One Morning in Maine: Why I don’t miss practicing medicine

If the world were merely seductive, that would be easy. If it were merely challenging, that would be no problem. But I arise in the morning torn between a desire to improve the world, and a desire to enjoy the world. This makes it hard to plan the day.

– E. B. White

This is one of the variations on a famous quote by the author. It is commonly referenced here on the coast of Maine, presumably because E. B. White lived nearby and, more importantly, because the mornings in Maine are so inspirational. [Ed note: E. B. White lived in North Brooklin, ME for the last few decades of his life.]

Yesterday, while riding my bike for exercise, I stopped to chat with a neighbor. He is a retired judge and occasional golf partner. He expressed surprise at my “Gap Year” plan and my retirement from private practice.

He assumed that my personal identity and professional identity were inextricably entwined, as were those of his brother-in-law, a family practitioner. He asked me if I missed my practice.

I did not skip a beat. “Not a bit,” I replied.

My Gap Year is to define a new relationship to time, space and family

He opined that I was likely to become bored, as he did after his forced retirement. He now does some part-time administrative judging. I pointed out that is what the Gap Year is all about. It is to allow me to define a new relationship to time, space and family. I will find something useful to do but it will be something other than private practice.

On reflection, I do miss my patients and I do miss my hand-picked group of colleagues, particularly my partner, who practiced with the sense of devotion and care that I did. I do miss my former office staff.

But the sense of relief that I am no longer trying to function in the most sophisticated, complicated, and yet dysfunctional healthcare system in the world is indescribable and far outweighs my sense of loss.

Enjoying vs. improving the world

For forty years I tried to “improve the world.”

The last ten years included my work as a trustee trying to nurture the hospital to which I had devoted my career. I am surprised at how easily I can let it go and more surprised at the anger I harbor toward the doctors who game the system, the administrators who perpetuate the system and the organizations that abuse the system.

When Lord Melbourne advised a young MP, to “try to do no good, and then you won’t get into any scrapes,” he did not mean to say “do bad things.” He meant that the willful act of doing good was likely to lead to unintended and unpleasant consequences.

For a year I will enjoy the world.

Transition: is it the new normal?

Sam has been writing a lot about measurable sign posts as our Gap Year progresses, week by week. In fact, he’s been writing a lot. Much more than I have.

I’m going to chalk that up to the eagerness of a first-time blogger. I’ve been blogging for a decade and I’ve developed some bad habits. I want everything I write to be original and fresh.

Fuhgeddaboudit.

That isn’t possible. And if you get stuck on that approach to blogging you will quickly become constipated, cramped and cranky.

In other words, there is nothing truly new on this planet. There is only originality of voice and perspective and the occasional gleaming turn of phrase… if you are lucky and in the flow.

Today’s topic: transition

Perhaps because of his 31 years in medical practice with office visits stacked one on top of another, Sam tends to be organized and goal-oriented. He talks about three weeks and six weeks into his Gap Year and what he has – and has not – accomplished.

If he (aka we) can just unpack the boxes… if he (we) can just declutter the house.

For the record, I think the guy is remarkably well adjusted for someone who has gone from 60MPH to 10 or 15MPH in the space of a few weeks. He has moments of anxiety but so far they relate to things like his frustrations with the U.S. Postal Service and Blue Cross Blue Shield. Specific, tangible problems that he can wrestle with, however aggravating.

But yes, we are both measuring progress by whether the boxes are getting unpacked in our new guesthouse. (Yes! See my new office above.) Whether extraneous stuff is being sorted through and disposed of.  Bottom line, whether the level of chaos caused by a semi-move to the coast of Maine is abating.

The grandbabies arrive, bringing new (delightful) chaos

But then… the grandbabies arrive and move into the guesthouse (with their parents). And more chaos ensues.

I am beginning to wonder if this kind of transition isn’t permanent. At least for a while. I am feeling much calmer than I was a few weeks ago when I wrote about feeling unmoored. Perhaps I am learning to drift.

Take today as an example. Part of the day will be taken up with the ebb and flow of grandbaby activities. I’m not responsible for constant baby care (thank goodness) but I love to dip in and out of what the little girls (ages one and three) are doing: playing outside, squealing, having a snack, making a mess…

I am so grateful that they are ensconced in our guesthouse next door. And not under the same roof with us. It’s only a separation of a few feet but it affords Sam and me a cushion of quiet and peace. And our daughter and son-in-law seem to love having their own place.

My new office is on the second floor of the guesthouse (see above) so I’m not using it just now. I’ve told my son-in-law, a law professor, to set up a spot for himself and he has happily obliged. The office has a panoramic view of the Deer Isle Thorofare. It’s marvelously bright. But it gets quite hot by the early afternoon. I will have to get shades. Tick. Another item for the To Do list. But I am looking forward to that.

Is transition good or bad? What does it mean?

Back to the concept of transition. What is it? What does that mean? What does it feel like?

Well, there is a sensation of gentle movement and of being carried along but in a not unpleasant way. And I am getting used to it. I know that this particular time is transient – this wonderful visit with my daughter and son-in-law and the babies. And I relish it, knowing that it is so special and that it will end.

But it does call into question: how does one measure time? How do you measure progress? Is it important to have goals? What should they be? Are they different when you are experimenting with how you spend your time?

You will note that I haven’t said a word about my work with authors or about my own writing. My writing on topics other than our Gap Year is suffering at the moment. The interruptions do affect me. I can’t deny it. I can hear three-year-old Dorothea shrieking through my window. I am going to investigate.

And yes, this blog post counts as a chunk of writing for today.

Real life during a gap year: battling the U.S. Postal Service and Blue Cross Blue Shield

Today and tomorrow are the big pushes to get “stuff” out of the house, where it clutters the floor and the mind, and into our new guesthouse. Hopefully the mind clutter will diminish.

A brief healthcare rant

Recently The New York Times reported that medical insurance premiums will fall by 50 percent in the state of New York with the advent of health insurance exchanges as mandated by the Affordable Care Act (aka Obamacare). [Ed note: there are 893 comments on the healthcare article in The New York Times. – Debbie]

A follow-up article in The New York Times attributes the 50 percent drop to the artificially high premiums people have paid since a 1993 law barring New York insurance companies from denying applicants with pre-existing conditions and mandating equal premiums for all people regardless of age or disease.

This meant that the premiums of young healthy people were inflated to pay for the care of the elderly. But, because the New York law did NOT include the universal mandate, many young people opted out of coverage. This shrunk the base of the pyramid further, elevating the premiums of those who do pay. The universal mandate of the Affordable Care Act will reverse this process and drop those premiums.

The frustration of applying for individual health insurance

Because of my self-unemployment I have been applying for individual coverage for Debbie and myself.  It has been a nightmare of missed phone calls, misplaced applications and denial letters from Blue Cross Blue Shield.

Over three decades my office paid tens of thousands of dollars in premiums to BCBS for my family’s coverage. We used it very little. Now that we seek individual coverage, Debbie has been denied a “premium” product because she had the temerity to actually use her coverage electively for a one-off medical procedure and some counseling.

This denial requires me to follow three applications (mine, her appeal application, and an open enrollment application) in three divisions of BCBS which do not communicate with each other and which refuse to speak to me about her applications based on HIPPA confidentiality issues.

The result is endless frustration and the anxiety that she may be without health coverage for a few months, after years of paying into the BCBS system. We are being punished for redeeming a tiny fraction of what we have paid in. They are cherry picking their applicants, even former “loyal” customers.

[Ed note: thank you, Sam, for dealing with this. – Debbie]

Researching the advantages of a single payer system

In the last week I have been looking into the site for Physicians for a National Health Program (PNHP). It has become clear to me that a single payer system is the only system that makes sense and that enterprises like BCBS exist to perpetuate themselves as a business entity and not to insure people as a service.

New and welcome distractions: the grandchildren

Our new guesthouse is now occupied. A new set of distractions has arrived in the form of family and grandchildren. After struggling with the passive aggressive behavior of the U.S. Postal Service and BCBS for three weeks I am giving up and giving in.

Our mail was lost in central processing; I am going sailing

Bills will be unpaid because three weeks of mail have been left in central processing. I might not be able to get Debbie insured for the next month because BCBS has mailed me an appeal notification rather than describe it over the phone. That mail is held hostage with my bills.

So, if you think a Gap Year is without logistical problems, think again.

Of course, if I had the bandwidth to deal with all these logistics before starting a Gap Year, I would be such an organizational whiz that I wouldn’t need a Gap Year.

I am going sailing with my son-in-law.

Finding structure without patients and hourly appointments; proton beam therapy and more

Six weeks into my gap year I continue to enjoy my freedom and I feel significantly less stressed. I do have, however, a persistent inability to apply structure to my day. I get distracted and am unable to follow through with my more important projects.

The structure of office visits and colonoscopies was a special luxury for helping with time management. During a procedure there could be no interruptions. During an office visit only a few things rose to the level of importance to allow for an interruption. The result was that everything non-medical, in terms of daily activities, had to be squeezed into a narrow window. This promoted both efficiency and stress.

Less stress means less efficiency

Now, with all the time in the world, there is less of both. I lament the fact that I have been unable to assert enough self control to carve out a block of time for reading, another for studying, a third for exercise, etc. Perhaps this will improve when the distractions of our construction project end. Perhaps I simply have to do better.

The euphoria of the World Domination Summit is waning. I really enjoyed the sympathetic qualities of the participants. I was inspired to develop my own writing project as a result. I hope it will become a short book. I cannot discuss the subject matter now because it could be seen as relating to a family member with whom I have not yet conferred. I am further inspired to maintain my disgust with the “market forces” in American health care.

When does unethical behavior become a crime?

While at the WDS I missed a New York Times Op-Ed piece by H. Gilbert Welch, M.D. who is trying to rally moral outrage against the high cost of medical care and the unethical, immoral (?), and to use his term “criminal” practices behind it.

Curiously, I was involved in two of the problems he cited: colonoscopies and proton beam therapy for special radiation treatment needs in Washington, D.C.

I have written about the excessive use of anesthesiologists during routine colonoscopies and how it has become the standard of care in well-to-do communities because doctors can leverage a higher income per procedure – not because it improves outcomes.

Because this practice runs counter to the recommendations of our professional gastrointestinal societies it is highly unethical. Because it is spreading based purely on medical mammonism, it is disgraceful. When does a professionally disgraceful and unethical behavior become a crime?

What you need to know about proton beam therapy

Proton beam therapy is slightly more nuanced and highlights a new set of issues. Specifically, we as a population are underwriting the expense of these unnecessary costs. But first, let me describe the benefits of proton therapy in laymen’s terms.

External beam radiation therapy is an important therapy for certain cancers. It has been refined over the decades to improve the focus and minimize the side effects, particularly the collateral damage to other tissue. Standard external beam therapy has an entrance beam and an exit beam and normal tissue in this pathway can be altered significantly. Some normal tissue will become cancerous at a later date.

If the heart is in the pathway, the risk of myocardial infarction is increased over time. Finally, surgical tissue planes will become fused by radiation and complicate surgery if indicated in the future. Therefore, standard external beam therapy is fine for palliative care where the long-term prognosis is limited but not ideal for curative treatments, especially in young patients.

Tomotherapy and Cyberknife therapy combine to improve the focus and to use multiple beams that overlap at the disease site so that the dose of radiation is appropriately lethal but the surrounding tissue is exposed to less damage.

The advantage (and higher cost) of proton beam therapy

Finally, proton beam therapy has special characteristics in this regard. It can be more precisely focused, it has a reduced entrance beam effect, and there is no exit beam. You will have to speak with a nuclear physicist for further explanation. It can be argued that this is very important for the treatment of children, especially with brain and spinal cord disease. However, it is very expensive and there are comparatively few cases of child hood cancers.

The total number of proton beam accelerators in the U.S. is currently small. They cost tens of millions of dollars to build and require a lot of space, much more than a standard radiation facility. Somewhere between 15 and 20 centers exist, mostly at university centers. Plans for many more are in the works but no one knows how many more are needed.

The backstory of proton therapy in D.C. begins in Baltimore where the University of Maryland obtained a CON (certificate of need) from the local authorities. Johns Hopkins Health System determined that it needed a proton therapy center to remain competitive and maintain its “brand.” Recognizing there was no conceivable way it would also get a CON in Baltimore, it looked to its affiliated hospital, Sibley Memorial Hospital, with lots of property in Washington, D.C.

Sibley is a community hospital in an affluent neighborhood. It is licensed for about 250 beds but does not run at full capacity because of local demographics and competition from several other nearby hospitals. Its budget is tight. The added income from proton therapy was very appealing to the hospital administration. I practiced at Sibley for thirty-one years and served on its board of trustees for ten years. When the proposed financing package to build the $130million Sibley/Hopkins facility looked doable, it was my fiscal responsibility to vote for the project and protect Sibley’s future.

But at what cost to society?

Immediately upon hearing the news of the Sibley/Hopkins plan, Georgetown University Hospital filed for a CON to protect its Lombardi Cancer Center brand. And that is how three facilities are in the pipeline in the mid-Atlantic region. Fortunately, no ground will break in D.C. for sometime and sanity might prevail.

But the point for all working Americans is this. If we over build proton beam facilities we will ultimately use them for patients without special needs, men with prostate cancer, for example. Of unproven benefit beyond the benefits of standard radiation, the cost of proton beam therapy is exponentially more expensive and the trade off is simply convenience for the patient.

Although the following numbers are very rough estimates, the order of magnitude is accurate. Standard radiation therapy for prostate cancer is 28 sessions and Medicare reimburses $25,000.

Cyberknife therapy is only five sessions and Medicare reimburses $125,000.

Proton therapy is done in a single session and Medicare probably reimburses the facility over $200,000.

Why would I want my tax dollars spent on the treatment of a cancer that is probably diagnosed too frequently, probably would not kill the patient, and which costs society eight times the standard therapy? So that the patient suffers less inconvenience?

Well, I don’t want to do that but I see ads for proton therapy for prostate cancer and I am outraged. It suggests there are already too many underused proton gantries.

As an aside, I believe some doctors are underpaid

As an aside, let me say that I think doctors are underpaid. This does not apply to overpaid specialists who exclusively cherry pick and treat the walking well. This does apply to treating doctors who care for the sickest of the sick in the trenches of the ER, the ICU, the OR emergencies, etc.

Doctors are the most highly educated and extensively trained professionals in our society. Good doctors deserve compensation consistent with the sacrifices they made and the professionalism they continue to exhibit. If we did not waste money on unnecessary and costly treatments such as proton therapy for prostate cancer (not to mention the hundreds of billions of dollars overcompensating the pharmaceutical industry, health care administrators, insurance company executives, etc.) there would be plenty of money to compensate providers for doing the right thing.

Start getting outraged, dear reader

Stop being satisfied with your personal health care system. Stop overcompensating unnecessary care, unnecessary executives, and unprofessional providers. Get outraged with the national health care dysfunction and lend your voice to the fray.

Sump pumps at 6 AM on the coast of Maine

Living on the coast of Maine is very special. It is a constant battle with the elements even when the sun is shining and the wind is calm. I began my day, which is cool and foggy, with a visit to the basement to explore the (disturbing) absence of noise from my sump pumps.

An E. B. White morning?

I found their pores clogged. I opened one pump’s inlet pores to make it operational for the impending showers. Then I put it back online. It worked, although the disrupted connections now leaked a bit. Still, I felt accomplished with my male version of The Happiness Project and even happier with my subsequent decision to call the plumber to muck out the drains and professionally reattach the pipes.

All of this before six in the morning. I love calling the local businesses at 6 AM and finding them open and ready to work. Do I sound like E. B. White yet?

I came back from the World Domination Summit with a renewed sense of self worth, even without a professional title. As part of the trip back, we paused for a night at the home of a childhood friend. He is a plastic and hand surgeon. He was late to greet us because of an add-on case involving the loss of three digits [aka fingers] to a band saw.

We had a great dinner and he left earlier the next morning than expected when he was called to the OR for an abscessed finger. I envied his energy and his professionalism. But I am still savoring my new freedom.

I also reminded myself that he has carved out a part-time practice, and although busy at the time of our visit, he generally works only four days per week and takes four months of vacation per year. I never figured out how to do that. A professional, caring, gastroenterologist had to be more available than that to keep a practice alive in Washington, DC.

What the word “profession” means

Medicine is a profession and should be practiced as such. The definition of a profession varies from dictionary to dictionary. The most common definition describes a profession as an occupation requiring rigorous and prolonged education and training. Another common definition refers to profession as “a calling” because of its earliest usage as a “profession of faith”. Finally, some definitions include the concept that a profession is an occupation with standards and obligations that its practitioners accept and meet.

This is what used to separate practitioners of law, medicine, and journalism from the average businessman.

In the course of a business transaction two parties will come to an agreement. If one party benefits more by the agreement than the other he is considered a good businessman. Both parties came together willingly and with equal standing in the transaction.

In the true professions (law, medicine, education, journalism) the relationship between the professional and the subject is asymmetric. The doctor or lawyer has a vast knowledge base that the patient or client does not. The patient or client relies on the doctor or lawyer to exercise judgment in the treatment or recommendations rendered. They pay for the expertise with the understanding that the professional will exercise restraint and in no way abuse the position of power and authority that they hold.

Journalists have power over their readers that requires the exercise of judgment and restraint in reporting events. In this asymmetric relationship the reader relies on the writer to tell the truth.

We all know how teachers have power over students. We expect teachers to inspire and stimulate students without abusing their position or teaching a misguided perspective.

My lament: professions have turned into businesses

Over the last few decades we have seen professions turned into businesses. In the realm of education we have seen for profit schools take federal loan money and churn out workers unable to find jobs.

We all know lawyers who complain that the business aspect of their firm’s activities must be satisfied first. One elderly lawyer has said to me that when he started practice the best legal advice he could give was independent of cost considerations. When he left practice the “best” advice was that which made the most money for the firm.

Journalism is a difficult profession to contain by ethical standards because it is so easy to slip into a PR mode or to shade the truth to sell a product. It is also easy to confuse rumor and opinion with news. The growth of the cult of celebrity in our culture compounds the problems in journalism as celebrity journalists become more influential than thoughtful journalists and the distinction between journalism and entertainment is blurred.

As I pour out this sanctimonious rant on professional behavior I remember Professor Wilmott Ragsdale’s favorite expression, “Journalism, a profession? I don’t think so. Boxing is a profession!” So, I recognize shades of gray in all professional activities. [Ed note: Rags, as we called him, was my journalism professor at the University of Wisconsin in the mid-1970s. He was the best teacher I ever had.]

Yet, I lament the loss of professionalism in medicine. For in medicine the business model has become paramount. Whatever makes the most money for the practitioner is the best medical care. It is sad to see and as I wrote about the use of propofol delivered by anesthesiologists for routine colonoscopies, it is a disgrace.

The largest group of gastroenterologists in the Baltimore/Washington/Northern Virginia region took a vote about the use of conventional sedatives (as recommended by the professional societies that guide subspecialty care) versus the employment of anesthesiologists that would allow them an additional revenue stream and more profit. The majority voted for the added revenue even though this does not improve quality of care. Do they discuss this with patients? No, they tell the patients what “is best” and the patient accepts the advice.

I am advised by other colleagues that whole hospital systems have adopted this use of propofol by rationalizing that they are standardizing treatment across a spectrum of care but the real reason is to increase cash flow in a world of increasing hospital costs and decreasing revenue.

Anything goes in a business transaction but revenue should not be the driving force in a professional consultation or treatment. As Dr. Steve Nissen, of the Cleveland Clinic said in the documentary Escape Fire: the Fight to Rescue American Healthcare: “When we made medicine a business, we lost our moral compass.”

Bless those who have the moral fiber to stand up to the commercialization of medicine.

I am going back to the basement to check my sump pumps.

Photo is of E. B. White writing in his boathouse in Allen Cove, Maine. Courtesy of Andrew Romano.

Tapping into the hunger for change at the World Domination Summit

If you can’t see the video above, click here.

After attending World Domination Summit 2013, I was bathed in the glow of connection and acceptance and graciousness of the 2,800 attendees. What a lovely bunch of people.

We convened in Portland, OR for a carefully curated fest of “community, adventure and service,” as founder Chris Guillebeau describes it. If there is a common denominator for attendees, it’s that they are in thrall to the idea – articulated on Chris’s blog – that you can live a remarkable life in a conventional world.

That may sound overly aspirational. But it is a marvelously sustaining thought and Sam and I are buying into it as we embark on our Gap Year After Sixty.

I want to tell you about my experience doing a short talk from the main stage (that’s me in the orange blouse) but first, a key observation.

WDS was *not* a sea of 30-somethings

From the write-ups of the World Domination Summit in 2011 [recap] and 2012 [recap], I expected a sea of 30-somethings. I was struck and pleasantly surprised to see many 40, 50 and even 60-somethings attending this year. WDS is definitely not just an event for Millennials.

I had been worried about the WDS demographic given the topic of my talk on taking a gap year… 40 years after you are supposed to. So I worked hard to prepare, rewriting my talk a dozen times and practicing at least 50 times.

I worked on it with Sam. And also got some very useful feedback from Ishita Gupta. As Ishita, who has worked with Seth Godin, puts it, “Seth says don’t go out on stage and address an audience unless you intend to change them.”

Hungering for change at the World Domination Summit

I only spoke for two minutes and thirty seconds but I think I succeeded. Let me amend that. I’ll snuff out my usual self-doubt and say it more clearly.

Yes, I changed the audience!

I’ve given many, many talks and keynotes over the past decade, but none that resonated more strongly than this one. I was astonished by the number of people who came up to me afterwards to say, “Were you the lady in orange? I loved your talk and here’s what it meant to me… “

That’s the part that was so gratifying. Not that the audience liked my talk but that they wanted to connect and share their own story about a gap year or time out or proposed radical change in their lives.

Either they are planning a gap year now or they know someone who just left their job to explore other options for work or in several cases (Caroline and Josh of Traveling9to5; Brittany and Drew of MrandMrsAdventure) they are traveling around the world for a year.

I tapped into something that this group, and so many other people, are hungering for: CHANGE. One of the main stage speakers reminded us that, according to a recent Gallup poll, 70 percent of U.S. employees are unhappy or disengaged at work.

The three important questions to ask

As I said in my talk,

“You don’t need to live your entire adult life… you don’t need to get to the age of 60 or 50 or 40… before you ask three important questions:

– How do you break out of your familiar patterns?

– How do you redefine yourself – and explore a new purpose?

– How do you embrace the uncertainty of life?”

Huge thanks to Genevieve Santos, who was sitting in the front row, for the informal vid of my talk!

Finding my voice at World Domination Summit 2013

I tend to do what I’m told (for example, Bollywood dancing at the closing party) so when Chris Guillebeau advised World Domination Summit 2013 attendees to go to a breakout session on a topic that might be uncomfortable or new, I took his word.

I decided to go to the Improv Workshop with Portland legend Gary Hirsch, knowing that improvisation would be a stretch of my public persona skills. I was 15 to 20 minutes early. But not early enough to get a seat. Was I hoping to be shut out??

Dozens of people arrived later than I did. I floundered for a few minutes and then decided to try the pirate-themed, glow-in-the-dark, miniature golf course a few blocks away in downtown Portland, OR. Chris had mentioned it several times from the WDS main stage.

Naah. I went back to our hotel room to write this blog post.

One WDS theme: becoming more self-aware

Although the guiding principle of WDS is how to lead a remarkable life in a conventional world, it is becoming clear that there are several sub-themes and several types of people here.

One theme is to find one’s true self and become more self-aware. This is frequently coupled with a desire to more comfortably express one’s self, particularly when speaking in public before a large crowd.

Because this is one of my great stressors I had hoped to start at the improvisational level. I am no good at improvisation because I always want to have the mot juste pass my lips. That means a mental block unless, of course, I have had just the right amount of beer.

So there was to be no progress in public speaking skills at #WDS2013.

In the photo above, we are participating in the river float on the Willamette to break a Guinness Book of World Record for longest floating human chain. Yes, we did it.

Another WDS theme: taking a gap year

Another theme coupled with finding one’s true calling is the sabbatical or gap year theme.  One speaker said that 70% of people want to change careers and a gap year appeals to most of them if they can swing it.

I suspect that’s why Debbie was chosen as an Attendee Story Teller: our story of my leaving a successful medical practice after 31 years and us moving from a big city to a small town resonated with many attendees. (Debbie is also an experienced speaker and has an online persona, which I do not.)

More importantly for me, even if I do not improve my public speaking skills at this event, is that I have learned that I must write about my anger and disgust with the way the private practice of medicine evolved during my career.

WDS has shown me that I have to purge myself of this even at the risk of alienating readers.

Well, as I find my WDS voice and as I try to transform myself, a bit, I need to clarify what contributed to my need for personal change.

Prepare yourself, dear reader

So, gentle reader, prepare yourself for some angry perspectives on medical care.

The speakers all come with a variety of skills, with the exception of one devoted and compelling attendee who could not keep it together on stage, and all had good presence.

But they do not all have the ability to move the audience.  Two of the first eight speakers were so genuine that they brought the audience to their feet. The others, in my opinion, were too polished or too self-absorbed to truly move the group.

Tess Vigeland, the former host of NPR’s Marketplace Money, was one of the genuine speakers who described leaving her job without a plan or established safety net. Her situation is perhaps the most comparable to mine in terms of the level of career “sacrificed.”

Tess clearly wanted to return to broadcast journalism and described for us the heartbreak of losing, very narrowly, the tryout to be the next anchor of Weekend Edition of NPR’s All Things Considered.

I am more comfortable knowing that I will never practice medicine again than she is considering she might not broadcast from a national stage again.

Why am I comfortable giving up the tiny celebrity of the successful physician?  Is it because I am most comfortable as an introvert? If so, why am I seeking a more public persona by starting a blog on medical excess and self-rejuvenation?

Go figure.

From the desk of Dr. Harrington: “The bubble over my head”

One of the most irritating expressions a patient can use is… “I am supposed to…”

It is usually verbalized just after a diagnosis is made and a treatment plan is being considered.

For example:

“Mr. Smith, your CT scan shows extensive diverticulitis; and, although no abscess is demonstrated your abdomen is very tender; I recommend hospitalization and IV antibiotics.”

“But Doctor Harrington, I am supposed to go to New York for the weekend.”

The bubble over my head wants to ask Mr. Smith, “What are you going to do there… address the United Nations and finalize a plan for permanent world peace?”

Instead I say, “Well, this is inconvenient but in the interest of your health I think hospitalization is best.”

The dictionary defines supposed to to mean (in order of decreasing usage):

– pretended, alleged, held as opinion (believed)

– considered probable (expected)

– understood, made or fashioned by intent, required by authority, and given permission.

When a patient uses the term it is invariably to tell the doctor that they are obliged (required by some unseen authority) to be somewhere or to do something that makes following the medical recommendations simply impossible.

“But Doctor Harrington, I am supposed to go to New York this week, not to address the UN but for something more important: I promised my granddaughter to take her shopping.”

Other variations on such an obligation might be: “I am supposed to go to the beach, it is supposed to be a lovely week end.” Or “I am supposed to go to Nantucket for the summer; my family and I have done it every year for 20 years in a row.”

What makes this response, this quasi-rationalization, most irksome is that it frequently comes from someone who has lived well and has high expectations combined with a sense of entitlement.

Indeed, frequently their illness is caused or compounded by the richness and overindulgence of their lifestyle.

The case in point would be an overweight, former smoker, with diabetes, hypertensive heart disease and degenerative arthritis who develops a bleeding ulcer from alcohol and NSAIDs, while taking a blood thinner for atrial fibrillation.

This is the type of person who will bleed into shock, get resuscitated, have a surgery-sparing endoscopy to clip and cauterize the offending ulcer and then will question the recommendation that travel plans be put on hold pending observation of their clinical status. “But I am supposed to… ”

Compound this scenario with someone who thinks they have some insight into their condition and it makes the responsible physician’s head explode.

[A little wordy but I think he needs to get this rant out of his system. – Debbie]

Take the following vignette:

The phone rings at 2:00 AM on a Sunday. The answering service reports that a Mr. Jones has abdominal pain and needs an immediate call back. The call is put through.

“Hello?”

“Dr. Harrington here, I am covering for your primary physician, Dr. X. How can I help you, Mr. Jones?”

“I have diverticulitis and I need you to call in some antibiotics.”

“How do you know this is diverticulitis?”

“Well, this is just like the last time and my father was a doctor, so I know.”

After a few questions to clarify that the patient is not critically sick, does not take any problematic medications, has no allergies and has been symptomatic for several days, I respond, “Well, it does sound like diverticulitis, but there are other possibilities.”

The patient could indeed have diverticulitis (alternatively, and much less likely, the differential diagnosis would include bowel obstruction, colon cancer, a ureteral stone or early shingles).

I continue, “The best thing to do would be to see your doctor in the morning and clarify the diagnosis. Ideally you should have some blood work, an abdominal exam, and possibly a CT scan to exclude a complication, such as a mass or abscess, before committing to antibiotics.”

“But, doctor, I am supposed to leave for New York on the 9:00 AM shuttle. My doctor treats me over the phone all the time and my father used to do that, too.”

“What are you going to do in New York?”

“I am giving a speech.”

“To the UN?” I wonder, aloud.

“No, to a group of lawyers, colleagues.”

This is where my head threatens to explode.

Here is a well-educated man who has had symptoms for several days but calls for help at the last minute; indeed too late to actually get the proper analysis, and has the expectation that he should get free care because he is supposed to do something “important.”

Yes, under other circumstances his personal physician might be willing to phone in antibiotics because of past experience, but as a lawyer he should know that an on-call physician has a different obligation and in some jurisdictions it is illegal to prescribe without examining the patient.

After giving him a not-so-diplomatic lecture on the meaning of supposed to, the inappropriate timing of his call, and the pathophysiology of diverticulitis, I did phone in the antibiotics and did report off to his primary MD later.

The expectation that all illnesses can be successfully treated and the added expectation that they can always be treated within the patient’s schedule is a real problem in the well-heeled population.

It is encapsulated in the phrase: “I am supposed to…” When I hear that I know I have a lot of patient education to perform, starting with a reality check.

More later on the problems of “expectations.”

Q. & A. with Debbie and Sam on “collaboration”

Debbie: Is this really our first collaboration? What about our three children?

Sam: That was different.

Debbie: You’re right; it was.

Sam: This is doing creative work together.

Debbie: And you don’t mind me being your editor? It’s not that easy.

Sam: You mean because of our different approach to quotation marks and periods and spaces at the end of sentences?

Debbie: No, because sometimes I don’t love every word that you write. Your prose is generally very, very good. But sometimes you are a little repetitive and not entirely clear.

Sam: What?!!

Debbie: OK, never mind. I shouldn’t have said that. You are an amazing and prolific first-time blogger. I only want to encourage you.

Sam: That sounds better.

Debbie: I take this blog very seriously, you know.

Sam: I do too.

Debbie: I have high standards.

Sam: I’ve noticed.

Debbie: I’m not entirely sure where the blog is going but I think it’s important to articulate what we’re experiencing.

Sam: How honest do you think we should be about how we’re really feeling one month into our Gap Year?

Debbie: Giggle.

Sam: Seriously, how much should we reveal?

Debbie: Well, as the resident blogging expert I would advise us to be authentic… but not to reveal everything. I don’t want people to know how discombobulated I feel, for example.

Sam: That will probably pass when we have established a better routine.

Debbie: But isn’t that the point? That we’re breaking out of our familiar routines?

Sam: Yes and no. Once we’re properly unpacked and settled on the coast of Maine we’ll feel better.

Debbie: What if I miss DC?

Sam: I don’t miss DC.

Debbie: I do sometimes. All this traveling (back and forth between DC and Stonington, ME; to Portland, OR for the World Domination Summit) makes me unsettled. I’ve been talking for years about how cool it is that my work is “location independent.” But so far I haven’t adjusted to a nomadic lifestyle.

Sam: Give it time. Imagine how I feel giving up my daily routine with patients at the office and the hospital.

Debbie: I worry about that a lot. Sometimes I think I’m worrying for you; that you might miss it too much.

Sam: OK, enough with the touchy feely.

Debbie: Yes, and… 

Written 33,000 feet up on Alaska Air #35 bound for Portland, OR.

Heading to the World Domination Summit… as a travel-hacking, old-age blogger

The first month of my Gap Year is over. Eleven months to go. I have had two business discussions about potential future endeavors but remain committed to holding off on serious talks until I have really separated from my practice by several months.

Over the weekend a patient called. She is one of the few who have my cell phone number. I instantly went back into the “Doctor” mode for a few minutes of advice. It was not comforting or comfortable. It just was.

We (Debbie and I) remain in limbo as the “transition” of the first month bleeds into the second. We have decamped to our cottage in Maine but because of construction delays we cannot completely unpack and settle in.

We are living in transit among boxes, suitcases and unhung art. This blocks the flow of progress. I cannot redefine myself if I have to devote my limited brainpower to organizing rooms.

We are also preparing for the World Domination Summit (WDS). I have my new business cards. This is a break from my past. The old cards were black on white with name, number, subspecialty and “By Appointment.”

Now they are in color, with a photo (avatar head shot), blog site, email address and motivational (or demotivational) quotes on the obverse.

My family will recognize most of them. For example: “Always be sincere, whether you mean it or not” – Michael Flanders. And “Neither man nor woman can be worth anything until they have discovered that they are fools” – Lord Melbourne.

And particularly apt, “Look on every exit as being an entrance somewhere else” – Tom Stoppard.

Of course my family will not be anywhere near me when I am passing them out and pretending to be a new age thinker.

Debbie was selected to do a two-minute, main stage presentation on Gap Year after Sixty. We are writing the talk together. She has done short talks before, for Ignite DC, and is a good choice.

This is our second collaboration. It is going well. The first collaboration is to allow Debbie to edit my rants. She is a good editor but is completely inflexible on certain punctuation issues. [Ha! – Debbie]

For example, why not end a sentence with the period outside of the quotation marks? It is good enough for the Brits and it is promoted by the space bar function on the old Blackberry. On my current iPhone a double tap on the space bar inserts a period before the next sentence.

This function also promotes my old habit, on a typewriter or full keyboard, of using two spaces between a period and the start of a new sentence. Where did I learn this? Debbie insists it should only be one. I cannot easily break this habit but it is killing her to eliminate the space between sentences as she edits. Who will crack first?

On to WDS, where I will try on a new persona as a travel-hacking, self-redefining, old age pensioner-blogger.

More medical rants with my next posts. They are therapeutic.