MACRA Payment Regulations Should Be Evidence-Based

Whether applied to policymaking for individuals, large populations, or administration of health services nationwide, it is imperative regulatory decisions be anchored to empirical evidence. The official MACRA rule has now been released.  It is 2,000 pages based on the opinion of many non-practicing physicians, Dartmouth economists, and government administrators with input from a few doctors on the front line. In my opinion, what began as a certain death sentence has commuted us to life in prison; MACRA will regulate physicians without representation. 

Let me acknowledge my opinion is limited by my own “small” practice bias. 380 thousand “small” practices (having 15 providers or less) will be exempted if they have less than 100 Medicare patients.  Your definition of small and mine are strikingly different.  Every single independent practice in my hometown of that “quasi-small” size, has sold to the local hospital already.  The “small” practices remaining in my community have 1 or 2 physicians, so I will refer to those as micro-practices for clarity.  My micro-practice serves more than 400 Medicaid patients, with a waitlist of more than 50.  MACRA rules do not seem to have an answer for when there are not enough micro-practices remaining with which to form a “virtual” group. 

I humbly suggest you expand the options in your “flexible” plan, to include a control group composed primarily of 1-2 physician practices.  Please, do not overlook the importance of tailoring interventions to the unique needs of small communities in order to ensure the existence of micro-practices in the long-term. The fates of millions of Medicare (and presumably Medicaid) beneficiaries is at stake.  It is absolutely essential that new payment plans are evaluated in comparison to a control group prior to arbitrarily being applied across the nation. 

A recent article in the NEJM evaluated early performance of ACO’s by using a control group, which is vitally important to the evaluation process.  Researchers concluded the first year was associated with early reductions in Medicare spending among 2012 entrants (1.4%, P=0.02) but not among 2013 entrants. Performance on quality measures was improved in some areas and unchanged in others.  And surprise, surprise, savings were consistently greater in independent primary care groups than in hospital-integrated groups among entrants in 2012 and 2013 (P=0.005 for interaction).  How on earth can CMS ignore yet another study showing independent primary care groups save money before someone important realizes MACRA (as it stands now) is on the bridge to nowhere?

Policymaking must use scientific research to guide decisions at each stage of the process in every branch of government. According to the Washington State Institute for Public Policy, there are three designations to grade the rigor of research methods and the amount of evidence available to guide sweeping program interventions: Evidence-based, research-based, and promising. 

Evidence-based programs have been rigorously studied; using randomized controlled trials, and found to be effective. Research-based programs have been tested using rigorous methods (studies using strong comparison groups, as I am proposing) but do not meet the evidence-based standard.  Promising programs have been tested using less arduous research designs and typically use well-constructed logic or theories to support ideas. 

Postulating and theorizing by Dartmouth economists has left us all on treacherous ground. These experts assembled data, “interpreted” it creatively, and then drew unsubstantiated conclusions upon which to base recommendations for creation of PCMH’s and ACO’s.  The fruits of their “promising, yet non evidence-based” labor have generated unimpressive outcomes, yet their poor quality decisions will not affect their income.  Culpability must be incorporated in the process this time.  Government agencies, their managers, and those economists now advising them must be held accountable for their outcomes this time before holding physicians responsible for ours.

Confidence in these experts is fading because Patient Centered Medical Homes (PCMH) and Accountable Care Organizations (ACO) are not holding up their end of the bargain, demonstrating miniscule savings at best, while making the life of a physician far more cumbersome.  A thorough critique by Kip Sullivan summarizes the research on three PCMH’s and three ACO’s showing little to any cost savings, further exposing the weak platform on which CMS has built their Quality Payment Program. 

In that same vein, CMS is estimating how much value-based payments will bring down medical costs while guiding patients toward better health.  The word “estimate” appears far too often in the Executive Summary of the MACRA Rule for me to be comfortable with this plan.  CMS intends to impose “promising, albeit not evidence-based” options on all physicians treating Medicare patients in less than 3 months.  Where is the conclusive data demonstrating cost containment and improved quality?  It does not appear to exist. What if your estimates are incorrect?  The consequences will be catastrophic for independent solo practices if your “estimates” are wrong.  Should I be forced to make this blind leap of faith without being certain?

Andy, good science will be good for your conscience. CMS policymaking must be based on rigorous research that is supported by empirical evidence, even if the results are equivocal.  Presuming, opining, and educated guessing are not adequate methods for imposing non evidence-based programs upon large populations.  Before CMS officially implements sweeping payment modifications on January 1st; please consider allowing a control group option, composed of small practices with 1-2 physicians.  I, for one, would like to be at the top of the list.  Do not throw the “fee-for-service” baby out with the bathwater before being absolutely certain your non-evidence-based payment models actually contain costs and are better for patient care quality than what is already in place. 

Don't Surrender Doctors... Fight. My Call to Action.

Independent physicians are at the beginning of a challenging movement as we fight to stay relevant and solvent during the transition of health care from independence to “regulation without representation”.     In 1773, British Parliament passed the Tea Act with the objective to help the struggling British East India Company survive. Opposition to the Act resulted in the return of delivered tea back to Britain.  Boston left the ships carrying tea in port and on December 16, 1773, colonists in disguise swarmed aboard three tea-laden ships and dumped their cargo into the harbor.  The seeds were planted for the Revolutionary War. 

Physicians in private practice are facing a war of our own, and make no mistake; we are battling for our freedom and our livelihoods.  Insurance companies and government control of health care has become “regulation without representation.”  Lofty guidelines are being imposed, while administrators, insurance executives, and policy consultants are wedged firmly between doctors and patients.  Ironically, when it comes to taking responsibility for a life, the physician is standing there all alone.  How dare we ask a fee-for-the-service we have rendered?  That would be ‘fiscally wasteful’ according to health policy pundits who know nothing of service-oriented occupations.  This is my call to action. 

Where is all the money going?  CEO’s of healthcare insurance companies are making millions. High level CMS employees undoubtedly have higher incomes than primary care physicians.  Where is the outcry from the media and public?  The media, with reason, jumped all over Mylan when they started charging $600 for an Epi-pen two-pack, but at least it is a tangible product.  These high paid middleman are sucking the life out of patients and physicians without any demonstrable need or benefit. Some insurance CEO’s make over $100 million per year, which amounts to approximately $280,000 a day. How many Epi-Pens can they buy with $280,000? 

The majority of physicians are beholden to third party payers, who decide what our work is worth, like modern day indentured servitude.  Instead of having conversations with patients, our time is spent buried in absurd paperwork, endless forms, and questionnaires to accommodate federal requirements instituted by elected officials while industry insiders are controlling the puppet strings.  Physician lobbying groups, such as the American College of Physicians, keep telling us to “roll over and play dead” because they are profiting regardless. 

While they may not be drinking tea, the business of healthcare is certainly having a party at the expense of physicians, patients, and taxpayers.  It is time the party comes to an end.  Physicians are being held accountable for outcomes yet have no influence on how we care for our patients in our own offices.  Medicare beneficiaries are forbidden from entering private contracts with their long-term physicians (DPC); the only way out is physicians must say no to Medicare and some private insurances.  

Last year, a large insurance company and I did not quite see eye to eye.  Family X already had two children for whom I provided medical care.  Their newborn was assigned to an adult nephrologist two counties away by mistake (I hope), so it seemed reasonable to provide necessary primary care for their third child.  This infant had a respiratory arrest at her two week appointment.  I resuscitated the baby and paramedics transported the infant to the children’s hospital for PICU care.  Imagine my surprise 2 months later when a “take-back” was initiated on the payment for this patient encounter after initially being compensated.  Dr. W in the appeal resolutions department told me to “lose his phone number”; he thought a few hundred dollars was too costly for just saving a human life.  Believe it or not, Dr. W was a pediatrician in private practice before “if you can’t beat them, join them” took hold. 

Ultimately, I had no choice but to bill the family for provided services (at a considerable discount) as cash pay and they obliged.  A threatening letter arrived a few days later from Mr. CEO that balance billing was illegal and there would be serious consequences if I insisted on any monetary payment for my work.  This by definition is worse than indentured servitude.  Balance billing is charging a patient the difference between what health insurance reimburses and the provider charged.   The fact I was not paid by his company nullifies his entire accusation. 

I fired off a response humbly suggesting he focus more on placating his stockholders, while leaving the work of saving lives to me.  Our practice cut ties with this company, notified patients it was no longer accepted in our practice, and most families changed their insurance plans.  You would think my David and Goliath-esque tale ends here; however our local federally subsidized Community Health Center is the only place accepting this exchange plan (for reasons that should be obvious at this point.)  There is no pediatrician available.  The tables suddenly turned.

Local insurance representatives inquired why patients were being turned away.  Never having signed a contract, I made it abundantly clear they had no control over anything.  If I did not receive back pay, there would be no further deliberations. Suddenly, ‘take-backs’ were being halted and back payments were being reversed from over a year before.  When a high level executive called to ask if I would reconsider accepting their patients, it dawned on me that physicians may hold more cards than we realize. 

Health policy experts and insurance executives are NOT physicians and they require our expertise; they have not foreseen the complications that will arise when supply does not meet demand.  Physicians are fed up with data collection requirements, cumbersome electronic record systems, and outcome measures that mean next to nothing.  The time has come to throw proverbial tea chests into the Harbor and refuse to comply with the regulations being enforced up on us.  “No Regulation without Representation” should be our battle cry.  My practice is terminating another insurance contract this week.  If we make smart business decisions, refuse to follow the rules while managing to survive long enough, we can win this war.  Patients deserve better.  Physicians deserve better. 

Acquiescent physicians have already been driven out of independence.  Those of us who remain are smart, resilient, capable, and now we must be resolute in our refusal to comply. We know how to provide extraordinary care, which is why our doors are still open.   My office is overwhelmed by patients clamoring for a living, breathing physician who listens, makes eye contact, and is not attached to a computer.  We must never give up, we must continue to argue, irritate, and aggravate healthcare bureaucrats at every turn, like those brave individuals who boldly tossed tea into the Boston Harbor many years ago.  Defiance will inspire progress. Do not surrender at any cost.  

America's Favorite Pastime

Baseball is one of the greatest sports of all time.  In this country, people have attended games, played games of catch outside with their children, and coached little league teams for generations in small towns everywhere.  This is a story about a few of those children with some interesting medical lessons sprinkled in for good measure.

My most recent experience with damage from a baseball involves a beautiful little child who was playing catch with her father.  As he recounted the story to me, he mentioned how well she was throwing her fastball.  It was both accurate and consistent; he became more impressed the longer he threw back and forth with her.   Over time, he slowly advanced his speed to 50% of his strength and still, she caught ball after ball.  That is, until the one time she didn’t catch it.  It hit her smack in the middle of her forehead.  According to dad, the sound was significantly haunting.  Her knees buckled from the pain and shock, she collapsed, however remained conscious throughout the experience.  This is one tough little person. 

Now let’s talk about the baseball bat.  My most striking case (literally and figuratively) involved a school-aged boy many years ago.  He was standing too close to the batter at a little league game.  His forehead was on the receiving end of another child’s full swing using a metal bat.  His father said the ghastly sound made him cringe as he ran out to help his son who was knocked unconscious by the blow to his head.  The boy remembers standing near the batter waiting for his turn and waking up under my care in the ER. 

When I reached his bedside, he was awake, alert, and talking with me but had the largest mound (pun intended) on his forehead that I have ever seen to this very day.  In fact, pressing on his forehead left an indentation from my finger in the large hematoma (medical term for very large swelling with blood below the skin.)  It still makes me a little woozy.  We did not exactly call every concussion back in those days and as long as they could “eat, drink, walk and talk”, they were cleared to be discharged home. 

However, I believed underneath that swollen forehead his skull had to be fractured.  I presented the case to my attending and requested an X-ray.  “It is not broken,” my attending said.  “Are you kidding me?  It has to be fractured in two”, I blurted.  He said, “since you are about to be in practice on your own, I think it would be a good lesson for you to order that film.  Go for it.”  I remained convinced this young man needed an X-ray, so I went with it and of course, learned something important. 

The bone was perfectly pristine and intact.  The boy was discharged home to follow up for the concussion.  “How did you know it would not be broken?” I inquired to my supervising physician.  “In 30 years, I still have not seen a broken frontal bone.  It is probably one of the strongest flat bones in the body.”  To this day, I have yet to see a fractured forehead bone.  I have lots of experience with small children falling out of grocery carts onto their foreheads; those accidentally whacked with sticks, bats, and balls, and have seen plenty of children recuperating after automobile accidents. 

Finally, the most common injury has been “little league” elbow which is due to overuse while pitching. It boils down to being conservative with pitch counts:  no more than 50-75 per game depending on age.  Make sure your child has time off after pitching using the rule of 20’s:  Twenty pitches or less requires one day of rest, 20-40 requires two days, and 40-60 needs three days.   There is one final rule to preventing injuries in young pitchers and that is not allowing “breaking” pitches such as curveball, screwballs, sliders, knuckleballs, and other variations.  Breaking pitches spin, as a result of applying finger pressure to the ball and snapping your wrist when releasing it. The mechanics needed to execute these pitches place undue stress on key joints in the elbow and shoulder.  The USA Baseball Medical & Safety Advisory Committee recommends only players over 14 years old should be allowed to throw breaking pitches.

So much time is spent these days talking about football injuries, I figured a quick collection of my own experiences over the years might lend a little perspective.  My best advice is to keep playing outside with your own children even if there are some stumbles and scrapes along the way.   And take heart; at least you are not the father who hit his daughter in the face with his own fastball at half speed.   

Building Better Metrics: Patient Satisfaction Can Be Done Right!

Recently I wrote about empowerment and the importance of letting patients make their own health care decisions.  Our job is to make sure patients are given information and then allowed to choose the best option for them.  Maybe we should even embolden patients; give them confidence and encourage them to take more control. Physicians tend to feel more comfortable advising according to the “standard of care” and we struggle handing over the reins when we believe we “know” the safest path to take. 

Every time I talk about building better metrics, I emphasize the significance of evaluating something physicians can change or control.  The intent behind measuring patient satisfaction was likely to increase patient autonomy, however, as with many things; the devil was in the details.  It turns out chasing higher patient satisfaction scores can result in higher costs and increased mortality.  Overall, the most satisfied patients were more likely to be admitted to the hospital and total health-care costs were 9% higher. Most strikingly, for every 100 people who died over a four year period in the least satisfied group, 126 people died in the most satisfied group.  At least they died happy and satisfied right? That notion can be difficult for some physicians to accept but might be more important than we realize.  

Looking at surveys Press and Ganey developed over their illustrious careers leaves me wanting something more than “Did your doctor listen to you?” and “How often were you treated with courtesy and respect by your physician?” Neither attribute ensures better health care outcomes as noted above.  If the goal is to empower patients, more objective questions are necessary to give more insight into this metric.  

1.     Did your physician give you a name for your condition?  (“I don’t know” counts.)

2.     Did your physician discuss more than one treatment option? 

3.     Did your physician ask you to choose a treatment for your condition?

4.     Did you ask a question of your physician? How many?  _________

(CMS bonuses $ per number of questions >1.) 

5.    What did you learn during your appointment with your physician? (Use lines below and there is more space on the back if necessary.)

A few winters ago, I had my opinion handed to me on a silver platter.  A new family with a 4 month old baby came in for a well child check-up and immunizations.  The mother mentioned concerns about a cough her son had for 7 days.  On exam, he was afebrile and well hydrated; yet, had raspy breathing that troubled me.  On exam, that observation translated into bi-basilar crackles with slightly decreased breath sounds on the right side.  Without a fever, a chest x-ray seemed like the best option to differentiate between bronchiolitis (not worrisome) and pneumonia (more distressing.) 

The mother picked her child up off the table and looked horrified at my suggestion to order a film. Fear and hesitation over an X-ray was a novel response, however I had seen this reaction about immunizations, blood draws, or other significant interventions before.  I inquired as to her concerns and reassured her radiation exposure was minimal compared to the risk of missing pneumonia in an infant.  We went back and forth with a more questions and answers.  I always try to be kind, courteous, open, direct, and honest and this situation was no different.  This mother did not want an antibiotic prescription and I was uncomfortable treating the baby with antibiotics and no definitive diagnosis.  She ultimately refused any further care, picked up her son, walked out the door, and went home.

This child was not necessarily on death’s doorstep, but I could not guarantee this child would get better on his own.  I communicated as much to the mother; she disagreed and it was her right to do so.   I explained my concerns, conveyed my recommendations clearly, and discussed symptoms she should watch for if the baby worsened.  I documented the encounter in the chart and there was nothing more for me to do. 

After the mother left, the student shadowing me that day began crying out of shock, disbelief, concern, and frustration at this mother for not doing the “right” thing.  I remember feeling this way years before:  there was always a right answer, it was our job to find it, and make things happen, but health care does not always work that way.  As a physician matures, they begin to understand more of the gray.   

The practice of medicine is an indefinite, sometimes clumsy art and as a result can be unpredictable as a science.  While it is difficult for physicians to comprehend, what we believe to be best for our patients may not be what they feel is best for their children or themselves.  It is a bitter pill to swallow.  We spend years in training witnessing good outcomes with intervention and death from “poor” decisions, but we must remain cognizant of the fact each patient may have a different goal.

Patient satisfaction seems to come less from the ultimate outcome, and more from feeling acknowledged and having played a role in health care decisions.  That is the key to true empowerment and autonomy.  Consider how this mother might have answered the survey questions. She would have been “satisfied” despite our disagreeing, which makes for a better metric upon which to evaluate quality. 

Patients are weary of being told what is best for them, what they should do, or what standard of care dictates.  Unfortunately, I have lost children as a result of parents not following some recommendations a few times in my career. In reality, I may have lost them regardless. 

Here is where the rubber meets the road:  The autonomy to choose the right path for a given patient may have dangerous and permanent consequences, but the authority lies with them for better or for worse.  A patient may be very satisfied one moment and dead the next.  It is time physicians embrace the fact that our aim and conduct should be to inform and educate, not to convince or influence and let the chips fall where they may.  And survey metrics should objectively reflect the importance of that vital patient concept. 

Building Better Metrics: Focus on Patient Empowerment

Growing up during the 1970’s and 80’s, the “Little House on the Prairie” television series was an iconic part of my childhood.  Doc Baker was the physician and veterinarian for all of Walnut Grove, in spite of limited resources.  Medical lessons were everywhere in the beloved television series:  Mary experiencing onset of blindness (most recently attributed to viral meningoencephalitis, likely from Measles), the death of Laura’s infant son by unknown cause, and Rose’s survival after smallpox infection.    

When patients ask me how to start solid foods, how to get a baby to sleep through the night, or how to treat minor injuries or burns, I frequently wonder if they would have asked the town doctor these same questions one hundred years ago.  Probably not, because they would know to watch their baby for hunger cues, let infants cry it out at night, or slap some egg white, aloe, or honey on their wounds or burns to prevent infection back then.  Empowering patients to treat themselves where appropriate has tremendous value to cut down on cost and consumption of precious resources.  It was also how medicine was practiced more than a century ago.

The other night I was reading comments of a local mom group on social media, when a question came up about how to treat thrush while breastfeeding.  A patient’s mother commented they should use gentian violet; paint their own nipples and their infants’ mouth lightly as well.  A mom asked, “What is gentian violet?” This mother discussed its antibacterial and antifungal properties and its topical use for oral candidiasis.  I felt a huge sense of pride watching her share knowledge with other mothers.  The cost of a 1oz. bottle of gentian violet is currently $3.69. 

Crystal violet (aka gentian violet) was first developed in 1883 by Alfred Kern; it is still listed today by the World Health Organization as a valuable topical antiseptic agent.  Gentian violet has antibacterial, antifungal, anthelminthic, and antitrypanosomal properties. Today, it is used for:  Marking the skin for surgery preparation, treating Candida albicans and related infections, such as thrush, yeast infections, tinea, jock itch, ringworm, and even Impetigo, primarily before the advent of antibiotics. Educating mothers on thrush and the use of gentian violet occasionally helps them avoid seeking care when unnecessary. 

Patient-centered care is often talked about as a virtue worthwhile to attain because it puts them at the heart of their healthcare team.  Empowerment goes one step further by actually giving power and authority to the patient.  It is a very important concept that is often missed in the world of big-box medicine today.  There is actually an organization devoted to this concept called the European Network on Patient Empowerment (ENOPE.)  According to them, an empowered, activated patient:

• Understands their health condition and its effect on their body.
• Feels able to participate in decision-making with their healthcare professionals
• Feels able to make informed choices about treatment.
• Understands the need to make necessary changes to their lifestyle for managing their condition.
• Is able to challenge and ask questions of the healthcare professionals providing their care.
• Takes responsibility for their health and actively seeks care only when necessary
• Actively seeks out, evaluates and makes use of information.

Empowering patients to care for themselves with shared decision making is the reason my doors are still open.  Fee-for-service can be a fiscally valuable model because for one office visit, a patient can receive diagnosis, treatment, and education from a single professional.  Physician ownership encourages patient empowerment because it prevents doctors from spinning their wheels needlessly.  There is no benefit to seeing a patient over and over for the same chief complaint. We want our schedule open for other patients who need our help.  To avoid the journey overwhelming burnout, we need to lighten the load in our offices. 

Over the last century, health care has morphed from a system valuing individual responsibility to one grounded in physician dependency.  Patients are viewed as clients who ravenously consume scarce resources, while physicians dispense answers and guidance for a price deemed too high by bureaucrats to be sustainable.  Knowing how invested patients are in understanding their conditions and their willingness to take responsibility for their good or bad choices are metrics worth tracking. It is important to remember physicians make recommendations, educate their patients, and would do best by engaging in shared decision making with those patients.  That entire process saves money and improves how patients view their quality of care. 

A 3 year old girl came in with a history of 3 days of vomiting this week.  “I have been pushing oral rehydration solution with a syringe like you taught me,” she said.  Her mother knew how to check for signs of dehydration using urination frequency and a few other tricks I have taught over the years.  She knew when vomiting persisted in spite of proper rehydration attempts, it was time to bring her daughter in for evaluation. Her child had lost less than 0.5kg due to her mother’s excellent care and diligence.  I could not have been more proud and shared that with her.  At this point, it was reasonable to prescribe her a medication to reduce nausea and vomiting, but no ER visit was necessary because this mother had confidence in her skills to care for her child properly, and if she needed her PCP, she knew I would be there. 

Better metrics must be about being better able to empower our patients.  They are tired of being told how to birth their children, how to immunize them, how to lose weight, quit smoking, or exercise more, and how to treat their elevated blood pressure and cholesterol numbers.  I am not suggesting we stop sharing our expertise and making recommendations based on good science.  However, patients want to make their own informed choices and we need to let them.  Doc Baker had it right.  Take another look at his practice model in “Little House on the Prairie.”  A system incentivizing self-reliance is far more sustainable in the future and is where we should strive to be.

Broken Paint Brush and Foreign Bodies

The foreign objects may have changed over the past century, but the time-honored tradition of children getting them into small spaces has not.  Recently an article was published online about a display in the Ear Nose and Throat department at Boston Children’s Hospital with items removed from children starting in 1918.  The collection includes a screw hook, a sardine tin key, Scottie dog button, and even a political pin for FDR removed from an esophagus.  The display is a tribute to the late ENT physician who worked there for 35 years and removed the majority of the items on display. 

Children commonly stick odd things in their ears and noses or swallow toys not meant for ingestion.  My father’s favorite story of a swallowed foreign body involved ingestion of three OPEN safety pins.  He spoke to a specialist at the local children’s hospital who said the items would pass through and no intervention was necessary. 

Many of you have seen the bulletin board behind my office door where I have kept all the items removed from throats, ears, nostrils, and other locations over the years.  Each piece is cleaned with alcohol before being labelled with a date, the patient name, and location of extraction.  As you would expect, there are a lot of ear tubes up there, but also beads, buttons, and even a pussy willow from a child’s nose.  Also Play-Doh, a micro-machine, and even a gum wrapper are tacked up there too.  

Nowadays, button batteries are more commonly swallowed and pose particular risk because the chemicals in them cause esophageal damage within a few short hours.  Other high risk objects in today’s world include latex pieces (from blowing up gloves or balloons), magnets, and those dishwasher detergent pods that are so popular and look like candy. 

Children with foreign bodies requiring extraction are usually between the ages of 2-7 and I suspect they are curious as to whether or not the item will fit in the space; they never think about the inevitable removal process.  They probably swallow coins or marbles for the same reasons; not thinking about the potential consequences.  Sometimes, the foreign object ends up in its unexpected location completely by accident.

About 10 years ago, I got a phone call from a close friend of mine while on her way to my house with her husband and 13 month old daughter.  Their little girl had been walking around with a child size paintbrush in her hand when she tripped and fell down.  She was crying from the fall and on the floor was half of the broken paint brush handle.  They found the other half of the handle in her nostril.  There was a little bleeding but otherwise she looked fine.    

I still remember the expression on their faces when opening my front door.  It was a mixture of fear, guilt (not that there should be any), and a little panic thrown in for good measure.  Both mom and dad had tears in their eyes.  Their little girl was crying too, though I am not sure if it was pain or fear in all the chaos.  She was awake, breathing fine, and looked stable. 

She did indeed have a portion of a pink plastic paintbrush handle up her nose.  My brother was staying with me at the time and it was helpful to have another strong person present and able to assist.  I do keep some basic tools at my house for times when this issue comes up.  Over the years, I have removed stitches, given shots, and reduced a few nursemaids’ elbows at home too.  You just never know who or what might knock on your front door. 

I got a pair of tweezers out of the bathroom.  We laid her down on my kitchen counter and two adults held her down as I grasped the handle and removed it from her nostril.  It was much longer than expected, my brother swore during the process out of surprise, and at last the paintbrush handle was successfully extracted (to be later mounted on my bulletin board.) 

There are a lot of satisfying things we do as pediatricians and this is definitively one of them.  As physicians, we need a few tools at our disposal including a thermometer and stethoscope, but a location where we can lay a child down flat with good lighting is priceless.  I discovered the real value of my kitchen counter that night and it has seen a lot of exciting things since then.  

How Do We Teach Resilience to Our Children?

Teaching resilience is an important life lesson for children.  It is hard to know when or how to best impart this knowledge.  I suppose some things just happen by accident and I guess that is as good enough a way as any other.  

My oldest son entered the second grade this fall and changed to a new school.  He had the option to ride the bus or have me drop him off and he chose the more independent route, the school bus.  We received a call letting us know the bus stop location and a rough 8:20am pick up time.  Transportation was unable to give us a driver’s name or bus number yet, which was alright, how hard could this bus-riding thing be after all? 

On the first day, my 1^st and 2^nd graders were awake at 4:15am asking how long it was until they could leave for school.  I promptly escorted them back to bed letting them know it was not yet time.  At 7am, my oldest was dressed, with his lunch packed, school shoes and jacket on, begging to go wait at the bus stop more than an hour ahead of time.  We finally arrived at the bus stop at 8:15am and one bus #79 drove right on by.  We started wondering if that was ours as we stood waiting because no other bus drove up until 8:30am.  When it stopped, my husband and I did not doubt for a second this was the right bus.  My son eagerly ran across the street, got on the bus, and it drove down the hill. 

Unbeknownst to me, he arrived at the wrong school that morning and knew it when they pulled up to the front of Brownsville Elementary School in Bremerton, WA.  He let Glenda, the bus driver; know he was supposed to be at a different location.  She radioed for permission to take him to his proper elementary school in Silverdale, which is the one he intended to reach that day. 

According to my son, he and the driver got off the bus to hand out some information packets to teachers; they divided and conquered.  He covered three classrooms and she covered three classrooms.  After their work was complete, they boarded the bus to head to the correct location.  It was probably a 15 minute drive and during that time my son was just as observant as he always is.  He told me all about the things that went wrong with transportation that morning in the school district.  He said, “Mom can you believe one bus driver forgot half of her route this morning?”  He started laughing as he continued on, “some kids were running down the street chasing after the buses they missed, can you imagine if that happened to me?”  Well, no.  I don’t want to imagine that right now, thank you very much. 

Indeed, he arrived at the school around 9:30am (start time 9:10am) so altogether, not a total disaster.  Here is the interesting part.  I heard this whole story at 4pm after I picked up my son from school.  The last thing I knew, he was on the bus and attended a full school day.  Transportation was not aware of what happened.  The Elementary school did not know this happened either just assuming the bus was running behind.  His teacher knew his arrival time which is how I traced his movements that day roughly backward from there after the fact.  A librarian friend of mine did see him at the wrong school, but I did not hear about him looking lost until much later. 

I did speak with transportation and was given the proper bus drivers’ name and bus number later that evening, which in hindsight, would have been two helpful pieces of information to have.  His second day was uneventful as he boarded the proper bus and arrived at the correct destination.  Either way, thinking back on this past week helped me appreciate how resilient my oldest son has become.  In reality, he thoroughly enjoyed his exciting adventure regardless. We pass Glenda and her bus driving home from school every once in a while and each time, he enthusiastically waves at her with a big smile on his face. 

There are fewer opportunities today when our children are left to their own devices to problem solve; so while he did have some help from a wonderful bus driver named Glenda, his own resiliency played a large part in getting him to where he needed to be.  After the surprise wore off, I ended up proud of him and his growing resourcefulness.  Also, I am truly grateful to Glenda, the bus driver who, literally and figuratively, went the extra mile for my darling son. 

I Wish My Patients Knew…

Referencing a recent New York Times article “What Kids Wish Their Teachers Knew” got me thinking about both sides of the coin.  Physicians are human beings and sometimes this fact gets lost when a patient is angry or frustrated seeking help from the medical system.  Here is a primer on what I wish my patients knew. 

I Wish My Patients Knew… My children started vomiting at 4am and I am completely exhausted. This happened about a month ago.  My third child threw up all over my clothes as I was leaving the house to drive to work.  I ran inside and quickly changed.  I put on flip flops at some point during this process and forgot to take them off as I ran out the door.  All day I walked about looking like I planned to go to the beach instead of the office and felt ridiculous plus I think I smelled like vomit as well. 

I Wish My Patients Knew… How privileged I feel to be an integral part of their lives.  Ours is a relationship forged in give-and-take conversation and in the sharing of knowledge built over decades that is difficult to replicate in any other profession.  I have seen so many poignant moments over the years reminding me of how fragile the human condition can be.  It is truly an honor to know my patients and their parents intimately sharing in their triumphs and tribulations.

I Wish My Patients Knew… I did not get paid this month.  At least once per week, a parent calls to ask if I could write off the cost of a procedure that was kicked over to deductible by their insurance.  Often they ask reasons a co-pay was charged with a well child exam when they brought a list of 15 questions about asthma, night terrors, food allergies, or a variety of other conditions requiring a prescription.  I have never said this out loud but really wish they could understand that I use my income to pay my mortgage and buy food for my own children.  At least one month each year out of the last 5, I did not receive a paycheck. 

I Wish My Patients Knew… How frustrating working with insurance companies can be.  These third party payers control the entire system except for the part controlled by the government.  Calling to obtain prior authorizations from someone who knows nothing about the medication I have prescribed drives me insane.  There are many people wedged between me and my patient, yet I shoulder the responsibility for decisions over which I have no control. 

I Wish My Patients Knew… The greatest thing about being a pediatrician is seeing my patients become adults.  Watching these tiny newborn infants grow up to be healthy, well adjusted, productive members of society are the stuff of which dreams are made.  Watching my patients become mothers themselves has truly been one of the most rewarding experiences of my life.  

I Wish My Patients Knew… How hard it is to make it through the day, week, and month when I have lost a patient unexpectedly.  A 12 year old girl who I deeply cherished died last year due to Influenza A.  I attended her delivery and held her in my arms before either her mother or her father.  She, like many of my patients, was very special to me.  This young girl was the first person who “informed” me my third pregnancy was a girl, despite my being resigned to delivering yet another boy.  She just knew it in her heart and she was right. I think of her every day, miss her smiling face and joyful demeanor, and occasionally catch myself hoping she will walk through my door. 

I Wish My Patients Knew… How hungry I am, how badly I need to urinate, or how much I need a moment to think.  There have definitely been days where I walk in to the examination room and want to dive into the bag of chips or fruit snacks my pediatric patient is eating.  Sometimes, I ask for a bite or two when I know them well enough.  It might be all I have to eat that day.   A bladder can clearly be trained to withstand a great deal of pressure and if you ask any physician, they would concur with this awkward ‘situation’.  When a frustrated person yells and curses at me, it is difficult to put aside; it would be fantastic to have a few minutes to collect myself rather than having to move on to the next patient and pretend everything is normal.    

I Wish My Patients Knew… I am late because an infant stopped breathing in the next room and I had to call an ambulance after resuscitating him.  I am still shaking and about to burst into tears out of fear the child will not survive the 45 minute ambulance ride to the nearest hospital that admits pediatric patients.  Your time is valuable and I mean no disrespect, but I am doing the very best that I can to stay on schedule.  That patient was in for a well child exam.  The respiratory arrest was purely coincidental and unexpected.  Some of my patients can read my face so well.  They say “take some deep breaths doc, we can wait”… I love and appreciate the sincere compassion shown at times like these.

I Wish My Patients Knew… It makes my day if you bring something.  Food is my favorite because it means I can eat while saying “thank you.”  Over the years there have been pictures, donuts, cards, coffee, flowers, farm fresh eggs, homemade jams, fruits, chocolate, music boxes and the list goes on.  It has nothing to do with monetary value; it is the sentiment I appreciate.  It tells me you understand I am giving my all, doing my best, and not holding back on your care and comfort.  It means the world to me. 

I Wish My Patients Knew… I would not change anything about my career choice.  Being a physician was my calling from the time I first entered a hospital nursery with my father at 5 years of age.  I knew it then as sure as I know it now.  Primary care comes with an unbelievable amount of responsibility, stress, exhaustion, and frustration; but there is also overwhelming joy, fulfillment, gratitude, freedom, and love.  I could not be more proud to be a physician and there is no other profession in the world that is more rewarding than mine. 

I Wish My Doctor Knew…

Recently the New York Times published an article What Kids Wish Their Teachers Knew.  As a pediatrician, I have spent a good part of my lifetime fighting for the health and welfare of our young people.  They are the future.  We owe our children a safe, caring, stable childhood whenever possible. Outside of a supportive family, a long-term family physician or pediatrician can be an important role model for impressionable youngsters.  For confidentiality reasons I have altered identifying details, but will give you some of the great things heard over the years and a few tragic ones as well. 

I Wish My Doctor Knew… There is not enough food at home.  Many years ago, I was seeing twins for a yearly checkup and giving them shots when one, older by 4 minutes, blurted out there was not enough food to eat at night when she was hungriest.  I contacted the school counselor to ensure both children were offered free breakfast and lunch at school.  They were added to the program sending home a backpack full of food every weekend.  At Thanksgiving, this family received one of the donated dinner baskets with turkey, mashed potatoes, and all the trimmings.  The children grew better and crossed percentiles in the positive direction; their grades improved as an added bonus. 

I Wish My Doctor Knew… I want to marry her someday.  A six year old boy informed me he was going to “marry me” when he grew up.  He was disappointed at 9 years of age when I married my husband.  He turns 18 this year and brought his girlfriend to the last visit which seemed awkward initially until she confessed I took care of her as a little girl more than a decade ago.  I definitely approved.

I Wish My Doctor Knew… My mother is drunk right now. When I smell alcohol on their breath, they should not drive themselves home.  Often there is a companion with them who is a designated driver, but if high on methamphetamines or intoxicated, I call the authorities, trying to distract the parent until help arrives. 

I Wish My Doctor Knew… I want to be just like her when I grow up.  I have this budding group of young future physicians.  They come with me when I draw up shots to “help”; many of them look forward to our time together.  The conversations while standing next to the immunization refrigerator are unbelievably candid.  After turning 16, I encourage them to follow me for a week and determine if medicine is really something they are interested in pursuing.   

I Wish My Doctor Knew… my daddy does not live at home anymore.  This one comes out unexpectedly every so often.  Parents have a hard time telling me because they are afraid I will be disappointed in their decisions.  I remind my families it is not possible to know what any of us would do ourselves until faced with the exact same circumstances, experiences, and entanglements. We are all doing the best we can. 

I Wish My Doctor Knew… How much I hate her right now.  This is my favorite kind of teenager.  Their statement usually follows startling recommendations for enforcing a curfew, punishing for smoking pot in their bedroom, removing computer or cell phone access due to failing grades, or unexpectedly curtailing their activities.  The angry teenager crosses their arms, glares at me, and tells their parent they are never coming back to this awful place.  I smile and tell them eventually they are going to love me, but until then, they need to be patient and give it time.  They shoot me a look that says, “Want to bet?”  It is a challenge I readily accept.

I Wish My Doctor Knew… I am scared of being deported.  A few weeks ago, a child said they were worried about who was going to be elected, because they were afraid of being sent back to El Salvador.  I asked if he was born in the US and he replied he was but his parents were not and he was afraid they would be sent away.  He is just seven years old.  I honestly did not know what to say. 

I Wish My Doctor Knew… I love when she has time to read me a story.  Once in a while, I get a break in my schedule and children will ask to have a story read to them.  I love reading to children.  I never read it the same way twice.  The shared time and resulting connection is absolutely priceless. 

I Wish My Doctor Knew… My uncle got me pregnant.  This has remained one of the most difficult situations I have ever experienced in my career.  Physicians face unexpected situations often but witnessing the consequences of depravity can be utterly devastating.  She looked much younger than her twelve years, yet delivered a healthy infant a few days shy of thirteen.  When I asked her if she had been sexually active, she answered ‘no’.  She was telling the truth because of course, she did not consent to what was done.  After transferring her to an alternate location for necessary medical care, I vomited into a garbage can before calling CPS and the police. 

I Can’t Wait to Tell My Doctor…I got straight A’s on my report card.  When kids come in beaming while holding up a piece of paper, I know it is going to be good.  It can be a college acceptance letter, certificate of achievement, or a sports award they earned for their hard work and dedication.  I like to make a copy and place it in the “friendship section” of their chart for posterity sake.  It is such a pleasure to watch a child revel in their own success. 

While this job is difficult beyond imagination, what I love about being a pediatrician is seeing how resilient children are despite the obstacles they face.  We do not give them enough credit sometimes; they are far stronger than we realize.  It only takes one adult who was supportive and willing to make sure the needs of the child were met to change the trajectory of their entire lives.  I have seen it, I have done it, and I will continue listen, encourage, support, and love these young human beings.   Be that one adult when a child in need crosses your path.