Not ALL Doctors Golf

The sun is shining. The birds are chirping. It’s time for fitness in the great outdoors. That’s why we love the Treasure Valley, right? And for doctors, this means dusting off that putter … right?

Wrong! It’s true I am a doctor. I love golf, but only about as much as I love shopping for tires or cleaning the lint out of my dryer. With so many triathlons and other outdoor activities that actually burn calories and release endorphins, I can’t figure out the draw of getting a little white ball into a tiny cup. In fact the “activity” involved in golf has always confused me. The only time I personally break a sweat while golfing is when running from cigar smoke on the 19th hole.

I realize that the golf course is supposed to be prime “networking” territory for doctors. I suppose that if one has difficulty with conversation, there’s nothing like watching people wearing plaid pants yell at a ball to break the ice. However, I have found that the practice of medicine comes with some degree of agility regarding small talk. I personally have yet to be at a loss for words whether the conversation is golf, questionable fashion choices or what a patient coughed up this morning. And although my husband might suggest that I personally have never been at a loss for words, I’m pretty sure there are other doctors out there who do just fine without breaking out the saddle shoes and knickers.

I did, however give it a try. After various attempts at “relationship building” on the back nine, including golfing while gigantically pregnant, I have chosen to practice what I preach, and reduce my anxiety and stress. That means no golf and more yoga. I came to this treatment plan after running out of my golf shoes as I chased a wayward ball. My shoes actually got stuck in the mud, and I did a faceplant in a sand trap, limbs flailing, shoeless. If nothing else, I provided the Gang Green at the country club with plenty of amusement as they shouted, “Give her a mulligan!”

I can’t even say I looked good doing it, since the last time I checked, collared polo shirts on women went out in the ’80s. To quote the great Dave Barry, “Although golf was originally restricted to wealthy, overweight Protestants, today it’s open to anybody who owns hideous clothing.” (Thank you, Tiger, for bringing a bit of style back into the game. We all liked you before you ran into that fire hydrant.)

If you’ve ever been to a golf tournament, you know that it involves very long, silent periods interrupted by roars of anger or joy, all directed at a tiny, white ball. And this is actual shouting at the ball, not at the golfers. So to be clear, there is mostly silence, punctuated by cheering and yelling, “Get in the hole!” Need I say more? Serious golfers can be observed examining the ball with the same degree of concentration and caution as an unattended brown package left alone at Newark airport. It’s the kind of silence that begs to be run through, yelling willy nilly at the top of your lungs, “Woo hoo … it’s golfin’ time!!!” I have promised my husband never to do this, on the golf course at least.

So it may be Wednesday, but this doctor is in – or at least is not on the fairways.

Why Doctors Should Do Handstands

I recently read an inspiring post in the NY Times, How Creative Is Your Doctor?  - which really reminded me of why I am who I am.  In the article, Danielle Ofri, M.D. talks about how important it is to exercise that part of our brains that allows me to do things like make huge trash sculptures in the shape of a giant peace sign on Earth Day, or do handstands on the sidewalk with my daughters.

We are trained in medicine so diligently to think diagnostically in algorithms, with rote memorization the backbone of our knowledge.  Our brains become rigid with fact after fact; with years of practice we become experts in information categorizing, our neural networks so programmed it becomes almost reflexive.  So much so that with standardization of health care, one could argue, what will we need human doctors for, after all?

Clearly the knowledge is imperative in what we do.  But how do you teach someone the art of talking, really talking, to a patient, in order to get the whole story?  You can't get the answer if you don't ask the right questions, and sometimes this has to come from the interaction you have with the person in front of you, not the patient. So many times clues about onset of illness, mechanism of injury, and associated symptoms come from first 5 minutes in the room, otherwise know as the "History of Present Illness."

My answer (for now) is to do handstands on the sidewalk.  In order to "Think Different", we need to allow ourselves that creative space and energy to loosen our neural networks and expand the connections in all directions.  Some of us are already built that way (I'm pretty sure Steve Jobs didn't need cartwheels to activate his inner genius)- but most of us need to practice the art of creativity.  In light of all the current changes in healthcare, information and technology, what we really need is doctors who are people.  And we need these people to be human, to think outside of the rigid confines of medical algorithms to get to the bottom of whatever is ailing them.

It's not always easy to break free of the structure, and even frowned upon at times by those entrenched in the system.

Never mind- I will be outside doing handstands.

Patient Centered Medical Home is not the only solution.

I used to think the Patient Centered Medical Home represented the essence of the new, improved vision of healthcare.  Currently, patients are frustrated, and many are getting lost in the cracks of the system.  Physicians, pressed for time and underpaid, are becoming more and more disillusioned than they are inspired.  

But maybe this is not the solution.  It is exceedingly difficult to define what patients need within the confines of a broken system.  Is a Patient Centered Medical Home truly for the patient?  Or is it for the doctors and the system?  Doctors want good care for their patients, and with the PCMH we can be assured, at least in theory, that patients will be connected to the caregiver they need when they need it, whether it be a family doctor, a home health nurse, or a specialist.   But who controls the information?  The data is stored in a central “location”, virtual or real, where it can be accessed by these providers to ensure the continuity that we all want.

This may work for some people, but for others it could create more hassle and headache.  If a working mom wakes up one morning and she needs a doctor, where can she go that will be what is convenient for her, not for her doctors?  What happens when she calls her regular doctor to make an appointment, but the first available appointment is weeks, even months from now.  There may be some slots saved for walk-ins, but she is guaranteed to wait. She could go to a “traditional” urgent care, and hope she does not have to wait for hours in a waiting room full of sick people, to be seen by someone she has never met.  And there is always the ER.

Maybe, just maybe, we need a new model.  "The best, most efficient (health) care is provided by teams of health professionals in the patient-centered medical home led by physicians, not independent practice by a single health professional”.  This is a quote from the AAFP.  But what if the PCMH is lead by the patient- as the name inherently implies.  Patients should have the right to organize their health care in a way that best suits their needs.  I think we will all look forward to finding a workable solution.

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...