Dr. Sour Puss

Of the thousands upon thousands of pages of policy I’ve been reading for school lately about health care reform, one recurring theme is how primary care is going to save healthcare. With our almighty power of coordinating the care of patients, paying attention to their quality metrics, making them do preventive care, switching them to the cheapest generic meds on their health plans, and viewing the latest fancy high tech interventions with our skeptical scientific eyes, we, the simple heirs to the old GPs, favor the time tested and cost effective evidence based care over the shiny and glamorous expensive new stuff that pays for our colleagues' Italian sports cars but makes little difference in the quantity or quality of our patients' lives. In his account of the Affordable Care Act’s design and passage, one of the key advisors in the Obama administration, Dr. Ezekiel Emanuel (Rahm's brother) writes of the role envisioned for primary care doctors in the Accountable Care Or...

Working in the urban primary care safety net for nearly two decades, I've personally witnessed the growing opioid dependence problem. Hell, as a physician who trained in the era of "pain as the 5t h vital sign" I had a role in creating the problem. Fortunately, I've also played an active role in the response to this public health crisis and have been providing medication assisted opioid treatment for the past several years. One of my latest projects has been working on an innovative treatment model to deliver "low barrier" buprenorphine in unique settings, including homeless support centers and needle exchange programs. This idea is supported by data out of Boston and San Francisco that by meeting people in a non-judgmental way in a setting that removes as many hurdles as possible you see similar treatment retention and engagement rates as with traditional chemical dependency programs and at lower cost. Further, by reducing heroin use, providing naloxone f...

I'm a big fan of the 10 year plan. I wrote my last one let's see...about 10 years ago! I've been carrying it with me in my work bag and it's funny because just putting it down on paper without really referring to it, I managed to achieve nearly everything that was important to 38 year old me. For some reason, I divided it into sections: "Lifestyle", "Money", and "Personal Fulfillment." Let's take a look... Lifestyle: Travel: check (England, Canada, Iceland, Vietnam, Cambodia, Dubai) Music: check (founded and played in Boeufcake which sparked the Wallingford Dad-Rock punk scene) Children: check 4 day work week: check minimum 4 weeks vacation, 6 better: check and check out of office by 6 pm: ha!  Money: mostly achieved salary goals, mostly achieved retirement planning and student loan repayment.  Personal Fulfillment: Spend less time dealing with insurance paperwork: actually, until the ACA, this was true Serving the unde...

Death by a thousand clicks This is an amazingly thorough examination of the state of EHRs today and how they are intertwined with the larger dysfunctional US health care system. Includes detailed discussion of both NextGen and Epic. Required reading for all clinicians. The only thing I’d add that wasn’t addressed in enough detail is how EHRs were designed with our insane reimbursement system in mind and in turn have made that system even more insane. I don’t personally see EHRs getting any less miserable to use as long as there is a private profit driven company on the other end expending all of their effort trying to prove delivered care was unnecessary or someone else’s financial responsibility.

This is what’s going on right here. I pretty much gave everything I humanly could to make a job I loved, serving patients I loved. I meditated, I did counseling. I sacrificed family and health. I unionized. I went back to school to become a leader and a change maker all for the radical idea that health care providers and patients should be in charge of the conditions of health care delivery because they can and should do better than insurers and business people. In the end, I  was squashed by business people who are too busy or too threatened to listen to this message, under the pretense that I couldn’t hack the workload, couldn’t be a team player, complained too much. That despite putting a huge amount of energy into managing my emotions and exploring constructive solutions, I just couldn’t stuff it enough and make the money I guess. Every provider I know is going through some version of this. Many have left medicine. Some have had mental health crises. Some have committed suici...

So it’s all true. Neighborcare and I have officially parted ways. It was an amazing 10 years of personal and professional growth and I am a far better human being because of my time there, thanks to the most amazing group of people with whom I’ve ever worked and the incredible patients whose stories and lives I had the high honor to witness were a daily gift that sustained me. I especially want to call out  Kristin Kurvink ,  Josephine Saltmarsh ,  Sandrine Ducos , Dan Kujawinski, Jessica Bergstrom, and Allison A. Fitzgerald all of whom made the impossible possible and brought magic into the world. We saved a lot of lives and even a few souls.

Here's something I wrote somewhere on the Inter-hoo after a day that was too damn long. I don't even remember what it was the got me ranting so hard. Here's the deal. I'm a motherfucking family doctor. I am a leader in the community in which I live. People come to me for medical care when they are in moments of crisis in their lives. I prescribe the pills, but more importantly, I provide the comfort, the wisdom, and the support they need to weather the crisis. I make a human connection in 15 minutes, whether you are an airline pilot, a grocery store clerk, a college student that smokes too much pot, or a delusional homeless person that thinks all white people except me are out to get you. I am the grease that eliminates the grinding of the gears of society. I am the person that can make a multimillionaire neurosurgeon see the reason why he/she should donate their time to help a struggling addict with a risky surgery because I believe with enough support this...

In honor of Halloween, I'm re-publishing something I wrote elsewhere on the interweb. The older I get in life, the more it is plainly obvious to me that ghosts exist and one would be well advised to conduct one's affairs presupposing the existence of otherworldly beings in our presence. When we bought our house, it was in an older part of town, and as we all know, older buildings are far more likely to house apparitions and spirits. Candidate houses were researched in crime data bases, and were evaluated for things like creaky floors, scary trees outside the windows, and architectural style (A Victorian home over a hundred years old in the United States is so likely to be haunted that I would never consider living or even staying overnight in one). It is a total misconception that keeping ones body parts under the covers is protective. I think this notion came from the "monster under the bed" tradition of night terrors which is of course silly. There are n...

Sometimes, when all the hateful narcissists of the world want to spread the misery in their lives all over you, you just need to come home for a rousing game of Belly Buttons on the carpet with your two boys. My life is great and I'm thankful for it every day.

To say that Anne Fadiman's book The Spirit Catches You and You Fall Down was hugely influential on my life would be an understatement. It's pretty cliche for a doctor to say this about her book (akin to someone saying To Kill a Mockingbird is their favorite book, simply because they haven't read much since high school). I admit that I am not a particularly well read person, mostly because a busy life in medicine doesn't afford much down time for reading. However, for many of us in health care, the revelations in the book are profound and true. Before my life as a doctor, I started out as an activist for homeless people. When deciding a career path, I realized the most important contribution I could make to help disenfranchised people at the margins of society was to become their physician. Before I was interested in anatomy, physiology, and biochemistry, I was interested in the stories people had to tell. How they got where they were, what their lives were like, an...

Ravi and rock out most every night together and honestly I didn't think much of it until we accidentally got caught on video by my sister tonight.

It's true, he looks exactly like his older brother. I was a little worried I'd be jaded by the time the Two-dle was delivered, but thankfully I'm just as over the moon as I was when the Doodle was born 2 years ago. After Ravi's intrauterine growth restriction and crash c-section for a 5 minute decel down to 70, we chickened out and decided to skip the drama, scheduling our repeat c-section well in advance. I have to say leaving the chaos of several consecutive 60 hour work weeks at the CHC and a 2 year old who literally bounces off the walls at home, I appreciated the calm control of an electively scheduled c-section, it was the least stressful 45 minutes I'd had in months. Overmedicalization of child birth be damned, this was civilized . I think our prep work with Ravi paid off big time. Within 2 minutes of meeting the baby, Ravi says, "I want to hold my baby brother!" Within 5 minutes, he was stroking his hair, kissing his face, then honked his nose. ...

Probably the only people in the world who think this is funny are in the picture.

At the risk of sounding self-important, there are times when my job feels like I'm staring all the pain, suffering, injustice, and inhumanity in the world straight in the face, alone, and yelling ineffectually as hard as I can at it. Today was probably the hardest day I've had since residency and I didn't even go in to the hospital.

She was 16 and unexpectedly pregnant. She had been randomly assigned to me by our Maternal Support Services nurse and I had never met her or her family before. During those first few visits with me, she was an emotional pancake, completely flat. Silent except for the most basic responses. Have you felt the baby move yet? "Yes." Are you having any more morning sickness? "No." Adopting my best sensitive doctor bedside manner, I would gently but repeatedly try to get inside her head, but she would give up nothing. How are you feeling about the pregnancy? "Fine." Are you anxious about it? "No." Is your family supporting you? "Yeah, I guess." Is there anything else you want to talk about? "No." I would later discover that she, her mother, and her younger brother became patients of our clinic after her alcoholic abusive father had finally driven their car through the front room of their house and they had fled to a nearby domestic v...