One Crazy Afternoon

In affirmation of the Universe's sense of humor, the first patient into my grand plan to create a brighter medical experience promptly passed out while trying to leave her appointment. She was taken to the ER in a stretcher and I can safely say that neither she nor myself had a spiritually fulfilling encounter.

There are many issues that could be addressed related to this case including the cost that is going to be charged the system for this (rough guess $15 thousand dollars by the time the patient is observed overnight and released) or how we deal with our increasing numbers of very ill patients that modern medicine has allowed to remain living in the community (a great success to be sure but a management nightmare).

Instead, I'd like to keep to topic and explore the visits for the rest of the afternoon. I saw a fairly typical mix of respiratory infections, medical follow ups, new patients seeing me because of insurance changes, and mental health. Though my "project" spurred me a bit to try to make the best of these visits, I certainly didn't feel great satisfaction at any point. One patient was, in fact, quite happy because we had finally found the right medication after months or even years of never quite hitting the mark. But there were none of the "Aha" moments that remind you why you went into medicine.

I felt that I had done my job adequately or even well in every case, and I think every patient went away at least satisfied. But my sense of presence and intensity of attention were not going to be at their peak. Which leads me to the simple idea that the key to the best encounters follow rules that have little to do with exam rooms, payers, personnel, or the tea party. The best encounters are simply when people give their real attention and their true energy in those moments to the relationship.

I feel these moments most often early in the process of treating mental health issues, but that's my personal interest, my niche in my local healthcare system. It occurs to me that optimizing health care may be, in part, the process of simply allowing these genuinely present human interactions to take place. And part of my job is to figure out how I can bring presence and not allow my frustrations with medicine as a whole ruin the one thing I truly do have some power over.

But given the fact that this is only the third patient in six years that I've had to call EMS for, I'll give myself a little break. A few points to ponder for the evening.

Brainstorming Health Care Change

I have done more than my share of complaining about how broken our health care system is, and have made the claim that health care reform has been my personal #1 issue when I vote. I've bemoaned the failure of the Clinton Administration's attempt to reform our system, and done my share of criticizing the 2010 Affordable Health Care Act. At the same time, I've also been vocal about my relief that we're at least doing SOMETHING.

All of that is rather vanilla opinion that probably isn't detailed enough for someone who takes comfort in the fact that I work in a Community Health Center. As I've been reading about efforts within the environmental movement to create change from the ground up, I've decided to explore, at minimum, what I really think health care should look like. At the same time, I want to welcome comments from friends and colleagues so that my views can grow. The hope is that I can form a vision for an intentional practice in the future, and perhaps all who enter here might help each other develop a more nuanced conception of our mutual problem.

So I start with some really basic observations from the exam room.

1. Patient priorities and provider priorites are quite different. Patients seek out care for pain and illness, hoping to be relieved of suffering. Providers / doctors want to diagnose and treat. Obviously there is a lot of overlap, but it is extremely common for my time in the exam room to involve me wanting to optimize blood pressure and blood sugars while the patient wants their chronic knee pain fixed.

2. Neither one of us really wants to deal with the money. Patients rarely know the details of their coverage, and I also avoid learning specific formularies, copay structures, etc. Always looming is the expectation that care is payer blind but in reality almost every single patient encounter is affected by cost.

3. Most everyone feels overwhelmed and powerless. The pressure to see more patients with less cost leaves both provider and patient unhappy. Patients know that their access to most modern healthcare technology must go through a trained gatekeeper. I hate being a gatekeeper. I would rather be an advisor and a guide.

So I'm sitting here staring at this list, just another bit of complaining. The inspiration for this blog was reading a book (NO IMPACT MAN) where a guy who was really upset about a problem just jumped off to try to make his part better.

What can I do today? Now?

After staring at the screen for 15 minutes, I realized that what I want most of all is to have meaningful encounters. Where I walk out and the patient walks out feeling something was accomplished. Time well spent.

So this afternoon, I am going to ask myself for each visit. Do I feel satisfied with that encounter? Do I think the patient did? Why?

We'll see where it leads.