“In another life, I would have been a good math teacher,” I once told a teacher friend. I don’t believe in another life, but I still have this one and realized I can become a good math teacher. I now substitute; based on my training and experience I ought be allowed to teach full-time.
I’ve often felt I never belonged in medicine. Indeed, looking back on what has given my life meaning, medicine ranks a distant fifth–yes, fifth–behind my wife, allowing my parents to die the way they wanted, the companion animals I’ve taken in and my experiencing the beauty of nature all over the world.
I did belong in medicine, just not here. I belonged in medicine where physician training was geared towards dealing with patients typically seen in practice. Surgeons are trained in and do surgery; radiologists interpret images; ED physicians field emergencies; dermatologists treat skin disorders.
I mistakenly thought that neurologists were consultants who treated neurological disease. Nearly half of my new patients had limb pain, spine pain, dizziness and headache. I counted. In my training, I learned little about headache and spine pain and nothing about dizziness and limb pain. Yes, we need to learn rare diseases, but we also need to learn how to treat the common ones. I had learn it myself. Too many patients with carotid artery disease were sent directly to surgeons, bypassing me. Yet, in 1984, I had city-wide data showing a 15% major complication rate for carotid endarterectomy (CEA), much worse than medical management. I sent my referrals to the only surgeon whose outcomes beat medical treatment. Locally, the complication percentage didn’t change during the next decade. I counted. I used outcomes data years before it was a buzzword and got blasted by my colleagues for using it to help my patients. I diagnosed and successfully treated depression a decade before it was mainstream, when still equated with being “crazy.” Got blasted for that, too, by patients, expecting a deadly neurological disease (which it is).
Much of my practice consisted of patients with normal tests, post-surgical disasters and chronic pain; the last I was unable to help. I was not taught how to diagnose irreversible brain injury, discontinue support and deal with families. While I was trained to treat epilepsy, most of the seizures I saw were psychogenic. I counted. In 1982, I proved statistically that perceived I’m-not-at-fault injuries dramatically increase the likelihood of chronic pain.
I belonged in medicine where counting was valued, not mocked, and we tracked important matters, like CEA morbidity and clean case surgical wound infections. I developed a non-discoverable reporting system for errors, so we could learn from and not hide mistakes. More legislators backed my bills than doctors; had the bills passed, we would have advanced the cause for liability reform, because they were primarily about helping patients, not decreasing premiums. Ironically, four immediate family members have suffered consequences of medical errors.
I was frequently asked “Are you busy?” but never “Are you happy?” Yes, I was busy–and no, I was not happy, because I was rushed, interrupted, and chronically tired, three classic setups to make errors, in order to pack in another “emergency,” an overused term increasing stress, cost, shortcuts and mistakes. Some ED clerks were instructed to call every neurological consult “stat.” I accepted that many neurological conditions couldn’t be helped; I grew weary of the many conditions neither diagnosable nor treatable. It took me too long to realize I could quit. I never regretted doing so.
In a better medical world, we would fix the numerous faulty processes that decrease quality, increase costs and suck the fun out of life. We would review every hospital death to see if a medical error occurred. With appropriate sampling, we would have a decent estimate, not the old, inaccurate infamous “100,000 deaths.” I once thought my experience in practice, administration, quality, statistics and writing would make me a valuable local resource. I was as mistaken, as those at GM who pushed for Japanese style quality outside of NUMMI.
My local and state medical societies should demand real-time data on breast and other cancer incidence, not difficult, rather than 4 year-old results (look it up). We should have city/state-wide standardized checklist approaches to central line insertion/care, ventilators and pre-op antibiotics, to name just three. Public health committees should discuss important issues they could influence: obesity in the young and annual motor vehicle deaths, the latter unnecessarily killing more local teens than Mad Cow, West Nile, mercury, terrorism, autism or kissing bugs combined. My challenge to the committee to change its approach received one letter of support; I resigned. Surveys, which I randomized for free, should take a quarter of a year, not a quarter of a decade, to complete. Yes, 2.5 years.
My solutions aren’t perfect, but every one is better than what we have. Waiting for perfection is like waiting for Godot. I’m not a shaker but a mover, moving so far ahead I’m no longer visible. In my lifetime, I will teach math, but in my lifetime I will neither develop nor see the medical changes that would have been so easy, effective and necessary.
Boreal B[l]og 