For now, you can call me Plain Mr. Harrington (S.)

Bad_Sir_BrianIt has been three weeks since I stepped into the void. Taking that step means I gave up one of the most responsible jobs in the workforce, making decisions for patients that had life or death consequences. Did I expect that change to make me feel small, reduced, insignificant? I think I did, and for a few days I felt that way.

I have traveled to and from DC several times since leaving my medical practice. The further away I am from the office and hospital the less I remember of my former self. I feel partially stripped of my former identity – in a good way.

However, the closer I get to the hospital or office the more acutely aware I am of what I have given up. Indeed, during my recent cardiology check up I felt particularly dysphoric.

On my current return to DC, I attended a retirement party for one of the most underappreciated (by the administration) but warmly loved (by the staff) nurse managers in our department. All my former colleagues were there. One doctor was receiving calls from the ER regarding consults for that evening. I looked around at the assembled MDs, all aging like me, and I felt fine.

In fact, I am quite surprised at how comfortable I feel without the constant responsibility I bore. I did it for decades and I did it well. I am done with it.

Dr. Harrington vs. Mr. Harrington

I also have a new consciousness of the distinction between Dr. Harrington and Mr. Harrington. At my former hospital an old-fashioned relationship between doctors and nurses was generally maintained. Most nurses addressed physicians as “Doctor” when asking questions or reporting on patients. This practice extended to less formal circumstances including retirement party etiquette.

In my many phone calls of the last three weeks I am conscious of people referring to me as Mr. Harrington even when the information in front of them indicates my professional title.  I do not mind.

My wife thinks I should correct them. “Once a doctor, always a doctor.” I do not agree. I feel that only doctors actually treating patients for true health care issues deserve that honorific and the attendant respect. In that regard my daughters are the “doctors” in the family.

A subtle variation on that theme comes to mind when I think of the flattening of the hierarchy of care that has evolved over the last few decades.  My elder daughter works in a neonatal intensive care unit in a team of neonatologists, physician assistants and nurse practitioners.

I think she generally is more comfortable working with her team on a first name basis.  I understand.  She thinks of the title as a solecism. I do not. [Note: I am trying to convince Sam not to use $5 words. I am not positive he has used “solecism” correctly here. In the interest of marital harmony, I am leaving it be. – Debbie] At the end of the day she is the doctor and makes the final call about therapy. She bears the responsibility.  She is the “Doctor.”

My younger daughter is a new surgical resident.  She is probably struggling to embrace the title as she is surrounded by nurses, PAs (physician assistants), and techs with more experience and skills than she has for the moment.  After a year in the crucible of internship I know she will have earned the mantle.

I respect the title so much, when applied to good and active practitioners, that I am comfortable without it as I define my new self as “Plain Mr. Botany (B.)” – at least for the duration of my Gap Year.

Sam is a big A. A. Milne fan. The illustration above is from the A.A. Milne poem, Bad Sir Brian Botany. The punch line is that Bad Sir Brian loses his battleaxe and his spurs and becomes Plain Mr. Botany (B.) – Debbie

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My first Nats game and a revelation about baseball’s “perfect game”

photo (17)I went to my first Nats game this week. I had never been to a game in DC’s gleaming new stadium. It was a perfect night for baseball. Warm but not humid. Not a cloud in the sky. And on June 21, 2013, the longest day of the year.

Our seats were spectacular (thank you Jerry), 12 rows up from the sparkling green field, near home base plate [oops]. The Nats’ dugout was below us so we could see the players coming and going.

It was a good game, I was told. The Nats beat the Rockies 2 − 1 with solid pitching, hitting and fielding by both teams. The game ended at the top of the ninth so it wasn’t too long either. But it was the concept of a Perfect Game that captured my imagination.

The friend who procured our remarkable seats took us up to the press level where we were able to study the Shirley Povich memorabilia.

shirley_povich_yellowI confess I am a complete sports idiot. I don’t read the sports pages. I don’t pay any attention to DC’s sports teams. And I don’t have a favorite childhood team, although I remember talk about the Brooklyn Dodgers when I was very young (I grew up outside New York City).

I had heard of Washington Post sportswriting legend Shirley Povich. But I didn’t know much about him and I hadn’t read his columns.

We were allowed into the hallway next to the elevators where there were several framed displays, including a copy of Povich’s column about the legendary 1956 World Series game pitched by Don Larsen: the Perfect Game where there were no hits and no runs.

Why is it a Perfect Game if nothing happens?

At first I was puzzled. Why was the game “perfect” if nothing happened? I had never wrapped my mind around the concept of a perfect game. The crack of the bat followed by the dash around the bases is what I think of when I think of a baseball game.

Why so much emphasis on the pitcher? And could there be a “perfect game” by both teams? Well, no, it was explained to me: somebody has to score a run in order for the game to end.

The “perfect game” reverberated in my head as we drove home, negotiating DC’s freeways on the southwest side of town and catching a glimpse of the monuments lit up and so familiar.

The connection to our Gap Year

It seemed related to our gap year somehow. But I couldn’t quite capture it.

Slowly the idea unfolded: a “perfect game” meant no errors, no mistakes, no fumbled balls because there are no hits. It is so unlikely and so unusual.

And then it hit me. It’s the not knowing. It’s the accumulated suspense of watching a “perfect game” unfold that is almost unbearable for fans and players alike. It’s the uncertainty playing out in front of you, pitch by pitch.

And that’s what Sam and I are doing this year. Step by step, if not pitch by pitch, we’re making up something in real time.  It is uncertain. It will be unusual. And it is once in a lifetime.

Thank you Shirley Povich for introducing me to this concept. And for your lovely columns, which I sincerely regret I didn’t appreciate all those years when I lived in DC and you were writing for the Post.

P.S. Extra credit

In the photo above, what does the “W” on Sam’s cap stand for??

Enough touchy-feely; let’s get to my peeves about resistance to government intervention

iStock_000019897999XSmallOk, no touchy-feely comments about my state of mind as I enter the third week of my Gap Year, keeping in mind that in 40 years of medical education, training, and practice three straight weeks is the most vacation time I have ever had and this on less than five occasions.

Let’s get to some of the peeves that caused me to seek this time off.

Robert H. Frank, an economics professor at Cornell, wrote a column in the New York Times recently, What Sweden Can Tell Us About Obamacare, that encapsulates the benefits of government-controlled health care and derides the critics of Obamacare.

The U.S. is ranked 37th by the WHO as a health care system, using a formula that balances outcomes and expense. And this is among developed countries. We spend vastly more per patient per year than other nations, yet our outcomes are demonstrably poorer in many areas and no better in most. These are inarguable facts, beyond dispute.

Two things piss me off

Two things piss me off. A large percentage of our population has such a philosophical opposition to government intrusion that they deny these facts, just as they deny the existence of global warming; and second, the leaders of all the major health care systems in the U.S. remain largely passive in this debate and by their actions.

1. The myth of government intrusion

First, the myth of government intrusion versus free market management must be exploded.

When Mitt Romney visited Israel during his Presidential bid he commented that health care consumed about 18% of US dollars versus about 8% of the Israeli economy.

He added that the difference indicated there were many economies of scale to be achieved in the US. He left unsaid – though as author of Romneycare he knew full well – the distinction: Israel has a single payer system.

The conservative perspective that government intrusion is bad and that free market forces will control costs is completely without merit.

All of the top health care systems in other developed countries are single payer systems or have a prominent governmental role. And, if the markets would bring down costs and improve health care, why have they not done so?

Because, as David Goldhill explains in his book Catastrophic Care: How American Healthcare Killed My Father and How We Can Fix It, they are not free markets and there is no free competition. They are highly asymmetric markets and the managers abuse the market to pump up their profits.

These managers include the leaders of the insurance companies, the pharmaceutical companies, the for-profit hospitals, to a lesser degree the not-for-profit hospitals, the device industries, etc.

2. Health care delivery leaders are not working for change

Second, all the leaders of the health care delivery systems (administrators, doctors, nurses) and their professional organizations (the AHA, the AMA, etc.) know that the present cost curves are out of control and unsustainable.

Yet, they do not spend the majority of their time on Capital Hill working for change. Instead, they spend the vast majority of their time consolidating their market share.

This was one of my great internal conflicts as a practitioner and a trustee at my small hospital.

As a practitioner I wanted to deliver the “best care” and control costs. However, delivering more care than needed is the American way and, specifically, delivering profitable outpatient care at my hospital supported its flagging finances.

More importantly, as a trustee I had to vote on issues with the economic well-being of the hospital in mind, even though some of those decisions ran counter to my desire to rein in health care costs.

For example, Sibley has an opportunity to start Proton Beam Therapy for cancer, but other area institutions already have this expensive technology or are competing to obtain it. [See this NPR story: Proton Beam Therapy Sparks Hospital Arms Race.]

Who has the power to lower healthcare costs?

The organizations that are working to lower costs and restructure our system have only the power to educate consumers and politicians and they are largely ignored.

The Institute for Healthcare Improvement and similar academic think tanks make the occasional impact with a study or movie but do not have any effective political support movement that can really make a change. Politicians respond to voters and voters like the care they get.

A related peeve is that currently health care “improvement” is largely an exercise in modifying the behavior of doctors and nurses to meet regulatory standards and “best practices” as defined by Core Measures (standards created by regulatory organizations which many clinicians think have questionable value).

Doctors and nurses are not paid more for achieving higher scores but administrators are because they control the purse strings and the organization that is keeping score.

A possible solution: I welcome your input

In my opinion we need an organization that oversees the administrators and creates a series of Administrative Core Measures and Administrative “Never Events.”

Let the CEOs of the health care delivery systems be subject to outside regulatory oversight and let their pay be tied not to the consolidation of their market share but to their cooperation and effectiveness in bringing down U.S. healthcare costs and improving our ranking in the WHO.

Such an uber-organization looks like a single payer system to me but I would welcome the opportunity to look at alternatives.

Unmoored and learning to drift

red_buoyNow this is a bit of a surprise.

Sam is two weeks into our Gap Year and apparently enjoying his freedom. He has the normal worries (logistics of packing and travel) but he doesn’t seem particularly anxious about his yet-to-be-made-up future.

I, on the other hand, am feeling confused and discombobulated, set adrift. I seem to have lost my bearings.

This doesn’t make any sense.

Nothing about my work life has changed. I’ve been a creative entrepreneur, making up my own story as a writer, speaker and Web consultant, for a decade. My work and professional identity are location independent. It doesn’t matter if I am in Washington DC or Stonington, ME.

And in fact I have spent a good chunk of the past five summers working from Stonington while Sam has mostly remained in DC, taking care of patients.

So what’s up?

I’ve spent much of our 13-hour drive from DC to Maine sifting through my anxious brain for an answer. It finally came to me.

For the past three decades, Sam has been tied to his medical practice, the hospital and his patients. He had a permanent mooring while I bobbed around him doing different things at different times. Thirty years ago that meant being the hands-on parent for our three young children. After getting a late-in-life MBA and enduring a brief corporate career, I struck out on my own and have been an entrepreneur ever since, relishing – among other things – business travel on my own to China, Australia, Dubai, Canada and Europe.

In fact I railed against Sam’s inflexible career. We couldn’t take a three-month trip through Asia. We couldn’t take a six or 12-month break to live and work in another country. Sam was tethered. We could not leave.

But it turns out Sam’s being tied down provided stability for me to come back to while I wandered through the Interwebs and foreign airports. I depended on it as a way to define my life.

And now we are both untethered and it feels… different. It is a little scary.

I know the freedom of our Gap Year will make adventure possible. I wanted this. Sam’s stepping back from medicine to pursue a second act was as much my idea as his.

Now I must learn to be comfortable with a flood tide of freedom.

Puncturing a lampshade and crossing the Rubicon

iStock_lampshade_000004703320XSmallAfter leaving Milwaukee I returned to DC. I needed to clear my desk and I had a medical check up scheduled. Getting close to the action created temporary feelings of inadequacy and purposelessness. But being a patient at the overly technological office visit reminded me of the outrage I feel at the complexity medical care has assumed.

For the last few days Debbie and I have been packing up about ten percent of our house and ninety percent of our stored memorabilia for delivery to our new cottage and storage space in Maine. Packing and sorting is always unsettling.

For Debbie the distress was compounded by the move of her office materials from Washington to Maine. For me it was a distraction from the feelings of loss I was experiencing. It is hard to describe the sense of loss.

I think there are two ubiquitous fragile stretches of cloth that people commonly encounter and occasionally puncture. These are the black cloth underneath upholstered furniture and the white lining inside fabric lampshades. The function of these membranes is subtle but significant.

For some reason I have always been unsettled on the rare occasion when I puncture one of these pieces of fabric. Perhaps as a child I did it intentionally or perhaps unthinkingly as a foolish adolescent. Was I, perhaps, sharply criticized by my parents after such an occurrence? I do not remember. Whatever the reason I remain very distressed when such a tear happens, caused either by myself or someone else.

Yesterday, while disassembling a lamp to take to my daughter I punctured the diaphanous inner lining of the lampshade. I have been unable to get this out of my head as we drive away from DC to meet our belongings in Maine. It is not our final departure but it has a sense of inevitability.

I feel that I have perforated some larger membrane. Is it the thin band of trust that I have violated by “abandoning” my patients? Is it that driving away from our house on O street is a sign that we can’t turn back? Have we gone from one reality to another lesser reality?

I don’t think so because I know that my point of no return – my Rubicon – was when I mailed the letter to my patients announcing my plans to leave my practice. I had not slept well for months before that. It was a secret plan that could not be leaked but was best disseminated quickly and broadly. I slept well the night the letter went out.

It is easier to look forward when driving away from the past. Certain torn fabrics can never be repaired; they can only be replaced.

Now, we have started the drive.

The luxury of time; the challenge of structuring it

Time For ChangeI am one week into my Gap Year. One friend emailed to ask how it goes.

Of course a gap year in the usual sense is for a young adult to gain perspective on life, blow off the initial energy of post high school freedom, explore the world and return to university with a more mature focus.

A gap year after 60 is quite different. It is not about focusing but about refocusing.

It is not about blowing off energy but about marshaling energy anew.

It is not about looking forward but about looking back, analyzing, then looking forward again – but with a less distant horizon.

Without a daily load of patient appointments and hospital visits, the first challenge for me is to structure my days.

I was a slave to punctuality

One of the rewards of medicine is the knowledge that your work is valued and valuable. Even if unable to heal, a physician can guide and comfort a patient. To replace that structure of appointments and procedures (and I was a slave to punctuality) I plan to impose a schedule of blocks of time to allow for more free reading, some exercise, writing, studying, and whatever errands and projects need to be done.

From the point of view of restructuring my day, Milwaukee might not have been the best first choice. To visit a 92-year-old man for the sake of catching up and reminiscing is to be a slave to his schedule. Meals, naps, treatments, etc. dictate the general rhythm of the day but the idiosyncrasies of the nonagenarian supply plenty of unexpected interruptions.

Of course, the point of the trip was to maximize face time so when he called I responded, dropping whatever mini-project I was working on. It was well worth the time. I hope to get back soon.

Time, what a luxury

Today is one of the first when I can set the schedule I have outlined above. Write, clear my desk, read, exercise, study, do errands and leave the evening free. Repeat tomorrow.

Clearly, if I were an exceptional person and physician I could have done this over the last few decades, but I didn’t have the energy or bandwidth. I never found the time. My work expanded to fill the gaps and I never blocked out enough time to grow in other areas.

Time, what a luxury for me.

Today’s project is to select our first load of furniture for the new rooms on the coast of Maine. It will be a test of my new relationship with Debbie, vis-a-vis time, space, and each other. [Editor’s note: ha! the new relationship is going well. Yet I fear that Sam is so organized… and I am not. – Debbie]

Parking permits, moving trucks and the D.C. government

Yesterday we went to the local police station to obtain a parking restriction permit for the moving truck, which is scheduled for later this week. What a farce. In years gone by the desk officer would simply handwrite the request and advise you to give your neighbors 72 hours advance warning.

Now the police station houses a terminal for the DDT (District Dept. of Transportation) that prints out the red parking restriction signs – for a hefty fee of course. You pay by credit card. The police have nothing to do with the new process and the desk officer is quite happy to tell the petitioner that she can’t help at all.

It took two college grads (with three post grad degrees between them and 31 years of experience with the D.C. government) an hour to work through the program. We came out with the wrong request (a moving container instead of a moving truck) and the wrong dates (five days of restrictions versus the intended two days).

If we hand modify the sign we are threatened with a fine. So goes it in DC.

You can see I like to get things done.  Doctors tend to be that way.  We see the patient, institute therapy, push for a cure and move on to the next.  More about that later.

Following in my footsteps, but in a new era of medicine

Sam_Amanda_ElizaI am indescribably proud of my two daughters who are both embarking on careers as M.D.’s.

Why, you might ask, am I leaving the practice of medicine just as they are starting?

It is an easy rationalization. My era is over.

Yet the medical profession remains the career with the most promise of honor, achievement, and excitement.

How can I describe my era?

I looked on it as an era of great promise. The advent of anesthesia, radiology, and antibiotics among others, each lead to a leap forward in progress. When I put on my intern’s white jacket and left for my first morning at Grady Memorial Hospital, I thought I would synthesize that knowledge into the most effective delivery system ever.

However, after forty years of training and practice I see the opposite. The promise I hoped for has not come to pass. I have seen the expense of medicine rise at an astronomical rate, while the benefit has plateaued.

I have seen a population over-diagnosed and over-treated at fantastic cost and yet life expectancy has improved by only a few years. I have seen, and I have participated in, vast screening programs that have found precancerous conditions and early cancers; yet the absolute number of cancer deaths has been minimally reduced.

Many studies say that the majority of the reduction in cancer deaths can be attributed to the reduction in smoking and not our prevention programs.

Of course there have been great strides during the past forty years. A notable one is the advent of minimally invasive surgery. I like to think that by embracing endoscopy in the early ‘80s I foresaw this. The treatment of bleeding ulcers and the removal of GI neoplasms with scopes was the original definition of “minimally invasive” and eventually replaced surgery for these problems.

Still, despite $2.7 trillion in expense, the U.S. health care system ranks 37th in developed countries according to the WHO. After forty years of trying to make a difference, I have changed from the scared but optimistic intern into an ex-practitioner who asks himself: “Why would I even want to be the best gastroenterologist in such a second-rate system?”

Sam_Timothy_May2013I have seen medications, technologies, screenings, and treatments layered upon patients with an exponential rise in the cost curve and barely a hint of change in the benefit curve. We are living in a crisis. This era must end.

My daughters are joining the profession of medicine during a great transition. Private practice is over. The next era is about teamwork and managing complexity. They will step in and become part of the solution.

grandpa_docOur family has a long tradition to uphold and my children (including my son, a lawyer) know it. The first cataract extraction in the U.S. was performed by their great great great great grandfather, a cofounder of Boston Eye and Ear. Since then there has been a physician in every generation.

My daughters are the seventh and eighth physicians in seven generations and I am pleased to note that my mother made her contribution as a nurse.

I am so proud of them all.