Will The Adults In The Room Please Stand Up

Uncertainty.  In particular, diagnostic uncertainty, would keep me awake at night, early in my career as a freshly minted critical care doctor.  Patients who deteriorated without explanation or haziness on CT Scans without an identified cause, fanned the flames of my insecurity. The scenarios would leave me edgy and uncomfortable impacting my life outside the boundaries of work. Like most doctors, over the years I learned to co-exist with this uncertainty.  Human sickness and disease can be challenging mysteries.

Recently, a new kind of uneasiness has invaded my world causing all sorts of havoc. With the politicization of health care reform and attempts at repeal and replace Obamacare, uncertainty is rearing its head with a vengeance. Twitter and Facebook give minute by minute updates on which senators are a “yes” or “no” and where public opinion currently lies. The evening television roundup details rumors that have leaked from behind closed door meetings. The background noise of it all is deafening. Most discussions are focused on the future impact potential budget cuts or regulation changes. But the uncertainty created by our polarized and tribal politics on any path forward for health care reform is having a real impact now. Every hour of every day, both in the hospital and in my office where I interact with my patients.

Walking through the halls of the hospitals, from the ICU to the general floors, the effects of this uncertainty have permeated everything. Hospitals have undergone significant strategic changes in the last seven years to adapt to the landscape created by the Affordable Care Act (ACA). These changes were made with the understanding that more people, not fewer, will have insurance coverage. They have counted on a stable and predictable reimbursement model. Uncertain of the future, hospitals have now become apoplectic with regards to investing in capital improvements or increasing staff. Holds on purchasing upgraded equipment, such as the bronchoscopes I use to diagnosis tumors in the least invasive way not only hinder my diagnostic ability but have a significant impact on the patient who must now undergo thoracic surgery to make the same diagnosis. Redesigning workflow and optimizing processes for efficiency and patient safety have stalled. Updating outdated patient rooms is tabled, denying recovering patients more comfort and privacy.  Increasing staff levels is a non-starter. Burnout among health care practitioners is already running high. Increasing patient to staff ratios, in the setting of escalating workloads, along with a constant fear of downsizing with the next round of budget cuts, adds to staff frustration, low morale and compassion fatigue. Our hospitals are frozen waiting to respond to a process in which they have been denied a voice, due to closed door meetings and back door dealings.

My office is not immune to this stress. Our staff is overworked and already squeezed throughout the day.  They are caring people and at times have gone to the ends of the earth to accommodate nervous, frustrated, and often angry and confused patients.  But they are getting worn thin. Uncertain times have led my group to hunker down and hold on hiring more support due to the increase costs and overhead of additional salary, office space and benefits. It’s hard to make a leap of faith and trust that hiring will lead to increased growth. In unpredictable times, we do not increase costs, for fear of declines in revenue. Therefore, we continue to task those on the front lines of our office to absorb and endure more, hoping that they won’t break.

And it is in this already stressed environment, that the relationship between doctor and patient suffers. Patients bring more angst and fear, not knowing if their chronic diseases will become pre-existing conditions next year. Will they be able to afford their premiums, their medicines, their equipment?  Will they still be covered for their anxiety or depression? These fears are often brought up before, during and after their fifteen-minute office visit. More time spent talking about these issues means something else has to give. There are only so many minutes in day. Do we skip that smoking cessation conversation? Do we run over and start the next patient late? Or does it come at the cost of adding to my own compassion fatigue?

As a physician, as a small business owner, and as a consumer of healthcare for myself and my children I find this situation unconscionable. I don’t have the answers to the flawed system currently in place. But one does not have to have solutions in order to recognize the current approach to improving the ACA is fundamentally wrong. Taking care of patients is not a political process and the current politicizing of health care reform is hurting people. I’m not talking about government reports of projected costs incurred or saved, or how many millions of people will ultimately not be covered on some future date. I mean the real distress affecting real people today!  Not just patients, but those on the front lines who care for them. The nurses and patient care techs within the hospitals. And the support staff in the office. By my family and children and my neighbors on my block and around the country. It’s is happening. Right now. And it’s time for the adults in the room to stand up. Are our elected leaders ready?

Sleepless Nights

You were closer to one year of age than two. Our family just three. Between surviving a combined internal medicine and pediatrics internship for me and navigating your young world for your mom, our days were challenging. But the nights. Those endless nights. As the sun would set on the cumulative fatigue of our day, the tension would grow and start to take hold. The rising dread would join our evening journey. Sleep, for you, was never easy. If and when it would come, its hold on you was more often brief and brittle. The crib lay empty and your room stood quiet, having been given up months ago. We entered nights with one goal in mind. Survive until the morning.

That night was different. The reasons escape me; exhaustion in your mother’s eyes or the frustration in mine. But that night I was determined to create a night of sleep for your mom. I pushed her out of our bedroom door, leaving just you and me behind.

You ran to the door, chasing after her. I grabbed you. Picked you up without looking you in the eye. I carried you to the far side of the bed and lay you down, tucking you under the covers. Almost before I could get to my side of the bed, you bolted up and slid off. Racing back to the door, hoping to get through and back to the comfort of your mother’s embrace. And thus it started. I rolled out on my side, intercepting you. I picked you up without looking you in the eye. I carried you to the far side of the bed and lay you down, tucking you in under the covers. Within seconds, you were sliding out of the bed. Repeating this dance. Again. And again. And again. With each repeated attempt, your determination and frustration grew. The cries louder and the screams stronger. I lost track of the number of times you bolted for that door, blurred by the tears streaming down my face.

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10 Tips For New Interns For Surviving and Thriving in the Intensive Care Unit

July is just around the corner. For hospitals it’s a dynamic time. A changing of the guard. Graduating residents moving on and new interns, fresh out of medical school with their clean and crisp long white coats, moving in. Out with the old, in with the new. The ICU rotation for medicine residents and medical students is stressful under the best of circumstances but always an additional challenge early in July. I remember as a resident, trying to glean from my peers who had already completed their ICU rotation, picking their brains for tips and tricks on how to survive and succeed. But often what we are looking for is not what we need the most. Acid base disorders and ventilator management seemed so daunting. But in hindsight, learning how to manage and treat specific diseases and conditions was not the hard part. Learning how to survive, mentally and physically, the rigors of the ICU and growing as a physician were much bigger challenges. Read more

The Moth Video: “Fathers”

About a year ago, I signed up and participated in a local Moth Story Slam here in Evanston, IL. I used one of my posts Family as the source for my five minutes on stage. The theme for the evening was “Fathers.”

I am currently working on a few stories but none are quite ready at the moment. Life sometimes has a way of throwing a curveball here and there. But no worries. More are on the way. In the meantime, if you have five minutes….

 

How did I get here?

And you may find yourself
Behind the wheel of a large automobile
And you may find yourself in a beautiful house
With a beautiful wife
And you may ask yourself, well
How did I get here?                         -Talking Heads

 

A middle aged father, critical care physician, triathlete, water polo goalie and Bob Mould stalker wakes up one day and asks, “How did I get here?”

The answer to that is probably longer than what is appropriate for this blog, the human attention span being what it is. But that question along with its logical follow up, “where am I going?” has been on my mind quite a bit.

How did I get here? Where am I going? My past. My future. With change coming just around the corner, it’s hard not to have my headspace taken up by these questions. But with some more introspection, I find that this is my brain’s default; to be looking forwards or backwards. I can be in the middle of a long run or bike ride, but instead of seeing the countryside around me, my eyes focus on last week’s battles with the kids, wishing for a “do over”.  Or I fail to see the sunrise in front of me, on my morning drive to work, as I have already mentally dived into the ICU to deal with the overnight admissions.

My past. My future.

But what about my present?

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We Failed Her

The alarm sounds, a painful reminder that it’s my week to cover the ICU. I take off my favorite sweatshirt, stripping away its warmth and comfort. I quickly jump into and out of the scalding shower, racing to get ready. Making my way toward the kitchen, I roll my eyes at my teenage daughter who is eating ice cream and waffles for breakfast. Her ride waits out front but before she can escape, I get a rare hug, her wet hair cool as it brushes against my cheek. I spy her melting, unfinished breakfast and I shovel what’s left into my mouth. The cold vanilla ice cream and maple syrup drips down my chin. Wiping away the evidence of my indiscretion, I get into my jeep with the top down. The twenty-minute ride is a guilty pleasure, with the spring air cool across my face. The coffee in my hand warms me from the inside out as I make my way to work. Read more

A Little Help From My Friends

The patient in front of me is trying to die. Elderly and frail, he is lying in the bed. His ribs outlined under skin that should be smooth. His temples are concave where they should be flat. Both are an outward display of internal damage from his lung cancer. More striking than his cachexia are the strained muscles in his neck and his pursed-lip breathing. He is working hard for each breath, drowning in the air around him. From his cancer or pneumonia or more likely both. It is my first night on call as a senior resident in the ICU.

It’s early in my second year of residency at the University of Chicago, where I am splitting my time between internal medicine and pediatrics. The ICU is outside my comfort zone, with its rapid pace, large volume of data to process, and the complexities of multiple failing organ systems to manage. I am both intimidated and inspired by those who seem to recognize patterns, synthesize information and anticipate problems with ease. I want to be like them. I want to face my fears head on. I have chosen to be here, to prove to myself that I can do this. I am capable of caring for the sickest of the sick. And now, in the middle of the night, without a supporting daytime cast of residents and attendings, I am anxious for my first test. And it happens to be the man in front of me struggling to breathe.

I want to be here. I want to be a critical care physician. I know what to do. Read more