Paying a Doctor

I had the opportunity to read an article early this morning while waiting for labs to come back.  This is my last day working in this particular hospital, owing to a change in venue and a new job.  I will post the link here below and I encourage you to read this.  Dr Megan Lewis, from rural Colorado, gives a good example - with my sense of humor.

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Although this blog (linked above) is not new, it was funny and insightful.  I didn't get mad because I feel this is the collective work of all the apathy of the physicians out there.  'They' were so busy with 'medicine' that the business of 'business' went unnoticed.  Congress decided to act for them and enacted a law that every year tries to decrease physicians' salaries.  I find it humorous (not humorus) that a Congress of non-physicians and many trial lawyers know better how to pay/run/ direct a medical clinic than the doctor who is there, with boots on the ground.  If there are anymore people out there who get their salary and job ability limited to such a degree by the government, please let me know!

I did want to say that with me now switching jobs, I have found life to be exciting.  The places where I work/worked have been very sad that I am leaving.  It is nice, in an odd way, to be missed.  There was a patient last night that I drained a couple of liters off from around her lung, who really wanted to follow me out to the midwest, where I am heading.  I have had many nurses tell me they wish I were staying, and I would be, if it were up to them.  I am glad to have worked with such great nurses and house staff (those who support the doctors).

Lastly, I wanted to comment on how a doctor is paid.  I hold my biases close, as do most people, but this is a thought I have mulled over many a time while driving my two hour commute to work.  I have invested ten years AFTER college to help save peoples' lives.  I know that there are others who did it in seven, but I chose to do it a longer and more in depth way, including teaching.  I missed out on earning a living wage during that time because I needed to study and not work a second job.  Ten years of compound interest have already put me well behind the eight ball.  I feel I would pay to have someone equally skilled to treat my family pretty much what they ask for, sometimes.  The patients I interact with agree with me.  What I see is the difference is the ATTITUDE of the physician that makes the difference in the perceived value of care and level of skill.  Those physicians who behave like Dr House, are not well liked.  As a consequence, the perception that their income is too high is easily justified.  I choose to be humble, likable, friendly and treat my patients like family.  My patients have not complained about my level of care, skill or cost.  I think that the whole patient care package needs to be viewed when the issue of cost comes up.  Am I a rushed waiter, throwing food at people or am I a Health Care Consultant, taking time and energy to partner with my patients in managing their health?  I choose the latter, and with it, claim the right to charge for it.

Please let me know your thoughts!  I would love comments.
Michael Chipman (after being up way too late, working one last 24 hour shift)

The Value of Education

  I write this after finishing my tenth year of "post graduate education."  I have been in school for a really long time.  I have a bachelor's degree.  I spent four years in medical school plus added a year for teaching in a Fellowship.  I then did a traditional internship plus three years of residency and added on a second residency/Fellowship.  That is a lot of school.  Was it worth it?
  The value of education is difficult to determine.  I sacrificed many hundreds of thousands of dollars to become more educated than other physicians.  I have received intangible benefits from doing so.  The question seems to boil down to money versus experience. 
  I must confess that I never do anything simple, and am shocked to find that I look down on those who do.  I feel those individuals who do a "shorter" residency or "faster" degree to save time in order to earn money are somehow not as "pure" as me.  Myself, and those like me, spent a longer time, delving in deeper and grasping a different yet somehow nebulous concept.  The family physicians who work with me in the Emergency Department feel they are my equal, while when the bad stuff rolls in, their lack of training is obvious.  The nurse anesthatist who tries to tell me how to manage an airway backs away from the unstable, vomiting drunk with bullet wounds.  I am shocked to find a small amount of pride in me when I do something that others would rather not handle. 
  I sometimes feel like I took the long road and others might mock me for not jumping in and bringing in the big bucks.  Yet, when that extra area of specialty is needed, I feel vindicated. 
  For example, my daughter came down with a fever and pain in her ears when we were flying home from a job interview.  She refused to drink Tylenol and was miserable.  I was able to take her in my arms, use osteopathic manipulation and not only break the fever but drain her ears.  I bet she doesn't regret me spending extra time getting good at that. 
  Another example, I delivered a baby - backwards and almost completely dead - and saved her life.  She is doing very well now!  I have seen her family many times (but not her) and they always express their gratitude.  I spent an extra year learning how to manage that more than just a paragraph in the book. 
  Other people may be able to manage what I do, but the fear factor from being unprepared is key.  The nurses tell me that they would rather have me on when the bad stuff rolls in than anyone else.  I am again shocked to find a little swelling of pride with that. 
  I do NOT regret my extra time in studying and love what I do.  I like using my hands, my head and my smiling personality to help people in their process of healing.  What I have invested in my education has helped people live, live more comfortably, and suffer less iatrogenic (doctor inflicted) harm.  I think my path to where I am has helped me become the doctor I would like to see.  And for that, I am well pleased.

What role do doctors have in healing?

I have been thinking on the role of doctors in healing.  I wish to share with you why I think doctors DO have a role in healing.  Pain.
  That's it.  Pain.
  Oh, and if the doctor thinks osteopathically, then there is more.
  My reasoning actually goes right back to my diagram of the mind-body-spirit triangle.


Pain is located near the body.  That is pretty much all a physician can help with.  The emotions and STRESS, located between the mind and spirit, is good with counseling and perhaps psychotherapy.  The bad habits we get into, such as addictions and bad sleeping habits, are between the mind and the body.  The motivation and frustration lie between the body and spirit.  Of all these, pain is pretty much the only thing a physician can help with.

I am biased and I simplifying this as well.  But, why else do you go see the doctor?  Their knowledge is their trade, for which you hand over a monetary equivalent.
 
As an osteopathic physician, I can help people heal themselves with a skill called osteopathic manipulation.  I can also help them understand the relationship they have with their mind, body and spirit, and direct them in a path of healing.  If they listen and get better, I get the credit.  If they don't listen and don't get better, I get the credit.  If I treat them with osteopathic manipulation and they get better instantly, or progressively, I still get the credit.  I win most of the time!  If all I did was throw a prescription pad at them, and entertain them until they get better, then I might get credit sometimes, probably for something I didn't even help with.
 Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing.   VoltaireI try to direct my patients and act as a coach.  I cheer them on.  I help with the pain.  I encourage them, I give them hope and something to focus on other than pain.  And they get better.  I am pleased I can help them.  I think that I am lucky to be able to help my patients.  I am lucky to be an osteopath.

Next step in improving

I want to share my second step in the Mind-Body-Spirit aspect of healing.  Let's start with a patient.
  She is a young lady, overweight, who hurts a lot.  She is on Methadone, or a long acting pain medication and goes daily to a clinic to be given her medication.  She smokes cigarettes and lives with her parents, her boyfriend and her son.
  I had previously discussed the mind body spirit approach discussed in the previous posts.

My next step is to give focus to improving the patient.  I use gioals - written and reviewed, as a way to focus the patient and to lay out a path of healing.  Since I do the same thing myself, I don't feel hypocritical AND I have experienced it succeeding.  

  The Goals are listed in the order of SPIREOF.

S - Spiritual

P - Physical

I - Intellect

R - Relationship

E- Emotional

O- Occupational

F-Financial

  I didn't develop this list myself, but rather I got it from someone who got it from someone.  

How this works:

  First, the goals are done for daily, weekly, monthly, quarterly, yearly, 5 year plans and 10 year plans.  I will focus mainly on the daily portion.  

  Since the Spirit portion of my chart is truly the Spirit within the individual, and not a religious object or theory, it works for everyone.  The Spirit is Life.  It is what animates our bodies and what hurts when we are yelled at.  When our focus is on ourselves, we become a "Natural Man."  (This idea comes from the Book of Mormon, in the Book of Mosiah, which I recommend for everyone to read the about God and improving.)  "The Natural Man" is the selfish part of us, that totally turns in and focuses on ourselves.  To improve the spirit, we need to look outwards and focus on others.  We need to sacrifice, volunteer, or help others.  By doing so, we help ourselves feel better.  This is a gift, that by giving to others, we give to ourselves.  

  Under the Spiritual portion of the list, we write down what we are going to do to improve our spirit.  This can be volunteering, sharing, complimenting people or even donating.  Religious activity fits there, if it is used to improve yourself.  Time and sincerity are more effective than money, as a general rule.  

 Looking up, I see this is getting long.  I will continue next time on the rest of the series.

Osteopathy in the Emergency Department

  I wanted to share an experience with you that happened to me over the weekend, which needed a different kind of manipulation.  I say that tongue in cheek, since I feel osteopathy is a mindset and not just a physical medicine modality. In plain English, I do more than just pop joints.

  I work in the Emergency Department in a couple of places and love it.  I like helping people.  There are many that come in with minor stuff, but they need help too.  This last Saturday I helped many such people.  However, I also had a patient who came in, who needed my help. 

  The ambulance brought in a lady, who was about 32 to 33 weeks pregnant, and in labor.  She had been having contractions all day and when she decided to go get checked out, her water broke.  It was her second baby and since babies are supposed to stay inside mom until 40 weeks, it was early.  The ambulance brought her to me, since I was the nearest physician.  The next closest Emergency Department, and the next nearest Neonatal Intensive Care Unit was 30 minutes away.  

  Usually, we can do a quick assessment and send the patient on her way to the experts.  However, this patient was too far along.  That, and with baby being so small, I was concerned that she would deliver in the ambulance if I sent her away.  Oh, and mom also told me that the baby was backwards on the last ultrasound.  

  I did my check and baby was indeed backwards and going to be out really soon.  Unfortunately, we don't normally deliver babies at my hospital and my surgeon would not make it in time to do a C-section.  We gathered what troops we had and got ready.  Trust me, I was on the phone with the high-risk OB doctor down the road and he stayed glued to my ear during this time.

  Now, it is said that the universe provides for everything.  I give credit to God, since I know him better than the universe.  Either way, earlier that day, on my trip up to work, I asked myself what to review (since I have a 2 hour drive).  I reviewed codes and then, based on a random thought, glanced through breach deliveries since I hadn't reviewed that in a while.  Boy, am I glad I did.

  Babies that age are small, yes, but the head is as big as the body and tends to get stuck.  I got everything out up to the head and it indeed got stuck.  I was getting desperate as eternities passed and I couldn't get baby out.  I used every trick I knew of, including several that one of my attending physicians mentioned way back in residency.  This physician had delivered a breach baby and the next day gave an excellent lecture on it to us.  I had that in my head the entire time.

  We got baby out after about 16 eternities and two gallons of sweat.  The baby girl was not moving, not breathing, was more black than pink, but did have a heart beat.  I immediately switched to resuscitation mode and hoped the mom would be ok.  The nurses did a great job in assisting the mom and myself.  I also had an internal medicine doctor there, who quickly learned what I wanted to do and did it without complaint.  We also had two EMTs from the ambulance, who were my extra hands.  As a team, we worked on the baby.  She lost her heartbeat after two minutes, so I started CPR.  Babies need oxygen, so I intubated her and we got her heartbeat back.  Yay!!  We all wanted to cheer.

  I did the resuscitation in the room with mom and dad watching.  I wanted them to see everything we did for their baby because to me, uncertainty and lack of information is the worse situation to be in.  We worked on the baby for 49 minutes before the team from the NICU transport team arrived.  I was glad to get up off my knees and to pass the baby on to them.  

  Then, I sat down with mom, dad, and grandparents and explained everything I did.  A cynic might say I did it to lessen the chance of me being sued.  Although that thought was always present, I did it because I would want someone to do it to me if I were in that situation.  As I explained everything, they sure seemed receptive.  

  I sent them both off to the hospital and wonder how they are doing.  I don't think I can just call up and check on them.  

  How did osteopathy play into this?  I used body mechanics and function to get that baby out.  I used physiology and knowledge to save two lives.  I was a physician, receptive to learning and responsive to inspiration.  There are only two Emergency Medicine trained physicians at that little hospital, and she came on the day when I was there.  

  My colleagues all congratulated me on the save, but I felt more humbled to be part of a bigger picture and accept the congratulations humbly.  It was a neat save.  I never did a CV4 or myofascial release, but I acted like I feel a doctor should, which is osteopathic, too.

  Thanks for sharing in my story.  My thanks goes to God for the knowledge, my team for support and the baby for fighting on!  

Electronic Medical Records - the switch

  Electronic Medical Records (EMR) are supposed to make the physician more productive.  I did my Emergency Medicine residency on one.  But then, that is misleading because each institute that I rotated at had a different system.  Not only that, but the adult Emergency Department at one place used a different EMR than the pediatric Emergency Department at the same place, right across the hall. 
  There are quite a few EMR companies out there, with big names and bigger price tags.  I would like to just touch on a few of the problems and how it plays into my work as a physician.
  First, the learning curve is rather big.  Trying to teach an old doc a new trick is difficult.  Teaching that old doc to use a computer on top of that is also difficult.  At my current work place, we are being trained on an EMR system that will be replaced in less than ten months.  So, all the old docs get to learn TWO systems in less than 10 months.  Welcome to efficiency. 
  Speaking of efficiency, everyone knows that we will need extra time to get used to it and productivity drops by at least 50%.  Yay, we lose 50% of our money and increase the risk for billing errors for 2-6 weeks. 
  Another problem lies in the audience for the EMR.  Most of the hospitals choose an EMR based on billing, not ease of use or 'doctor friendliness.'  So, the ones who bring in the money for the group or hospital get a crummy EMR forced on them by the administration, which does not bring in any money at all.   Hopefully, you can see the potential for conflict and ill feelings.
 
  All in all, EMR is here to stay.  Or to be erased by a virus.  Or a power outage.  Or user error.  And what about those old antique charts that we are trying to get rid of?  We have them filed away, just in case.

The "A-Ha" Moments in Medicine

I wanted to jump ship and jump to a different topic than the last post by sharing what my colleague Dr Bell calls the "A-Ha Moment."  I use her words as they describe the feeling that really gets a physician excited.
  These moments are the few times in the day or month that a physician feels like he (or she) really helped someone.  Most of my "A-Ha" moments come from using osteopathic manipulation in the course of treating a patient. (Please keep in mind that being a good osteopath is more than just doing manipulation.  It involves the mindset and process behind the treatment.)

  I had one just this last week.  A lady came in in pain, with muscle spasms in her back and hips.  She had seen her doctor and was recommended to see me. I had just had two tough patients that were not getting better and was feeling a little down.  Listening to her problems, I came to believe I could help her!  In fact, I drew for her a diagram of her muscles in spasm according to what she had said and it matched exactly.  I was able to relax the muscles and she felt much better.  I walked out of the room doing a fist pump and feeling like I was a good osteopath again.

  My first true "A-Ha Moment" came while I was doing a family practice rotation in Pikeville, KY.  I was there to sneak all the learning I could from Dr Ed Stiles, and still see if I liked the program enough to apply there.  I was "shadowing" a resident (following him around like a shadow) when he got behind.  I was bored and quickly took him up on an offer to see one of his patients, while he finished off another.  The lady was there for the results of her thyroid test.
  I glanced at the chart (like a good ER doc) and hustled into the room.  Talking with her, I quickly found out that she had no energy and that her wedding ring wouldn't fit on her left hand because the hand was swollen for some reason.  Our conversation from there went something like this:
  "Ok," I said.  "Having a low thyroid level will make you feel pretty tired.  In addition, it also will make your hair feel course and thick, and also decrease your libido.  Does any of this seem familiar?"
  She stared at me like I was crazy and said, "You described me to the tee!"
  Feeling more confident, I did a quick physical examination and found her collar bone (clavicle) to be very restricted on the left, with her left 4th rib also posterior, or pushed back.  There was some bones in her neck stuck in rotation to the right, or away from the problem.  As such, I offered her my reasoning, again, paraphrased at follows.
  "If your thyroid is off and you are feeling lousy, that will not enhance an already low libido.  If your husband is typical of most men, then he will not be the most understanding of your decreased attention to him.  That stress, which affects your ribs here, combined with the dysfunction in your neck and collar bone, will all pinch down on the blood supply to your arm, blocking up the returning blood.  That is probably why your hand is swollen.
  "Now, if that is true, then let me fix this... and this... and this..." I fixed the problems in her collar bone, neck and ribs and stood back.  "I am willing to bet you, now, that your wedding ring will fit."  Indeed, her hand was visibly smaller than prior to treating her.  "Do you have any questions?"
  She shook her arm and rolled it around then looked me right in the eye and asked, "Where are you going to practice?"
  I walked out of there on air, told this to the bored resident and got her a prescription for some thyroid medication.  I am still willing to bet that she had a great response to that medication.  I couldn't follow up on her, due to heading out for another rotation, but I never will forget that feeling when she asked me where I was going to practice!  I felt like I succeeded!  That is an "A-Ha Moment."

  I hope all doctors have these moments scattered throughout their day.  It makes medicine so much fun!  They are fun to share and fun to remember.  It keeps me moving when the patients seem to be stuck on "whine" mode.  Best of all, it makes it fun to be here.