The right thing

Recently, I had to go to a meeting where we reviewed our HCAPS scores and other quality metrics. If you don't know what these are, then you're lucky. And we've had industry experts come in and talk to us about "Here's how to get your HCAPS better!" or "Shaving down your length of stay" or some other talk, in order to game our numbers and earn ourselves a few extra nickels. Most of the time, I play on my phone the whole time, or zone out completely. I have open disdain for such talks, not because quality of care is important, because it is. Quality of care is extremely important. But average LOS and HCAPS and HEDIS and all these quality metrics are all surrogates. I can make those numbers better, but that doesn't mean that I'm a good doctor.

However, one of these speakers said something that reached me. "The most important thing," he started. "...is that we do what is right for our patients. That's job #1. Then, we should figure out how we can get paid better for it. But even if we can't get paid better, at least we know we did what is right."

I spend a lot of time doing what is right, rather than what is expedient or what gets me more money. And that sounds so estimable and noble, but in reality, that is hard work. That is spending time arguing with an insurance company over a refused prior authorization, or seeing that patient who came in so late to their appointment but with acute problems that can't wait till next week, or spending 5 extra minutes writing a good note that most likely no one will ever read.

I used to be a little bitter that here I was, doing the right thing, and getting no credit for it. As well, there were plenty of others doing a fairly terrible job, and no one was calling them out for it. And it took this line from this industry expert to remind me that the goal wasn't to get credit. The goal was to do the right thing. That's the reward. Getting credit is just a pleasant side effect, should it happen.

When I was in college, I was the proverbial "nice guy" who never got the date with the girl, and I was similarly bitter back then. Here I was, such a nice guy, but ignored by so many women. And I was reminded by a very wise old lady that goodness is its own reward. If you are being nice to women only for the expectation of a reward, then that's not chivalry. That's being a creep.

Choosing a specialty

Recently, I was talking to a 3rd year student, and he was trying to figure out what to do with his life. He was still a little lost, like most people in their 3rd year. Everything either seems fun or horrible. Everyone expects that moment of, 'This is what I want to do with the rest of my life!' but in reality, few of us get that moment. I can't tell you when I decided on internal medicine. I just did.

I tell most people that they should go with the pathology. Whatever diseases interest you are probably things that will continue to interest you, because the patients can't all be winners. This student told me that he wanted to do ER because he didn't want to see the same thing over and over. I was polite enough not to laugh in his face.

The truth is that every specialty has its bread and butter. For me, that's hypertension and diabetes. For the surgeon, it's gallbladders and appendices. And all specialties have their chronic patients. You can't choose a specialty aiming to avoid these chronic folks or to dodge the routine diseases. The only way to dodge that stuff is to go into a field without direct care: radiology, anesthesia, path...

When I was trying to decide, I posed a simple but profound question to myself: what is my staple diet? Sometimes I get a taste for Mexican, but I can eat rice every day for the rest of my life. And that's what choosing a specialty is like to me. What can I see again and again and always find satisfying? That's the specialty for me.

In an alternate universe

the gospel reading by danielkedinger

Going over this blog, I am surprised that I have not had any posts regarding probably the biggest choice in my life which I made sometime in high school, and that was simply: doctor or priest?

For those of you who may not know, in high school in the midst of my morose, teenage existence, I very seriously contemplated the Roman Catholic priesthood. In the end, I couldn't do it. I thought and thought and thought, but I decided against the priesthood. I just couldn't reconcile being alone for the rest of my life, without companionship or love or intimacy. It was too much of a void.

But fifteen years later, I have had all of two relationships, a number of dates that I can actually count, a complete absence of physical intimacy, and without a date in the last two years somewhat by choice. Now I question my teenage decision. I seriously wonder about such a strange choice, made with the presumption that I would probably be married by now, possibly with children. The plan was never that I would still be single.

I made that choice with the hope of love. I made it with the dream of finding another person to complement me, to share my life. I made that choice based on potentials and possibilities, and not about what I had or who I was. It was a decision of what was outside of me, outside of my control, and not anything to do with what was within me, except the intense desire to be loved.

And still, I have this intense, burning desire to be loved. It's not as much to love; it isn't reciprocal. I want to be loved, to be welcomed, to be held tightly. And honestly, I don't want to love someone as much. Still, I would love to love, to give my heart to someone, but I the idea that I am loved, that I am necessary, this is what has motivated my life.

My decisions and actions since this life changing, teenage choice, they have all boiled down to me being needed. My patients, I treat them with such compassion and earnestness because I seek their approval. I need them to see me as necessary, and to accept me. I am at heart a very selfish person. It is just that my selfishness is manifested by such altruism. It is like what Emerson said: "It is one of the most beautiful compensations of this life that no man can sincerely try to help another without helping himself."

Today, I find myself in such a quandary, because I find that decision in front of me again, and I'm not sure if I made the right choice. I don't know that I would choose the same path, knowing what I know now. It would be nice if I could look into an alternate universe and see what that other life would be like. Maybe I would find it to be the better choice, but I don't know that there is such a thing as better.

Part of what makes this choice not quite as disturbing these days was that when I was thinking about it more than a decade ago, it was with the knowledge that both choices were good ones, that I could live with either. I could never look upon a life as a doctor and say that it was a worthless endeavor. I couldn't see being a priest as a waste of time. It was a choice between two goods, not two evils.

Really, it's not about which choice was better, but which was right for me, because I didn't make that choice based on intrinsics but on what was extrinsic. If I think about who I am (or rather who I was) I'm not sure that I chose right. I'm still not sure, on the cusp of being an attending physician, if medicine was right for me.

I know that I have done good work. I have held the hands of the dying. I have comforted the sick. I have healed when I could, and done my best. I have without a doubt in my mind done good. If the scales of my life were to balance today, I would tip in the right direction.

I remember one of my patients was dying from florid sepsis, and the patient's sister refused to let the patient's boyfriend visit. She barred him from the ICU room. I sat her down in the nursing station and told her, "Your sister is not long for this earth. I have done everything I can do with medicine. There is no other drug I can give or procedure I can do. You have the exceptional duty to carry out her wishes, so please, whatever you may think of this man, please think of what your sister would want." She relented and let him see her as we turned off the levophed and dopamine. They wept and hugged, and she thanked me, she THANKED me, the man who let her sister die. Because love always beats hate.

And I had one patient with severe mental retardation without any family, and I held her hand and sang to her happy birthday, as the nurses turned off the vent and let her expire from sepsis. There was no one there to celebrate that day but me and the nurses. And after exactly 64 years on this earth, I stopped her life and closed her eyes.

There is not a doubt in my mind when I meet my maker that my soul is defensible, that I have done good with my life, and that was never the question. Because everyone is capable of doing good. The question is what was right for me. Because it's not like being a man of God is not without its own benevolence.

I remember I was in the hospital one day, and I met my priest there, standing over the body of one of my patients, a very wonderful lady who blew a vessel in her brain and was now brain dead. My priest thanked me for helping the patient's family. I pronounced the patient dead and left. I have to admit though that I was envious of that priest, that his job was just beginning and mine was done. And I wonder if maybe I made the right choice.