It Only Takes One

Sometimes it only takes one.  One wrong word, one missed moment, one poorly timed gesture, one misstep or quick step to break or make a human connection.  Sometimes one pebble in a pond, like a butterfly’s puff of wing, sends that tiny ripple which can unsettle your whole ocean.  The older I grow the more grateful I am for one wonderful patient among many who have colored my life of service from day one.  His ripple continues to echo in a life of service and commitment to empowered patients in the sacred beauty of calling on people at home.  If i had not taken an odd step, if i had spoken one more too many of my many wrong steps, I would probably not be the physician you see today.  It only takes one.  Thank God for those ones.

Mr. A. was a one of a kind patient, but don’t worry, for there may be an infinite number of kinds.  Time may have blurred some of the clinical details, but his indelible impression on my practice remains.  He was a person – let’s not reduce him to merely a patient – he was a person who could stand to live life in no box nor chain.  This man before you, as a young intern, would ride that wild Cony Island roller coaster of life in brief snippets with A. over, under, and around 3 years of residency training.

It begins with an everyday tour of duty in the Emergency Room.  A sweet little old lady with breathless bright smile, surviving her latest CHF & COPD complication, asks this young intern if he might have a look at her son.  ‘He’s outside in the car.  He won’t come in.  He hates doctors and hospitals.’  Well, this does leave the question of how an intern in the E.R. seeing patients can step ahead of triage, out of the E.R. itself, leaving all oversight of attendings and likely all malpractice and legal coverage… but those, those are the d-mned questions that only now occur to an aged attending’s polluted mind.  Thank G-d this young intern still cares about the patient and not the rules.

This is of course an Emergency Room rotation, he does have an emergency, and good lord here our patient sits idling in an aging Buick right at the curb between the ambulances.  A big man, mind you, a full 400 pounds easy of Indian might, and don’t you go calling him a ‘Native American,’ he’d say proudly “I’m an Indyin…” with sores and pustules draining through the ratty wraps around his hands and wrists as he holds the car wheel… seems he cares for his mom in their double wide, offers ‘protection’ for you -know-what at biker events for a living, and has been shooting up cocaine or heroin for so many years the veins are long gone.

This first visit isn’t our last.  Time will prove that these skin popping abscesses of MRSA have eaten the flexural tendon sheathes from palm to elbow.  Heavy smoking still burns his lungs, sleep apnea keeps him up all night, and he lives a severely hypoxic life barely able to walk.  He doesn’t offer much ‘protection’ to clients these days and he certainly can’t ride that full dress Harley on his front porch any more.  Before our house calls and three years of training have closed the circle, though, he has offered me freebase in a spoon, driven from our office anoxic, delirious and half unconscious, and even scared attendings into calling the police to commit him for being asleep at the wheel.

The police, now, they actually responded to that last call and, having a greater respect for Mr. A.’s extensive career resumé, they did more than just knock on his door to say ‘hello.’  They called out the SWAT.  With that cordon of armored trucks, men in black and a very, very angry patient (of course it would grow – what would this story be without that?) our relationship grew strong.  Despite his odds and less-than-common career path, Mr. A. continued to return honor for honor, respect with respect, tolerating us even more than we learnt to tolerate him, and along the way, sometimes, he listened and sometimes he agreed to follow our advice.  Years after he would likely have died he kept on and kept giving back, in his own way, to his mom and community.

Freedom, respect, honor, tolerance, education and empowerment are beautiful, tough, and vital, and we need more of them in this two way street between healer and healing.  Mr. A. and real life teach us this.  My rural practice in Franklin County continues to struggle to stay outside the box for ten years now and still running, negotiating life’s rapids with our patients, breaking the rules when we must, following a heart’s call to heal for the adventure and the fun of helping those who may be able to turn, if only with a little ripple and for a brief moment, from the darker side of this life we share.

Thank You

‘Thank You’ *

As old doctors retire – four gone this year – and I become the last young country doc standing in Franklin’s “West County”, I have taken up with something I swore I would never do – work day and night, sweep our creative art and community actions aside, and see patients from early morning house calls to late into the evening office hours. Some would say that is some seriously medieval old school medicine.

This evening as I return from house calls to step up onto our lit porch, I slowly set my key into the lock and again unlatch our door for evening hours. It is another day almost done. Our first patient, one old farmer, had taken ten years to come back again to see me. By now diabetes has wacked both his heart and kidneys hard. They are failing and the hospital saw fit to both change and increase his medicines … so now, as sometimes happens, he is faring even worse.

After we stopped all of his medicines his body did as expected. It got better. He grows stronger for today and after days bed bound he stepped out onto his sunny porch way up in the hills just a mile shy of Vermont. I had learned that he hated school, left school early, and then went farming for 75 years. He has what we would today term a severe learning disability. Swimming upstream against diseases he does not understand it is hard for both of us.

Still, we carefully discussed his Do Not Resuscitate papers. After trying again to agree on something, he shook his head saying he wasn’t “never going to die”. His niece smiled as they stood up to go and shook my hand saying “I think he understands a little now. We’ve made it farther today in this discussion than we have in all the others together. Thank you.”

This elderly patient, one of my first when I came here to work 12 years ago, one with whom this egghead has perhaps nothing in common but a stubborn streak, shook my hand farmer-firm and broke out in a huge grin, “You are a very good friend.”

As this warm summer evening began wrapping up and winding down with my friend creeping slowly out, our last patient came to be hobbling in just as slowly on double-barrelled crutches. I braced for the worst. Here he was a young man, a family man with young children, with chronic pain, with opiate dependence and yet another surgery to make his crushed body a little more right… here was a man who knew we had not yet begun to cut down the pain killers – which we had agreed to lower – after his surgery and before his physical therapy would begin. I had even suggested a medicine called suboxone, a safer sort-of opiate, which he had adamantly declined to take last time.

He opens this last visit of a long day with a surprise as well. “I want to stop my pain meds, start suboxone, I know I have to do it.” Talk about a telepathic motivational interview, I thought, we have got to publish this technique! The brunt of our shared time over before it has begun, our talk then turns to his family, his love for them and likewise theirs for him, other more personal concerns that weigh on his heart, and worries that one of our smaller pharmacies might have mistreated him over the years because of the pain medicines he cannot live without.

We talked, I shared, he smiled, and then he leaned back up slowly to stand on his crutches to leave telling me “You know, I consider you a great doctor… Thank you. You listen, you’re honest, you really care. But I do want you to know [as if it might not be ok] that I also consider you a great friend.” We talk about meeting out on the water, his family in their fast boat and mine sailing, for a picnic “one of these years,” and I answer truthfully “I’d like that.”

Here are two very surprising human beings back to back to end another long twelve hour day. Despite a lack of time to steal from tonight’s rest for tomorrow, it inspires me to write this now and enjoy our success in creating a truly “patient-centered” healing home, a practice so different from all the approved “medical homes” in real life instead of on paper, and feeling deeply that the one person truly saying “Thank you” is me.

  • all names and clinical details have been adjusted to protect the innocent

Portrait of a didactic seminar

Craggy angled smooth skin around smiling eyes
all gazing over glowing black screens
Tap tap tapping the clickety clack keys
while sonorous droning brings us to our knees

Stage left windows to a tiled ceiling
floor carpeted softens intense discussions
Stage right the white noise static of light flurries rushing down, no accumulation on the ground

Drugs are dealt on every corner of our table
warm rice carbs, tea and coffee sweets
but from birth to death despite the rust, heady knowledge newly known gives the greatest rush

We are doctors here, adult learners, shaped and chosen
for our hard knowledge and objective reason
Yet we find warm love care compassion and smiling joy in our peers
so human despite their training no need to fear

Thank You

‘Thank You’ *

As old doctors retire – four gone this year – and I become the last young country doc standing in Franklin’s “West County,” I have taken up with something I swore I would never do and that is to work day and night, sweep our creative art and community actions aside, and see patients from early morning house calls to late into the evening office hours.  Some would say seriously medieval old school medicine.

This evening as I return from house calls to step up onto our lit porch, I slide my slim key slowly into the lock and again unlatch our door for evening hours.  Our first patient, one old farmer, had taken ten years to come back to see me again.  By now diabetes has wacked both his heart and kidneys hard.  They are failing and the hospital saw fit to change and increase his medicines … so now, as sometimes happens, he is faring even worse.

We stopped all of his medicines and his body did as expected.  It got better.  He now grows stronger.  Today after days bedbound he stepped out onto his sunny porch way up in the hills just a mile shy of Vermont.  I had learned that he hated school, left school early, and then went farming for 75 years.  He has what we would today term a severe learning disability.  Swimming upstream against diseases he does not understand is very hard for both of us.

Still, we carefully discussed his Do Not Resuscitate papers.  He shook his head saying he wasn’t never going to die.  His niece smiled and as they stood and shook my hand she said “I think he understands a little now.  We’ve made it farther today in this discussion than we have in all the others together.  Thank you.”  My elderly patient, one of my first when i came here to work 12 years ago, one with whom this egghead has perhaps nothing in common but our stubborn streak, shook my hand farmer firm and broke out in a huge grin saying “You are a very good friend.”

As the warm summer evening wrapped up with my friend creeping slowly out and our last patient hobbling just as quick in on double-barrelled crutches, I braced for the worst.  Here was a young man, a family man with young children, chronic pain, opiate dependence and yet another surgery to make his crushed body right… a man who knew we had not yet begun to cut down the pain killers which we had agreed to lower after his surgery and before his physical therapy would begin.

He brings a surprise for me as well.  “I want to stop my pain meds, start suboxone, I know I have to do it.”  Talk about a telepathic motivational interview, I thought, we have got to publish this technique!  Talk turns then to his family, his love for them and likewise theirs for him, other more personal concerns that weigh on his heart, and worries that one of our smaller pharmacies might have mistreated him over the years.

We talked, I shared, he smiled, and then he leaned back up onto his crutches to leave telling me “You know, I consider you a great doctor.  Thank you.  You listen, you’re honest, you really care.  But I do want you to know [as if it might not be ok] that I also consider you a great friend.”  We talk about meeting out on the water next year, his family in their fast boat and mine sailing, for a picnic “one of these years” and I answer truthfully “I’d like that.”

Two patients back to back to end another 12 hour long day, I inspired by lack of time to steal from my tomorrow’s rest so as to write this down tonight, our success in creating a truly patient-centered healing home in real life instead of on silly paper, feeling deeply that the one person truly saying ‘Thank you’ was me.

* all names and clinical details have been adjusted to protect the innocent

Technical Paper (old) – the Need for Complexity in Family Physician Education

Complexity in Health

Nonlinear dynamics sustain the living world.  We find complexity in medicine which grounds our family practice philosophy while profoundly limiting the utility of our laboratory measures.  I find every student with whom I round places too much emphasis on what they have been taught in medical school.  This means they use outdated naive linear understandings of human physiology, health, and disease.  They read too much into what too little our lab tests tell us.  They don’t understand the importance of the individual patient, their values, their role in their own health and healing.  Teaching medicine is a constant re-calibration to help students’ apply of knowledge in wiser ways.  Teaching management is a casting-off of industrial age Taylorian mis-management to return to older wisdoms anew.

I share with colleagues the goal of bringing knowledge for knowledge’s sake to bear on the practical application to human problems.  The Santa Fe institute has done some good descriptive work, but I prefer NECSI’s creative application of complexity principles.  Although modern physicians had predicted that we would find greater simplicity as we broke the body down into its smaller parts, we have been overwhelmed by siloed reductionism ad absurdum.

Much good work has already been done in the macro realm of managing healthcare systems – how health care teams interact and grow and provide care.  We are still beginning to understand complexity’s practical role in the micro realm of health and human life.  Complexity tends to tell us how little we know rather than how much we mistakenly thought we knew from our quantitative reductionist measures of patients and patient health.

In the discipline of Family Medicine Gayle Stephens and other physicians attempted in the 1970‘s to describe complex health problems as a whole.  Their efforts to describe and define their healthcare mission stalled as they attempted complex qualitative work without the aid of rigorous observation and the many tools of complex systems study.  Since 2008 doctors have begun to use chaos and complexity metaphors but misunderstanding complexity as ‘complicated’ and getting it all backwards.

Medicine today struggles with a horribly inadequate understanding of human health – the very complex thing we aim to study and improve.  It is bizarre but true that we had no theory of human health.  Until now we only had very fuzzy philosophies of health that neither predicted nor could be tested.  Without a clearly understood definition of our main subject – health itself – we had no compass to guide us.

Lab measurements are nonlinear, LAG, TOLERANCE and REBOUND live everywhere in human physiology, patient emotions, human desires that make or break our interventions.  Patients with pneumonia begin feeling better even while their white blood cell counts may continue to rise.  Should we even be surprised by or even need to teach about obvious and predictable rebound hypertension when beta blockers are suddenly stopped?  Is a normal testosterone level truly ‘normal‘ when the population range of normal varies so widely?  Why should we presume that a normal potassium is a healthy potassium no matter what the illness suffered by our patients, and why are we surprised when fixing low potassiums kills more patients?  The entire old linear expedition of medical care into the vast swirling waters of human health falls on the rocks of these uncharted isles, catches up in the whirlpools and eddies of untested assumptions and unexpected consequences;  we never come close to our goal of caring for human health in all its complexity.

We can advance the theory of complex systems in human health the way any scientist does – with creative modeling tested against available data.  Pictures are literally worth thousands of words and even millions of words if the pictures also move (agent based modeling).  Patients should heal faster and leave the hospital sooner if attendings attend to the complex aspects of our patients’ human physiology and identity… this is the big test ahead.

Current Projects

1) Exploring complexity for new tools in the art and science of medicine.

2) Defining health through health trajectories and basins of attraction over a lifetime.

3) Testing health trajectories in ∆ historical socioeconomic periods.

4) Finding new and better ways to measure health and test theory.

5) Using CA and networks to model common health problems instead of the current linear research of intake surveys, populations ‘quantified’,  and % outcomes ‘predicted.’

Models have been built for the following problems:

-Substance abuse – alcoholism & patterns of drinking, function, and full relapse.

-Recurrence patterns of other illnesses compared to substance abuse.

-Family structure – old isolated large nucleus vs. present smaller dispersed but communicating family structures.

-Why do medical interventions fail? – changes in therapy, behavior, education all regress to the mean and fail… because our methods spring from old linear reductionist assumptions run amok – similar to syndemic theory.

-The Health Paradox – if healthy behaviors lead to + feedback, why are they not pervasive? Where is the survival advantage of insufficient positive feedback? Why are young adults relatively insensitive to this feedback compared to older individuals?

6) Apply a single or multiple tensor (spring) model to a theory of health and disease.  Compare it to general distribution curves as a model of health and disease.  Use it as a model of acute community acquired pneumonia.  Test assumptions of tension, strength, damping in predicting individuals’ recovery curves.  Apply it to evolutionary adaptation.

7) Outline for healthcare colleagues the profoundly nonlinear life processes they are working with and organizational structures they are working within.  Recognize the caveat of enumerable unforeseen stochastic events and biases of averaging.  Correct the misunderstanding of complexity and the ‘butterfly effect’ as they are inaccurately portrayed by physicians today.

Personal Goals

Our current goal is to improve individual health, health care, and the ‘healthcare’ system in that order.  The entire ‘healthcare’ system needs to be reconstructed from the bottom up.  The modern north american physician has become too alienated from the ideal calling and practice of healing.

1) Bring clinician knowledge and experience to research in health and healthcare.

2) Bring manager knowledge and experience to managing health and healthcare.

3) Support the theoretical study of healthcare systems.

4) Apply this theory to practice in our ‘test tube’ medical practice.

5) Advance the theoretical study of health and disease at the human level by

-Modeling to find new questions and predictions to test.

-Finding new and better ways to measure health.

-Using these measures to test the new questions and predictions.

WEBSITE LINK:   http://www.cottagemed.org

WHO:   Stefan Topolski, MD

Assistant Professor,  UMass Medical School

Country Doctor,  Trailside Health,  Shelburne Falls

Founder and Director,  Caring in Community, Inc.  501(c)3

TRAINING:   Brandeis University & The University of Maryland School of Medicine

Why a Country Doctor

WHY RURAL HEALTH?

There are appropriate scales to human relationship.  As children we live and grow in small communities and intimate families.  In the full flower of adulthood we learn the larger limits of relationships we can enjoy before the threads of our connections thin and the texture of our life begins losing its color.

Rural health care is for me the most human scale with the most extended family and the least alienation of strangers for neighbors and friends.  Nature is close at hand.  One can feel the land.  Recreation abounds.  Traffic is few.  Quiet is bliss.  The more distant we stand from organized medicine and government power the more freedom we may find to explore all of medicine and practice it as best possible.

Our rich physician history of healing, our human values, our traditions of the house call, barter, and compassionate free care survive in rural niches far from the rushing mainstream of for-profit doctoring in 5 minute visits with tests and referrals for all.  Yes, one can be too rural, isolated and alone for healthy living, but I suspect it far easier and far too common to be isolated, alone, unhealthy and sad in the midst of the crushing anonymity of suburb and city.

So while I have lived in country, suburb and city on boat and on land, I have found rural life to be the simpler, less regulated, less expensive, freer and more sustainable life.  Rural life celebrates a smaller scale of human interaction where the beautifully spontaneous and the unexpected are the norm.  Among friends and family in a small town where everyone knows everyone our synchronicities can produce a synergy of community which gives us real hope for our future.

WEBSITE LINK:   http://www.cottagemed.org

WHO:   Stefan Topolski, MD

Assistant Professor,  UMass Medical School

Country Doctor,  Trailside Health,  Shelburne Falls

Founder and Director,  Caring in Community, Inc.  501(c)3

TRAINING:   Brandeis University & The University of Maryland School of Medicine

parking lot on a thanksgiving day 2012 #3

Nina Beauty Supply

Beauty ’tis only hair nail skin deep
armpit bad breath taco smear deep
each hairy ape of us primping prancing
not hiding our unsteady selves insecure in
calm confidence Equanimitas

Sitting in another parking lot
Shiny boulders strewn on a blacktop beach

Exhausted Doin’ very little

parking lot on a thanksgiving day 2012 #2

Seagulls swirl awheal above
witecaps of polar sheen, a cold glisten of
glass and metal waves over streaks of yellow on a blacktop sea

Dwarfed by red-tipped Sea Trees grasping for sky light
Sharp Sun breaks thru yielded water too thin a whispery veil
No Shield from sharp here we can’t remain in the grey

Winnebago whale wallows slowly thru the shallows
by the cliff-face “Marshalls.. Old Navy… Dress for Less”
each whale tagged by the watchers

The sealife – multicolored bipeds heads up among
schools of shoal seals
omegas following alphas

A Rogue wave Toyota Tundra rolls through the breakers
undernourished desperate females bleach their fading beauty
wishing for assurance to breed before drying up to die

So many whales bulging over their belts
so much blubber – not in their bosoms – wasted while
Everything mine now slowly sings slowly wastes away