January

      My vision of structuring my clinic along the lines of a Direct Primary Care (DPC) practice this month was partly successful. Before describing the changes I've made, I must first give a bit of background. For most of last year, I simply tried to see as many patients as possible each half-day in order to make the quickest progress toward the 1650 patient visits required for graduation. Often, than meant feeling rushed and not fully addressing some of the more peripheral concerns patients would bring up during the course of an encounter. As I reflected on this and became exposed to the DPC model, I came to realize I was practicing sub-optimal medicine, which unfortunately cannot be labeled sub-par because it is the norm in our current third-party payer fee-for-service model.

       This month, however, I've been taking as much time as I feel I need with each patient in order to do a good job, and have resisted the urge to feel rushed at any point or even check how many patients are waiting as I interact with each patient. Sometimes, this has meant spending the better part of an hour with a patient who presents with multiple conditions and complaints.  Fortunately, these visits are often balanced out by quick 5 to 10 minutes encounters, many of which are prenatal visits or well-child checks. My rock-star nursing staff helped me at the few points where I did fall very behind, for example when I did a circumcision in the clinic on a patient who turned out to have mild hypospadias.

       Two crucial recent modifications of my schedule are that I have asked to only be scheduled to see 7 patients per 3.5-hour half-day (which seems to be my sweet spot) and having the first slot of the half-day always double-booked. Only once did one of the two patients scheduled for the first slot have to wait more than 30 minutes; all the other times the first visit was fairly brief or one of the patients did not show up. Though this is not something I plan to do in my own practice, double-booking is a necessary evil given the waiting room wait times and significant time needed for nurses to room each patient in my clinic, neither of which can I change. In my future practice, it will likely take no more than a minute for a patient to be roomed by my nurse (if they are roomed by a nurse at all), and I will likely have a much lower no-show rate, obviating the need for any double-booking.

       A final piece I have made progress on is my and Brandon Alleman's longitudinal project for the year, the Paleo Health Group. I recruited a few patients in the course of my clinic and have started to solidify the structure the meetings will likely take. Brandon and I just discussed our plans with a few attending physicians today at a Research Meeting, and they essentially reinforced our plan. Also, I booked the space for the first meeting and started a GroupMe text messaging group for us to start using in a few months. I was also able to hit two birds with one stone by making this my Practice Management project, which was nice.

      As I peer into February (and early March), I am re-motivated to pursue my goals of 21 intubations, 21 surgeries, 21 French words a day, and 21 blogged cases from my trip to Togo. I will probably type the cases up on my computer and post them all sometime in March, as internet and time will be limited. But we'll see; I'll try to post at least something on this blog while I'm there!

      I'd like to end this post, and every future post this year, with a reminder for you to quantify your goals and put them out there for the world to see, whether it be on a blog, a facebook post, in a small group meeting, or on your front door. In what specific way do you plan to better your life during the month of February? What skill set can you master or project can you complete that will make you healthier, wealthier, happier, or more filled with love? Seriously-- give this some thought. You grow old fast and Old Man Time is not your friend.

N of 1: 21 Days to Expert Enough

      What I am about to describe is next year's plan of self-experimentation, which has its origins in the things I've been reading and thinking about this year. A foray into the quantified self movement this year using the AskMeEvery service and numerous articles on methods of becoming "expert enough" have convinced me of the need for a structured program for self-improvement. A blog is perhaps the most useful tool to keep the self-experimenter on task; I first experienced the power of this motivation at the end of medical school, when I reflected on a number of William Osler's quotes during the first half of April. I still carry in me the lessons I learned from that time.

     Specifically, I am laying out a calendar of 12 21-day self-improvement projects I plan to accomplish over the next year. I chose 21 days because it takes at least that long to ingrain a habit (recent research actually puts the number at 66 days), and because it gives me wiggle room to miss a few days each month. This blog will be the site for my reflections on each project. The specifics will probably change, but as of now, my plan is as follows:

21 Days to Expert Enough

January: Approximate a direct pay primary care clinic in my clinic 

February: Blog about 21 cases in Togo, learn 21 French words a day, intubate 21 patients, and perform 21 surgeries (Caesarian deliveries, D & C's, exploratory laparotomies, etc.)

March: Teach medical students or interns about 21 different topics

April: Read 21 books

May: Build my website

June: Go through 21 medical journals (including back-issues of NEJM, AFP, JAMA)

July: Establish 21 new professional contacts

August: Quantify 21 areas of my life using the Apple Watch 

September: Establish a long-term financial plan   

October: Update my website or blog 21 times

November: Start a YouTube channel

December: Re-pursue one of the above projects, and do it better.

     A longitudinal project I'm pursing this year is a monthly Paleo Health Class (set to start in April and run for one year) for patients, staff, and faculty of Via Christi. The website and Youtube projects are even more long-term projects I've been hoping to start for the better part of the past year. My longest-term project will be the establishment of my own (or partnered) Direct Primary Care practice after residency, location TBD. Perhaps I'll be able to expand to multiple locations after a few years, as the Atlas MD folks are starting to envision.

     Rather than list out a bunch of resolutions you vaguely hope to accomplish but probably won't, why don't you consider committing to a more structured program of self-improvement? As 2015 begins, I hope I can inspire you to begin the process of quantifying yourself with the goal of becoming more effective, efficient, healthy, wealthy, wise, and happy.

     Be well.

     Dan

Jany Moussa

Twelve reasons why Dr. Jany Moussa is the man:

-He listens

-He is genuine

-He is warm

-He cares deeply about his patients and residents

-When he is upset, it is for a good reason

-He doesn't pull any punches

-He challenges us residents to be better

-He expects us to be good

-He encourages us when we do things right

-He believes in us

-He is a superb clinician

-He is always seeking to improve himself and others

For these reasons and others, everyone loves Dr. Moussa. I had the privilege of spending two weeks with him in June and seeing first-hand how he operates, and it was the most transformative two weeks of my first year of residency. I've since been trying to emulate many of the things I've listed above, and although it is slow going, hopefully I'm making some progress. These qualities fall under the three components of charisma that I learned from The Art of Manliness and am seeking to exemplify in my own life: Presence, Power, and Warmth. My new mantra.

My prayer of failure

     God, give me the true humility that thinks of myself less, others more, and puts your kingdom first. Mold me into a disciple-maker. When reviled, you did not revile in return, but entrusted yourself to the Judge of all things. When weary, and the crowd sought you, you welcomed them, healed them, taught them, gave them bread.

     I am dust. My sense of worth comes from things of no more lasting value than dirt-- my intelligence, my skills, my personality, my wit, my looks. I have dishonored You by this and I repent. I turn from my self- absorption. All these things are corrupted and will fade sooner than I realize. They could be gone in an instant. All that will remain will be You.

     You give me good things: joy, peace, love, hope, faith, reasons to believe You exist and that You are who You said You are. You will use my doubts to speak into a doubting world. You will use my times of trial to melt and mold me into a vessel fit for your service. Your Spirit will use me to make disciples. You will wash away the dirt. Thank you.

Personality, empathy, and relationships

       On a recent application I was filling out, I was asked to describe my personality. I recall testing as an INTJ on a Myers'-Briggs Type Indicator while working as a camp counselor in college, so I googled "INTJ" and came up with the following Wikipedia description:

INTJs apply (often ruthlessly) the criterion "Does it work?" to everything from their own research efforts to the prevailing social norms. This in turn produces an unusual independence of mind, freeing the INTJ from the constraints of authority, convention, or sentiment for its own sake ... INTJs are known as the "Systems Builders" of the types, perhaps in part because they possess the unusual trait of combining imagination and reliability. Whatever system an INTJ happens to be working on is for them the equivalent of a moral cause to anINFJ; both perfectionism and disregard for authority come into play. Personal relationships, particularly romantic ones, can be the INTJ's Achilles heel ... This happens in part because many INTJs do not readily grasp the social rituals ... Perhaps the most fundamental problem, however, is that INTJs really want people to make sense.

—Marina Margaret Heiss^[11]

INTJs are analytical. Like INTPs, they are most comfortable working alone and tend to be less sociable than other types. Nevertheless, INTJs are prepared to lead if no one else seems up to the task, or if they see a major weakness in the current leadership. They tend to be pragmatic, logical, and creative. They have a low tolerance for spin or rampant emotionalism. They are not generally susceptible to catchphrases and do not readily accept authority based on tradition, rank, or title.

INTJs are strong individualists who seek new angles or novel ways of looking at things. They enjoy coming to new understandings. They tend to be insightful and mentally quick; however, this mental quickness may not always be outwardly apparent to others since they keep a great deal to themselves. They are very determined people who trust their vision of the possibilities, regardless of what others think. They may even be considered the most independent of all of the sixteen personality types. INTJs are at their best in quietly and firmly developing their ideas, theories, and principles.

—Sandra Krebs Hirsch^[12]

Hallmarks of the INTJ include independence of thought and a desire for efficiency. They work best when given autonomy and creative freedom. They harbor an innate desire to express themselves by conceptualizing their own intellectual designs. They have a talent for analyzing and formulating complex theories. INTJs are generally well-suited for occupations within academia, research, consulting, management, science, engineering, and law. They are often acutely aware of their own knowledge and abilities—as well as their limitations and what they don't know (a quality that tends to distinguish them from INTPs). INTJs thus develop a strong confidence in their ability and talents, making them natural leaders.

In forming relationships, INTJs tend to seek out others with similar character traits and ideologies. Agreement on theoretical concepts is an important aspect of their relationships. By nature INTJs can be demanding in their expectations, and approach relationships in a rational manner. As a result, INTJs may not always respond to a spontaneous infatuation but wait for a mate who better fits their set criteria. They tend to be stable, reliable, and dedicated. Harmony in relationships and home life tends to be extremely important to them. They generally withhold strong emotion and do not like to waste time with what they consider irrational social rituals. This may cause non-INTJs to perceive them as distant and reserved; nevertheless, INTJs are usually very loyal partners who are prepared to commit substantial energy and time into a relationship to make it work.

As mates, INTJs want harmony and order in the home and in relationships. The most independent of all types,^[13] INTJs trust their intuition when choosing friends and mates—even in spite of contradictory evidence or pressure from others. The emotions of an INTJ are hard to read, and neither male nor female INTJs are apt to express emotional reactions. At times, INTJs seem cold, reserved, and unresponsive, while in fact they are almost hypersensitive to signals of rejection from those they care for. In social situations, INTJs may also be unresponsive and may neglect small rituals designed to put others at ease. For example, INTJs may communicate that idle dialogue such as small talk is a waste of time. This may create the impression that the INTJ is in a hurry—an impression that is not always intended. In their interpersonal relationships, INTJs are usually better in a working situation than in a recreational situation.

        As I've thought about spiritual gifts, empathy, and relationships over the past few months, I've been reminded again and again of Bryant and Rachel Ward's dog Wallace. My roommate Ben Carr and I experienced Wallace for a long time only as a large, energetic dog in a small apartment who was always jumping onto the Wards' guests and having to be restrained and locked away. Neither Ben nor I had had an especially high opinion of Wallace-- we thought of him as rather goofy and ridiculous, in fact. But the story doesn't end there. Last year around this time, Ben and I went hiking with Bryant, Rachel, another friend, and (you guessed it) Wallace. I also spent a week and a half living with the Wards in their house, which had a nice big yard for Wallace to run around in. In both situations, Wallace was a completely different animal. He was happy AND well-behaved. He had found-- or returned to, depending on how you look at it-- his niche: the outdoors.

       

Bryant and Rachel-- happy birthday (and parenthood!)

       At various points in our lives, we all feel like Wallace in that apartment, or "like a fish out of water," as the idiom goes. At other times, we're in our element. What I want to communicate to you all is that, when we interact with people, we should make allowance for the effect of setting on behavior. People need grace-- especially when they're sick or think they're sick. As my personality description above implies, I struggle with providing this grace, especially when the person or patient is being irrational. I truly want and expect people to make sense, like Wallace when he's on the trail, a salesman when he's making a pitch, or a housewife who's cooking a meal. But the challenge of our post-paleolithic existence is that most of us are out of our element most of the time. We can make some progress in our own lives by moving towards a paleo lifestyle, improving our strengths, eliminating weaknesses, et cetera-- but the most important change we all need is a new, softer, more Christ-like heart.

      We are enjoined to desire and seek the kingdom of heaven as a precious jewel—the kingdom in which everything will be made right and we will all truly be in our element. My prayer this week has been 1 Timothy 1:5, that the “aim of our charge” would be “love that issues from a pure heart and a good conscience and a sincere faith.” May these things become more of a reality in our hearts today and each day of our lives as we wait for the ultimate fulfillment of our hearts’ deepest desires-- the day when our individual weaknesses will become obliterated as we experience perfect oneness in the Spirit in the worship of the Father and the Son.

Another post on empathy-- because I'm a slow learner

      Much as I'd like, I cannot do much to change the beliefs, assumptions, and thought processes of the patients that come into the Emergency Department or the clinic. Patient after patient over the past two weeks have vividly revealed to me the importance of uncovering a patient's true expectations. Even though I may have done the right thing from a purely medical standpoint, patients have sometimes been dissatisfied because I have failed to meet their expectations in some way. As physicians, we obviously should not always give patients what they want-- but we should endeavor to acknowledge, respect, and address their underlying concerns. This can only be done well when we possess true empathy, for it is only with empathy that we can see a thing from another's perspective. That is what we should all endeavor to have in ever-growing quantities, and it is why we should continually seek to catch fresh glimpses of the "Man of Sorrows" whose whole life was a perfect portrait of other-directedness.

Sunday Repentance

      God speaks in the quiet of a Sunday morning, whispering truths about my life and the lives of others. I recognize a need in myself, a need for more empathy-- to see life through the lens of others. To be a better friend, leader, brother, son, healer, colleague.

      For the Christian, prayer is the time to gain this perspective. Constant prayer is how we maintain it. If we are prayerful throughout the day, the Holy Spirit will cause our soul and spirit to see and care about the thoughts, feelings, and needs of others. On Sunday mornings, I'm especially reminded of the love of Jesus. This helps me see my deficiencies as symptoms of deeper spiritual bankruptcy, not merely as character flaws, and also to be reminded of our perfect example of empathic, selfless, furious love. Prayer and corporate worship brings my thoughts, emotions, and will in line with God's, and thereby has the power to multiply my emotional wealth.
     
      I have a friend who made a prayer guide for our house church this week. I didn't do a great job of sticking to it, but one thing that stood out was yesterday's injunction to pray for each member of house church, specifically regarding our spiritual gifts. As we've thought about our gifts together, it's helped me see strongholds in my own heart and the hearts of others close to me. Few things are more important than praying to break down the strongholds of sin in our hearts with the overwhelming grace of God.
 
      Father, be gracious to us. Our spiritual weakness stems from prayerless faithlessness. Forgive us. As you drew near to the Israelites when they repented, make your Presence known in our lives today as we serve you and love your people. We praise you that you are always faithful to forgive and heal. You never forsake us. Help us long to never forsake you.

      

On the Tip of My Tongue

Not pretty things

Not words of power

Not ideas to discuss for an hour

Bitter feelings

From a smaller heart

Self takes the leading part

Prayers whispered

With a curse

This or nothing-- which is worse?

Take this filth

Make me speechless

Reveal Yourself-- I am helpless