Mourning a mistress

Much I learned from Medicine;
Much I saw her healing art.
Much I loved this mistress sanguine;
Much she offered from the heart.

First, the wide-eyed disbelief
In pain, to watch a young man die:
Faceless victim, carved relief:
Steeled—no breath—unseeing eye.

Early on, the ebb and flow
Of flailing heart; a pallid face—
Her story stoked with gasps and woe—
Whispered words and clouded grace.

There were the books, those countless books—
Formulae, facts, learned by heart;
Signs and symptoms, on tenterhooks
Recalled, as required by the art.

Humanness sustained me always;
Grief malnourished sleepless nights.
If not to cure, then listen always;
Don the cloak of second sight.

Then, of late, betrayal, riven;
Bought by value-added verse,
Healthcare digitally driven
By Masters of the Universe:

Enterprising party payers
Snatch their complement of coin;
Ivory-towered emerald cities
Meld the meek, together join.

Long ago I learned the taste
Of bitter copper on the tongue;
Now, at eventide, I mourn
My former mistress, lately gone.

Gone to lie with other lovers,
Spin another golden thread;
Leaving only one silk stocking
Draped across an empty bed.

Much I learned from Medicine;
Much I saw her healing art.
Much I loved this former mistress,
Much she offered from the heart.


When the art of medicine becomes business as usual

It’s Saturday morning, the last day of my 6-day workweek. Twelve hours have elapsed since I finished my previous shift at the after-hours care center. I step in through the front door, valise in hand, to find my assistant seated behind the reception desk. “How does it look?” I ask him.

“Ten appointments so far,” he says, “last one at 10:30 a.m.”

I do a quick mental calculation — roughly 9 minutes allotted for each patient. And there’s no telling how many additional walk-ins might show up over the course of the morning. more»

Interested readers can now access my latest Art of Medicine column — When the art of medicine becomes business as usual — recently published in the Journal of the American Academy of Physician Assistants.

Please note that all of my previously published Humane Medicine pieces can now be accessed here.

Mindful practice: Drive-through medicine

Although I recognize the need for sentiments — in both the patient and myself — many times I no longer have the luxury of time necessary to provide them. more»

Interested readers can now access my latest Mindful Practice piece — Drive-through medicine: The McDonaldization of modern medical practice — recently published in the Journal of the American Academy of Physician Assistants.

Please note that all of my previously published Humane Medicine pieces can now be accessed here.

Carving and painting the medium through which we look

It is something to be able to paint a particular picture, or to carve a statue, and so to make a few objects beautiful, but it is far more glorious to carve and paint the very atmosphere and medium through which we look, which morally we can do….Every man is tasked to make his life, even in its details, worthy of contemplation of his most elevated and critical hour. —Thoreau, “Where I Lived, and What I Lived For” in Walden

Lines intersect, triangles form; a flat plane becomes three-dimensional space, and morphs into space-time, which, if theoretical physicists are correct, folds in on itself, and the past connects with the present in this moment.

I first heard the name of Henry Ossawa Tanner in an NPR interview with Bill and Camille Cosby when they discussed loaning 62 pieces from their extensive collection of fine art to the Smithsonian Institute. Henry Ossawa Tanner was an African-American artist who attended the Pennsylvania Academy of Fine Arts in 1879, where he studied under Thomas Eakins. Tanner would later emigrate to France; there he discovered a society where the issue of race mattered little.

It was during a return visit to the states that Tanner painted the piece for which he is perhaps best known, The Banjo Lesson. In this rendition a white-bearded black man sits on a chair, cradling a young black boy and a banjo in his lap. The older man supports the instrument as the young boy fingers the frets and plucks the strings: a moment of mentoring, captured in time. The pair is enveloped in light: a soft blue-white glow from the left, a warm brighter illumination from the right. The boy and the old man seem to be caught up together in this interactive moment. What they share is something more than a mere instrumental lesson.

Henry Ossawa Tanner: "The Banjo Lesson"

Henry Ossawa Tanner: “The Banjo Lesson”

Tanner’s portrait brought to mind a long-ago summer afternoon when I sat on the front porch of our house, reading a book to my granddaughter. Someone snapped a photograph of the two of us. Like Tanner’s portrait of an adult and a child, this photograph captures something more than the mere reading of a children’s book.

I think back to my early days of clinical practice, when I first learned the ropes: how to interact with a patient in the privacy of the exam room. As part of my post-graduate training I worked at an inner city clinic in the north end of Hartford. One day a boy’s name appeared on my schedule, a young Jamaican boy, recently discharged from the hospital with a concussion sustained when he was struck by a car while riding his bicycle. The discharge summary stated that he still exhibited some soft neurological signs. During this and a string of follow-up visits, it became apparent to me that something more was going on; this boy was clinically depressed.

I subsequently learned that he had been culturally displaced from his grandmother’s home in rural Jamaica when he was sent to live with his mother in an urban New England setting. During our visits the boy spoke little, but little by little I learned about his former life: how he would feed the chickens in the yard outside his grandmother’s home, the plantain trees in the yard, a lazy cat resting on the porch in the noonday sun—and the day his dog died a traumatic death at the hand of a neighborhood bully.

Much of this history I gleaned from pictures that the boy drew for me: simple pencil sketches of the house, the trees, the yard and the dog. During office visits we would look at the pictures together, and the boy would talk about what he had drawn. Little by little I learned about his life, little by little he opened up, and little by little his depression lifted.

Those were the days before the advent of SSRIs, those magical pharmaceutical substances that allow outpatient office visits to be compressed into a mere 9 minutes of time; those were the days when I had the luxury to sit with a patient and give them the time they needed—and the time I needed—to gather the data necessary for an adequate clinical assessment, to give them time to heal.

An article cited in Becker’s Hospital Review indicates that in a recent survey 65% of clinicians voiced disillusionment with clinical practice, largely because they no longer felt they had the time to listen to their patients. In short, they had lost the opportunities for those mentoring moments, when clinician and patient step outside of time into a different dimension, a place where the two of them are bathed in light—perhaps a soft blue-white glow from the left, a warm, brighter illumination from the right.

From across two centuries of space-time the thoughts of Thoreau break into my brain:

[I]t is far more glorious to carve and paint the very atmosphere and medium through which we look, which morally we can do….Every man is tasked to make his life, even in its details, worthy of contemplation of his most elevated and critical hour.

Clinician burnout: A hot topic

Lately, clinician burnout has become a hot topic.

Judging by the speed at which Shanafelt et. al.’s study “Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population” has seared through cyberspace, the problem of professional burnout seems to be resonating with large numbers of practicing clinicians, especially those who work in the front lines of primary care medicine.

Why the surge in interest? Because the problem appears to be widespread, perhaps much more so than anyone in the business of medicine realized. And it seems to be most prevalent in specialties involving front line access to care.

Compared with a cohort of 3,442 US adult workers, doctors were more likely to manifest symptoms of burnout and to express dissatisfaction with work-life balance.

Professional burnout negatively influences the quality of medical care and increases the likelihood for medical errors. On a personal level burnout contributes to severed relationships, alcohol abuse and thoughts of suicide. And burned out clinicians are more likely to opt for early retirement.

In a career path that has the potential for meaningful and fulfilling work, why do nearly half of all clinicians report symptoms of burnout? Has this always been the case among medical professionals, or are these latest data straws in the wind?

Perhaps a relative loss of autonomy might be a contributing factor. Fifty years ago most physicians set up private solo practices. As individual entrepreneurs, they set their own hours, charged their own fees and took no orders from third-party payers. All that has changed dramatically. Nowadays, the majority of physicians work as employees in hospitals, clinics or large group practices. Administrators determine their salaries, daily patient load, hours worked, benefits accrued. In short, modern clinicians have experienced a loss of autonomy, a factor which contributes to lack of work satisfaction.

But there might be more to it than that.

Physicians are highly educated workers. Yet compared with high school graduates, individuals with an MD or DO degree have a greater risk for burnout. Interestingly, individuals possessing undergraduate or graduate degrees (including doctorates) other than an MD or DO degree are at lower risk for burnout. Perhaps the relative lack of respect afforded to doctors as a group by society at large might be a contributing factor.

(Lest you think this observation a bit far-fetched, in my defense I offer a bumper sticker which I chanced to encounter just the other day: “Be Kind to a Nurse: After all, someone has to intervene on your behalf to make sure doctors don’t kill you!”)

Most highly educated professionals are not employees in a service-based industry. Clinicians work in stressful environments, caring for folks who are vulnerable, sick and depressed. When problems arise (as they inevitably do), doctors are expected to take things in stride and roll with the punches. Many times they find themselves in precarious situations where the likelihood of getting sued is high. I don’t imagine that tenured university professors fall into the same category.

A more important question is how to deal with the problem of physician burnout. After all, the healthcare system itself stands to suffer immensely with the loss of significant numbers of practicing clinicians already in short supply.

Dr Richard Gunderman offers some wise words to this end:

Only by keeping what matters most at the forefront can we reap a full harvest of professional fulfillment. Burnout is not a disease. It is a symptom. To combat it, we must focus primarily on what underlies it. And here the key is not eradicating the disease but promoting professional wholeness, which flows from a full understanding of the real sources of fulfillment.

In Dr Gunderman’s words: “Medicine represents one of life’s greatest opportunities to become fully human through service to others.”

On that score I think that William Osler and Albert Schweitzer would agree.

Albert Schweitzer in Aspen, Colorado (Life Magazine)

“Notes from a Healer” — Frustrated

These are the days of pediatric practice that try clinicians’ souls.  more»

My latest installment of Notes from a Healer — Frustrated — is now online, newly published in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine is an online journal fostering discussion about the culture of medicine, medical care, and experiences of illness. Interested readers can access a list of editorial board members and regular contributors here.

In and out of medical practice

At the age of 46, disillusioned with modern medical practice, Dr. Margaret Kozel decided to end her 17-year-career in primary care pediatrics. She cites some of her reasons in her blog post, Confessions of a worn-out pediatrician.

“Our system of paying for health care and the stresses on today’s families were pitting my best medical judgment for the child against all the other worries and desires of the parents,” Dr. Kozel writes. “The economics of health care trickled down into my exam room, into the conversation between doctor and patient, distorting the relationship.”

High on her list of complaints are the inequalities inherent in our American healthcare system. Those who need pediatric care the most—poor and underinsured children—are the least likely to access it. And in those cases where health care is available, third-party payers dictate standard of care, sometimes with substandard results.

“Private insurance companies decide who gets paid for what, so pediatricians treat serious mental illness with little psychiatric training, use nebulous tools to diagnose attention deficit disorders, and valiantly tilt at the windmill of childhood obesity not because we can do this most effectively, but because we are the only professionals who can get paid to do so.”

“At the other end of the treatment spectrum, free market forces often urge us to over-intervene with minor illness, where less really would be more.”

“Clinical truth has only grown more obscure since my medical school days,” Dr. Kozel muses in a separate NYT Well blog post. “Today, as we take on the hard work of health care reform, doctors continue to work under an avalanche of pharmaceutical marketing, malpractice threats and shortsighted health insurance strategies.”

“In an age when public health issues like obesity are what pose the greatest threats to our children, pediatricians will need to move out of the confines of the fee-for-service exam room to advocate for effective healthcare policy in the wider community.”

Dr. Kozel has fleshed out her career in and out of medicine in her book, The Color of Atmosphere. Interested readers can glean much of her sentiments from an online video interview here.

Despite her misgivings, Dr. Kozel maintains a positive outlook for the role of pediatric healthcare in the future.

“I believe our society will eventually see the economic sense and moral imperative of universal health care coverage, paving the way for healthcare to be designed by health professionals, and to be viewed as a right and a responsibility, rather than a commodity to be purchased. I believe that pediatrics can evolve, too, in a way that will truly meet our society’s health needs.”

Follow Dr. Kozel’s opinions on these and related issues at Barkingdoc’s Blog.