangutan comes in handy.

I also don't compost... yet.  Remember, I have been busy Mommying and Doctoring.  Not much time for  anything else, until now.  So bucket list, here we come!

So I had this great idea to wander into a second hand materials store, and got a whole bucket of tiles for only $20.95.

Look how nice they look against the side of the house!  I have essentially outlined a raised bed that is gracefully curvy, not square.


Since this is my first attempt at growing things that actually live (upstate New York soil was awfully beautiful but clay and rock is not really conducive to flourishing roots, and whatever did grow was quickly consumed by deer and rabbits), I will be happy if I can say we use anything from what we grow by the end of the summer.  Even if it is one or two basil leaves.  Actually, one of my dreams has always been to say, "I'll be right back, I'm going outside to get some salad".

So here is what we have:

Squash:

Tomatos and Peppers:

They do need a bit of water.  The entire area is about 15 square feet.  I have planted also planted pea, bean and corn seeds directly in the original soil with just a bit of supplemental potting mix on top.

Peas:

Corn:

 We will see, but if all else fails, I have my basil, and I am one step closer to a more organic existence.

Why is it important for physicians to teach?

Much has been written about educating patients.  This can be in the form of educational materials provided during the office visit, providing access to accurate online medical data, or even educating patients about wellness- how to be well, stay well and live well.  As physicians, I believe that part of our responsibility is to teach.  As the familiar adage from residency goes: “see one, do one, teach one” – we have a responsibility to teach patients and to teach each other.

This is why social media is so crucial to the development of medicine today.  With forums such as Twitter, physicians can communicate real time with each other to discuss current practices and share experiences.  To me, this is invaluable in a time where the amount of useful information is inversely proportional to the amount of actual information available.  Many of us utilize resources such as Up To Date, which offers textbooks and articles that we can pore through to find the answers we need. But suppose we are outside of the confines of residency, cowboys alone in the “field”, and want to discuss how long a patient should take steroids after being discharged from the hospital for ITP.  Certainly we could read the textbooks or look this up on Epocrates.  But it is also just as certain that practices would vary from physician to physician, hematologist to hematologist.  What if you send a tweet out to the medical community and get several real time opinions?  This also presents a wonderful opportunity to keep current, to see what everyone out there is doing and thinking.  It’s how we as physicians operate best, in our own lingo with other physicians, sharing stories and inspiring each other to learn and grow:  seeing one, doing one and teaching one.

The same philosophy applies to teaching patients.  The extra five minutes it takes to explain to someone why it is important to lower their cholesterol not only influences how likely they are to listen, but how likely they are to return to the office.  If patients feel respected, which is what happens when we take the time to explain things, they remember the encounter as a positive experience and I believe are more likely to return and to take our advice.   

As the world of medicine becomes more connected through electronic medical records and sharing of data, I believe it is important that we as individual physicians stay up to date and present in this realm.  It is human nature to be reluctant to change.  This is precisely why physicians, as accumulators of information and trusted leaders in the community, need to lead the way.

Full Time Mommy

It's been quite some time since my last post, and the most notable update is that it has been a full 42 DAYS since my temporary retirement from clinical medicine.  Wow, has the time flown by.  Here are the facts:  I love medicine, and I love my family.  I love cooking, decorating, making crafts.  Hate cleaning.  But what I didn't love was cranking through patients every 15 minutes with that feeling of urgency... as a patient might be describing the intricate details of how their family dynamics precluded them from taking their medicine, I'm thinking...  "How can we wrap this up, the next 3 patients are waiting and I need to be done by 3:30 to make the bus... "- looking ahead at my schedule knowing that my last patient might be extra depressed today and despite my experienced interpersonal abilities, there are not many graceful ways to interrupt someone who is talking about thoughts of death to say I have to get my kids off the bus.

I would race out of the office like a banshee at 3:30, on the phone with my nurse wrapping up whatever I left in the middle of, only to arrive in the nick of time at the bus stop to get my lovely but tired and cranky children from a 40 minute bus ride (because their mother needed that extra time to commute from the office).  Trying to calmly work out squabbles, console, calm and feed my little people, and transport to activities while simultaneously doing homework and projects, knowing that I have at least 2 -3 hours of charting left to do after they were in bed.  Throw in an extra complicated homework assignment or a bad day at school, and all bets were off.

Basically, my mind just exploded.  I felt like a half-ass mother and a half-ass doctor.  Terrible to feel bad at everything, especially when one relishes the idea feeling like an expert in all things.  Clearly this is hard to achieve, but it doesn't hurt to have a dream!

So here I am, decorating, crafting, swimming, and summering with my little people.  I'm sure I'll miss medicine soon.  But not now, I have some chocolate popsicles waiting to be made...

Welcome Back

This is more of a welcome back to myself, as it's been many months since I have had the luxury to sit down and write.  Such is the life of any professional mother, isn't it?  We have since bought a house, moved, helped our girls adjust to life at a private school, and sorted through many, many other details.

A side note- we lost Bob.  We are in fact on Bob 3, and judging by the looks of the little guy perhaps Bob 4 in a day or so.  I am making a mental note to research how to keep a goldfish alive.

On keeping my sanity while raising three active girls, trying to be an attentive wife, and being a good family doctor, a patient I recently saw said it best.  "Girl, you're gonna wear yourself out.  You gotta detach".  This from the mouth of an ill-appearing, elderly woman who wore the face that only results from those who have endured so much in life.  As I listened to her detail her latest battles with health, family and aging, I realized as she interrupted herself with her "blurt" (as my 7 year old calls it)  that I must have lost my professional composure and shown too much empathy on my face.  What I had been thinking was, "there but for the grace of G_d...", what a truly treacherous path so many people have in life.  I only hope I can offer some advice or comfort, if not a solution.  Sometimes words are the only medicine we have to give.

But in healing, it takes great skill to give of yourself while at the same time remaining in tact, shielded, 100 per cent of the time.  The truth is the best advice comes from the heart, and a little bit of you goes along with it.  So incredibly difficult as a family physician, when most of our encounters are with families we have come to know.  In dealing with medical issues, we must also delve into personal lives, stories, experiences.  It's all part of how a person feels when they come to the doctor, and helps determine what they need to get better or stay healthy.  How to "detach", this is the question.  Some colleagues I have know do not.  But this is trickier for mothers, who need to switch instantaneously from telling a patient they have cancer one moment, then discussing the importance of a "no blurt" day in school.  It's the art of medicine, and the art of mothering.  All I can say is it wears down the spirit if we don't pay attention.

I aspire to write more often, possible to give insight to any other working Mom MD, working mom, or anyone else who might be entertained by my musings.