Dr John M

cardiac electrophysiologist, cyclist, learner

Doctors in the crosshairs…

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Let’s start with a disclaimer:

I am not complaining; I’m just stating the facts.

Honest fact: The morale of doctors in the real world is low–and sinking lower.

I know what you are thinking. “Come on Mandrola, you are nuts if you expect us to feel sympathy for doctors–of all professions.”

Well…you can think that if you wish, but I’m calling it as I see them. And here is why it matters:

Because when you are sick, an available, rested, un-rushed and talented doctor is really important.

You know this: quality health care–real quality, not spreadsheet or Internet quality–stems from basic human-to-human interaction, between patient and doctor. Healthcare reform, with its emphasis on metrics, prevention of fraud and cost-cutting measures has forgotten the basics. Namely, that humans, who have dedicated their life and committed their self-esteem, practice medicine. To take care of people well, doctors need things:

  • We need face time with the patient–not with a computer screen.
  • We need time to listen, to examine and to treat.
  • We need to feel trusted.
  • We need our self-esteem.
  • We need leeway to be human.
  • And of course, we need to be paid a fair wage for the years of training that it took to acquire these skills.

In support of this view, I’ll call your attention to four posts from real doctors:

–My colleague Doctor Wes Fisher talks of the growing culture of hostile dependency towards caregivers. Wes is rightly disturbed by a sensational and one-sided book review (WSJ) of surgeon-author Dr Mark Makary’s Unaccountable. Agree or not with Wes, his words come from the heart of a man who hangs a lot of his self-esteem on the doctoring peg. Wes is a guy I would want to have as a doctor. If healthcare reform keeps going in this direction, patients will have fewer Wes Fisher’s around to pull them out of fires.

–Here’s a quote (via email) from an esteemed colleague–another guy you would want as your doctor.

We doctors are absolutely being demonized.  Every day something new is written pinning our healthcare crisis squarely on our shoulders.  It’s really affecting me emotionally.  I’ve actually started to think it might be a good idea to take a media holiday for a while.  I appreciate that you still have the energy to fight.  I’m getting pretty tired.

–One of the most obvious unintended consequences of cutting healthcare costs on the backs of doctors providers is the flight of good primary care doctors to concierge medicine. One of the best posts I have read on the topic of Dropping Out comes from Dr Rob Lamberts. Dr Rob is a beautiful writer and another passionate practitioner of Medicine. I’ve been reading his stuff for years, and it is clear that Dr Rob has unequivocally mastered the obvious.

–Finally, there’s me. I wrote an In the Prime post today about the two sides of the canvas of healthcare reform. It was in response to a nicely written opinion piece in the Courier-Journal. A local doctor pointed out that we must not settle for anything less than universal insurance coverage. He’s right; but there is also the important question: What good is universal coverage if there are not enough caregivers?

Doctors don’t expect sympathy. That’s not what we want. We want the people–our patients–to know the consequences of hostility towards caregivers–be it in mistrust, hyper-regulation or lower pay.

We welcome reform, but we can’t sit still and watch it destroy the practice of Medicine.

JMM

Don’t take my fun away

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“Did you sign those (three) consents?”

“This patient needs a short form; your office letter was done 30 days and one hour ago.” (just over the legal limit)

“The insurance ‘people’ in area code (***) denied the stress test.”

“Mr Smith’s son, an alternative medicine specialist in California wants a phone call to discuss herbal therapy of AF instead of ablation.”

To these, and the infinite list of similar hassles, I have been responding with a new plea, “Please don’t take the fun out of doctoring.” Saying it out loud, like a childhood prayer, reminds me of the truth: that doctoring is, still, a really a great job.

This week two unusual things happened to me that reinforced this truism.

First, an internist called me to say there was a near-100 year-old that had heart block requiring a pacemaker. She is an enlightened doctor and knew my gut reaction, so she quickly added, “this patient is a good 95, we’ve already been there.”  And then she said one more thing, “I have a fourth-year medical student who is rotating with me…can she come watch? I have no idea how a pacemaker is installed, maybe you could show her, and she could tell me.”

We are within only a scant few miles of the university, but yet a Berlin-wall-like barrier seems to exist between the private world and the university. Every once in while though, a “younger” escapes on some elective rotation. They are sent out into the deep dark forest of the private practice world. Such escapees are always young, and as time passes they appear even younger.

To us non-academics, there is nothing quite like having a motivated youthful escapee to listen to your show-and-tell. She had never seen an EP lab, a cephalic vein isolated, a simple peel-away sheath, or a pacemaker lead. Who knew that basic physics 101–the flow of electrons–would apply so directly to patient care.

“While she was there it wouldn’t hurt to show her some more stuff,” I thought.  Then there was a cardioversion.  So simple to us, so ‘shocking’ to the fourth-year medical student, who jumped a little with the patient. “Ok, it’s time to go, I know you need to get you back to your primary care rotation.”   But on the way out the young escapee peered into the interventional lab, as if to say, “what’s going on in there?”  So we went in, to see the “squishers.”  I am not sure what impressed her more, the visual-only miracle of a 90% blockage being reduced to nothing, or the fact that the doctor was passionately chastising the ‘versed-ized’ patient on the dangers of persistent smoking while he squished.

“Dr Mandrola,” whispered a cath lab nurse, “I think I like having medical students around too.”

The second occurrence was late on a Friday, as I was rushing through the usual Friday-afternoon feast of documentation.  He was interviewing for a job, and I was to be talked with about our medical community. He was just out of training at a major university in a major city. He was young, with small children and a wife who was a doctor as well. He asked about our medical community, and whether I was happy.

I started to talk, and a surprising thing happened: only the good things seem to come to mind. Not that I was trying to bamboozle him, but, the ‘cubicle-doctors,’ the forms, the pharmacy requests and even the covert rationing of care were all suppressed, in an involuntary way. The joy of doctoring came to the fore. Truths like: we have hard-working, good-hearted and well-educated colleagues (nurses and doctors) to work with, we have the support of a benevolent (if not increasing stressed) hospital administration and mostly, we have many grateful patients. I stayed and talked later than I should have. Because it felt good to reflect on what is still right with the system.

My academic colleagues interview incoming prospective faculty and students frequently, and as part of their charge, they get to show neat stuff to youngers every day. I’m envious of this, for sure.

Such opportunities for reflection (on what is so good about our profession) are less common on the speedy private-practice treadmill.

So when they occur they should be savored.  Writing them down helps me remember.

Grin.

JMM

Inspiration from a nine year-old…

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It is the day after a long weekend.  Invariably, there are procedures to add to an already busy schedule, colleagues are on summer vacation and of course, there are many “action tags,” or “tasks,” or other likewise unreimbursed chores to check off the to-do list before clicking in the pedals for a pre-dinner ride.  And so it was today.

Today though, Jack was visiting.

A good decision it was, to ask Jack, our nine year old nephew from Hoosier-ville, to accompany me for some evening errands.

I had forgotten the unabashed curiosity of a nine year old.  Nine is indeed a good year for children–a sweet-spot so to speak.

After asking me if he could have my iPhone, in a test-the waters sort of way, Jack then asks me, Hey, John, do you like your job?

Yes, very much.

Do you cut people open?

Yes.

Is it gross?

No.

How do you know you aren’t screwing up?

Pause…thinking of something smart to say,  I ask, “how old are you Jack?

Nine.

It took me more years than you are old to figure it out, and even then, doctors are not perfect, but I try really hard not to screw-up.

Hey John, can I see your iPhone?

Thanks, Jack, for making me proud to be a doctor.

JMM

Memorial Day: A grateful citizen of an awesome country…

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This Memorial Day makes me think of a recently deceased patient of mine. We had known each other for years. He benefited from many of our modern EP procedures and implanted cardiac devices, and I benefited from knowing him and his devoted wife. It was as he entered the final innings of his life, that Mr S shared with me some of his war stories.   In November of last year, I wrote,

I know him well. He lay in the ICU bed with a concerned look. I approach and he makes eye contact. I must have looked worried because he studied me intensely. I say, Mr S, “I am sorry to see you here.”

We talk, he tells me the story. I knew the story beforehand. His chart was all bad news. He is an octogenarian (medical speak for a person in their 80’s.) Although, my office patients await, I sit, pause and present the “y” in the road. Neither way is good.

Mr S pauses and I wait. He begins: “I was drafted at age 18 to fight in WWII. They sent me to Europe with an M1 rifle. Initially, I was scared, really scared. Soon, as my friends were killed, I became angry. Angry at the situation. This made me a better soldier, as I realized that I would be killed as well. Accepting the inevitable gave me peace. Once home, I stayed in the service and was subsequently sent to Korea for 2 years. It was rough. I wouldn’t trade these experiences, but if given the choice, I would not go through them again. You know, Doc, these experiences have prepared me well for the choices I have to make now.” 

Pause, silence. I stand. I shake his hand and hold on longer than usual. “We can talk more tomorrow,-thank you” I say.

On a sunny and warm Spring morning, while our family enjoyed the annual Memorial Day “Mayor’s Ride,” I can’t help but to be grateful for those who serve our country and fight real wars, with real guns and real explosives.

In our busy lives, it is easy to take our freedom for granted. Not today though.  I say a very loud thank you to all our soldiers, past and present.

JMM

PS:  Will, Staci, and I enjoying the freedom of riding on closed city streets with thousands of other cyclists in Louisville, KY this Memorial Day.

The question…

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Reading news reports on the future–and present–of doctoring can get gloomy.

The question came from the quiet one in the back.  Self-reflection came upon me immediately.

There were so many technical questions: AF ablation, when to use an LV lead, who gets an ICD, and how do you decide on warfarin–just to name a few.  The staff of my recently joined group wanted to know about electrophysiology.  An electrophysiologist’s bag of tricks was new to them.

Over dinner and with my trusty Macbook,  I answered their questions and provided an EP show-and tell.  The how and why of seemingly crazy things like, burning the heart or implanting a shocking device were discussed  They work hard, many are parents, but they gave their time after a busy Monday to learn more.

So far, it was purely informational, objective and factual. Many lists were made. Then, her hand went up.  She is young, little in stature, and very shy. In the office she sits behind our most savvy procedure scheduler, never talking, always paying attention.  Her focus gives me comfort.

“Dr Mandrola, I want to know why you became a doctor–was it your family…What do you like best about what you do?

Oh my.

How cool a question was that?  Where does one begin?

During the long pause required to answer such a surprising question a flood of memories flow pleasantly through my mind. Thoughts like…

–The sensations of making money by delivering the morning newspaper in the pre-dawn cold.  (Why does delivering newspapers as a boy always come first when I think of the doctor journey?)

–The guidance counselor who said my SAT score was too low, and I clearly wasn’t smart enough to be a doctor.

–The first semester in college where I discovered the notion that tests are super easy if you study hard for them.

–As a medical student, the excitement of running around the CCU late at night with the cardiology fellow when I was supposed to be on Medicine call.  (That was the era where heart attacks were treated with Swan-Ganz catheters.)

It was time to stop, even though the pleasant memories of the journey continued flooding my mind.

Gosh, I am thankful she asked.

Working with dedicated people who share the same goal of caring for others is yet another joy of doctoring.  It is still way good.

Grin.

Huge Grin.

JMM