As sand falls through the hourglass...

It's June 30, and another academic year is coming to a close for thousands of residents across the U.S. 

This time of year has fascinated me since my residency days.  Certainly, most programs have graduation events for their senior residents, but they are typically earlier in the month of June.  So, June 30 itself comes and goes with little recognition.  Sure, hugs and handshakes may be traded and "congrats!" will be shared, but the patients still need care, the work still needs to be done.  In those small moments of talking with patients and making decisions, writing orders and checking up on labs, the significance of this last day is easily forgotten.  The end of the day inexorably comes, pagers are turned in, sign-out given - and, just like that, it's over.

I suppose I'm especially contemplative this year as my last day nears as well.  Sure, I've had my "last day" as a resident and fellow here, but I always knew I was coming back.  Now, I'm preparing to leave for good.  At each stage of my life, I've always wondered ahead to what the next milestone will be like - and my final exit from this hospital is looming.

I caught a rerun of the series finale of "Scrubs" this past weekend.  J.D. wants his last day at Sacred Heart to be special, magical almost, yet he knows that the deep meaning of his years there can't be captured in the few available moments of what is just another busy day for everyone else.

As the episode ends and J.D. prepares to leave for the final time, he fantasizes that he is walking through the hallway to the exit doors flanked by staff members, colleagues, and patients he's known during his time there.  Of course, he ultimately exits through the doors alone, but he's taking the lessons and camaraderie of those relationships from his time at Sacred Heart with him.

I'll walk out of the door of my hospital in a few months, and I'll have no more fanfare than today's residents when they leave their residency training sites later today.  I am confident that none of us will let the anticlimactic nature of those final minutes take away from the rich experiences and memories that we have accumulated.

A part of me, though, wishes that J.D.'s fantasy could be true for all of us.

9 things I shouldn't have stopped doing

So I was standing in line at the grocery store over the weekend when I saw the following article advertised on the cover of Cosmopolitan:

"50 Things You Shouldn't Have Stopped Doing"

Now, I admit that I read my last Cosmo over a decade ago.  I also suspect that the 50 "things" on their list are rather different than where my thoughts started to go after seeing that phrase. 

Residency education is a curious field.  For my type A-ish personality, a main source of stress is knowing that my "to do" list will never be finished.  I follow up on my patients' labs, fill out their paperwork, and field their phone calls and e-mails just like private practice family docs.  (And my hat is truly off to those of you who do that for 100% of your week and not my measly 30%!)  My academic duties* are the ones that truly consume me, though, and with our move out-of-state little more than three months away, I have a ton of projects to wrap up and duties to hand off.

So between that work and the effort of finding a new house, selling our current house, getting a new state license, and applying for privileges in a new hospital, here are a few things that I shouldn't have stopped doing:

Connecting with in-town and out-of-town friends
Listening to (and loudly singing along with) Broadway showtunes
Driving with the windows open and the radio off
Eating at the dinner table
Reading for fun
Running
Sleeping in on the weekends
Going on dates with my husband
Blogging

I am quite grateful to that article headline for the self-reflection it prompted.  In the four days since, I have managed to run twice, sleep in once, and even go to the park with my husband.  I'm not fooling myself - life won't really achieve any level of normalcy until we're settled in to our new home in our new state with our new jobs - but at least I'm starting to feel like myself again.

So, what's on your list?

* For those of you who are curious or looking for a great way to induce sleep tonight, here's the list of my current responsibilities that I recently compiled for my program director:

Maintenance of own patient panel: 3 sessions/week

Outpatient precepting

Tues & Thurs afternoons
“Fill in” prn (average 2-4 additional sessions/month)

Inpatient teaching service supervision 4-6 weeks/year

 

Assistant Medical Director of our outpatient office

Coordinator of weekly “Core Content Series” educational time for residents

 

Ongoing support for outpatient EHR issues

2 Hospital committees

Management of Point of Care device policy for incoming residents

6 EHR Committees

Medical Decision Making course – assistant session leader

Provide feedback to presenters (and support fellows doing so) when lead faculty not available

Assist lead faculty with developing annual curriculum and canon of articles

 

Faculty Development Fellowship activities

Presentations: advanced precepting skills, precepting with the EHR, presentation skills, writing skills

Support for fellows at regional and national meeting
1-on-1 preceptor training

Support for residents’ presentations at regional and national meetings

FMEC
STFM

NAPCRG

Faculty advisor for 7 residents - biannual reports on & quarterly meetings with each advisee

Coordination and team-teaching of weekly tech curriculum

Recruitment

                        Tuesday afternoon FHC tours

Fill in for interviews as needed

AAFP National Conference in KC

FMEC (formerly NE STFM Region) Conference

The underrepresentation of primary care

Like many in the FM world, I was saddened to learn yesterday of Dr. Barbara Starfield's death.  Also, like many in the FM world, I was disheartened to see the scant amount of coverage in the medical news sphere about her passing.

Dr. Mike Sevilla had a great post on this same subject yesterday.  He included links to Dr. Starfield's research and an embedded video of her receiving the FMEC Lifetime Achievement Award:
http://www.familymedicinerocks.com/family-medicine-rocks-blog/2011/6/13/passing-of-family-medicine-friend-our-silence.html?lastPage=true&postSubmitted=true

I left a small comment at the bottom of Dr. Sevilla's post that I'd like to expand upon.  It's baffled me for years that Dr. Starfield's findings have not enjoyed greater publicity in the lay press.  With all of the national chatter about heath care costs, why hasn't the media broadcasted the message of primary care's cost-saving and health-prolonging benefits?

Her findings are pretty darn news-worthy:

US counties with more primary care docs per capita have lower mortality rates; counties with more specialists per capita, well, don't.  (1) 

Inappropriate medical interventions (unnecessary medications and procedures) - which are more likely to be done by specialists - are actually the 3rd leading cause of death in the US.  (2) 

After controlling for other factors, Canada's better health equality (compared to the US) is likely due to its robust primary care infrastructure.  (3)

Instead of sharing these critically important findings, however, the lay press focuses on health scares (cell phones!  tanning!  meningitis!) and picking apart the the Affordable Care Act (you'll have to pay for insurance!).  Sure, occasionally a primary care story makes the national media rounds (remember Dr. Gawande's NY Times article about Dr. Jeff Brenner? [4]).  Apparently, though, robust primary care doesn't sell ad space as well as bedlam and furor.

Perhaps we're not selling primary care correctly; after all, primary care is downright fascinating.  Yesterday I treated a child's asthma exacerbation, buddy taped a middle-aged broken toe, and juggled an older patient's insulin doses.  Today I could see a septic newborn, someone with a psychotic break, even someone having a heart attack.

And infinitely more interesting than the diseases are the people.  The professor whose trigger finger is keeping her from her enormous garden.  The college athlete whose football talent made him the first in his family to get past high school.  The 40-year-old who became a mother (again) and a grandmother in the same week.

These sometimes brave, sometimes witty, and always genuine human beings pepper our careers with depth and meaning.  Their stories happen countless times every day in primary care offices across the country.  I applaud the primary care bloggers out there (some of whom are featured in that column to the right of these words) who are fearlessly sharing our stories and perspective with a wider audience.

What might happen to our national sentiments about health care if the lay press started picking up on those stories?

1 http://content.healthaffairs.org/content/early/2005/03/15/hlthaff.w5.97/suppl/DC1
2 http://bostonreview.net/BR30.6/starfield.php
3 http://content.healthaffairs.org/content/29/5/1030.abstract
4 http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande

From doctor to daughter...and back again

I suspect that most physicians have, at some point in their training, heard the following phrase:

"Treat the patient like she's your mother."
Or, this variation: "Remember that every patient is somebody's mother."

Well, this past week, it was my mother.

I always thought that these phrases were intended to remind us of the individual humanity of our patients.  Especially on busy and overwhelming days, it's not difficult for Mrs. Smith to become "the COPD-er in 627."  These phrases also seem to echo the golden rule ("do unto others' mothers as you'd like others to do unto your mother").

But after sleeping on the floor of my mother's hospital room for four nights and interacting with her many caregivers, these phrases have a new hollowness for me.  I'm sorry, but even the most conscientious, compassionate, and caring health professionals cannot care for my mother as if she was their mother.  She's not.

My mother's caregivers were kind, thoughtful, and available, and the medical care that she received was excellent.  (Believe me, as a physician-daughter I was watching!)   But her family supported her emotional and physical needs in ways that no one outside of her family network could.

Yes, our patients deserve humane and compassionate care.  Yes, it's important for us to get to know our patients.  And, yes, all of the patients under my care are somebody else's mother, father, daughter, son - but they aren't mine.  I see now that pretending that they are is utterly impossible and that being the best doctor I can be is good enough.  I will leave the daughter-ing to the daughters and the mother-ing to the mothers.

After all, doctor-ing is hard enough on its own.