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Every month, hundreds of thousands of people look for a doctor on Google. As an amazing practitioner, your site deserves to be seen by these patients, and that means being on the first page of search results.  Getting on that first page can be tricky, but there is one ridiculously easy thing you can do to improve your chances – and it takes less than 7 minutes.

Searching for a doctor

When searching for a doctor, people normally see results that look like this:

A Google search for “San Francisco Doctor”

Notice all the results with the lettered balloons to the right of them? Those are coming directly from Google Places – Google’s version of a business directory. By making sure your business is listed in Google Places and looking as good as possible, you improve your chances of showing up on the first page, getting clicked, and getting new patients.

Sign up for Google Places

To list your practice in Google Places, and customize your page, simply head on over to Google Places and click “Get started.”

After clicking “Get started” you’ll be done in 7 minutes.

Google will walk you through a step-by-step guide to completing your practice’s Google Places profile. Be sure to enter as much information as possible. Enter your hours, write a description of your practice, and, if you have them, upload photos and videos. Basically, enter every bit of information that you can and remember to keep your prospective patients in mind – this page is for them. Google is giving you a page to show off your practice so be sure to make the most of it.

Google explains the many uses of a Google Places page.

Validate Your Listing

To prove to Google that you’re authorized to update your listing, you’ll need to verify the information you entered by phone or by postcard. It’s a piece of cake and prevents people from adding false information about your practice.

Validating your listing ensures that only someone at your practice can make changes.

Well, that was easy

Believe it or not, that’s all there is to it. You now have a verified Google Places page that will make it much easier for patients to find you and will improve your chances of showing up on the first page of Google.

Phil Sharp is a team member at Practice Fusion, the fastest growing free electronic medical records community.

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I recently wrote about the ways in which residents’ lives change dramatically during the transition to practice. For many, this transition feels like a complete 180.

I’m going to devote today’s post to introducing the concept of a “Life After Residency Alliance,” which is a group of people you can rely on for support, guidance and direction as you transition to practice.

The concept is taken from Napoleon Hill’s Mastermind Alliance, a philosophy of assembling a select group of people (Masterminds) to achieve a definite purpose. Each person contributes his or her strengths and talents, and helps to form a stronger alliance.

Creating a Life After Residency Alliance — a special type of Mastermind Alliance for new physicians — will make your transition to practice much easier.

As I stressed in my last post, the majority of your advisors were assigned to you during medical school and residency. Now, it’s up to you to assemble your own team.

Let’s walk step by step through the process of assembling a Life After Residency Alliance:

1. Determine your purpose (beyond being a physician). You wouldn’t board a train without knowing where it was going, right? The same should apply to your work and life — what’s the point of putting effort into something unless you know your ultimate goal?

Determining your purpose beyond being a physician can be a difficult exercise, but with a little effort and reflection, it’s not as hard as it seems.

Because of space constraints here, I’ll point you toward several purpose-determining exercises from the Adventures in Medicine Resource Library, which you can find here: Adventures in Medicine Stage 4: Life, Money and Career Priorities.

Once you’ve developed your purpose statement and vision, you can proceed with the next step.

2. Select the members of your Life After Residency Alliance. Navigating life after residency can be extremely confusing, and you might not have any idea which kinds of people you want in your alliance. I’ve outlined my suggestions below, but you might think of other people to approach, too.

No matter the types of people you select for your alliance, remember the following two principles:

• First, choose alliance members because of their ability to do the job well. Don’t just pick people because you know and like them.
• Second, keep in mind that you — and your alliance members — must work in a spirit of harmony with others. Without harmony, the alliance as a whole can fail.

Here are five types of people I’d suggest approaching for your alliance. You may want to include more:

Attorney: Choosing an attorney who specializes in healthcare and physician employment contracts can be a lifesaver. Have one picked out and go over your preliminary needs before you actually seek his or her assistance.

Contract negotiator: A contract negotiator can be a great addition to your alliance, especially if you’re uncomfortable with negotiation. He or she should be an expert in physician compensation, physician productivity bonuses and compensation structures.

Life/career coach: This invaluable member of your alliance can help you develop your personal mission, vision and values. Then, he or she can show you how to incorporate them with your significant other, family and employer. Iris Grimm of the Balanced Physician is a highly recommended life and career coach who specializes in helping physicians.

Financial advisor: Getting a healthy start on managing your finances post-residency is essential. Choose an alliance member who can help:

• Create a plan for paying back your student debt
• Advise you on what to spend on a house
• Educate you on how to invest with your first paycheck

Physician recruitment advisor: This individual will help you uncover physician opportunities that align with your mission, vision and values. Choose your recruiter wisely, and make sure he or she isn’t just trying to push you into any old job.

3. Nurture and maintain your Life After Residency Alliance. Once you’ve assembled your alliance, be sure to keep it healthy with consistent communication. Above all, this is the key to learning from your alliance members and maintaining sound relationships with all of them.

Everyone leads a busy life — especially yourself — but by taking extra time to stay in touch and up-to-date with your alliance members, you’ll have more of an opportunity to grow. Remember that they are part of other alliances, too, and that if you go out of your way to treat them well, they’ll serve you better in the long run.

Adriana Tobar is a family physician and resident advisor for Adventures in Medicine.

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I was recently appointed the Assistant Director of the Yale Cancer Center with the portfolio of Diversity/Disparities. While I’m not sure I’m the most qualified for this, it has gotten me thinking a lot about diversity, disparities, and what it means to achieve health equity. Too often, I think, we are plagued by narrow thinking … the impression that our only objective is to ensure minority accrual to clinical trials. It seems to me, however, that diversity is so much more. It is truly at the core of what we do, particularly as oncologists.

I was recently at a talk by Marc Nivet, Chief Diversity Officer for the AAMC, who defined diversity like this:

Diversity as a core value embodies inclusiveness, mutual respect, and multiple perspectives, and serves as a catalyst for change resulting in health equity. In this context, we are mindful of all aspects of human differences, such as socioeconomic status, race, ethnicity, language, nationality, sex, gender identity, sexual orientation, religion, geography, disability and age.

Today, “personalized medicine” is a buzzword in our circles, as we ponder the genetic and genomic differences that lead to varying predispositions to malignancy and tumor behavior. To me, however, this concept goes beyond the framework of tumor biology and targeted therapies. It encompasses an understanding of an individual’s personal context—their socioeconomic situation, racial and ethnic background, cultural beliefs, and family/community circumstance. The richness of this understanding allows us to focus on how to provide the best care to our patients, avoiding a cookie-cutter “one-size-fits-all” approach.

Our patients have different degrees of health literacy, and access to quality oncology services is not uniform amongst all populations. As we think about our global village (both at home and abroad), it becomes abundantly clear that while the world is shrinking with modern technology, disparities remain that separate the “haves” from the “have nots.” How we translate knowledge across borders to improve cancer control globally is needed, but perhaps more importantly, developing innovative means of improving care in low-resource settings is of critical concern. One only needs to hear stories of patients presenting routinely with fungating cancers and the dire lack of critical supplies (like running water) to understand how rampant poverty in low/middle-income countries is a significant barrier to achieving health equity across the globe. ASCO has done a lot in terms of trying to address some of these disparities with the work of its International Affairs Committee, but there is still much work that needs to be done.

The delivery of patient-centric care is predicated on an understanding and appreciation of the kaleidoscope of factors that make us different, and an ability to tailor therapy accordingly. This requires a broad view and an imperative to work in a participatory fashion with our patients and communities to understand the issues that are of importance to them. We need to reflect on our internal biases and rise above these to provide compassion and care to patients of varying backgrounds.

A few months ago, I had a transgender patient who had a clear distrust of the conventional medical system. I think she expected that people would treat her in a demeaning way since she was so overtly different … but as we talked about her locally advanced breast cancer, she came to understand that, to me, she was first and foremost a patient with cancer, and I was committed to helping her in any way I could—and I would do so in a non-judgmental fashion. She had been using vitamins and “detoxifying regimens” to shrink her cancer, and while she absolutely refused neoadjuvant chemotherapy, it was meaningful to me that she came to a point of embracing surgery as part of her naturopathic regimen to reduce her tumor burden. Perhaps more importantly, she felt that she had been heard. Sadly, at surgery, she was found to have a 9.4 cm invasive lobular carcinoma with 25/33 lymph nodes positive… as a breast surgical oncologist, I felt ill; and as a public health advocate, I wondered how we (as a society) could have done better, how we could have made her feel more welcome such that she might have sought screening or treatment before her disease had gotten so advanced.

Diversity is important—it’s what makes us all different, and provides color to the tapestry of human experience. But as we embrace diversity, we must be cognizant of disparities, and we must actively engage in breaking down barriers both within our borders and outside if we are ever to achieve health equity for all.

Anees Chagpar is an oncologist who blogs at ASCO Connection, where this post originally appeared.

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How do you define a “good” doc?  I was reading the patient responses to an article here on KevinMD.com and was saddened by how many of the patients were angry with their docs.  Anger is an unhealthy emotion!  One of the respondents was particularly angry about the “unnecessary” tests her doc performed on her and her family.

I have written about the vagaries of the term “unnecessary” in the past.  What makes a doc brilliant?  What makes a doc lousy?  How can the same doc be perceived as “brilliant” by some patients and “lousy” by others?

When I order a test that saves a man’s life, I’m brilliant. That patient and his family tell all their friends that I made a brilliant, lifesaving, diagnosis.  ”Go see Dr. Segal; he’ll take good care of you.”

When I order a test that fails to shed light on a diagnosis, I’m a lousy doc.  “Don’t see Dr. Segal, he orders too many tests.  He never did come up with a diagnosis for what is making me sick.”

No matter how many brilliant diagnoses a doc makes, there will be diagnoses he can’t make (or misses) and patients who will be unhappy.  So, what’s a doc to do?

Docs formulate a list of differential diagnoses.  Based on the list of possible causes of a particular problem, docs order diagnostic tests and procedures.  When I started in medicine over 30 years ago, we called the process ”rule out,” meaning we ordered tests to narrow the list of possible diagnoses until we found the right one.  The more complex the disorder, the more tests are ordered.

In reality, docs don’t own a crystal ball.  If they did, they would know which tests were going to be positive (necessary) and which were going to be negative (unnecessary).  Since docs don’t have the ability to see into the future accurately, diagnoses and test ordering boils down to an educated guess.

To make matters worse, diseases are dynamic, forever changing.  An eighteen year old comes in with a severe tonsillitis.  Her mono test is negative.  Obviously, the test was not necessary since the test is negative. Right?  Wrong!  Ten days later she is seen again by another doc.  Her mother states, “I took her to Dr. X 10 days ago and he didn’t know what he was doing.  He wasted my money on a negative mono and strep test.  Can you help her?”  After explaining that a negative mono test is meaningless (as Dr. X had previously warned her), the new doc orders a repeat test which is now strongly positive.  Diseases are dynamic and our ability to diagnose them correctly often improves with time as the disease evolves and changes.

In “You’re Damned If You Do and Damned If you Don’t,” I review the dilemma docs face on a daily basis.  Going back to the original question, What makes a doc good, I think the answer is a caring attitude.  If your doc cares about and for you, he will do what he feels is in your best interest.

As a doc, I am acutely aware that I spend your time and money in pursuit of good health and I try to spend it as wisely as if it were my own.  Sometimes, what I think is necessary turns out to be unnecessary.  Sometimes, I like being wrong!  If I think you have a life-threatening disease and you don’t, I actually rejoice in being wrong.

Do I do too many tests?  “Too many” is in the eyes of the beholder.  Necessary is a word best defined when looking back in time.

Stewart Segal is a family physician who blogs at Livewellthy.org.

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I was skeptical when a doctor casually mentioned that 2% of all pregnancies are ectopic pregnancies (in which the fertilized egg is implanted somewhere other than the uterus, usually the fallopian tube). Without treatment, a common outcome is fallopian tube rupture, which jeopardizes the life of the mother. It is a serious medical concern. I shot a confused look at a fellow first-year medical student. Two percent? It seemed way too high.

I checked the literature, and the doctor was indeed correct. Indeed, 2% of pregnancies are ectopic pregnancies, and ectopic pregnancies constitute 6% of pregnancy-related deaths. Why was I never aware of this? Many women I have encountered in my life have undoubtedly had ectopic pregnancies, but no one speaks of it. Illness lurks in people’s lives much more than they make apparent, and my medical training is making me acutely aware of that discrepancy.

In the past few weeks, I’ve become increasingly aware that my medical training and white coat constitute a sort of “all-access pass.” Recently I was passing through our hospital’s ER on a personal errand. Upon seeing my white coat and badge, the rather aloof security guards smiled and simply waved me through the entrance to the medical bay.

In the ER, I spotted a med student I knew who happened to be rotating there. She and a resident were about to examine a patient, and on a whim I joined them. Saying little, I listened to the patient describe deeply private aspects of his life: his methamphetamine use and drinking habits, his family problems, his history of mental illness, and his hopes for the future. I watched as the medical team debated the patient’s diagnosis and treatment. And after about half an hour, I went on my way. A year ago, I would have been stopped at the entrance to the ER; now, no one questioned why I was there. I am part of the club. It feels so strange.

Practicing medicine involves a tension between isolation and connection. On the one hand, I am quite estranged from people. I have so little free time that when I interact with someone, they are usually either my patient, my family, or someone in the health-care field. And yet I learn about and am witness to the most intimate aspects of random people’s lives. Learning medicine is a lonely pursuit, but by accompanying people as they grapple with illness, will I become more connected to my fellow man?

So far, the answer is no. Medical school has transformed how I view people and interact with them. When I am at a party and see someone with an abnormal gait or a cold sore, I automatically start reasoning through a differential diagnosis. When I chat with my seatmate on a plane, I find the need to whitewash what I encounter in the hospital, because people understandably prefer not to hear about illness and death more than they have to. Doctor and patient do not behave as equals, and even though I am not yet a doctor, and even though the people I encounter are not my patients, I can’t entirely ignore this feeling of detachment, of otherness.

“Reflex Hammer” is a medical student who blogs at The Reflex Hammer.

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The first thing I noticed when I walked into the physician’s office were the tall cabinets filled with manila folders, tabbed with names and organized alphabetically. There were three of these cabinets, taking up the entire length of the back wall, filled with hundreds upon hundreds of patients’ records.

“I see you still have paper records. Do you plan on implementing an EHR anytime soon?” I inquired.

The doctor paused for a moment and said, “No, not really.” Surprised, I inquired why.

“Well, there are a couple of things holding me back. The first is cost. There’s an initial set-up fee, a maintenance fee, a technical support fee, a hardware and software fee. The fees just keep piling up and it isn’t sustainable for a small practice like mine. Second is compatibility. The local hospital here uses Epic, but we use an Allscripts based system for logging in patients. It’s not a full-fledged EHR, but the point is that it isn’t the same as Epic. There’s a lot of training involved in using all these programs, which means you need time to learn – time I don’t have.”

I shadowed him for the rest of the day, watching as he spent a good five minutes writing down pertinent information after every patient encounter. By the end of the day, I realized in the four hours that I had shadowed him, nearly an entire hour had been dedicated to writing. Wouldn’t an EHR system make his workflow a lot smoother?

Today, we have a plethora of new EHR systems – Allscripts, Epic, GE, ADP, and MediTouch are just a few of the many brands available. As a relatively new market opportunity, there are bound to be hundreds of offerings from all sorts of companies, big and small. Navigating this sea would be difficult for any physician pressed for time. A recent study on EHR adoption in New York, the state with the most incentives for EHR implementation, showed that even hospitals had adoption rates no higher than 25%. If the big budget hospitals can’t adopt it, why would independent physicians?

What’s more interesting, however, is the incompatibility between the market economics of emerging EHRs and the realities of medicine. Medicine, at its core, is about sharing helpful information through uniform and easily accessible scientific channels. Free market capitalism is essentially a competition for dollars that leads to product diversification and stratification over a long period of time. With the introduction of 32 million newly insured patients with the Affordable Care Act of 2010, the need for streamlined patient information is greater than ever before. If EHRs are going to flourish in the rapidly expanding world of medicine, we’re going to have to quickly implement two very anti-capitalistic initiatives: standardization and consolidation. I’ll explain momentarily.

Medical history is a mobile platform that moves with the patient. Considering the extent to which patients see various specialists, physicians need to employ patient-centric records that are easily transferred from one physician to the next in any clinical setting. This means a patient’s information from a primary care physician’s office should seamlessly integrate with whichever hospital or clinic that patient visits.

The Health Information Technology for Economic and Clinical Health Act of 2009 already attempts to enact this seamless transition by requiring EHR companies to build up software on standardized data formats. Congress rewards physicians who employ such EHRs with financial incentives, calling their decision an example of “meaningful” use of medical technology.

While this level of standardization is progressive, I would suggest we take it further – the user interface for EHRs should be uniform in geographic areas, if not nationally. It makes no sense that local clinics use Allscripts while the nearby hospital uses Epic, especially when physicians practice in both places. Asking physicians to orient themselves to a new user-interface every time they visit the hospital or clinic would be a waste of time and money. Even if the underlying data transitioned smoothly, the physician can’t access it as easily as on the EHR he or she was trained with. The usefulness of that patient information becomes moot.

What makes more sense is employing a uniform EHR throughout a geographic area such as a large city or county. As you expand the geographic boundary requiring a uniform EHR within, physicians practicing in that area will have an easier time consulting at hospitals and clinical local to them. No time will be wasted learning new program interfaces, which translates into more time with patients.

Capitalists would be eager to point out that as the EHR market is allowed to develop independently, a dominant EHR platform will emerge and the entire idea of a geographic EHR will be useless. While that’s true, it would take an exceedingly long time for any one EHR to jump to prominence. With newly insured patients flooding physicians’ offices, rules that can be quickly and easily implemented have to be put into play. A regional EHR is one such rule. If, in ten years, the inevitable dominant EHR develops, then we can reconsider our options.

This is where the concept of consolidation gains importance as well. Currently, EHR companies independently vie for individual physician choice, but, given the amount of EHRs, inadvertently make physicians’ choices difficult. The cost of having an incompatible EHR with local medical establishments can outweigh the benefit of having an EHR in the first place.

Regional EHRs will pave the way for a new business model that will likely be more successful than current ones. In this new model, companies can propose enterprise-class EHR software for a geographic area, which will directly lead to system-wide savings through regional consolidation. Local physicians will pay lighter fees into a pool for regional EHR hardware, software, maintenance, and technical support instead of taking on larger fees for a private EHR system. EHR companies benefit by having steady and stable micro-market dominance. When it comes to EHRs, value stems from uniformity.

Of course, nothing is simple when it comes to healthcare in America. HMOs, PPOs, and other insurance schemes may restrict patient mobility. For example, Kaiser Permanente, one of the nation’s largest HMOs, has their own EHR called KP HealthConnect. It allows for all Kaiser Permanente hospitals and physicians to access any Kaiser Permanente patient’s records. Any patient outside of Kaiser’s HMO policy may not be in the system. Having an EHR tied to an insurance policy makes it difficult to supply healthcare to patients who enter the emergency department without Kaiser coverage. This not only complicates the physician’s job, but may put the patient at risk. Furthermore, any single geographic area is likely to have multiple hospitals that accept a number of insurance policies. Restricting a hospital to a private EHR would hinder its ability to properly serve the public in this regard.

Healthcare is radically changing in the 21st century. We have more patients, fewer physicians, and less time for them to interact. If we want EHRs to have a substantive impact on healthcare, they need to be regionally standardized and consolidated. Only then can we be sure that EHRs will increase physician efficiency and efficacy while improving patient mobility.

Roheet Kakaday is a premed who blogs at The Biopsy and can be reached on Twitter @TheBiopsy.

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The end of my residency and beginning of my practice was the most wrenching experience of my life.  I was woefully prepared for the transition.  Full disclaimer: I was trained many years ago when residencies were acknowledged brutal demeaning processes.  Things have changed considerably, but the psychological passage I endured still holds.

I think my process of becoming a surgeon was fairly typical, with the exception that there was no one in my family in the medical field.  All the doctors in my family, including all my siblings, are PhD types.  So through basic education, I was generally the smartest in my class, with all the baggage that entails; especially an growing up in the streets of New York.  Socially ostracized, socially inept.  Family outings were things like a Sunday drive to West Point to watch the Military Band concerts.

Then off to an Ivy League School to enter the contest for medical school admission (only 10% got in in my era.)  Not really difficult, but did involve a lot of studying.  I had 8am Saturday classes every semester.  No Friday night parties for sure.  Acceptance to med school upped the ante.  Now it was time for serious studying and ridiculous memorization; most of which has since become outdated.  All to get good grades and a good match for residency.

Then off to another hospital for residency, where you are treated alternately like a slave, and a social reject.  It has now been essentially your entire adult life with no training in any of the social sciences and the art of human interaction, and minimal normal social interaction.  The hierarchy of hospitals could only be called normal in the military.

Then you finish your residency and move to a new practice, and when you walk into your new hospital, you are afforded God-like status.  Where in this process is there any time or training to become a social, reasonable individual?  You train for years to be as perfect as possible, and then are damned for being a perfectionist.

In addition, I had a problem that compounded my difficulty.  I have no memory of ever wanting to be anything but a surgeon.  When at age 9 I broke my arm, I told the surgeon who treated me that I was going to be a surgeon when I grew up.  He responded condescendingly.  So now, I was a surgeon … what to do with the rest of my life?  What goals to strive for?  A very heart-wrenching experience indeed.  It took me over 5 years to get my head even partially screwed on straight.

Medical schools should offer courses in negotiations.  I took one at a law school, and found it very helpful.  Also human growth courses are also helpful.  My favorite place to go is Esalen, though I haven’t been there in years.  Any intensive course, taught by a competent psychologist will be helpful.  Learn how to interact with people and separate your professional perfectionism from your social realm.  Become a part of your community.

Paul E. Smith is a surgeon.

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I was honored to be part of a beautiful experience in late January of 2011. It was the death of my mother-in-law at the direction of Trinity Hospice in Aiken, SC. Having never thought I would describe death as beautiful the word choice comes as a surprise even to me, a Sagittarius and straight shooter, and in combination with mother-in-law, I would also guess, very suspect. However, sharing in her passing alongside her loving husband, sons, daughters and grandchildren, I found hospice to be a brilliant choice made by Shirley and all so dear to her.

Having worked in and around healthcare since 1998, I quickly learned that medicine is anything but a perfect science. The first time I walked through an ICU I was taken by the silence and the lack of life in the hushed hallways. Patients were housed in their individual rooms, hooked to ventilators, tubing and softly beeping machines. Not one room had a visitor or loved one sitting nearby on this day. Not one patients’ hand was reassuringly being held extending the one universal source of healing—touch.

A few years later I was in another ICU. I was talking with a nurse who shared with me a study they were working on. Family members do not understand just exactly what “do whatever you can” for their loved one means, she shared. Cracking ribs to resuscitate someone who has days or even weeks to live is useless for many, yet familial guilt or duty or feeling the need to do something, forces healthcare providers to perform actions they know in their heart are so far from the best interest of the patient. This particular study was allowing family members in patient rooms to witness the truth behind “do whatever you can” in hope that painful, costly procedures inflicted upon patients could be avoided.

When hospice came that unseasonably cold January evening in Aiken, a wonderful nurse who was unafraid of truth, or of death, told us all that it wouldn’t be too long before Shirley left us. She had lost the ability to communicate because, as the nurse explained, those who are dying become dehydrated from their inability to take in liquid or food making their vocal cords useless. When the nurse left, we sat vigil waiting for death to come. We Googled “stages of death” to better understand what we and Shirley were facing, and found both relief and comfort online in an outline of the bodies’ universal. We talked to Shirley, held her hand as she lay in her enclosed backporch, surrounded by windows that gave view to a golf course — the game she loved so very much. Photos of family and familiarity surrounded her until her final breath.

I encouraged my husband, his sister and my father-in-law to continue to talk to her when their own grief, fear and concern left the room silent. I could only put myself in her place and know that I would crave constant touch and a voice nearby saying, “It’s okay,” because dying is indeed just that. Sometimes better than okay, and for a woman who at 83 had battled the cancer that had first attacked her breast, then lungs, then back, then bones, since her 40s in the process of raising four children, a husband, three grandchildren and was loved and admired by many friends—her death was now a blessing. An avid socialite and athlete, all who knew Shirley knew that being confined to a bed for over six months was killing her spirit—a fate much worse than death.

A few hours before her death, my husband recalled to his mother memories of vacations they had taken over the years. Shirley tried to communicate something as he spoke. An unintelligible syllable here—a grumble there. We believe she heard him and was trying to join the conversation. We will never know what she was feeling or trying to say, if anything. But what I do now know is that the best way to die is at home if at all possible, with family around recalling trips to England, a soapbox derby 2nd place finish, or the hope that maybe the daughter she buried from the same cancer fifteen years earlier would be waiting to greet her in heaven. Perception and belief create our reality—I choose this one over the sterile, cold, often intrusive, unnecessary, loss of control that occurs when you surrender the care of your loved one to a healthcare system that tries but often falls short in this life passage.

Watching someone you care about suffer is hard work. Many shy away from it and give this gift to a stranger or healthcare provider. But being present for this transition is a gift—like birth, like graduation, like marriage. Dying is something we all must do and to miss this life passage of those you love most seems like the ultimate instance of not being there when someone most needs you. Shirley had those she loved most at her bedside that early January morning, and even if she couldn’t acknowledge us with intention, I know she felt our presence when it mattered to her most.

Tracy Granzyk is a health care writer and filmmaker.

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I believe the greatest challenge in medicine today is keeping the “care” in healthcare. One of the most frustrating aspects of practicing medicine for me had to do with how difficult it had become to incorporate caring into my practice. I am not necessarily talking about the kind of caring associated with having a long-term, close and mutually appreciated association with my patients: if that had motivated me, I would have gone into family practice or oncology instead of emergency medicine. I am referring to the type of caring that led me to make “comfort rounds” on the patients in the ED, finding a pillow to put behind someone’s head (there were never enough around the department), or an extra chair for a family member at the bedside, or cranking up the knees of those thin-mattressed gurneys to take some pressure off the bony sacrums of elderly women.

I’m talking about the kind of caring that requires the extra step to redo that suture to make sure its placed just right, or ensures the patient with the fractured femur gets enough pain meds, or sends you out to find a urinal when there are none left in the exam room and the staff is on break, or prompts you to place follow-up calls to your patients one or two days after their ED visit to see how they’re doing.

Keeping the “care” in healthcare was never an easy thing to do, but it has undoubtedly become more challenging. Physicians have had to adapt to the transition from the practice of medicine to the business of medicine in order to keep the lights on in their offices, or provide for all the uninsured patients in their ED. Its not easy to maintain caring when your hospital insists that if the patient can’t afford their co-pay, they don’t get their prescription. There’s plenty of pressure to maintain patient satisfaction scores, in hospital and in private practice, but there is also pressure to ‘move the meat’ and pack more patients into an hour’s office time; and frankly, everything in our lives has become increasingly transactional. It used to be that a waiter would take your lunch order. Now, an impersonal speaker attached to a porcelain clown in a box blares into your car window, and you have to pay first before you get your food; and many prefer it that way! Already, a host of physicians are communicating with patients over email (is there a caring emoticon?), and how do you project caring to the patient at the end of a robotic surgical arm?

Granted, when it comes to keeping the “care” in healthcare, patients are sometimes their own worst enemy. It strains one’s consignment of compassion when, after spending an hour repairing a patient’s self-inflicted lacerations, you discover that she has pulled a razor blade out of some cheeky hiding place and sliced up the other arm, seemingly out of spite; or when, on a dare, a teenager downs a fifth of vodka, and then vomits on your shoes; or someone with a nasty personality decides to spit in your face when you ask, “how are you feeling?” Caring works both ways: it was a lot easier for physicians to be caring in the days when physicians were universally respected in their community; and the erosion of caring in the profession has undoubtedly undermined that respect.

Some practitioners argue that the threat of malpractice suits also gets in the way of caring, though I’m not really convinced. Granted, I am fortunate in that the only time I have ever been sued was by a patient who I never saw, who was treated in a hospital where I never worked two years after I had retired from clinical practice. My name was dismissed from the suit. Perhaps if I had suffered through the months of self-doubt, the adversarial depositions, the accusations in open court, and all the rest; I might have come away with a significantly diminished capacity to care for my patients. I believe, however, that caring might confer a modicum of immunity from malpractice suits, though pure luck probably has more to do with my escape.

Many physicians now complain about these changes in healthcare, and my sense is that it has affected a lot of them in a very personal, and very discouraging way. All sorts of people go into the profession of medicine, and of course not all of them have caring or compassion or empathy leading them into the fold, any more than all firemen have bravery or policemen the urge to protect guiding their choice of careers. Physicians, however, invest more time and money, and make more sacrifices, than most (though not all) professionals to obtain the privilege of plying their art. They say that medical school is so grueling that it tends to squeeze all the humanity out of young doctors, but in fact a few short years in practice reignites, for most physicians, the spirit of caring that led them to aspire to the white coat in the first place. Caring is its own reward.

Now that I am retired from clinical practice, and older, I am more likely to find myself on the receiving end of healthcare. I hope that my own physicians can find a way to keep the care in the healthcare they administer to me, not because I expect to need a lot of hand-holding, but because I think caring healthcare is better care.

Myles Riner is an emergency physician who blogs at The Fickle Finger.

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