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Dr. Darrell White's Personal Blog

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Archive for December, 2016

Why Private Practice Survives

“I’m surprised these kind of places are still open.” –Physician employed by World Class Medical Center

“And yet, here you are, bringing your mother in for a visit.” Technician checking in mother.

In my day job I am an ophthalmologist, an eye doctor who takes care of medical and surgical diseases of the eye. Our practice, SkyVision Centers, is an independent practice, what is often referred to as a “private practice”. As such we are neither connected nor beholden to either of the large organizations here in Cleveland, both of which have large ophthalmology practices with offices near us. The mother in question was originally seen on a Sunday in my office through an ER call for a relatively minor (but admittedly irritating) problem that had been ongoing for at least a week.

That is not a typo; an ophthalmologist saw a non-acute problem on a Sunday.

Now Dr. Daughter swears that she tried to get her Mom in to see a doctor all the previous week. “She” even called our office (more in a moment) and was told all of the doctors were booked. Strictly speaking, the staff member who answered the phone was absolutely correct in noting that our schedules were full (actually they were quite over-booked in the pre-Holiday rush), and that we would not be able to see a patient who had never been to our office. Dr. Daughter works for a massive health system that advertises all over town–on billboards, in print, on the radio and online–that anyone can get a same-day appointment with any kind of doctor in the system, including an eye doctor. In fact, we saw several dozen existing patients that week for same-day requested ER or urgent visits with the urgency determined by the patient, not our triage staff.

What’s my point? Dr. Daughter never made a single phone call. She had one of her staff members call on behalf of her mother; neither I nor my staff is responsive to proxy calls from staff. I know Dr. Daughter and much of her extended family. Over 25 years practicing in the same geographic area and populating the same physician panels she has sent me barely a handful of patients, even though I care for a substantial majority of that extended family. Despite that my staff would have moved Heaven and earth to find a spot for Mrs. Mom if Dr. Daughter had called either my office or me personally.

I know what you’re thinking: Mrs. Mom would get in because her daughter is a doctor. Nope. Not the case. I may have taken Dr. Daughter’s phone call for that reason, sure, but Mrs. Mom gets an on-demand ER visit despite it being our busiest time of the year because she is the family member of other existing patients. We treat family members as if they are already SkyVision patients; we just haven’t officially met them yet.

Now you’re thinking “what does this have to do with private practice?” Without meaning to be either too snarky or self-congratulatory, this is precisely why private practice continues to not only survive, but in many cases thrive. We have the privilege of putting our patients first. Really doing it. Same day urgent visits? No need to put it up on a billboard; we just answer the phone and say ‘yes’. Lest you think we are simply filling empty slots, or that we have open ER slots we leave in the schedule just in case, let me assure you that this couldn’t be further from the truth. We. Are. Booked.

Well, it must be that we are so small that the personal touch is easy. Surely if we were huge we couldn’t get away with this. Sorry, wrong again. A bunch of my buddies are orthopedic surgeons in a massive private group on our side of town. Like 15 docs massive, with all of the staff you’d expect to go along with that many doctors. Got an orthopedic emergency? You’re in. You may not get the exact doctor you’ve seen before on that first visit, but you won’t be shunted to either an ER or an office an hour away, either. The staff members making appointments for a particular office are right there, sitting up front. The same goes for the enormous Retina practice that spans 4 counties here in Northeast Ohio. Ditto for the tiny little 3-man primary care practice up the street from me, lest you think only specialists do this.

The private practice of medicine survives because the doctors go to work for their patients, and they don’t leave until the work is done. Private practice docs bend their own rules on behalf of those patients. Every day and every night. You know what happens when private practices are acquired by massive medical groups like the two 800 lb. gorillas in Cleveland? All of those rules get made by people who don’t really take care of patients at all, and they never bend a single rule ever. Those former private practice doctors become shift workers beholden to an institution, no longer working for their patients at all.

That family doctor or specialist who was routinely asked on a daily basis if someone could be squeezed in is not only no longer asked, she doesn’t even know the question was there in the first place. Everything is handled by the institution’s call center, somewhere off in a lower rent district, with no sense of what is happening at that moment in the clinic. Your doctor might have a cancellation and a spot open to see your emergency. Indeed, if she’s been your doctor for a long time she would probably rather see you herself because that would make for better care.  But there are now someone else’s rules to follow, efficiencies to achieve so that they can be touted, and institutional numbers to hit.

“I’m surprised these kind of places are still open.”

“And yet, here you are, bringing your mother in for a visit.”

On her way out, after impatiently waiting while her mother thanked me profusely for seeing her when she was uncomfortable, Dr. Daughter extolled the virtues of her employer. Fixed hours. Minimal to no evening or weekend call duty. A magnificent pension plan that vests rather quickly. I should join up, she said. She was sure that World Class Medical Center would love to have me.

I smiled and wished her, her Mom, and the extended family a Happy Holiday Season. As I turned, shaking my head a bit, my technician put her hand on my arm.

“If you did that, who would take care of her Mom?”

Holiday Passages

A pop psychology author, classmate of my parents, once examined life’s stages in a book titled Passages. While I am no fan of her work (somewhat shallow and bereft of any real insight), her choice of a term for major phases of our lives is pretty good. “Passages”. Kind of evokes a journey of sorts. That part of her writing was pretty good.

Our family  will gather this weekend and this has me thinking a bit about those passages. All of our children will spend part of the Holidays with their in-laws; our boys will spend a bit of time with us. Young people truly become a kind of real adult when they take on the responsibility of nurturing a third entity, their marriage. Beth and I used to joke that we would feel like we were “real” adults when we owned our own washer and dryer, but really, we’d gone and grown up as soon as we consciously put our marriage ahead of either of our individual selves. This realization is all we really ask of our young marrieds in these, their middle passages.

This year many of our Christmas tables will have empty seats, or seats that will empty earlier than usual. That final passage demands as much attention as the first one, childhood; it just doesn’t really end as well. Still, it’s also a miracle that we go so very long before that last passage begins, both for us and for those we love. I am struck this week with a single thought: slow down and stay. Stay tiny. Stay young. Stay vibrant. Stay here and now.

Just stay.

In the end all of these passages are a one-way trip. You never back up. You don’t stand still. There’s really no such thing as a Mulligan or a do-over. It’s amazing how much help we need as we start our journey and then again as our journey comes to an end. In the middle, well, we have control. Dwelling in either the past or the future diminishes our present. Doesn’t it make sense to look at each day as its own kind of little miracle? Perhaps aware of what came before (a baby) and conscious of what lies ahead (an empty chair), all the while rejoicing in the miracle of right now.

Safe travels to all on their Holiday Passage.

We Have Today

We are not promised tomorrow.

If tomorrow comes we are not promised a “good” tomorrow. If we lead a virtuous life, whatever that may mean for each of us, we hope that our efforts will translate into a “good” or at least “better” tomorrow. Or not. All we have in hand is today. And every today has something, some thing little or big, that makes it a good day. Each of our privations, every challenge can be borne if we realize that there is some one thing, or if we’re lucky some several things, that are good in each day.

We can hope for tomorrow, and that tomorrow might be as good or better than today. But what we HAVE is today. In the end, that’s all we ever get. There was a time when I awoke each day and checked to make sure that I was still the father of a daughter. That’s all I needed. EVERY day was a good day. Like today.

There’s nothing particularly special about this today, about Tuesday December 20, 2016, except that this is the one you got when you woke up. What’s good for you today? Who’s special to you today? Did you tell them? Do they know? You may not have a tomorrow, but if you are reading Random Thoughts you do have a today, right here and right now. There are only two kinds of “todays”, good ones and great ones.

You got one. Don’t waste it on tomorrow.

Santa Claus, The Real Deal

“Santa is the Spirit of Giving. He is always real.” –Beth White

Once again my Better 95% knocks it out of the park. We have a couple of little ones again in the White family, and because of that we will have a healthy dose of Santa in our lives. While I realize that Beth and I will not really have a say in whether or not the whole Santa Claus story plays out in our grandchildren’s houses, what he stands for is important. Important enough for us to have had him in all his splendor and glory when The Heir, Lovely Daughter, and Lil’bingo were growing up. Important for us to draw out the time before Lil’bingo came to the realization that Santa was not a real person for as long as possible, so deep was his love for the furry fat guy.

Rest assured, the parental units in the White family did struggle with how to handle the inherent subterfuge that is necessary to have the Santa Claus story as part of our children’s upbringing. From the very beginning, though, the message was about the giving, about generosity and caring enough about someone else that you not only gave them a gift, but you gave them a gift that let them know how much you cared about them. You know, the “spirit” in the Spirit of Giving, if you will.

No matter how you massage it, that day of reckoning when your child finally realizes that the character Santa Claus is nothing more than the figurative representation of that concept can be fraught with all kinds of emotional trauma. For sure you might get a dose of “you lied to me”, but in my now decades of experience being around parents it’s actually rather rare for this one to pop up. What you generally face is sadness, with maybe a touch of disappointment and even mourning tossed in just to add a little sting to the moment. Like so much else about parenting, or even just about kindness, these are times when you get to talk about and teach really important lessons. Here the lesson is about giving of yourself, with or without a physical gift to actually give.

While thinking about this we stumbled upon a lovely little story about how one family handled both the “Santa isn’t real” revelation and the “Santa is real” in spirit thing. Heck, the story may even be true! A Dad sensed that his son was pretty much on the cusp of discovering that the guy in the red suit wasn’t really the real deal. His approach? He talked to his son about how he sensed that he, the son, looked like he was not too sure about the Santa Claus character. The Dad complimented his son on being a caring young man: “Everyone who cares, who is generous can be a Santa. I’m very impressed by how kind you are. I think you are ready to become a Santa, too.”

The Dad went on to ask his son to think about someone in his world who looked like they were sad. Maybe a bit lonely even. He tasked the boy with thinking very hard about what that person might really like as a present. Something they needed, and something that would express that whoever gave it to them realized this need, and cared enough to give them a present that helped to meet that need. There was a catch, though: the recipient was never to know who gave them the gift. For the son the satisfaction was in the caring and in the giving, not in the recognition and praise that might follow.

It doesn’t really matter who the child chose or what he gave; you can trust that the story–true or not–is just lovely right to the end. What matters is that this very young boy is escorted through what can be a very sad stage in a young life by a caring and thoughtful parent. On the other side of this journey emerges a young man who has learned the true meaning of Santa Claus in the secular Christmas story. He has learned that what matters about Santa Claus is real indeed, and always has been.

Santa Claus is the Spirit of Giving. He will always be real.

 

Sunday musings…”Certainty”

Sunday musings…

1) Bufflehead. The official duck of Clan bingo.

2) Tortiere. Official cuisine of the occupied according to the NYT.

I dunno. Does occupation taste better if it has a fancy name?

3) Friendship. “Friendship without loyalty is like a lake without water.”

That’s pretty deep.

4) Reality. There are a number of movies that have just come out that deal, either directly or incidentally, with poverty. Characters are either in the act of overcoming their poverty, or are inextricably affected by poverty as they attend to whatever theme the movie other wise addresses. I am struck by a certain detail that I simply cannot ignore in each and every example: the actors all have perfect teeth.

Not only is there not a single tooth askew in the entire cast, but there is nary a blemish to be found on an incisor. Heck, I’ll bet that even the lowliest Grip or Best Boy has a perfect smile.

Don’t know about you, but I just think the mountain men of “Deliverance” or “Winter’s Bones” would have seemed a whole lot less dangerous if they had all of their teeth.

5) Certainty. There are some really big decisions in a life. I mean huge, consequential decisions that simply must be made. To do so is very, very hard. There is simply no escaping that fact. You reach a point where you have to make a call on something that matters. Really matters. Like, rest of your life hinges on your decision matters. As part of this monumental process you must make peace with the concept of “certainty”.

You can–you really must, actually– be certain that this is a really big decision, but you must at the same time be cognizant that you cannot be certain that you are making the best decision possible.

I am forever in search of a better vocabulary to describe things I know or things I feel very deeply. In that never-ending search I came across an article about the former GM of the Philadelphia 76′ers, Sam Hinkie. Mr. Hinkie is a polymath who is at any particular time either wildly sentimental or icily objective. Fascinating guy, actually (you can read the article in SI 12/5/16). Throughout the article it was somewhat difficult for me to establish common ground with him (except for our shared devotion to precise language) until I came upon a brief discussion of “certainty” in decision making. Both Hinkie and I had the same decision to make–to prioritize our courtship and subsequent marriage over other pursuits like education and vocation–and we both not only made the same call but continue to describe it as the best call we ever made.

We were certain of its importance, and in response at some point we went “all in” on the decision. Here is Hinkie on the process:

“You have to be careful that you are thinking reasonably. People are too willing to scratch the itch of the near thing. Discipline is the difference between what you want and what you really, really want…I think people often don’t bring that kind of rigor to whatever it is, if it’s important. Because they’d rather make lots of little tiny decisions that a few big ones.”

Certainty is a sword that cuts both ways. The only cut you control is the one of knowing that something is really big. Something you really, really want. Something that matters. You cannot be certain that you will make the right decision, but the only way forward once you are certain about something is to pour everything you have into whatever that thing is.

Hinkie: “What wouldn’t you pay to make it so, if it’s right?”

I’ll see you next week…

–bingo

You Don’t Need That Selfie

My thoughts on the making of memories,first written 2 years ago, re-printed here in response to GoPro’s “discovery” that the selfie is harmful to your potentially most cherished memories to be.

 

“Every strike brings me closer to the next home run.” Babe Ruth.

“Friendship is the vehicle that delivers innocent people from that space between the rock and the hard place.” D.E. White

Like the Babe I’ve taken my swings, often and hard, at the corrosive effects of communication technology on human communication. For every time I’ve hit it out of the park–face to face over a glass of wine with Beth, a close friend, or one of my kids–I’ve whiffed on one that was low and outside hurled by new tech. For instance, Snapchat came and went and got sold for a Bazillion $$ before I even really knew how to use it.

Now, I’m hardly a Luddite. I’m sitting at a kitchen table littered with droppings from Steve Jobs’ imagination, pecking away at one of them while another serenades me, yet one more beckons for a response. It’s all really pretty OK though, because there’s no one here, really physically here, who wants or needs to talk to me at the moment. Even Abby, the world’s most curious Border Collie, isn’t interested in chatting.

This is not a “be here/be now” lament about focusing on the real, live person who is physically with you rather than your phone and its irresistible access to someone who is somewhere else. Nope. I lost that battle as spectacularly as any swing and a miss by the Bambino, at least on a societal level. For sure, every now and again, I hit a bloop single and get one of my kids to put down their phone and “be there” for a whole meal, but no grand slam big picture win on that one. (As an aside, who wouldn’t love to see a Sesame Street re-do of “Put down the Duckie” substuting “iPhone” for Duckie? Google it.)

This is about the most recent tech attack on the human experience as we know it–the “Selfie”. It’s not real unless you took a picture of it. You weren’t there unless you have a picture of wherever there was, whatever what was. And the most damaging of all, it wasn’t significant enough, it wasn’t truly magnificent or epic, unless you shared it with at least the first 4 degrees of separation.

The camera on your phone is stealing your memories.

But how can that possibly be? How can memorializing the momentous make my memories disappear? There are two insidious effects of the nearly compulsory grab for the phone and the shutter. The first is the simply that you’ve stopped the moment in question, interrupted whatever is wonderful about that singular now. Everything stops for the camera. You’re frozen, right then, right there, in that exact click. Your flow is gone. What might have come next, following as naturally as your next breath, is forever lost as soon as the camera appears. The re-boot is as jarring as emerging from the breath hold of a frozen dive.

Memories, the good ones at least, are like poems. Returning to those memories over time is like re-reading a beloved verse. The basic facts, like the words in the poem, remain the same; it’s around the edges of the memory that we find the smiles. In poetry it’s the message between the lines. In music it’s the space between the notes. This is where the magic lives. We shrink these spaces in the memories that hurt but won’t fade, and we spend as much time as we can engulfed in the happiness that lives in the space around our best memories. The foundation for growth here in this space is being fully engaged in simply living in each “now” rather than engaging your cellphone camera and Instagram.

You can’t really take a picture of how you feel, and in the end isn’t that what makes the memory?

Triggered by Slimy Language (From Sunday musings…)

There are words in any language that have been co-opted in a great conspiracy. Actually, they’ve been co-opted into every conspiracy, wether great or small. I’m talking, of course, about all of the hedge words like “may” or “might” or “could”, words that can be inserted into basically any statement and simultaneously present a point of view while distancing the writer or speaker from any responsibility for either that POV or the consequences of writing/stating it. You know what I mean. Simply take a look at any of the Sunday papers and read a headline or two. “The election may increase blankety-blank in thus and such.” “So-and-so said blabbity blah which could result in a decrease in the weinerschitzel index.” “We think CrossFit might cause a significant change in the daily usage of pitbull greenhouse gas effluent.” Stuff like that simply litters our information pipeline.

A defining characteristic of statements like these is that the exact opposite may also occur. Indeed, it is entirely possible that the obverse is actually more likely to occur. Accuracy of this sort is precisely not what the speaker or writer is interested in, though. No, what people who write or speak like this are interested in is the projection and proliferation of a worldview that may or may not stand up to either data or reality. Even more so, they are doing this without regard to the consequences for those who may share the sentence with the slippery and slimy hedge words. The reality is that they typically mean some sort of harm to that person, institution or idea.

They just lack the courage to not only place their flag in the sand, but to also stand next to it, defend it, and face the consequences.

Come on. Anything COULD happen. There is certainly enough uncertainty in the world that any statement with “might, could, or may” in it would turn out to be accurate. The reality is that we also live in a probabilistic world in which data can be used to give a bit more guidance. In so doing we can put the fire to the feet of those who are so careless with their regard for the effect of these words on other,s and too cowardly to willingly step on the fire.

How many times have we read or heard someone look at a CrossFit WOD like Deadlift 1-1-1-1-1-1-1 and say: “CrossFit may be dangerous; it might cause injury in individuals who are lifting heavy weight.” A fact-based examination of this WOD would certainly acknowledge that injury is a possibility, but the more likely outcome is that “athletes who perform a full-body functional movement like the deadlift using proper technique with relatively high intensity will gain strength.” Will. Flag firmly planted.

There most definitely IS a lesson here: statements with “may”, “could”, “might” and similar hedge words are a warning that you are reading or listening to someone who is either unsure of what they are stating, or that they are very sure that they can neither prove their thesis nor defend themselves if it is shown to be false. An agenda too often lurks behind these words, and it behooves us to look for that agenda whenever we are triggered by these words.

Sadly, there is no safe space in our connected world for us to escape this kind of slime.

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