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Thursday, August 21, 2014

The Yeshi Dhonden dx, and other business

I first acquired and read this amazing book 40 years ago. It remains among my prized literary possessions.

Blessedly, it is now out in Kindle, with an update preface. A favorite excerpt I have quoted elsewhere:
On the bulletin board in the front hall of the hospital where I work, there appeared an announcement. “Yeshi Dhonden,” it read, “will make rounds at six o’clock on the morning of June 10.” The particulars were then given, followed by a notation: “Yeshi Dhonden is Personal Physician to the Dalai Lama.” I am not so leathery a skeptic that I would knowingly ignore an emissary from the gods. Not only might such sangfroid be inimical to one’s earthly wellbeing, it could take care of eternity as well. Thus, on the morning of June 10, I join the clutch of whitecoats waiting in the small conference room adjacent to the ward selected for the rounds. The air in the room is heavy with ill-concealed dubiety and suspicion of bamboozlement. At precisely six o’clock, he materializes, a short, golden, barrelly man dressed in a sleeveless robe of saffron and maroon. His scalp is shaven, and the only visible hair is a scanty black line above each hooded eye.

He bows in greeting while his young interpreter makes the introduction. Yeshi Dhonden, we are told, will examine a patient selected by a member of the staff. The diagnosis is as unknown to Yeshi Dhonden as it is to us. The examination of the patient will take place in our presence, after which we will reconvene in the conference room where Yeshi Dhonden will discuss the case. We are further informed that for the past two hours Yeshi Dhonden has purified himself by bathing, fasting, and prayer. I, having breakfasted well, performed only the most desultory of ablutions, and given no thought at all to my soul, glance furtively at my fellows. Suddenly, we seem a soiled, uncouth lot.

The patient had been awakened early and told that she was to be examined by a foreign doctor, and had been asked to produce a fresh specimen of urine, so when we enter her room, the woman shows no surprise. She has long ago taken on that mixture of compliance and resignation that is the facies of chronic illness. This was to be but another in an endless series of tests and examinations. Yeshi Dhonden steps to the bedside while the rest stand apart, watching. For a long time he gazes at the woman, favoring no part of her body with his eyes, but seeming to fix his glance at a place just above her supine form. I, too, study her. No physical sign nor obvious symptom gives a clue to the nature of her disease.

At last he takes her hand, raising it in both of his own. Now he bends over the bed in a kind of crouching stance, his head drawn down into the collar of his robe. His eyes are closed as he feels for her pulse. In a moment he has found the spot, and for the next half hour he remains thus, suspended above the patient like some exotic golden bird with folded wings, holding the pulse of the woman beneath his fingers, cradling her hand in his. All the power of the man seems to have been drawn down into this one purpose. It is palpation of the pulse raised to the state of ritual. From the foot of the bed, where I stand, it is as though he and the patient have entered a special place of isolation, of apartness, about which a vacancy hovers, and across which no violation is possible. After a moment the woman rests back upon her pillow. From time to time, she raises her head to look at the strange figure above her, then sinks back once more. I cannot see their hands joined in a correspondence that is exclusive, intimate, his fingertips receiving the voice of her sick body through the rhythm and throb she offers at her wrist. All at once I am envious— not of him, not of Yeshi Dhonden for his gift of beauty and holiness, but of her. I want to be held like that, touched so, received. And I know that I, who have palpated a hundred thousand pulses, have not felt a single one.

At last Yeshi Dhonden straightens, gently places the woman’s hand upon the bed, and steps back. The interpreter produces a small wooden bowl and two sticks. Yeshi Dhonden pours a portion of the urine specimen into the bowl, and proceeds to whip the liquid with the two sticks. This he does for several minutes until a foam is raised. Then, bowing above the bowl, he inhales the odor three times. He sets down the bowl and turns to leave. All this while, he has not uttered a single word. As he nears the door, the woman raises her head and calls out to him in a voice at once urgent and serene. “Thank you, doctor,” she says, and touches with her other hand the place he had held on her wrist, as though to recapture something that had visited there. Yeshi Dhonden turns back for a moment to gaze at her, then steps into the corridor. Rounds are at an end.

We are seated once more in the conference room. Yeshi Dhonden speaks now for the first time, in soft Tibetan sounds that I have never heard before. He has barely begun when the young interpreter begins to translate, the two voices continuing in tandem— a bilingual fugue, the one chasing the other. It is like the chanting of monks. He speaks of winds coursing through the body of the woman, currents that break against barriers, eddying. These vortices are in her blood, he says. The last spendings of an imperfect heart. Between the chambers of her heart, long, long before she was born, a wind had come and blown open a deep gate that must never be opened. Through it charge the full waters of her river, as the mountain stream cascades in the springtime, battering, knocking loose the land, and flooding her breath. Thus he speaks, and is silent.

“May we now have the diagnosis?” a professor asks.

The host of these rounds, the man who knows, answers.

“Congenital heart disease,” he says. “Interventricular septal defect, with resultant heart failure.”

A gateway in the heart, I think. That must not be opened. Through it charge the full waters that flood her breath. So! Here then is the doctor listening to the sounds of the body to which the rest of us are deaf. He is more than doctor. He is priest.

I know ... I know ... the doctor to the gods is pure knowledge, pure healing. The doctor to man stumbles, must often wound; his patient must die, as must he.

Now and then it happens, as I make my own rounds, that I hear the sounds of his voice, like an ancient Buddhist prayer, its meaning long since forgotten, only the music remaining.

Then a jubilation possesses me, and I feel myself touched by something divine.

Selzer, Richard (1996-04-15). Mortal Lessons: Notes on the Art of Surgery (Harvest Book) (Kindle Locations 302-320). Houghton Mifflin Harcourt. Kindle Edition. 
(BTW: That's not the cover; I did that in Photoshop from one of the illustrations in the book)

I have all of his books in hardback. What a writer. Rare erudition and passion.

Fast forward 40 years.

When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic. Many of my colleagues are similarly struggling with the loss of their professional ideals. Of course, the relinquishment of one’s ideals is standard fare in the midlife phase. In this period, fundamental questions about life often arise: What is its purpose? What is my ultimate aim? Depression and nostalgia can take hold as middle-aged adults struggle with responsibility, regret, and the nagging awareness that their lives are half over.

I used to think that my life would settle down when I got to this stage, but I was wrong. The insecurity and ambivalence of my youth have persisted, though in different forms. In my twenties, hamstrung by my passions, I yearned for consistency in my core beliefs. I obsessed about what I was going to do with my life. Those ruminations now seem like luxuries. The challenges I face now— supporting my family, navigating the precarious domains of job, marriage, and fatherhood while trying to maintain personal and professional integrity— seem so much bigger (if no less insoluble). As a young adult I believed that the world was accommodating, that it would indulge my ambitions. In middle age, reality overwhelms that faith. You see the constraints and corruption. Your desires give way to pragmatism. The conviction that anything is possible is essentially gone.

It occurs to me that my profession is in a sort of midlife crisis of its own. In the last four decades, doctors have lost the special status they used to enjoy. In the mid-twentieth century, at least, physicians were the pillars of any community. They made more money and earned more respect than just about any other type of professional. If you were smart and sincere and ambitious, the top of your class, there was nothing nobler or more rewarding that you could aspire to become. Doctors possessed special knowledge. They owned second homes. They were called upon in times of crisis. They were well-off, caring, and smart, the best kind of people you could know.

Today medicine is just another profession, and doctors have become like everybody else: insecure, discontented, and anxious about the future. In surveys, a majority of doctors express diminished enthusiasm for medicine and say they would discourage a friend or family member from entering the profession. In a 2008 survey of twelve thousand physicians, only 6 percent described their morale as positive. Eighty-four percent said their incomes were constant or decreasing. The majority said they did not have enough time to spend with patients because of paperwork, and nearly half said they planned to reduce the number of patients they would see in the next three years or stop practicing altogether. American doctors are suffering from a collective malaise. We strove, made sacrifices, and for what? For many, the job has become only that— a job.

Consider what a couple of doctors had to say on Sermo, the online community of more than 125,000 physicians:
I wouldn’t do it again, and it has nothing to do with the money. I get too little respect from patients, physician colleagues, and administrators, despite good clinical judgment, hard work, and compassion for my patients. Working up patients in the ER these days involves shotgunning multiple unnecessary tests (everybody gets a CT!) despite the fact that we know they don’t need them, and being aware of the wastefulness of it all really sucks the love out of what you do. I feel like a pawn in a money-making game for hospital administrators. There are so many other ways I could have made my living and been more fulfilled. The sad part is we chose medicine because we thought it was worthwhile and noble, but from what I have seen in my short career, it is a charade.
Another wrote:
I loved what I did, running an ICU. But I was on call 11 of every 14 days for more than 25 years. Over a third of my work weeks were 100 hours. I quit when I was 56 because my wife developed a terminal illness and I wanted to return all the lost hours I had promised her “when we retire.” In my last year of practice I asked the billing department to collect all the actual money we had collected on one particularly long and difficult weekend on call  … After overhead, I was actually paid $ 11.74/ hour. Who would do that again? Fool that I am, I probably would, but my wife and I brought up our sons from an early age to be totally against the idea of medical school. They were clearly bright enough, with full academic scholarships. And while they respect physicians, they are not doctors. And I am glad they are not.
The discontent is alarming, but how did we get to this point? This book, chronicling my experiences in my first few years as a new doctor, is my attempt to answer this question.

Jauhar, Sandeep (2014-08-19). Doctored: The Disillusionment of an American Physician (pp. 6-7). Farrar, Straus and Giroux. Kindle Edition.
A bit more:
Because insurers had been slashing reimbursement rates, that summer my LIJ colleagues and I were told we had to increase our “relative value unit” collections, or RVUs (the currency of medical payment). With all the cuts in reimbursements over the prior few years, academic medical departments across the country had suffered sharp downturns in revenue. Some physicians had responded by upcoding— claiming greater complexity in patient encounters than was in fact the case— and fraud investigations at some centers were under way. Obviously I wasn’t going to upcode, so what the department’s directive meant for me on a practical level was that I had to see more patients. I reduced the time in my schedule earmarked for new patients from sixty minutes to forty and for established patients from thirty minutes to twenty. With administrative tasks, conferences, teaching, chart reviews, and letters and phone calls to physicians, hospitals, and pharmacies increasingly gobbling up my day, I began to rush through visits, hurrying patients along in subtle and not so subtle ways. I stopped making small talk. I interrupted histories after a few seconds to get patients on point. I even urged my patients to breathe a little faster when I was listening to their lungs. “Doctor, I just want to know…” “One second, ma’am, please, one second…” (pp. 224-225).
Related readings of mine:

Another awesome book, reported on here.

Yet another:

Reported on here.

Periodical literature has been rife with recursive reports of the dismay in recent years.
The Root of Physician Burnout

Incentivizing with money is a self-fulfilling prophecy of cynicism. We must promote compassion, courage, and wisdom among our physicians before we "make a sordid business of this high and sacred calling."

A colleague of mine in primary care medicine has decided to leave the practice of medicine. She is very well trained, has impeccable professional credentials, and works in a thriving practice. Over the past several years, however, she has noticed an unrelenting decline in the sense of fulfillment she derives from her work. She feels increasingly frustrated with what she calls the "bureaucratization" of medicine, and resents spending "more time filling out forms than caring for patients." My colleague is suffering from what is commonly described as burnout...

The Epidemic of Disillusioned Doctors
We all know medicine has become a frustrating profession. But surveys show that a younger generation of doctors are more resilient to burnout

By Danielle Ofri, MD

Last week I was ready to quit medicine. I was seeing a new patient with diabetes, heart disease, anemia, hypertension, osteopenia, hypothyroidism, reflux, depression and pain in every part of her body. From a bag she produced 18 pill bottles — from about as many doctors — and piled them onto my desk. She pulled out a form from her job that needed to be filled out, plus a prior-approval form that her insurance company required, as well as a stack of photocopied records from the other doctors. She didn’t speak English, so we waded through her complicated medical history via a telephone interpreter. I don’t like to write while I am talking with a patient, but I couldn’t afford to fall behind in my documentation, so I typed madly into the 50 required fields of our electronic medical record while the patient recounted her complex medical history.

In the middle of this, the computer seized up, then turned a shade of gray that in an ICU would elicit the code team. I didn’t want to lose the interpreter on the phone, so I fiddled with the control-alt-delete buttons while I continued the interview, moving on to the refresh buttons, the escape buttons, finally squatting awkwardly under the desk to yank the on-off switch of the computer.

Forty-five minutes into our 15-minute visit, with an interpreter telephone in one ear translating back and forth into Bengali, my office phone in the other ear, on hold to tech support, my desk swimming with insurance forms, pill bottles, MRI reports, and mammogram referrals, the computer flashing ominous error messages, plus six more patients waiting outside, eight phone messages from yesterday still to return, I thought: “That’s it, I quit!”...
I got off into thinking about this in particular after reading this on THCB:
An Open Letter to Primary Care Physicians

Dear Doctor,
The future is in your hands.

You have the opportunity to make primary care better.

More efficient.

More accessible.
And more affordable.

We know you and other primary care doctors have more responsibilities than ever. But you also have great influence, along with the ability and opportunity to change this country’s health care system for the better.

Primary care is essential to the quality of health care, and we need you now more than ever.

Maneuvering the Minefield

According to research firm Harris Interactive, “the practice of medicine is … a minefield. … Physicians today are very defensive – they feel under assault on all fronts.’’* Harris questions, “how much fight the docs have left in them. Some are still fired up … while others have already been beaten down.’’

Those who feel frustration, anger and burnout say they are squeezed by administrators, regulators, insurance companies and more. They worry about the possibility of a lawsuit that could destroy your career.

The question is: What can be done about it? Some of you may choose to remain in the status quo. Some of you have chosen to retire early or otherwise leave the field of medicine entirely. Yet some of you have said enough is enough and found specific solutions that mark a pathway forward. You sought – and found – specific solutions that mark a pathway forward.

If you’ve rejected the status quo and joined your fellows in search of innovations from other practices that you have applied at home, congratulations. You’re a physician leader who’s doing great things for your patients, your colleagues and yourself. You are undoubtedly more satisfied in your work than before, and you are quite likely providing better care.

To those of you who aren’t sure of how to proceed, there is a way out. But you have to act...
A lot to think about. The authors continue:
If you have the courage to stand up and lead, you will quickly find that identifying great practices from which to learn isn’t that difficult. Don Berwick, MD, former head of the Centers for Medicare and Medicaid Services (CMS) for the United States, puts it this way: “It’s not hard to describe the health care system we want; it’s not even hard to find it. … Among the gems and the jewels throughout our country… lie answers; not theoretical ones, real ones where we can go and visit these organizations and see how good they are.”

So, when we add these elements together, the pathway forward emerges:

  1. Step forward as a leader
  2. Identify problem areas within your practice
  3. Find practices that have done a nice job of solving those problems
  4. Learn from others
  5. Apply what seems like the best fit to your practice
Ah, that "Leadership" thingy I've been working on.

Which leads me to another book I have underway.

This book is about a naturally occurring pattern, a way of thinking, acting and communicating that gives some leaders the ability to inspire those around them. Although these “natural-born leaders” may have come into the world with a predisposition to inspire, the ability is not reserved for them exclusively. We can all learn this pattern. With a little discipline, any leader or organization can inspire others, both inside and outside their organization, to help advance their ideas and their vision. We can all learn to lead...

Sinek, Simon (2009-09-23). Start with Why: How Great Leaders Inspire Everyone to Take Action (p. 1). Penguin Group US. Kindle Edition. 
Got hip to him from that TED talk in my prior post. Again, "Talking Stick culture," anyone?

See also my citation of the book "When Doctors Don't Listen" in my post "Philosophia sana in ars medica sana." (scroll down)

Saturday morning, Jerry woke up with tightness in his chest. It hurt when he sat up and he figured he must have pulled something while he was moving. But his uncle or grandfather (maybe both?) had heart problems, and Jerry’s wife persuaded him to go to the ER to get it checked out.

A generation ago, a doctor might have heard Jerry’s story and told him that he had a muscle strain. He would have left and felt better. Not so on this particular day. The nurse who greeted Jerry noted his “chief complaint” of chest pain and called over a tech, who took off Jerry’s shirt and attached him to a monitor that beeped and displayed waves and numbers that made no sense to him, but Jerry trusted the folks around him to make sense of it all. He was given some aspirin to chew and another tiny pill under his tongue that tingled a bit and gave him a headache. He was brought to a treatment room where another nurse came in and asked a series of questions about his “chest pain” before proceeding to take several vials of blood and shuttling him off to the next destination, the radiology suite for X-rays. When he finally got back, a doctor stopped in and went over yet another checklist of questions, these seeming even less relevant to why he was there. (“ Why did it matter whether I had blood in my stool or slept on two pillows at night?”) But while long, convoluted, and confusing for Jerry, the whole process nevertheless appeared routine and procedural for the ensemble of medical professionals coming and going...

Wen, Leana; Kosowsky, Joshua (2013-01-15). When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests (p. 2). St. Martin's Press. Kindle Edition.
Issues at every turn. I'm sure physicians feel shot at from every direction every day.


...A third player is increasingly encroaching on the doctor-patient relationship, and more and more doctors are beginning to suspect that it may be the vector of much of contemporary healthcare’s pathology. Who is the third party? Its precise identity is often difficult to pin down, but its seat in the doctor’s office and at the patient’s bedside is often occupied by a hospital, a health insurer, or a government agency.
This third party usually does not see individual patients. Instead it sees aggregates, such as rates of mortality, disease incidence, and the utilization rates of particular tests, procedures, and pharmaceuticals. It tends to be particularly interested in parameters such as efficiency, safety, cost, and revenue.  Because it is largely blind to individuals, however, its risk of developing certain disorders is dramatically increased...
From THCB. Nice. Will there be an ICD-10 code for that dx?

But, wait! There's more...
Another such disorder is hypermechanosis. Many third parties envy the kinds of productivity and quality gains that have been achieved in other industries through the application of various forms of statistical process control. For example, six sigma focuses on reducing variation, usually treated as error. If only we could run medical practices the same way Toyota manufactures automobiles, Southwest flies airplanes, and Disney treats its theme park visitors, proponents argue, we could revolutionize healthcare...
Yeah, hahahaha.... Good for laughs among the Perpetually Pissed At Their Loss of Clinical and Business Autonomy, but, more than just a bit of Straw Man there.

More to come...

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