The miracle of a day off

For the six and a half years that I spent practicing full scope family medicine for UCSD, I’m not sure I ever really had a day off.   True, the work rules which protect nurses and medical assistants from abuse would temporarily halt the influx of patient messages and refill requests from 5 pm on Friday until 8 am on Monday.  But not once during that time did I ever say to myself “I’m done.  I no longer need to think about work until tomorrow morning.”  Well, the cycle of perpetual responsibility for patient lives has finally ended.  And it is amazing!

Our kids were sick last week.  Just a cold that they probably picked up while traveling, nothing serious.  But significant enough that our baby sitter couldn’t take them.  And, it also happened to be a day when my wife had an important work meeting which she couldn’t cancel.  If such a circumstance had ever arisen while I was a practicing clinician, staying home with the sick children would have involved canceling patients at the last minute, double booking them at a later time, triaging those who needed to be seen sooner to another provider and so on and so forth.  And my lack of physical presence in the office would have no bearing whatsoever on the quantity of work flowing in.  Patient calls, patient emails and refill requests would not abate in the slightest.   Oh, how jealous I was of those hourly workers who are off when they are off and who get paid when they are not off.  It would seem to be such an intuitively fair system.  But in clinical medicine, even if you’re not getting paid to be at work, the work keeps coming.  Just because your shift has ended or just because you have finished seeing the last patient of the day doesn’t mean that your professional obligation has ended.

“But,” you may protest, “Why can’t a colleague (who is not taking the day off) cover my inbox the same way a medical assistant might for one of her colleagues?”  They can…to a degree.  But, there are major barriers.  For, doctors don’t simply follow protocol.  They get paid the big bucks to make big decisions.  They get paid to accept the responsibility for any bad outcomes their decisions might produce.  And a doctor who has had the benefit of spending an entire visit with a patient has already gone through that decision-making process.  So, for that doctor, the calls that come in later can be answered quickly.  A colleague covering for me needs to open the chart and figure out what the heck is going on before they can determine whether that methadone refill is appropriate.  The nature of current medical practice is a huge barrier as well.  The idea that having a single primary care physician to act as your advocate and to be the director of a team-based approach to care has been shown to be both cost effective and to yield better outcomes.  But, it results in a culture that rewards doctors who give up their personal time in order to help their patients and stigmatizes doctors who try (and mostly fail) to approach their job with an “on the clock/off the clock” type of attitude.  I am, and have always been, decidedly of the later mindset.  I believe in hard work and I believe that life is most rewarding when one performs to the best of one’s ability.  I would always strive for excellence in clinical practice as I now strive for excellence in utilization management.  But work does not equal life.  There is so much more than work that we need in order to be fulfilled spiritually, physically and emotionally.  Work has its place.  That place is a box.  A box with unbreakable sides and a hermetically sealed top.  It must be kept in its box.

Hence, the day off that I had last week was kind of a novel experience.  Every 30-40 minutes my brain would reflexively turn my body towards the nearest internet capable device in order to log into…wait.  There’s nothing happening today that requires my personal attention.  The work will all get done.  I’m not getting paid to work today, dammit – why am I thinking about work?  17% of my brain cells which had previously spent their entire lives worrying about whether I had killed anyone that week suddenly had nothing to do!  It was as if I could I could hear the song Celebration playing somewhere in my head.

On a particularly contentious peer to peer discussion I had today, a doctor said to me, “I’m sorry medicine didn’t work out for you.”  The only thing I could think to say at the time was, “Buddy, you have no idea how inaccurate that statement is.”  I didn’t say that.  I bit my tongue, allowing him to finish his temper tantrum.  After all, I was in that doctor’s shoes not long ago.  And it sucked.  And I’m so much happier now, because medicine has worked out for me better than I ever thought it could.

San Diego Academy of Family Physicians Annual Symposium

The SDAFP (San Diego Academy of Family Physicians) Annual Symposium is this weekend.  I’ve attended this conference every year since moving to San Diego in 2011.  The conference runs Friday-Sunday and it is jam packed with educational talks given by (mostly local) physicians.  I love these conferences.  The reasons I love attending medical talks include, but are not limited to the following:

  1. I’m a nerd who likes school
  2. It gives me the chance to catch up with old colleagues whom I haven’t seen in awhile
  3. There’s usually some free food and maybe even some free swag involved
  4. Hotel ballrooms tend to keep the ambient temperature around 60 ℉
  5. I can sit in the back of the room and form snarky opinions about the speaker without ever having to justify them to anyone
  6.  Knowledge is power

Reason #6 may sound trite, but it truly is the most important motivating factor for me.  Ask any physician in active clinical practice whether he or she knows everything they need to in order to be competent.  I defy you to find a single one who gives you an unqualified ‘yes.’  Nobody is an expert on everything, nobody gets 100% on their board exam.  It just isn’t possible to robustify one’s knowledge to point where you can be prepared for everything that walks in your office door.

The breakdown of content of a good talk on any given topic (heart failure, menopause, diabetes, etc) may look something like this:

  • 25% basic knowledge which I already knew (phew, that’s something I’ve been doing right)
  • 25% basic information which I didn’t know (I’ll do that differently in the future.  I’m a better doctor now – cool!)
  • 25% esoteric/specialized information (don’t know, don’t care, I’m just going to keep referring those patients)
  • 25% opinion (speaker doesn’t know what they’re talking about, going to check the score of the Cubs game and/or tweet something snarky #SDAFP2018)

In a certain sense, it’s like gambling.  Like the blackjack player who always has one more card coming – one more chance to beat the dealer – the conference attendee always has one more bit of knowledge coming.  Maybe that next piece of information, that next study they cite will be the one that changes everything.  Maybe that will be the final piece of the puzzle – the last thing that I need to know in order to be a fully competent physician.

I’m still enjoying the conference, but things are a bit different now.  I’m so fortunate to have a job where the quantity of information I need to have mastered in order to be successful, while still quite a lot, is finite.  It is well demarcated, well defined and has neat, straight, blue lines drawn around it.  This is one of the things I have deeply longed for.  And now I have it.  And I’m so much happier.

Isle of dogs…and a moose and a flying squirrel

An authoritarian ruler who poisons his rivals, manufactures a crisis for which he can blame and marginalize a single group and who uses a combination of propaganda and brute force to suppress the media; Wes Anderson could not possibly have predicted the level of relevance his movie would have in the era of Trump. Go see it. It’s bloody fantastic. In this extended metaphor for the holocaust, the opposition party leader is (spoiler alert) poisoned before he is able to expose a corrupt ruler. It’s so prescient as to be almost too “on the muzzle.”

In other pop culture news, please check out Glen’s Weldon’s new post on NPR’s Monkey See Blog. He breaks down, in hilarious detail, the reasons why you never knew you needed a Rocky and Bullwinkle reboot.  I sometimes have daydreams in which I can express my thoughts with the same level of clarity and wit that he does with regularity. His writing makes me insanely jealous. So, for now, I will congratulate myself on my aptitude for recognizing quality – even if I am unable to produce it.

A true conversation with my voicemail

I had some free time at work today and decided it was time to get my voicemail set up.  I lifted the receiver to my ear, pressed the button with the envelope picture and surrendered myself to the automated prompts.  A neutral, female sounding robot voice came on.

“To listen to your messages, press 1.  To send a message, press 2.  To change your greeting press,” the long beep as I anticipated what she was going to say and pressed 3.  I imagined that the face these words came from was neither smiling nor frowning – emotionless.  I can work with that.

“Please enter your password, followed by the # sign.”  I entered 1+2+(my 4 digit extension), what I understood to be the default password on our phone system.

“That is an incorrect password.  Please enter your password, followed by the # sign.”

Hmmm, I’ll try one more time.  Maybe I had inadvertently transposed 2 of the digits.  I pressed the 6 keys in sequence, more carefully and deliberately this time.  The response of the automated attendant, who I now imagined was 45 years old, slender with straight, light brown hair and still wearing the same blank expression came back on.

“That is the same incorrect password.  Please enter your pass-”

I cut her off and reached for the keypad a third time, mildly annoyed by her editorializing.  I pressed  1; I pressed 3; crap!  She had gotten me so flustered, my finger had slipped!  There’s no backspace on an automated phone menu.  I’d have to abort the process and start over.  Figuring there was no point in entering the remainder of my 4 digit extension, I hit #.  Again the voice, neutral and nonjudgmental, but without empathy and clearly with no vested interested in my success.

“You must enter a password before pressing #.  Please enter a-”   Jesus, work with me lady, please! I stopped, took a deep breath and resolved to make one more attempt.  1+2+(4 digit extension).  I held my breath.

“You have made too many attempts to enter your password and have been locked out of the system.  Please contact your administrator for further assistance.”

You win this round, automated voice menu lady.

The reason(s) why I left clinical medicine

From medical school interviews, to residency interviews, to discussions with friends and family, I have had to answer the question of why I decided to become a doctor literally hundreds of times.  In answer to this question, I would tell a story.  And, like all good stories, the ones I would tell contained a bit of truth and a bit of fiction.  I would try to balance what people wanted to hear a doctor say motivated him to enter medicine (or, at least, what I perceived people wanted to hear) with the truth.  The answers I would give varied and aren’t important right now.  Because part of what I want to do with this blog is to provide some true insight into of why I became a doctor and then left clinical medicine.   So, why did I become a doctor?  Here’s one true answer – I did it for the same reason that I run (or attempt to run) marathons.  Namely, it is a challenge that uses my capabilities to their fullest, leaves me stronger in the end and where success is not a fore drawn conclusion.  In my opinion those are the best reasons to do anything in life.

Got it, so why did you leave?  Based on my conversations with doctors over the years, I’ve come to realize that my love-hate relationship with medicine is far form unique.  The happiest doctors find their interactions with patients rewarding, don’t mind spending their free time reading journal articles, are well supported by capable office staff and have families that show understanding when unexpected, yet urgent, job related obligations arise.  But, even under the best of circumstances, there is no way to avoid the occasional phone call at dinner time about your 11:20 am patient…”Her d-dimer is how high?  Chest x-ray is normal?” (sign) Looks like I need to send the patient to the ER because she might have a pulmonary embolism.  Or do I?  Was she really that short of breath?  Maybe the d-dimer is more likely to be a false positive.  While I ponder the clinical scenario, I try to appear interested as my son excitedly shows me a robot he made out of a cardboard box.  Four minutes tick by, then five.  I consider all the possible outcomes: a) send the patient to the ED -> diagnose a PE -> save the patient’s life, b) send the patient to the ED -> CT is negative -> patient is ok but exposed to unnecessary radiation, time and expense -> dinner is ruined c) enjoy dinner with my family -> patient is ok,  d) enjoy dinner with my family, patient dies.  Crap, I’d better call the patient.

The above scenario is common and in no way rewarding.  Which is why, even in an ideal world, there are aspects of clinical medicine that kind of suck.  Rather that attempt to summarize everything about clinical medicine that compelled me be both to stay and eventually to leave in a few neat paragraphs, I plan to tell a series of stories.  I hope they will resonate with clinicians and nonclinicans alike.

This website will never collect your personal information

For the past several months, I’ve mostly abstained from the use of social media.  I could blame it on Facebook – their carelessness with the personal information and data which I, and billions of other users, generate for them.  I could say that I’m tired of being used, sold and marketed to.  But that would be disingenuous.  As an actual matter of fact, I don’t much care what Facebook does with my data.  I’m not sure that I even consider it to be “my data” anymore once I’ve posted something.  No, my  lack of communication via social media (as well as more conventional methods on communication like mail, telephone and ravens) is more accurately attributable to laziness.  But, that’s neither here no there.  The point is, I worry that my writing skills – such as they are – will irreversibly atrophy if don’t start using them again on a regular basis.  To that end, I introduce you to “Tim’s personal privacy page.”

“What is Tim’s personal privacy page?” you ask.

A fair question.  The answer is, “I don’t know yet.”  What I can tell you is that I am not particularly interested in continuing to interact with an advertising platform with some social media capability – by that, I mean Facebook.  I can tell you that this website will never contain advertising.  And, I can make the solemn pledge that no information about visitors will ever be collected, shared, sold or used to influence an election.

So, thanks for stopping by!  I’ll post again tomorrow with some further explanation and updates regarding some recent life changes (most notably, switching careers).  If you want to follow my blog, click on the RSS feed link to subscribe.  If you don’t use an RSS feed reader, you may continue to follow me on Facebook as it will be updated, but only with links to new blog posts.  Take care!

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