I like Art Caplan a lot. He’s a respected medical ethicist who does a pretty good job of describing why physician burnout is, or should be considered, a public health crisis. The video and transcript are behind a Medscape paywall, but here’s the gist:

More than half of all doctors in this country are saying, “I really feel that some aspect of my work as a doctor is making me feel burned out.”

This is really trouble. It’s trouble because a doctor who feels this way can commit more errors. They suffer from compassion fatigue, or just not being able to empathize with others because they have their own emotional issues. They may retire early, thereby reducing the workforce. They may have problems managing their own lives; 400 doctors committed suicide last year, which is double the rate of the population average. There’s trouble for patients in having a workforce that’s burned out. There’s trouble for doctors in terms of their own health and well-being. We don’t talk about it much. We like to think that doctors can handle everything, but it’s clearly not true. It’s a problem and there ought to be some solutions.

Sing it, brother! Couldn’t agree more.

Unfortunately, he offers some “solutions” that frankly cracked me up:

One type of fix is to make sure that hospitals and other healthcare environments try to create better conditions for a happy workforce and for happier doctors. This might include yoga, mindfulness training, having more therapists to talk to, encouraging people to come forward when they feel this way, peer groups, and better mentoring.

Are you kidding me? Physician suicide is out of control and you’re suggesting yoga? Seriously, Art??

Want to fix physician burnout? It’s a ridiculously simple process with only two components:

1. LET US DO OUR DAMN JOBS.
2. PAY US APPROPRIATELY.

That’s it. As professionals, internal motivations far outstrip external ones. We became physicians to help people, not to enter data into computers or check off boxes for billing clerks. Let us get back to doing that without administrators and bureaucrats breathing down our necks, compensate us fairly and transparently, and watch burnout disappear.

I guarantee it.

 

 

I was showing off my phone to a friend who isn’t quite a Luddite, but who only carries a “dumb” phone. He was impressed with all the things I could do with Siri, even though I don’t really use her much at all in my day-to-day life. However, there are other voice-controlled features that I do use sometimes, with particularly amusing results in this case.

DDS was out to dinner (yes, without me; it happens) and I wasn’t sure if he’d given the dog his second dose of medicine before he’d left. No biggie, I thought; I’d just shoot him a text. Just to save some time, I decided to use the dictation feature.

However what my friend saw was me speaking into the phone saying, “Has the dog gotten his pill yet tonight?”

He was impressed. That was a really smart phone.

The great divide: science and religion. One of my new favorite blogs, Science ACEs, recently took on this topic. Here’s what they said. This is my take:

There is no conflict between science and religion (or at least there shouldn’t be) because they have fundamentally different purposes.

Science is the word we use to describe the process of discerning the physical world around us. We use our senses to make observations, which we then use to make hypotheses, which we then test with further observations, which we call experiments. Gravity, temperature, microorganisms, photosynthesis, and many other things and processes that exist can now be described with great accuracy thanks to science. Science is the only way to understand the universe around us; what it is and how it works.

Religion isn’t really about understanding. Religion is about emotion. Religion can (or should) provide hope in times of fear, comfort in times of grief, and even greater joy in times of happiness. Religion provides an emotional context to the world around us, and helps us come to terms with the unknown.

Ah, the unknown. That’s where science and religion come to blows.

Science says there is no such thing as “the unknown,”  only “the not yet known.” Religion butts in where it shouldn’t by claiming to know “everything,” even when most of it consists of making stuff up. This is the opposite of science, but when you don’t understand or refuse to believe science, it’s all you’ve got.

Science steps on the toes of Religion by discounting its importance to very large segments of humanity. The definition of faith is “not requiring proof.” Whether or not I understand how sunlight is refracted by atmospheric water vapor, seeing a rainbow still feels holy.

Intellect and emotion are the yin and yang of the human psyche. As humans, we do ourselves a disservice when we try to divorce ourselves from either. I have no qualms about considering myself a scientist into the very fiber of my being, while still lighting a candle and reciting ancient Aramaic words on the anniversary of my mother’s death.

There seems to be a great deal of misunderstanding about Medical School. There are valid questions about curriculum, defined as what should be taught, and when, and who should teach it. But recent calls for students to “gain fluency in [health] systems” are completely misplaced. Here’s why.

What do you need to know to be a doctor?”

IT DEPENDS.

What kind of doctor are you going to be, and what kind of setting are you going to practice in (if you’re going to practice at all)? Because what you need to know to be a self-employed general surgeon in a rural area is completely different from what you need to know as a hospital employed pathologist. Or a suburban solo family doctor. Or an urban pediatrician. Or an academic rheumatologist.

It’s neither possible nor appropriate for medical school to claim to teach everything every kind of doctor needs.

The good news is that actual medical schools and other institutions involved in medical education really do understand this. As always, it’s the suits, bureaucrats, consumers, politicians, and policy makers who stridently insist that this or that “needs to be taught in medical school,” when most times all they’re doing is taking valuable time away from what really needs to happen in medical school.

What is medical really about? Two things.

First, you need to learn a huge volume of basic information about the human body, how it works, and how things go wrong with it. That includes anatomy (gross and micro), biochemistry, physiology, pathology, microbiology, and pharmacology. That’s your first two years right there. Most of the other stuff (statistics, sexuality, ethics) is to keep you from going crazy, but the firehose of information is the whole point. Although the testing process makes it seem as if you need to memorize it all, you really don’t. There’s nothing wrong with knowing where to look things up. BUT you need to know about it. That’s the main difference between PA and NP training (and what leads to the not-knowing-what-you-don’t-know debacle).

Next, you need to learn to apply all this information to the process of dealing with actual humans. This includes learning how to elicit information from your patients (how to take a history, a skill you then spend a lifetime refining), performing a physical exam, and interpreting diagnostic tests and imaging.

Notice that you don’t learn a whole lot about treatment. That’s because treatment is what you learn AFTER you are technically a doctor, in postgraduate (residency) education. That’s where people learn to be whatever kind of doctor they’re going to be. Each specialty uses the material from medical school in different proportions. Surgeons use their anatomy knowledge a hell of a lot more than psychiatrists. Pathologists don’t use as much of their pharmacology as pediatricians. And so on.

I like to say that undergrad teaches you what you need to get through the first two years of medical school. The first two years of med school teach you how to get through the second two years. And medical school teaches you what you need to know for residency, which is where you actually learn to be a doctor.

All this other crap, like “systems” and contracting and payment models are important to know about, but not in medical school. Valid concerns have been raised about the current structure of med school curricula, but losing sight of its primary aim — learning what you need to know TO BECOME a doctor, not TO BE one — isn’t going to help.

 

There’s a proposal in Philadelphia to tax sugar, specifically sugar in beverages like soda, sweetened iced tea, energy drinks, and other sugary beverages, and I know you’ll be shocked — shocked! — to hear that there’s a robust advertising campaign gearing up against it:

The American Beverage Association, a national trade group, has been running radio ads since March calling it a “grocery tax on the kind of drinks we buy for our family.”

I’ve heard the radio commercials: a woman’s voice (I’m pretty sure she’s supposed to sound “black”) complaining about how much the new tax will add to her grocery bill. To which I respond, Cut me a break! No one needs soda, or other sweetened drinks. It’s an expensive luxury that’s not even good for you, as I tell my patients with diabetes, many of whom are obese, over and over and over.

We’ve been telling parents for years that children should only drink water and milk. Even juice has been a no-no for quite some time now. But that doesn’t seem to stop anyone from getting their children addicted (yes, I’m using that word on purpose) to sugary drinks.

What’s really happening here?

Sugar in large quantities is bad for you. No, it doesn’t make kids hyper, but it  does cause rapid fluctuations in blood sugar, insulin spikes, and weight gain, which in turn contributes to obesity, heart disease, and in susceptible individuals, diabetes. It can also cause cravings, leading to more sugar consumption, and so on around and around in a vicious cycle. Sugary beverages are one of the major sources of excess sugar in the American diet, so anything that results in less consumption of them stands a pretty good chance of being good for health.

Ah, but lowering consumption of something means decreased revenue from its sales. You’d better believe the beverage manufacturers of Big Sugar are howling bloody murder at Philly’s proposed 3 cents per ounce levy. Hence the ad blitz.

Interestingly, though, Philly isn’t touting this as a nanny state scheme to get people to drink less sugar. That’s more of a desirable side effect. They’re earmarking the tax revenues to pay for universal Pre-Kindergarten, which is another intervention shown to improve school achievement, especially in children from impoverished backgrounds. Who could argue against helping out the kiddies?

Here’s my take: Sugar is just as bad for you as tobacco. No one seems to have any trouble with steep tobacco taxes, which are just as regressive as the sugar tax; the higher your educational/socioeconomic class, the less likely you are to smoke OR be obese. So if you want to keep damaging your health by swigging down gallons of sugar water, the least you can do is give back to your community. You’ll be “taking” from them plenty as your diabetes gets worse and you start having heart attacks and strokes. Then again, all you have to do is make do with water. More money in your pocket and better health as well. The ultimate win-win.

All we have to do is stand up to Big Sugar like we eventually did to Big Tobacco. They’re killing us just as surely.

Reconciling medication lists — keeping them up to date with a patient’s correct meds — is an important task that I try to do at each visit. Sometimes a patient has stopped taking a pill for some reason: it was too expensive, or another doctor told them to. They may be taking new meds from different doctors. Sometimes, thanks to the way my EMR handles electronic refills, I have duplicate entries on the list.

True story:

Reconciling the med list for a diabetic lady the other day, I noticed that I had two entries for metformin. The first was correct and had her current dose (two pills twice a day, increased from the previous visit.) The second must have been a pharmacy-generated duplicate.

“Oops,” I said as I set about correcting my records. “It’s in here twice.”

“Is that because you told me to double up on it?” she asked.

After LMFAO, I asked her if I could blog the story. Not only did she agree, but she begged me to use her name. I declined. She asked why. I thought about it and realized I don’t use real names on this blog for anyone. Not for my kids or other members of my family, much less patients. The closest I’ll come is real initials. SO; this one’s for you, GP. 

 

 

Being a doctor is hard. There’s a lot you have to know, whatever specialty you go into, and that includes rote information about how the body is put together, how it works, how it goes wrong, and how to fix it. We also must always keep in mind that these are people we’re dealing with, not just bodies, so we need to learn how to take care of sick people.

As doctors, our job is to figure out what is wrong with our patients (diagnosis) and what to do about it (treatment.) We don’t necessarily do this all by ourselves. We have colleagues who help us by performing consultations, studies, and procedures. But the bottom line about being a doctor is we are the ones who make the diagnosis and figure out the treatment, even if then carried out by others.

We can also turn to many other people who can help us take care of our patients: nurses, physical therapists, social workers, home health aides, and so forth. They can help provide us with information, sometimes crucial, that help us make the diagnosis or refine the treatment. But diagnosis and treatment is the definition of medicine. It is our job as doctors.

Medical school is where we begin learning how to be a doctor. It’s a process that continues through postgraduate residency training, and throughout decades of practice. It is laughable to think that medical school is the only place we’ll ever learn what we need to know. It’s four years that seem forever at the time, but in retrospect seem scarily short. Same thing for residency. Looking back, Imposter Syndrome seems entirely justified.

Of course it’s vitally important that those four years are used wisely. Which is why things like this really piss me off:

Many medical school students don’t know the difference between Medicare, which is for seniors, and Medicaid, which is for the poor.

It doesn’t hold them back in medical school. But after they become doctors, not knowing the basics of the health care system can prevent them from understanding why their patients can’t do or get the things needed to be healthy….

The AMA’s Dr. Susan Skochelak said “what [doctors] haven’t been good at is often what patients care the most about.” That includes things like finding their way through the health care system, understanding what their health care providers are telling them, and overcoming financial and other barriers that might prevent them from taking medications and otherwise following their doctor’s orders.

In addition to everything else we have to know, med schools are adding “Health System Fluency” in order to fix this grievous defect in medical education. Students will now be:

[S]ent to a local family medical practice, and given the role of health care “navigator” for three patients.

Her role involved becoming familiar with the patients’ ailments, talking to them on the phone and visiting them at home. In the case of one who claimed to be taking prescribed medications, but whose blood work suggested otherwise, a home visit by [the student] revealed the patient’s neurological condition prevented the patient from opening childproof bottles, resulting in missed doses. Contacting the pharmacist provided a remedy.

Another patient who had a high sodium level told of regularly dining on spaghetti with red sauce, which didn’t seem like a problem. But [the student] in her navigator role discovered the patient was eating canned spaghetti that was very high in sodium.

Leaders of the effort say doctors need such glimpses into the real lives of patients in order to fully grasp their illnesses and fully serve them.

Hey, I get it that home visits provide tons of information. Even though we may not have done them in medical school (mainly because we were still too busy learning all the basic stuff we didn’t know yet) of course we were taught that the hospital environment was terribly different for our patients. I did house calls in residency, where they taught me how to function in an environment other than the exam room or hospital ward.

Look again at what Dr. Skochelak lists as things doctors haven’t been good at that patients care about most:

• Finding their way through the health care system
• Understanding what their healthcare providers are telling them
• Overcoming financial and other barriers that might prevent them from taking medications and otherwise following their doctor’s orders

Everyone talks about the “health care system” as if it’s a thing. What the hell is the “health care system” anyway? One of the most important things to help people “find their way” would be hospital signage. Where do they park? Where do they check in? Where are they supposed to go? I can and do give people very detailed directions and instructions, but a lot of this “system” stuff isn’t medicine and doesn’t require 7+ years of post-college training to provide.

Understanding what we’re telling them? All through medical school, even as we learned the specialized terminology of our profession, our jargon, we were also told not to use it when talking to patients. Some of us are better at it than others. I often listen to other doctors talking to my patients and cringe. But just because many people don’t use clear enough language when speaking with patients doesn’t mean we weren’t taught it. Keep teaching it, by all means, but don’t kid yourself that this is something unique to 21st century medicine.

And what about these barriers? Already in medical school we are taught to use simple regimens (once daily medication dosing whenever possible), generic medications, easy-open pill bottles. We know this stuff. Again, we may not always do it as well as we could; some more than others. But there’s nothing innovative about it, despite the fact that medical schools are finding new ways to siphon away precious curriculum hours.

Here’s what I want to know, though: how is doing the work of a visiting nurse or social worker going to help medical students with any of those three things, or anything else, for that matter? You can list objectives, but what good is it to design a program that doesn’t address any of them? It may achieve different objectives, but are they worthwhile ones? Seems like rather a bait-and-switch to me.

Here’s their bottom line:

Without a solid understanding of the health care system, doctors can’t fully function as “change agents,” said Dr. Jed Gonzalo, the associate dean of health systems education at Penn State Hershey College of Medicine.

I’m a doctor, dammit, not a “change agent.” Whatever the hell that is. Medical students need to learn to be doctors, and not let themselves be sucked into the “system.”

In the end, the best way — the ONLY way — to help the patient is to be the best damn doctor you can.

 

 

This post is by request from a long time reader:

Dear Dr. Dino:
Would you consider writing a blog entry on medical trials? Clearly medicine wouldn’t make much progress without them, but to put it in patient vernacular, they seem very scary…[Details about a specific medical condition and a chance to participate in a clinical trial that]…[I]nvolves a cutting-edge technology and drug which might at some future date be shown to cause serious, unanticipated health problems.  I am at a loss trying to balance the benefits with the hazards…
…[W]ould you be willing to write a column that details an organized way of thinking about medical trials, and some of the questions that patients should ask?

Obviously clinical trials are important. Few people like the idea of being “guinea pigs” or “experimented on.” Fewer still are altruistic enough to participate with an endeavor explicitly for the benefit of others (for “science”) when there is none that will accrue to them (at least when clearly so stated. The vast majority of late stage cancer treatments fall into this category, and too often patients and families are allowed to believe it could be a “miracle” for them when it really isn’t. But I digress…)

Participation in clinical trials requires a much more detailed Informed Consent form than most routine medical procedures. These consist of pages upon pages of detailed descriptions of the proposed interventions, side effects, risks and hazards. Frankly, they work very hard to downplay the benefits, which I think is fair. Thus, a full reading of the consent form will usually provide most of the necessary information. The main thing you need a doctor for is to make sure you understand all the terminology and exactly what the form is saying.

After that, the decision really is up to you.

I understand that being faced with a long list of risks and benefits can be daunting. The old advice to write down all the pluses in one column and all the minuses in another and then see which is longer isn’t usually all that helpful in real life. I find whenever I do that exercise, I end up trying to justify the decision I really want to make.

Which means that balancing benefits and hazards comes down to very personal values; how much are you willing to risk (potentially) for how much (potential) gain? It always comes down to your gut.

But it has to be yours! Mistakes and misgivings come from trying to substitute someone else’s feelings/reasons/values for one’s own, which usually happens in high stakes decisions and people you care about a great deal. ie Older person willing to forego cancer treatment but acquiescing to kids/grandkids “You can’t die! Do it for us!” and ending up miserable.

I don’t think there is any way to “organize” those thoughts. After you’ve read the consent form and everything else you can get your hands on about the condition and the study, go with your gut, and know that it’s okay to do it that way. Ultimately, it’s a decision you do not have to justify; not even to yourself.

There are several things you need for the perfect birthday. One, of course, is to survive another year. <check>

Then you need people you love to celebrate with you:

Finally, you need a kick-ass cake:

Done, and done. (Complete with my age in binary from left to right on the spine.)

So grateful to the NinjaBaker for turning me on to the web comic, Saturday Morning Breakfast Cereal:

The title is in quotes because it’s also one of the alt-texts for the cartoon.

The other is, “I await your hatemail, pertussis enthusiasts.”

I love this guy. I recently supported the Kickstarter for his latest book Religion: Ruining Everything Since 4004 BC, and got great use out of the Mini Bible (“Abridged Beyond the Point of Usefulness”) on my recent trip to Israel.

Apologies to Mark Twain, but reports of the death of private practice are somewhat exaggerated. There are still plenty of us around and most of us are making out quite well. Not all, though. I’m quite sure the howls murmurs of discontent have reached many ears by now. So much so that many doctors unhappy with the status quo have taken action. One such action is to “go Concierge.”

“Concierge” practice, also known as Retainer medicine, is basically an arrangement where the patient pays a fee up front (generally quoted as an annual figure, often payable in monthly installments) for the doctor’s professional services.The idea is that for their usually rather hefty annual payment, the patients receive “enhanced” services, most often as longer, more leisurely office visits, and greater access to the physician, typically his cell phone number.

Here’s the thing: I’m already doing all that. Standard appointments are thirty minutes; longer if you need them, same day if necessary. As for my cell phone, all you need to do is ask. Actually, if you want me to text you with test results, you’ll have my cell number forever after. No one has ever abused it, just like my residency director told me thirty years ago (though he was talking about the home phone number; same idea.) Leisurely appointments whenever you want them and total access all the time.

Ah, but what am I getting paid for all this, you ask? As long as I’ve been in practice, I’ve taken almost all insurances. How do they pay? Put it this way: I’m not getting rich, but I’m not starving. Still, I’m providing Concierge level care at insurance prices. Why do I keep doing it?

After all this time I’ve amassed an incredibly diverse patient panel (even though I don’t know how big it is) encompassing a wide span of socioeconomic class. Working class folk, professionals, white and blue collar workers alike are equally welcome. I can’t afford to give away a lot of free care, but once you’re an established patient, I’ll work with you on payment issues for as long as you need. I like it this way. Just as Family Medicine doesn’t limit me to one organ system, gender, age, or set of diseases, taking all insurances provides me with a further variety of patients; people from all different income levels and walks of life.

That means one big reason not to go Concierge is so as not to betray the 99%, or whatever fraction of my patients couldn’t afford the annual fee. Besides, the actual transition would be nigh impossible, since I’m not sure what more I could do in the way of “customer service” than I already am.

There’s another more subtle issue, though, that I’ve seen more outside the office setting; mainly from friends who have signed up with Concierge doctors. The amounts of money involved tend to create an entitlement mentality, shifting the physician into more of a “servant” role, running the risk of compromised medical care. My concern is hearing a patient say something like, “Hell, for $2000 dollars a year, the least you can do is give me some goddamned amoxicillin.”  Frankly, dealing with stuff like this scares the crap out of me.

I’ve actually looked into Concierge, finding out exactly what’s involved. I spoke with a reputable company, including many doctors who were pleased with them and were incredibly happy with their new practices. I thought about it long and hard. But in the end, the two things above (deserting my patients, and dealing with newly enhanced entitlement issues) confirmed that this is not the right model for me.

There’s a variant of this known as Direct Primary Care in which the fees are much less, and the contracting is generally month-to-month. While it’s an awesome new model that I may embrace sometime in the future, it’s still not right for me now. Why? To be continued…

Now and then I get requests for guest posts on my blog. To date, I have never allowed them. However this time, I am prepared to make an exception for my Dearest Darling Spouse, who asked if he could add to the Back-Dated Travelogue on our Israel trip:

I think Dr. Dino’s travelogue posts provided a nice overview of our trip, some of the marvelous sights we saw and things we experienced. I’d like to thank her for the opportunity to add some of my observations.

Several people both before and after our trip asked us if we had concerns for our personal safety. Beforehand, we responded that we felt confident the tour operator would do whatever was required to assure our safety. Upon our return, we can confirm that we did indeed feel completely safe at all times throughout our stay, which included walking around on our own and taking public transportation. In fact, the cold, blustery, rainy weather had a greater impact on our itinerary (via the washed-out road to Masada) than anything related to security. Bottom line: we were never in any danger.

The most compelling parts of the trip for me were the visits to Yad Vashem, and the military cemetery at Mt. Herzl. The impact of walking in the darkness of the Children’s Memorial is indescribable. The sight of Mike Levin’s grave, and my sister’s reaction to finding the grave of the child of friends of hers, had a very deep impact on me that will never be forgotten.

The real highlights for me, though, were the things that were unplanned and unexpected, like discovering that our guide at the Western Wall tunnels and I had been at the University of Delaware together in the 1970s, and sharing our study session at the Jordan river with two bored IDF soldiers.

I too hope to return someday, if that is G-d’s will. Though in the meantime I agree with Dr. D that there is nothing better than Shabbat in Jerusalem.

The flight back was much calmer than the one over. We even got to sleep some, though of course not nearly enough. Having left New Jersey in over two feet of snow, we were less than thrilled to return during another snowstorm. At least this one was slated for more northerly climes, and it stopped the moment we crossed the Delaware river. Still, it was a gray, messy, slushy, miserable drive.

We were both seriously jet-lagged for several days. We even ducked out of our traditional Super Bowl party at halftime to go home and pass out. The nice part about conking out between 7:30 and 8:00 pm was that I awoke on my own, refreshed, around 4:00 am, which let me get to the office bright and early enough to clear up all the accumulated busywork there.

A friend at the party asked, “What was the one biggest highlight of the trip?” I couldn’t answer her. I could come up with the highlight of each day, but so much of it was so very special that there was no way a single moment could truly sum it all up.

I know these posts have been terribly superficial; mainly an excuse to share a few of my 200+ pictures. Even the journal I kept couldn’t keep up with it. Luckily I have a notebook full of readings and texts, only some of which were used in formal study sessions, to go back over again, when I get the chance.

All in all, it was the kind of experience that pleads to be experienced in real time, in the moment, as events unfold, without trying so overly hard to keep a record, whether photographed, handwritten, or blogged. I’ve got my memories — which I’m happy to share with anyone who’s interested — but they’re still mine to treasure. And I shall.

Shalom.

The last day of the tour, and it was back to Mount Herzl, this time for to see the tomb of Herzl himself, the guy who started the ball rolling toward what is now the State of Israel. We also toured the military cemetery there, which included the graves of many of the Prime Ministers.

Herzl’s tomb was a square black marble slab sitting in a circular plaza, itself surrounded by enough wide open space to accommodate the annual Israeli Independence Day festivities held there. Herzl never actually lived in Israel, as it wasn’t founded until after his death. So at his tomb the irreverent thought came to me that here, he was a square peg in a round hole:

The military cemetery was very different from Arlington. Instead of wide open fields of green covered with acres of white crosses, this was terraced into a hill and thick with trees. The graves, identical for all ranks, look like beds: cream colored brick biers about half a meter high with a blanket of rosemary, and a headstone that looks like a pillow. Five star generals rest between privates, corporals, and the current Prime Minister’s brother. In death, all are equal.

Some of the newer graves were a little more personalized with things like flowers and flags. Turns out the military authorities understood the need to accommodate mourners’ needs.

We headed for the memorial for Ethiopian Jews who died on the way to Israel. Much of the group took a longer, more circuitous route in order to avoid a rather steep flight of stairs. But our guide led me and several other more hardy souls up the more direct route. At the last tier of graves, we stopped for a moment. To our right were three soldiers who had died the same day in the 2006 war with Lebanon. I gasped.

The one on the left was plain. The one on the right was unusual in that it had a picture of the soldier, which was what the guide wanted to show us. A young Ethiopian kid, his machine gun slung over his shoulder. So young. But the one in the middle…

I’d had a vague recollection of a kid from Philly who had made Aliyah [moved to Israel] and died while serving in the Army, but I never would have dreamed of asking to try and find his grave. But here it was. Michael Levin, from Bucks County, PA. At the head were two Israeli flags. Covering the stone were patches and medals and dogtags. Off to the left was a pile of baseball caps, mostly Phillies. There was a bar rigged up that held lanyards and kerchiefs and more flags. The bed was piled high with stones, bracelets, knick-knacks, cards; library cards, college IDs, drivers licenses, all kinds of things. It’s the custom on visiting a Jewish grave to leave a small stone or pebble atop the marker, but this was staggering.

My Dearest Darling Spouse nudged me and pointed something out. Near the bottom, under a Temple University guest pass and an ID bracelet, sat a yellow and red Wawa gift card. The same as the one we’d left for the Jock (almost exactly four years younger than Michael) to use while he was house sitting for us. That’s when I lost it. Laughing, crying, I couldn’t tell the difference, but neither could I stop the tears.

DDS was silent. He was thinking about his previous visit to Israel when he was 17, in 1968. At the time, he told me, he’d considered staying. He did the math. He would have been 22 in 1973, the year of the Yom Kippur war, the same age as Michael when he was killed.

That could have been him.

Without a word, DDS slipped the lanyard with his ID for the tour off his neck, and added it to the dozens of others swaying in the gentle breeze of Mount Herzl.

Michael Levin (2/17/84 – 8/1/06)

I wrote:

No words.

A monument and a name: Yad Vashem.

Too many words.

As we pulled into the Yad Vashem complex, we began in the Grove of Righteous gentiles. Walking over to a random group of benches (that [our guide] swore was indeed random) what do I see but a plaque bearing the names Jan and Miep Gies, from Holland. Anne Frank’s Miep! Tears began to well up.

It feels blasphemous to say it, but all…the readings and discussion felt like a distraction. Every other thing [our guide] said sent me off onto my own thought tangents. Even if I’d tried to share them, it wouldn’t have worked into his conversational flow. So I held them, like shells collected on a beach for their odd colors or interesting shapes.

The grove: all those trees; so many who helped. But the only names there were those who were known. How many more? How many people helped — or tried to help, failed, and had to live with that — without anyone ever knowing about it? A huge part of the Shoah tragedy is the idea of people not just dying, but of being forgotten. They’re trying so very hard to compile those names and those stories, the six million. But what of the forgotten Righteous, the unknown among the Gentiles, who also helped but have no tree, no plaque, no little numbered tag to cross-reference their story in the Archive? To them, as we stood to go, I offered a silent collective “Thank you.”

…Then the museum. So many words. Pictures and artifacts and stories. So very many words. There must have been more than six million words, but it still wan’t enough. Never enough. How could there be? How can mere words ever manage to convey the totality of it? It started seeming presumptuous to try. But we are human, and words are the way we share our stories, along with songs, and pictures, and objects, which then in turn need even more words of explanation. All in vain. Trying to explain the inexplicable.

Not enough words. Never enough words.

The Hall of Remembrance specifically calls for silence. That didn’t stop our group from saying Kaddish, though even if the group hadn’t done it, I had every intention. They were just words, but they felt right.

The Children’s Memorial. No words. Just five candles, and enough mirrors to create an infinite expanse of specks of light: all the descendants who never existed, of a million and a half murdered children. Walking through it in the dark was terribly disorienting, as I’m sure it was meant to be.

Engraved in the concrete arch over the exit, words from Ezekiel:

“I will put my breath into you and you shall live again, and I will set you upon your own soil.”

At the exit from the museum stood a podium with a book. Blank pages. No lines. And a blue ball point pen. I picked it up and wrote without thinking:

No words.
Too many words.
Not enough words.
No words.

I signed it and walked away.

 

 

The Golan heights, or “up north” to Israelis, is one of the areas of contention between Israel and Syria, with many different types of pros and cons around the issue of “giving back land for peace,” which we went over at some length during our morning study session. Getting out and seeing the land, though, was wonderful:

The first picture is through the mountain passes heading north. The second is from the “heights” looking down across the fields where the Syrians fired pot shots at Israeli farmers working the land. Finally there’s the war memorial to those killed in the 1973 war (the Yom Kippur war.) There were a lot of memorials like that all over the country, though it seemed like we passed more of them in the north.

By midday we headed to a planned city called Katzerin, where we had an amazing lunch and a fascinating discussion with one of its founders. Her take on the Golan, specifically about whether or not it should be returned to Syria, was that whoever made best use of the land had the strongest claim to it. Before the Israelis came, she told us, it wasn’t really used for much; just some disorganized grazing. But under their current stewardship, the industries of farming and tourism were booming. So was this industry, though to be honest, it was the only brewery we saw in the whole country:

I realized she was essentially articulating the terms of the Organian peace treaty from Star Trek TOS, most famously applied to Sherman’s planet, where the Klingons plan to cheat was foiled by none other than…tribbles. I found it amusing to contemplate.

 

Imagine a magnificent medieval city high in the mountains, streets terraced into the hillside, stone buildings dating to the 1500s and before, water collected in 45 meter deep cisterns, once the center of Jewish mysticism now known as a thriving artists’ colony. No need to imagine: that’s Tsfat.

Having arrived after dark we had to wait until morning to appreciate the view. But what a view!:

The hotel used to be a Turkish inn, and the art about town was unbelievable. Something amazing at every turn:

We finally had an opportunity for shopping actually built into the program. The stated aim was to help the struggling economy of Tsfat; all I can say is that we did our part:

 

Travel day, heading north. Of course given that the whole country is about the size of New Jersey, it was kind of like driving up to Hackensack. But this was Israel, and we were traveling back in time…to Caesarea.

Caesarea, the Roman capital of Judea when they ruled, now filled to overflowing with Roman ruins and luxury housing, more like Moorestown than Hackensack. But I fell in love with the ruins, and spent the day happily clicking away:

There was also the Bird Mosaic, a mosaic floor in remarkable repair that was once the courtyard of a sumptuous, palatial home:

I wrote:

Although the study sessions have been truly fascinating…in a way, I would have loved spending more time in that space. In the rush-rush, look-here, wow-look-at-that, I didn’t feel I had the chance to really absorb the feel of it all. I wanted just to sit quietly, and maybe let the ghost of a little girl who used to play there, back when the house — her house — was still there, come shyly up to me. I’d smile, and she’d smile back, and I’d ask her without words about her life there, and she’d tell me without words (because she’s shy, and not just because she’s a ghost) that the yellow flowers she was picking were for her mother’s hair, because there was a big party tonight, but she couldn’t go because she had to go to bed, because she was just a little girl. And I’d think about how little girls and flowers and ghosts and courtyards with beautiful mosaic floors could all exist in the same space, the space I’m sitting in right now, despite the separation of centuries.

We traveled on, and explored the catacombs and caverns of Beit Sharim. Finally we headed up to our destination for the next day, arriving after dark so that we had to wait until morning to appreciate the unbelievably amazing views.

Ever have one of those friends where even if you don’t see them for years on end, when you finally get together again, the years fall away and it seems like you saw them just last week?

You meet their kids for the first time, realizing that some of them are older than you were when you first met, and they’re wonderful and amazing, and you wish you lived closer than 3000 miles away so you could spend so much more time with them, but you have to settle for subscribing to their YouTube channel and making them laugh by showing them YouTube videos of your kids, and then watching other videos, and then sitting down to a huge Shabbat lunch together.

And you hug and you talk and you hug some more. Your husbands don’t mind because it turns out they’re in the same industry, so they chat companionably. But you just keep hugging her because you can’t believe you’re finally seeing her again after all these years, to the point where you worry a little that you’re annoying her, but not really.

And you swear to get together again sooner than another twenty years. And you really mean it.

This:

I wrote:

Although I have every intention of coming back some day, life, as always, is unpredictable. So it is possible that I will never again experience Shabbat in Jerusalem. Yet if that is Gd’s will, at least I’ve done it once, and can be grateful for that.

I wrote:

Began with a study session on Jerusalem itself; the city. After than came an experience I never would have thought I’d…have (and which may or may not in fact have been all that good an idea): we were sent off to various Jerusalem neighborhoods to find someone — a stranger — and ask them questions about themselves, their opinions about living in Jerusalem and Israel, and various other things. Really? Really.

[DDS] and I chose French Hill, described as “a comfortable upper middle class neighborhood with many academics and Anglos due to its proximity to the University.”

We took the bus. It was about a 30 minute ride through a series of fascinating neighborhoods. Early on we passed the Great Synagogue of Jerusalem…through Mea She’arim, which yielded views of black hats of all descriptions. The people-watching was fabulous. All sizes, shapes, and colors…We heard some English and struck up brief conversations.

Almost no one paid cash for the fare, as we had. Most people seemed to have smart cards, with readers on poles inside the bus. One older lady had trouble with hers, so a little boy, maybe about 10, helped to show her how it worked. A moment later someone else had the same problem. The kid got up again and helped that guy as well. When in doubt about technology, ask a kid.

We actually did manage to find someone to interview, who wasn’t overtly offended by our request, and whose answers were friendly and insightful. An American from an observant family in the states, her reason for moving to Israel boiled down to, “I had a lot of questions about Gd, and it took living here to get comfortable with the idea that there are no answers.”

Our next errand was to pick up assigned snacks for our next group study and schmooze the following day. We had been tasked to procure roasted cashews and milk chocolate. Mission accomplished on Ben Yehuda, a pedestrian shopping mall and tourist heaven.

Although the idea of heading out into a city to interview a stranger was terrifying enough to give one pause, after that part was over it was nice to finally have some time to ourselves to wander around a little, shop, chill, and watch the people.

I wrote:

So it turns out that Tel Aviv is a really cool city. Probably the first “planned community” in the Middle East.

Cool shot of the ancient port city of Jaffa, contiguous with Tel Aviv:

Several study sessions. Mosaics. Independence Hall (Israeli version.) Falafel. Wandering the shuk (market). Bialek house. Amazing Yemeni restaurant for dinner.

Busy day in a busy, bustling city.

Turned out that we couldn’t entirely escape the weather. The first week of the trip was rainy and cold. They said there was a little snow although it didn’t stick around, but compared to what we’d left, we were unimpressed. However today it caught up with us: the road was washed out, so we never made it to Masada. It was okay, though.

We began at Qumran, the site where the Dead Sea Scrolls were discovered in 1947, and within minutes of our arrival I was planning my next novel. Suffice it to say that I listened to the stories of the sect who wrote the scrolls through the lens of a psychological anthropologist, answering for myself the question, “Who would want to live like this?” Now there’s a story puttering around in my brain, yet another one clamoring to get out onto paper. Some day.

The caves:

The archaeological site:

Next we had a study session in a bombed out open air restaurant, and a guy walked in with a camel:

Finally, instead of Masada, we went to Qaser El-Yahud, a baptismal site on the Jordan river right across from Jericho. It’s the site where Joshua led the Jews into the Promised Land after 40 years of not asking directions, and it’s also where John the Baptist did his thing. So it’s an important site for several different religions, for different reasons.

Contrary to all the old spirituals, the river Jordan is muddy and brown. If it weren’t for the historical and religious significance of the site, you might even call it disgusting:

Then again, the amenities were nice enough, and we even caught sight of a group who’d come for their own religious experience:

 

We were based in Jerusalem, which was fabulous. The first morning we were at the Shrine of the Book, home of the Dead Sea Scrolls.

After driving around the outside of the city to get a sense of the geography, we went in through David’s gate and made our way to what seemed like a perfectly nice little restaurant for lunch and a study session. But when I turned my head, I was startled by the view:

Yes, that’s the Dome of the Rock, the big golden dome that pretty much defines Jerusalem in terms of images, and yes, it was right there. I kept snapping pictures of all the other gorgeous landmarks, but I kept coming back to it.

After lunch we made our way down to the Kotel (the Western wall, the only remaining part of the original holy Temple Mount).

I wrote:

I found myself approaching slowly, not quite sure what to think. Certainly didn’t have any specific prayer in mind. I just tried to keep myself open to the place and the moment…I let thoughts of my patients flow through me, offering up generic prayers for health and healing. Above all, I just thought, “Peace.”

I stepped all the way up. Next to me was a slightly older woman, both hands and one cheek flat against the cold stones, sobbing softly. Without quite understanding why, I teared up as well. It’s a powerful place.

Later, after I backed away slowly, reluctantly, we noticed a group of Korean girls clustered beneath the flagpole in the middle of the plaza. To our amazement, they began singing Hatikvah. Turns out they were a choir group on tour. Talk about magical.

But in a way, the magic was just beginning. Archaeologists have excavated along the Western wall all the way to the end of the Temple Mount, and we got to go in and see. The most amazing part was our guide, an ex-pat whose English was perfect, and who literally acted out the history of the Temple Mount for us. Her name was Batya Davis, and you don’t just listen to her, you experience her.

All in all, a powerful, packed first day.

We were so smart.

To get ahead of the monster storm forecast for the day of our departure, we decided to drive up to Newark NJ the day before and stay in a hotel. It worked like a charm: we were comfortably ensconced at the Holiday Inn before a single flake fell. The joke was on us, though, as well over two feet of snow proceeded to bury us, dashing our hopes of a departure that would have allowed us to arrive in Israel a day before the beginning of the formal program. So we stayed in the hotel an extra night, and arrived at our destination with a mere 25 hour delay, leaving our car pretty much buried in snow:

The flight itself was dull, boring, and uneventful. Just kidding! I made the mistake of heeding the call, “Is there a doctor aboard?” and wound up nursing a passenger who had fainted. He was fine, although while trying to take care of him we hit a nasty pocket of clear air turbulence, which only bothered me because I ended up strapped into a rear-facing jumpseat. Everything came out okay, though, and I was rewarded with a bottle of wine from the grateful crew.

 

So it turns out you change the date and time settings on a blog post willy-nilly. So even though it looks like I’ve gone dark and silent for a month, it was only because I was traveling. And what a trip I took!

I was out of the office for two weeks — the longest time I’ve every been away from the practice — encompassing an 11-day trip to Israel. And what a trip it was. To study biblical texts while actually at the site those texts either occurred or were written, well, to say it adds another dimension to bible study in quite the understatement.

I took a ton of pictures, of course, and have already posted several on Facebook. I therefore apologize to the overlapping readers who may already have seen them. I also kept a journal, so I have a record of contemporaneous reflections. One day I wrote a poem.

It’s nice to be back, and yes, there are several blog topics itching to get out of my head onto the screen, but it’s been hard to stop thinking about this trip. So please forgive the indulgence of nearly two weeks of back-dated blogging. (For the record, I’m writing this on February 15th.)

Here we go…

Another email from the patient who did not have tuberculosis (lightly edited):

I did something stupid. Last night I woke up at 2:00 am to my cats hissing. I turn on the light and they have successfully surrounded a sock. So, I pick up the sock nervously expecting a spider or something but there is nothing. So, I put the sock down and an itty bitty mouse runs out of the sock and all the cats leap for it. I grab a shoe box and after about an hour, trap it. My plan was to put it outside. But I then realize this isn’t [Florida (from where the patient had recently moved)] and it is freezing outside. So I sequester the cats in my room, and explain to the mouse he has 60 seconds to beat it to wherever he lives in the house and he should remember how dangerous it is out here and I let him run off. So I guess someone can say at my funeral that [I] wouldn’t hurt a mouse, but my worry is that said funeral will be soon because [I’m afraid] I may get plague now from messing with the mouse.  Are there any symptoms from mouse exposure I should look for?

My response:

Given that plague is spread by fleas on rats, rather than mice per se, no, you do not have to worry about plague. I think you need to be more concerned about your cats taking out their frustration on you for having absconded with their plaything.

Gawd, I love my patients.

On the phone with an older doc, who keeps saying, “What can I do for you, young lady?” and “Yes indeed, young lady.”

I fought the urge — oh I fought so hard — to say, “Wow, you must be really old if you think I’m young.” Sadly, I succeeded. I was polite throughout the encounter.

Even at the end, when he said, “Happy holidays to you, young lady,” and I managed not to say, “And to you as well, old man.”

This is why I love my patients.

Actual email exchange with an actual patient:

SUBJECT: Do I have Tuberculosis?

I had a cold like a week ago and I am better now but I still have a cough that wakes me during the night and produces gross phlegm in the morning. But it is mostly just snot by late morning. It sounds like Keats’ description of his tubercular cough except he thought it was blood instead of phlegm because in the 19th century he probably did not know the difference. Do I need to come in to see you?

My response:

>RE: Do I have tuberculosis?
No.
>>Do I need to come in to see you?
Only if the cough lasts more than 3 weeks, or you start coughing up blood, or if you want to.

Patient:

I suspected that was the case when I failed to write a single poem nor turn pale and thin with that late Romantic wasting away quality and did I mention thin. Sigh. Days of only soup while I was sick and no weight lost.

Are sonnets the equivalent of a tumor marker for TB? Does this mean we can scrap the PPD and all those newer, more expensive proprietary TB tests, and just monitor our patients’ poetic output along with weight and degree of pallor?

 

Closing a medical practice to new patients is like cutting off the very top of a tree. It’s the beginning of the end.

The top of the tree, the crown, is where the newest leaves are. It’s also the part that continues growing ever upward, at least until it reaches it’s maximal genetic height, depending on environmental factors like the availability of water and sunlight (both of which also depend on how many other trees are competing for them nearby.)

When you cut the top off a tree, the tree will die. Not right away. Sometimes not for many years. But its death is now inevitable. (By the way, see here for a discussion of why “topping” — basically killing your trees — is never a good idea, despite being widely practiced.)

I don’t believe in a “closed panel” of patients. (I don’t even really know what that is.) Patient populations ebb and flow. No matter how good I try to be, there are a certain number of patients who, due to circumstances beyond my control (and often beyond theirs) leave the practice. Whether moving away, transferring for work, switching insurance plans, getting pissed at me, or even, yes, dying, there is always going to be attrition. New patients are the lifeblood that keep those numbers up. Active patients generate the office visits, which produce the billings that brings in the money.

I know some people with a subscription-type practice model who have a “full practice” and a “waiting list.” Frankly, managing those kinds of lists feels like so much more trouble than it’s worth. If someone calls for an appointment, I’d rather just give it to them instead of trying to figure out if they’re “on the list.”

Some people think that Closing to New Patients can be a temporary thing. They’ll just close for a while until the list shrinks a bit, then open up again. Most of them learn the hard way that once word gets out that you’re “closed” it’s not that easy to open the spigot again. Besides, what if you do, and patients come flooding back, and you’re stuck closing again? Most practices have a variety of referral sources, and it can be really hard both to keep up with them all, and for them to keep up with whether you’re open or closed this month.

There’s also the question of how “closed” is Closed?

“Doc, my mother-in-law is in town for the week and she forgot her blood pressure pills. I know you’re not supposed to prescribe without seeing her, so can we just bring her in for an appointment? I know you’re “closed” to new patients, but she’s family.”

Hard not to make the exception without seeming like a jerk. But then there’s:

“Doc, my mother-in-law is coming to live with us. I know you’re “closed,” but she’s family, and we’ve been your patients for twenty years. How about it?”

I’ve seen practices describe their status as, “Open to families of existing patients only.” What about dear family friends? Will you make that exception too? Doesn’t that mean you’re basically open to anyone referred by current patients? How are you going to work that? When a new patient calls for an appointment, do they need to give the name of your current patient who referred them? What if it’s someone who’s moved away and isn’t technically a “current patient”? What if it’s someone you may not have seen for a while and the person answering the phone doesn’t recognize the name? Can’t someone who really wants to become your patient lie about being referred? How are you going to police that? Like the waiting lists, it all seems so much more trouble than it’s worth.

Another solo physician in my town recently retired and I’m enjoying a nice little uptick in new patient calls as her former patients try to find a new doctor. Obamacare has also produced a nice little pool of the newly insured who are lighting up my appointment book.

I have no problem “closing” to certain insurances. Been there; done that; may do it again. In fact, if your hidden agenda is to prune your populations, that may be a pretty good way to go. Just don’t say you’re “Closed to new patients.” Unless you’re looking to retire. Because closing to new patients is the best way to slowly kill a practice. Which is why I have no intention of doing it.

 

Dr. Robert Centor has an important post about hubris. It’s not a long post, if you want to click through and quickly read it. It’s about the danger of overweening pride and overconfidence that can come from blindly believing the praise that is often heaped upon us by those in our care. Essentially Dr. Bob is saying that we must avoid believing all the wonderful things our patients say to us.

One the one hand, I agree completely. Pride indeed goeth before a fall, and in our line of work, the pain of our falls is literally felt by others. The line between the confidence we need in order to do what we have to do, and over-confidence that leads to potentially fatal errors of judgment is painfully narrow. All too easy to slip over without even realizing; the only safeguard is constant vigilance.

There’s a phenomenon known as the Imposter Syndrome that affects basically everyone early in medical training (and many other endeavors as well.) It occurs when someone tells you how smart you are, or what a good doctor you are, and you think, “Geez, I really have them fooled. They have no idea that I haven’t a clue about what I’m doing.” Although this feeling gradually (oh so gradually) abates over years (and decades) in practice, I’ve always felt that hanging onto at least a shred of it functions as a bit of a “hubris safety net.” Being able to honestly say to oneself, “It’s nice to hear that, but I’m really not as great as they think,” is, I think, a good thing.

On the other hand…Yes, there is another hand here:

I’ve been in solo practice for a long time now. Days can go by without talking to another physician; weeks without seeing one. No residency director is evaluating me every six months, yet I’m pretty sure I’m doing a good job. Once every few months or so, I get the equivalent of positive feedback from a colleague. Usually a patient returns after seeing Dr. X telling me how Dr X regaled her about how great I am. Sometimes another doctor will also say it to my face, though frankly I still wonder a little that they’re just buttering up their referral sources.

So how do I keep up my morale, my self-confidence, my emotional well-being? Dr. Bob and others in teaching situations have the immediate and ongoing positive responses from their learners. In the inpatient setting there are always plenty of other physicians as well. Hubris can indeed be seductive with so much positive feedback around, but how can one maintain one’s emotional well-being from patients alone, without succumbing to the dreaded scourge of hubris?

I believe I have the answer.

I got the following letter earlier this month, reprinted here in its entirety with permission from the author:

When I was pregnant with [my son] you asked me if you would gt to care for him as a patient. I was slightly offended. The doctor that kept me calm through an ovarian mass in my 20s, a depressed suicidal husband in my 30s, always answered the office phone with a same day appointment, always answered my frantic phone calls or responded to my messages asking for help, saw my daughter through every illness and age related medical milestone, wrote me a note to stay home from work when I was too mentally stressed to work the day after our beloved dog was put to sleep, a doctor that I trust my own life and the rest of my family’s life with, asked if she would be graced with my baby as a patient. Well I certainly didn’t want him in a giant practice with a million doctors that have no clue about our family history and that wouldn’t recognize him at the grocery store. [We often run into this family while food shopping.]

You are brilliant, funny, and obviously the best doctor ever! Thank you for being awesome and for choosing your calling of medicine. We appreciate it! May the universe bless you with abundance, always. Love…

Obviously reading this feels wonderful, and it’s not hard to understand slipping into hubris while doing so.

The key is to appreciate and accept the expressed emotions of gratitude and affection instead of taking it as an objective assessment of my superior knowledge or abilities. It gives me warm fuzzies whenever I think about it, and that’s good enough.