Grand rounds is up this week at Health Business Blog. It’s very well done, and exceedingly readable. Thanks, Dave!
No thanks, though, for pointing me to a post at Medical Pastiche, which has a link to a real estate blog called”Don’t cry for me, just get me my principle reduction“, which then led me to dozens of real estate blogs chronicaling the bursting housing bubble all across America. Reading these blogs is addicting, as one after another tells the story of housing speculation gone bad. Tales of “Super Flippers“, bad real estate agents, tricks being used to fool buyers into thinking a house has just been put on the market when it’s been there for months, entire blocks in Southern Califronia where every other house is in forclosure. These bloggers have the benefit of public records and google earth photos, and have a “take no prisoners” approach to blogging. No one is spared their critical eye as they chronicle the death of the housing market at the hands of greedy speculators.
Reading these blogs is positively addicting. Consider yourself forwarned.
Shuna Lydon has written the most amazing post about teaching and learning in the restaurant kitchen. It’s a must read for anyone who has ever had a mentor. And for anyone, who like me, is enamored of the culinary world. It’s the kind of behind the scenes look that we front-of-the-restaurant types are rarely given. I read it, and all I want to do is read more.
No.” Eric said to calm them a bit, “Stand over here, I’m going to show you how to put out this table, I’m going to show you how to cook, how to work like a team, how to put out just one ticket.”
And then he did. He cooked every single course, by himself, with not another soul on the line touching sauce pots or spatulas or garnishes. He jumped this way and that, gracefully, using every part of his body, talking, admonishing, telling, teaching, showing, explaining as he went. It was the most amazing thing I ever saw in a kitchen…
When the line resumed their positions, every single cook knew just who
they were. Cooks.
As I’ve written before, so much about the culinary world reminds me of medicine. Shuna has given me yet another example of that – how our mentors influence us throughout our career. Her description brought to mind the great teachers I had who helped me become the doc I am today.
So, the other night, I’m listening to The archive of Dr A’s radio interview with Paul Levy, the CEO of Beth Israel Deaconess Hospital in Boston and author of the Blog “Running a Hospital“. And I’m really enjoying it.
“This guy’s great!” I yell to Mr TBTAM, who is reading in the living room. “Did you know he used to run Boston’s sewer system before he took over Harvard?”
Levy talked about how he had brought a new transparency to the Boston health care marketplace when he began to post Deaconess’s outcomes on his blog. I liked that. A lot.
Then he took on the technology must-haves, asking what data existed that robotic prostatectomies were better than good old fashioned procedures.
“Those machines cost a million two or a million five..When you consider that the margin on a prostastectomy… is $10,000 how long does it take to get a million and a half back?…Well, you never get it back… Those hospitals that have bought them have picked up market share from other hospitals in the field, and there’s just no clinical reason for this.”
And I’m thinking – this guy reminds me of Dr Wes. Looking for the evidence before jumping on the bandwagon and spending our healthcare dollars just to get market share. Great!
When Levy started to get on Dr A and his colleagues for not washing their hands, I was right there with him. After all, I’m an obsessive hand washer – always have been. I even began washing my hands in front of the patient years ago when a colleague of mine did a survey of adolescents, and discovered that the most important factor in their choice of doctor was whether or not she washed her hands before examining them.
So Levy and I, we’re simpatico, right? And I’m thinking – I’d like to work with this guy. Wouldn’t you, if you heard him say this?
“I never pretend to to practice medicine. They tell me what they need done in order to do their job and we do out best on the administrative side to get it done.”
Yes! Paul Levy! You are THE MAN! I begin imagining what it would be like to live in Boston…
And then he says it.
What He Said
It was a discussion he and Dr A were having about negotiation. About how docs don’t know how to do it very well, because it’s not a skill that mixes well with the quickfire decisions needed in the OR and in emergencies. I’m thinking “He really gets us…”
Dr A, who’s got an administrative position himself, joins in about how hard it can be to get consensus and change old ways. He asks Levy for his advice on what to do when a physician says “Do it this way or I’m leaving your staff and going to the competition.”
And Levy says this –
“My usual response to that is “Great. We need the office space anyway. And when will you be leaving?”
You could almost feel Dr A pull back from the mike. In fact, there was a massive shift in the universe as every one if us docs listening to the interview pulled back from our computers and began readjusting our position on Levy. (Okay, I’m willing to admit maybe this was just my own reaction.)
And I knew it, right then and there. He was not one of us. He was one of them. An administrator, not a doctor. Not getting that if a doc is threatening to leave, then maybe what you want him/her to do might be just a tad unreasonable. Maybe that EMR you are insisting he use isn’t quite ready for prime time. Maybe one can’t see a patient every 15 minutes without extra support staff that could have been paid for with just a minuscule portion of the ad budget. Maybe you’re not giving him the support he needs to make the change you want him to make. A change that may be good for the administration, but bad for the doc.
Easier and cheaper to let that guy go, rather than take the time to figure out just why he is so upset. Replace him with someone who is willing to play along without a fuss.
And it hits me. Again. The way its been hitting me for the past 20 years since I left residency.
We docs are really not in charge. The administrators are. Administrators who have never practiced medicine.
Why this is so hard for me
I have a confession to make. I became a doctor because I wanted to be in charge.
It was the summer of my junior year in college, and I was working full time in a nursing home, trying to find out a bit about this field of medicine that I was considering as a career. Trying to decide if I should become a nurse or a doctor.
I was doing private duty for a little old lady who had just moved into the home, spending the majority of her waking hours with her on the day shift.
She had Alzheimer’s disease. She figured that I was granddaughter, and that we were in a hotel. But she remembered that her son lived down the road (he did), and saw no reason why she shouldn’t be walking there whenever she wanted. And she couldn’t understand why, if I had a car, she and I couldn’t head over to the mall for some shopping. This made her mad.
As the days progressed, this little old lady got madder and madder, and it was becoming harder and harder to rein her in when she started to walk off down the driveway.
So they called in a shrink. A doc who she had never met. He came into her room and spoke with her for, maybe, 15 minutes. Never asked me a single question about her. Wrote a prescription for Haldol (an anti-psychotic) and walked out.
That Haldol dose was too much for her. She became lethargic, somnolent. Wouldn’t get out of bed. Began soiling herself. Lost all touch with reality. After a week, her brother, a retired doc, came to visit, assessed the situation and went ballistic. The Haldol was stopped. But she was never the same.
And I think – Wow. A doctor can come in, change a woman’s life in a really bad way. Another doc can come in and save it. And no one stops to ask me, the nurse who has been with her more than any of them, who knows her now better than anyone, what I think.
I want to be the doctor. I want to be the one in charge. No one is going to be the boss of me.
But I am not the boss of me
I know, I should just quit academic medicine and head out into private practice, where at least I will have some semblance of control.
But not really.
Because somewhere between the administrators, Big Pharma and the insurers, we gave away medicine. Gave it away because we were too busy taking care of patients to step up and fight. Gave it away because the battles were fought on such a large scale, and we were a bunch of unorganized small shops.
Some docs got smart and went back for their MBAs so they could talk the language and play the game with the suits. Some just became the suits.
But most of us didn’t go into medicine as a business. So as we were taking care of patients, those around us built up this huge business of health care around us. A business that is now turning non-profit medical centers into profit making enterprises. A business that is making insurance company CEO’s some of the highest paid CEO’s in America.
A business where the doctor, the one who is actually responsible for the patient, the guy who gets sued if anything goes wrong, the guy who that patient is coming to see in the first place, the guy who may not have taken Paul Levy’s negotiating class because he was too busy taking care of patients, that guy…that guy is as replaceable as a worker on an assembly line.
I get it.
I really do. I’ve been living it for 20 years, and I accept it. I know the rules and my place in the game, and I think I play it fairly well.
As for Paul Levy, CEO, well, you don’t just play the game fairly well. You play it really well. You’ve turned around a major medical center, which is no small feat. You know that. I know that. As good a doctor as I think I am, I could never accomplish something like that. I don’t have the skills you’ve got in this arena. Probably never will. And the truth is, I greatly admire you and what you have done. Heck, I even love your blog.
But I will ask you this.
The next time a doc threatens to leave, don’t be so quick to show him the door.
Stop and consider who he is and how he got to be in a place where he is willing to leave over whatever the issue is you are arguing about. Grant him the respect for what he does all day (and night). Remember what you said up there about never pretending to practice medicine, and how negotiating skills are not something we docs inherently have. Put yourself in his shoes. Go the extra yard to figure out why he’s so upset. Odds are, it’s because it’s going to effect how he practices medicine.
In the end, that’s really what this business is all about, right? Medicine.
And he is still, after all, the doctor.
___________________________________________
Levy responds in the comments below.
Once again, vegetarian dinner guests have challenged my culinary creativity. This time, rather than turning to the Moosewood or other veggie tome, I decided to cull a meatless dinner from a more classic source – Julia Child’s Mastering the Art of French Cooking. This Provencal vegetable bean soup has everything one could ask for in a meal. Add a sourdough baguette and a salad and it’s more than enough for dinner for eight.
Soupe au Pistou
3 quarts water
2 cups diced carrots
2 cups diced leeks
2 cups diced potatoes
(I also added about 1/2 bulb fennel, diced )
1 tbsp salt
2 cups canned white cannelloni beans, rinsed and drained.
1/3 cup broken spaghetti or vermicelli
2 cups diced green beans
1 slice stale white bread, processed in the food processor to make crumbs (I used a stale pita)
pepper
pinch of saffron (I used turmeric)
1/4 cup chopped parsley (my addition)
For the Pistou
4 cloves mashed garlic
1/4 cup chopped fresh basil
1/2 cup grated Parmesan cheese
1/4 t 1/2 cup fruit olive oil
4 tbsp tomato paste or 6 tbsp fresh tomato puree
I used 3/4 cup prepared pesto (without pine nuts) instead of the first 4 ingredients and just blended in the tomato paste by hand.
Add potatoes, leeks, and carrots to 3 qt cold water with 1 tbsp salt in a large soup pot. Bring to a boil and simmer for 40 minutes.
Twenty minutes before serving, so the green vegetables retain their freshness, add the beans, spaghetti or vermicelli, bread and seasoning to the simmering soup. Simmer another 15 minutes or until the green beans are just cooked. Correct seasonings.
Prepare the pistou while the soup is cooking. Blend garlic, tomato puree or paste, basil and cheese either by hand or in the food processor till smooth. Add the olive oil gradually. (If using prepared pesto, just blend in the tomato paste to the pesto). Place in the bottom of the soup tureen. When the soup is ready for serving, beat a cup gradually into the pistou. Pour in the rest of the soup. Serve with hot french bread or with hard-toasted bread rounds basted with olive oil
Makes 6-8 servings.
Forbes Magazine has published an article listing the reasons not to become a doctor.
JaneMarieMD counters with her Top Ten Reasons to Become Doctor.
I’m with JaneMarie. But read them both. Decide for yourself.
Which reminds me of the old SNL Point-Counterpoint, except in this case, JaneMarie is no ignorant misguided slut.
Several readers have requested an updated photo, so here it is. Eight weeks post-op from a bilobed flap reconstruction after a Mohs procedure for superficial basal cell carcinoma. (See the whole story here. Posts are in reverse chronlogical order – start from the bottom. Photos are here.)
My plastic surgeon is not thrilled with the lower part of the incision, as the scar ended up a bit wider than he’d like. He is expecting we will do a revision sometime in the future. The top part of the incision is a bit bumpy, as you can see, so I spend a lot of time massaging it really hard to break up the collagen fibers. It periodically itches, which is an odd feeling because it is also somewhat numb.
Truth is, it was really hard to get a photo that shows the incision, since in real life, it’s actually barely noticable, especially when I wear makeup (which I am not wearing in the photo.)
Head on over to Suture for a Living for this week’s best of the medical blogs. Plastic surgeon and quilt maker RL Bates has done a fabulous job compiling this week’s posts, not to mention giving us a little photo tour of her home state, Arkansas.
Not only is this week’s grand rounds is a treasure trove of posts, but but this blogger has also discovered a few new blogs to add to her blogroll.
Marianas Eye – An American Opthomologist living and practicing on a tropical island of Saipan. Think South Pacific meets MASH. (He even has a book!)
Denialism Blog – The Hoofnagel brothers and PalMD take on those who would deny scientific and medical fact. PalMDs post in today’s grand rounds is wonderful, but I was most impressed by an old post in their blog called “The Denialists Deck of Cards. This is a blog that’s going to keep me busy reading back posts.
DocGurley – How I missed this blog till now I’ll never know. She’s smart, she’s funny and she calls a mean fight, as shown in her last week’s Grand Rrounds Smack Down.
Tales from the ER and Beyond – A Canadian blog by Dr Couz, ER resident and new mom. For such a youngun’ she speaks with the authority and wisdom of one beyond her years.
Thanks, RL!
California teen gives birth in shower, walks to hospital
LONG BEACH, Calif. (AP) — A 17-year-old girl gave birth secretly at home, then walked four blocks to a hospital with the baby still attached by its umbilical cord.
“I was just a little nervous” when the labor began, Xochitl Parra said Friday from St. Mary Medical Center as she cradled her 8-pound, 3-ounce son, Alejandro.
The boy was normal and “eating like a champ,” said Dr. Jose Perez, director of the Neonatal Intensive Care Unit.
The teenager said she was alone and taking a shower around 5:30 a.m. Wednesday to get ready for school. Then the contractions took over.
“I felt his head coming, so I sit down and pushed so he could come out,” she said.
Parra did not call 911 because the home phone was disconnected, and she did not want to wake the neighbors because it was so early. Instead, she wrapped the baby, got dressed and went to the hospital on foot. (More of the story and a photo at Yahoo News)
Lots of folks find it hard to believe a teen could hide a pregnancy for 9 months, but it’s not as unusual as you might think. You can’t do it if you are rail thin, but heavier teens have an advantage in that folks just think they are gaining more weight. The oversize t-shirt look helps, too.
I had one teen patient some 20 years back who managed to hide her pregnancy even as she made time trials for the swim team one week before delivering a full term infant. This young woman was tall and stocky to start, and the coach just thought she was gaining weight. Her pediatrician didn’t even consider the diagnosis of pregnancy when she presented to him in labor – he sent her to the ER as a possible appendicitis.
By the way, she also managed to keep her A average throughout the pregnancy. As I told the shocked and ashamed mom, this was one pretty amazing girl. I don’t think I could have accomplished what she had at age 16 while pregnant, let alone holding that secret for 9 months.
Vagina Dentata – that’s one they left out of the textbooks. (via Feministing)
Medblog Addict, who describes herself as “a bored attorney who spends too much time reading medblogs at work” has interviewed me as Doctor of the Month on her blog Addicted to Medblogs. April happens to be one of my favorite months of the year, so thanks, MA.
You can read the interview here.
“Jennifer J____ is here”, said my secretary. “She says you are expecting her.”
I had never heard the name, and I had no appointments that afternoon.
“Is she a patient?” I asked.
My secretary spoke into the phone to the front desk receptionist, then turned to me. “No. But she says you asked her to come in to see you.”
“Go out and see who she is,” I suggested.
Turns out Jennifer was a drug rep with a new product to sell for osteopososis. She had no appointment because I stopped seeing drug reps over a year ago.
“Tell her nice try,” I said.
But for arguments’ sake, let’s say I had agreed to see her.
Why would I believe anything she had to say about her drug when she had already lied to get into my office?
I don’t always agree with the Randy Cohen’s advice in The Ethicist column in the New York Times magazine, but this week he got it right. In advising a 61 year old man that he did not neeed to share his prior history of treated gonorrhea with potential girlfriends, Randy said this –
…Contracting an S.T.D. is not a misdeed, not a moral failing, not an indication of your character; it’s a medical problem.
Well said, Randy. Except the new acronym is STI – Sexually Transmitted Infection. A more appropriate word than disease, especially for infections that for the most part, are transient and treatable.
We don’t pass judgement on one another when we give each other colds, the flu and strep throat. Let’s stop doing so when we give one another STI’s. These infections are after all, just the end result of a virus or bacteria looking for a mucus membrane to invade.
Sometimes, however, getting an STI can be a wake up call that it’s time to limit your number of sexual partners. That’s not necessarily a moral judgement – it’s simple mathematics. For some women, having to deal with an STD that resulted from a one night stand or an encounter with someone whose feelings for you are unclear is much more difficult than having acquired an STI from someone who really cares about you and who you also love. Again, this is not a moral judgement. Just something I’ve learned from treating many women over the years who have had STI’s.
I just got a congratulatory email from a favorite patient of mine. Apparently, I have been listed in today’s New York Times Magazine as a Super Doctor, “one of the top 5% of New York City physicians in more than 30 specialties“.
I have never heard of Super Doctors, and have no idea how I made the list, especially given what I perceive as a marked absence of some of the best docs I know from the list. I also note that the Super Doctors list is not published by the New York Times per se. It is paid advertising. You know, one of those special “Pull Out” sections of the magazine.
Super Doctors is published by Key Professional Media, which also publishes “Super Lawyers” and “Super Dentists”. The Super Doctor list is generated from surveys of physicians, who are asked to list docs to whom they would send a family member. The list is then vetted by the top ranked members of the list, which seems a rather odd process to me. Super Docs then proceeds to sell ad space in the publication to the members of the list. (St Lukes/Beth Israel and Lenox Hill Hospital seem to have bought most of the ad space in this issue.)
Super Doctors appears to be setting themselves up as the major competitor to Castle Connolly’s America’s Top Doctors, another “Best Doc” list generated annually from surveys of physicians. Here in New York, New York Magazine publishes the Top Doctor list every year, and then of course, sells ad space in the publication to the members of the list. In Philly, Philadelphia Magazine publishes the list, and I suspect each town has their local publication that does the same thing.
The difference between Super Doctors and Castle Connolly’s Top Doctors is that the Top Doctors list is published jointly with the magazine in which it resides, as opposed to being just paid ad space there. Although Castle Connolly’s list is much larger and more comprehensive than Super Doctors, the Top Doctor list published in New York Magazine is only abbreviated version of Castle Connolly’s results. If you want to see the entire list, you have to purchase Castle Connolly’s book. Since most patients do not purchase the book, the magazine version becomes, in effect, the definitive list of Top Doctors. Which gives New York magazine an incredibly powerful position in the final vetting, a process they do not reveal in any detail.
I have always had very mixed feelings about these “best” lists. (Although I have to admit, I was always jealous of the docs who got listed.) Do these lists really measure quality? I don’t think they do. If there is no vetting of who gets the surveys in the first place, then the results are really just a mish-mash of referral patterns across and between specialties. I’ve always been surprised at seeing who is on and off Castle-Connolly’s list in New York Magazine, since it seems more hit and miss than anything else.
I don’t remember, but I probably got a Super Doctor survey and threw it out at some point. Which may explain why so few of the amazing docs I know are in the list. I do recall getting a request to purchase ad space on the list, which I know I threw out. I guess the fact that I am still listed despite not buying ad space means the process is not entirely ad-driven.
Despite my mixed feelings, I would like to thank all the docs who listed me in their survey, whoever you are. I promise next year I’ll fill mine out so at least the great docs I know will get a shot at making the Super Doctor list.
Whatever it means.
