Against the Algorithm

The Business of Medicine -vlog link

In youth I used to dream of being an athlete.  Growing up I was fast, I would carry the 8th grade guys on my back when we played “kill the man with the ball”.  (Think of me walking one step at a time with a dog pile of guys trying to weigh me down to drop the ball) I was amused that my legs could carry a lot of weight but just went with it hoping no one would figure out to grab my legs. In youth I used to dream of a lot of things so why is it we stop dreaming?  You only hear of the rare human like Steve Jobs or Elon Musk or even earlier scientists like Einstein or inventors like Edison coming up with a concept that “sticks” for the rest of time.  I submit to you its all based in day dreaming.

Currently best visions come at 430-500am when ideas overflow (if I allow them).  I wake do my 478 breath exercise, go downstairs sit overlooking my backyard while waiting for kettle to boil then sit more while brewing my gyokuro tea anticipating the first taste all the while imbibing nature therapy.  Ideas flow like a fire hose opened full force. 

This wasn’t so about 18 months ago; I would wake anticipating the tasks of the day and open my computer, log into the electronic medical records and start preloading patient data while downing a pot of coffee.  I remember my wife coming down one morning asking me something and I remember snapping at her as she was interrupting my flow and I only had 40 more minutes to do these charts as the ones from the day before were not complete and as soon as I entered the gauntlet of the office every second would be accounted for. 

This sounds blown out of proportion BUT its true.  One would think its should be easy to type, in prose style as the patient is speaking; come up with a diagnosis and a treatment plan all on the fly BUT it is not! What overshadows the time spent with patient is the arduous “CI’s” (clinical integration?) that is required for all doctor offices employed by hospital to fulfill in order to assure you get all the requirements for clinic site to get bonus.  The “CI’s” go into asking about recent vaccines, Pap smears, colonoscopy, prescription meds, blood pressure... ALL not what the patient is presenting for the day of BUT are necessary as a “by the way” while you are here can we get our bonus.  AND those questions and key strokes take seconds to minutes in an office visit to accomplish. (If your doctor is running 15 minutes behind and In addition now has to go through those CI questions; then enter data by checking boxes-this will take an extra 5 minutes (IT JUST FURTHER DELAYS AN ALREADY DELAYED DAY!!!) And that is just second patient of a 25+ patient day. 15 minutes behind x 25 patients = extra 375 minutes end of day (6 hours delayed to go home and eat dinner).  20 minutes behind x 25 patients = extra 500 minutes (8.3 hours delayed to go home).  Now for the rare doctor running on time, adding an extra 5 minutes per patient for average 25 patients = extra 125 minutes (2 hours delayed to go home).  THIS IS ONLY PATIENT CHARTING AND DOES NOT INCLUDE THE PATIENT THAT IS CALLING IN WITH A NEW PROBLEM, OR TO FIND OUT ABOUT RESULTS OR CALLING FOR REFILL OF MEDS OR CALLING FOR A 4 PAGE DISABILITY FORM TO BE FILLED OUT (all these things mentioned are hourly occurrences!!!) 

So if I would be a slave to the task-master of the day (the electronic medical record) then even adding a few extra key strokes adds up.  GOD FORBID IF A PATIENT HAD AN AFTER THOUGHT QUESTION AND I HAD TO LEAVE THE NEXT PATIENT ROOM TO REENTER THE ONE I ALREADY LEFT.  No wonder I hear some docs are answering questions while walking out the door or literally doctor “spent 5 minutes in the room” is a common occurrence.  My wife would wonder why I wouldn’t check my text messages and its because I just wanted to run out the back door after I finished the most crucial work (leaving some unfinished questions to be answered on next days schedule) and get to the sanctuary of my home.  This gauntlet would occur 5 days a week and infect my “time to day dream”.  In fact it induced a stress response that would wake me up at 420 for fear that I didn’t preload the charts in time to be out the door in the am to drive my son to school.  No wonder heart attacks occur across the world mostly on Monday!  

Turning on the stress response can be useful for getting out of life threatening situations.   It’s not like you have to manifest full fight or flight and carry a machete In the clinic but the rapidity of the tasks demands you think fast and use algorithms to survive the day.  Here is the rub, average patient doesn’t give a shit what the doctor has to go through, the patient is suffering and just wants it to stop.  Patient demands attention from the provider and demands focused problem solving to come up with answers and a plan of action.  The average corporate paid doctor WILL provide that BUT it will be in algorithm form.  To survive the day, every patient’s verbalized symptoms will be keyword focused.  Front desk and clinic area will be focused on listening for keywords of symptoms IN ORDER to lump patient into a treatment algorithm and produce a rapid solution.  The more rapid the solution, the more on time clinic runs, the MORE CI gets accounted for and the faster staff leaves to get home and spend time with family.  

Unfortunately, every person notes a common symptom but the rest of what they are feeling may not be understood by a layman thus its not divulged to staff when making the appointment or at check-in on the visit day.  Typically the doctor is supposed to question further (“outside the box questioning”) to make sure the symptoms are not from a deeper root cause.  BUT WHO HAS TIME!!?  

Patient: “...but doc its my 4th bladder infection this year”.  Doctor: “...its ok as women are allowed to have UTI’s frequently...any other final questions?”

When doc is thinking in stress response 5 days a week, it doesn’t allow for “dream time”.  This time is when you think “outside the box” to become inventive.  More importantly become inquisitive.  When patient is coming in over and over again with bladder infection symptoms ...is there something else lurking in the body that is starting to express itself?  Naaa... if it was important it’ll declare itself and we can get the specialist to cut it out, burning it out or melt it out!  Or more appropriately if it keeps coming back, it probably needs a prescription thrown to keep it from recurring again.  

Doesn’t seem like a fulfilling career, or a great work schedule BUT nice paycheck!!! (Average primary care salary in Illinois is $181,000 annually.) BUT that’s the guaranteed base salary as you are “starting out” working as an employee.  As you get established in 3 years your paycheck gets smaller and smaller as a “reverse incentive” to make you work faster and get back to the huge paycheck like the “protected” first year of working.  The only way to stream line everything mentioned above in the daily schedule is to treat the whole week as an algorithm.  Assume most patients will be sick from infection or sick from over eating or stressed out from life.  Preload all the days of the week with the typical algorithm answer of antibiotic, diabetes pill, or mood altering drug.  In fact, may as well just preload the entire month and year for figuring most patients you see will fit into the usual categories so anyone that calls with the smallest of symptoms or the beginning of a disease on recent blood test results should be placed on the most rapid medicine for the general population. 

When docs don’t have time to think in abstract and go into personalized-time-consuming-problem-solving, all patients are treated like cattle and branded to end up same way. THIS IS CALLED THE ECOLOGICAL FALLACY.  It is assumed the data from the individual is treated as the research outcome data coming from a larger group.  Does this sound familiar?  Patient Lives Matter!!!  Medical community should not assume all patients coming in with symptoms will be successfully treated based on the data of the general population.  If I was to give metformin to anyone overweight with an elevated glucose and assume they are not going to lose weight or change lifestyle, you pigeon hole those patients that would otherwise have committed to change and reversed their disease.  BUT WHO HAS TIME TO DIVE INTO PERSONAL INVESTIGATION TO FIGURE OUT WHO THE OWNER OF THE SYMPTOMS IS AND WHAT IS THE ROOT CAUSE OF ALL THIS!?!

When I do lifestyle coaching online, I can sometimes spend 1.5-2 hours trying to figure who this person is...the proverbial meet the client where they stand.  However ask the hospital you work for if you can spend 1.5-2.0 hours and just see a fraction of patients daily as compared to the ‘average” and you will be laughed away pointing out you are “not keeping up”. There is a saying in social work to meet the client where they are / instead of being prescriptive, try to improvise to co create a plan of action PERSONALIZED to the individual.  Going right back to where I started this blog, improvising is a learned talent... or should I say its a natural talent from youth displayed in day dreaming.  It’s a natural talent that in adulthood that is “unlearned” to allow algorithm medicine and the ecological fallacy to anchor. 

• Doctors: Don’t be afraid to Dream BIG!!! 

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What I did on my Summer (covid) Vacation

 I had an grounding conversation with Dr Pat Massey. For those of you who know me, I followed Pat from the 90's forward when I came across Alexian Brothers article about a doc that taught Tai Chi to patients with "Failed Back Syndrome" and got them off their medicines feeling no pain.  This syndrome is when a patient goes through major surgery to correct an acquired defect and either; has persistent symptoms or suffers more than before surgery. I had just finished my Sports Medicine Fellowship in 1995 and felt very empowered as a primary care physician with "extra training" to have a more tools in my toolbox for problem solving disease manifestation in patients (see Annual Sickness Visit post). 

Nutrition wasn't sexy in the 90's and physical medicine was booming.  Rehab, trigger point understanding, exercise (marathon training and working out at Bally's) was the rage as some folks were able to take a non doctor modality (fitness) and apply it to alleviate some key deficiencies in American lifestyle.  Just by adapting this available form of exercise,  a small percentage of people were bitten by the running bug and reversed the onset of hypertension, high cholesterol and heavier weight.  I don't mention Bally's memberships as only a sliver of gymrats have grandfathered into the newer expressions of working out at all in one 24 hour gyms.  In fact the average person that jogs will run year round, the average person that exercises in a gym will weight training for a few weeks after Holiday eating.  So by default, weight training on your own will be a temporary modality pulled out when inspired to attack new years resolutions.  

My theory is that the runners high (endorphine and enkephalin secretion) makes people feel euphoric, is addicting and DOES NOT require vast knowledge on what to do.  No matter what speed you run (even hike) the feeling from the event;

-keeps you in the moment (erasing the need to ruminate on the laundry list of things to do that day), 

-gives you a bump of invincible-hormone (as our genetic code rewards the endeavor with the neurotransmitters to solidify that this habit will preserve the species so do said act again), 

-moves stretches and perfuses muscle with oxygen to take away muscle stiffness, lower blood glucose and increase sex hormone,

-reinforces circadian rhythm to induce a deeper refreshing sleep (resulting in repairing trained muscle and reinforcing neural tracts to adapt new coping skills learned during the day)

The post work-out high:

-gives you a bump of invincible-hormone

-sometimes reinforces circadian rhythm (but highly depends on what stimulant you use to get through the work out -ie caffeine, red bull sugar, metallica ...)

...thus the high quit rate with working out UNLESS YOU GET SOMEONE TO DESIGN/REDESIGN and keep you on task!!!

Now that nutrition has: multiple authors, weight loss centers, patented box diets and supplement companies that have the newest Dr Oz vitamin for slimming waist line, the American public has kinda made nutrition education a needed modality to build up.  Since the hospital systems do not acknowledge personal nutrition design as a domain they control...the Nutraceutical/fitness industry has taken it over.  Note I said “kinda” as most Americans will not read a text cover to cover and just adapt the cliff notes on a nutrition practice from watching a YouTube video. (Super biased and sometimes poorly interpreted by vloggers that may or may not have a nutrition background).    

So now the average citizen has 3 modalities that can be used to reverse/prevent disease manifestation. One roadblock is that for the power of nutrition change to take effect, its not as easy to find your groove as putting on a pair of running shoes and going outside.  

-Nutrition has to be personally designed

-Weight training has to be personally designed

-Running can be initiated and fine tuned even by a high school runner

Insurance based medicine doesn't cover nutrition counseling unless you have crossed over and been rewarded with the label of diabetic or heart stent candidate or cancer patient!!! 

Insurance based medicine doesn't cover exercise unless you have acquired an acl tear, back spasm, shoulder impingement or an overuse injury from work.  

Medical insurance was supposed to be used "just in case" a catastrophic event occurs, that way you are ‘insured‘ to not go bankrupt or get turned away by a hospital.  Now a days patients rely on medical insurance to cover an annual wellness visit (see Annual Sickness Visit) at which point the laundry list of issues are brought to the doctor to address and inevitably either doc says "don't worry about that one-trust me" or s/he proceeds to give a pill/referal to address the remainder of the complaints.  My theory is medical school and residency is jam packed with curriculum now with the advent of electronic medical records and there is no time to teach lifesaving nutrition, exercise prescription (even some orthopedic specialists) or cultivation of mindful practice. These 3 key components are how blue zone citizens reach the age of 100+ while maintaining independence, bladder function and memory.  

Luckily these modalities can be undertaken without a doctor BUT the more efficient way to engage change is to have investment in a coach to teach, apply, adapt and refine to the individual.  If you have a favorite author then you may be able to try on the practice IF you read cover to cover and have a good fund of knowledge.  As I alluded to earlier America has become fixated on social media and watching a book is easier than reading one.  Condensing long concepts are like cherry picking your data to invent a new law of thermodynamics.  

This brings me right back to my original sentence, my conversation with Dr Massey.  He preceded me to develop a footprint in the area for "a different type of medical practice".  He also confided in me that he took a lot of bumps in attempting to intertwine successful life changing protocols to the confines of a hospital system (JUST LIKE MY LIFESTYLE CLINIC BLUE PRINTS WHICH I WAS TOLD WOULDN’T WORK THEN SUDDENLY THERES A WEIGHT LOSS CLINIC?!!)  I am now convinced if you try to sell a screw driver user a new tool called a hammer, they will look at you like you're speaking a foreign language.  I have finished the gauntlet of learning to use the screwdriver, the hammer, the flash light the prybar and the glue stick (and will continue to adapt newer tools as the horizon demands) and I feel penalized when I wield these tools like a martial artist of lifestyle design. I guess it was inevitable to butt heads with "standard practice" when I embraced "alternative and complimentary approaches.  I was hoping to just maintain a regular paycheck and do what I feel was right (on the down low) as my contemporaries still look at me like I'm speaking a foreign language when I speak of energy medicine, yoga breath, supplement effects, gut microbiota, medical cannabis application and "hand holding". 

Looking back to last week, if felt so wrong in taking care of my patients and:

-NOT going over the allotted time for a visit

-NOT suggesting weaning down on pain meds/weaning up on medical cannabis

-NOT providing lifestyle coaching outside of insurance reimbursement

-NOT suggesting looking at my youtube tutorials to educate

The root word of doctor is “docere” which means To Teach.  

The root word of patient is “patiens” which means To Suffer or Bear

The root word of heal means To Make Whole...I do not agree with a drug or a surgery to make you Whole (drugs/procedures maybe  necessary to stop severity of suffering but the next step should always be taught!)...there are a few primary care docs who practice from the heart but its only a matter of time before comparison is made to the performance of all other US docs with speed medicine (lazy medicine)...at which point you “eat what you kill”...(if you dont want to see high volume-then you will need to moonlight to pay the bills)

The true healers I am collaborating with are good at what they do since they can’t rely on screwdrivers.  I am sharing my tools with my new team to develop a parallel option to the embedded disease care system (see Annual Sickness Visit).  Looking forward to the future, I feel so RIGHT to dive 110% into all things NOT suggested within the walls of a hospital system.  I am now unemployed (which is not the first time -thanks to medical insurance reimbursement!!!) but I am unafraid as the warriors that have reversed there suffering under my care are sending out threads of compassion to sew my proverbial parachute. 

2020 is life changing!!!  #fallingwithstyle

Hammer Time

 I go to the township board meeting letting them know with my “special care plan”, my neighbors lawns are healthy my neighbors houses are strong and my neighborhood is safe. 

I want to offer a wider template for the whole town to reap the same rewards.  I offer my services at a discount as it pleases me to see neighborhoods thrive but the board says they have seen these programs in the past and don't want to invest as past experience says its not worth it.

I accept that perhaps My “special care plan’ may not be for everyone and maybe its by-chance a few properties are finding great benefit. 

I keep it to myself but share it with close neighbors, and friends of neighbors as word is getting around that I can get grass to grow, houses to withstand Mother Nature, I take their success and feel good about giving and doing my small part with a small subset making a small but important impact.

THEN I find out one of the board members retires and goes on to become the first head of a “special care plan” clinic to change the town by making lawns healthy, town homes strong and the town and country safe!? And all the other board members are congratulating him stating he will make a great impact with this needed investment?!

WTF!!!

My house is smaller than the other township board members, 

My neighbors houses don’t need big hammers and nails to repair what needs fixing,

My title according to the township is “average towny” with average experience in rebuilding neighborhoods, 

My neighborhood impact is farther reaching and more sustainable than multimillion dollar infrastructure planning blueprints the board suggests to revamp neighbors,

My personal design takes a house at its face value and creates peace, longevity and blending with the landscape by embracing individual strengths and acknowledging weaknesses (not all houses will adapt into a one size fits all blueprint).

I have personal investment as I have rebuilt my own “average” house from the point of demolition to the current warm, resistant, and forever lasting.

Gonna have to find a new town but this time I’m taking my tools with me and building a city.

Get out of the way!!!

(given by an instructor at a Harvard class)

From a March 2019 Deepak and Oprah 21 Day Meditation Challenge-

"when you feel struggle... pause... try to take a step back...give yourself a moments time to find your center...that struggle is a gift a whisper your true self tapping yourself on the shoulder ever so gently to look again cause you always get to choose.  Do you react to an obstacle as a negative or do you embrace it as an opportunity with the open hearted knowledge that ... All Will Be Well"

My Dad a gynecologic surgeon used to tell me stories when operating on someone and critical life and death didn't seem like it was going the patients way... he would pause, take a step outside the operating room take a deep breath and open his heart and mind to find the answer OUTSIDE the turmoil of forces trying to make him take the easy way out and "call it".

I usually will tell new patients with insurmountable lists of ailments if we go back in time and think about what happened during the time period before shit hit the fan...we can find the answer of what to reverse.  It seems too simplistic BUT I believe if we act to reverse the biggest root cause...all the other subordinate roots will fall into place like a wack a mole game allowing you to see all the moles to hit.

I have made every excuse not to take the proverbial step off the staircase and have dis-empowered myself.  My ego gets in the way ruminating on every unlikely scenario that might occur if I go the route of starting my own brick and mortar clinic but honestly with all the complaints I hear from docs who have started and survived without having to be financially rescued by a major health care system...I'M NOT LIKE THEM!!!

I have always had a passion to nurture the human body, fine tune the muscular system, support the digestive system, embrace the spiritual practice of ancient cultures push human performance (both athletic and regular Joe/Jane) to it maximum.  I kept on telling Mama I wanted to be an athlete but she reiterated that being a physician would guarantee financial security anywhere in the world. (don't think she would have fathomed how google reviews could make or break even a Harvard graduate).  I so appreciate her pushing me into this direction but look where I am:

-sports medicine trained
-integrative medicine fellowship (nutrition)
-yoga instructor and middle aged athlete/coach

When a complicated patient comes in for help, I like listening to their story as I will always try to find the answer they are looking for in the words and language they use.  I feel most of use can heal ourselves but just refuse to see the way out of the pit as it is seemingly so difficult to initiate the first step.  We have become accustomed to existing in the level of daily suffering and soaking in waves of sympathy every time someone asks "are you OK?"  I'm not belittling chronic disease and admit wholeheartedly that I am a fibromyalgia sufferer IN REMISSION but I am not using this as an excuse for not moving on.  I've worn the concrete suit that disease gives us and recognize that it is just a chore to get through a single day let alone see a higher calling.  My own stumbling feet are intentionally getting in the way of finding the next milestone of aging called wisdom.

I painfully wish my Dad was around just to bounce my ideas off of but I know he gave me the answer to my query a long time ago ... I just have to extract it from his many late night lessons sitting a the kitchen table with a few beers talking about "medicine".  I'm taking a moment, finding my center knowing that throughout this struggle I have your spirit behind my shoulder pushing me forward.
I miss you so much but I know what I have to do.

Osmundo N Saguil, MD

Puppy Love

So my goal with medical practice is to help patients define a goal.  In creating my annual DrRic's Hiking Excursions....it started as a goal for me to keep activity as top priority.  Modern lifestyle keeps activity and exercise on the bottom of the "totem pole" regarding multitasking.  When we keep shoveling other tasks atop the required daily move count, before you know it January first rolls around and your 5-10lb heavier, still tired, and planning a check up with doc to most likely get started another medicine since nothing changed from the previous visit.  That is why I find it easier to daisy change small tasks and have mini successes so life isn't overwhelmed with ONE BIG GOAL OF LOSING 50 POUNDS BY SPRING.  (...individual goals may vary but you get the picture about procrastinating on health) 

During the dreaded annual wellness exam (15-20 minutes max as allowed by medical insurance reimbursement)...when I hear "I know what to do I just have to do it"....I immediately retort "please don't rely on failed routines as if your technique failed to give long term success then if will fail you again" and we don' want to have the same conversation next year. 

A common benchmark for success or failure is levels of glucose, cholesterol, and vitamins.  If your deductible is too high to invest in getting blood tests or fancy imaging studies ...then we go old school. 
-new school = test blood levels and get xrays or ct scans and determine if change has occurred.
-old school  = measure waist line, weight, level of fitness, blood pressure, diet or number of meds (the more medicine prescriptions you have accumulated / the more health has "left the building")
So the inherent problem with doctors of functional medicine is they follow numbers not the person.
If you feel good now after fixing the lab values....okay but you have just accumulated more vitamins and herbs instead of medicine prescriptions!!!  If there was a way to add old school guidance to new school measuring....that would be perfect.  Using old school ways will change the basic ways of eating sleeping activity and stress tolerance....it should be recognized as a 360 degree change but that takes motivation (in your face accountability every day during the weakest times of the day.)   A coach for keeping eyes on your activity and making you aware of goals short and long term, a nutrition expert to remind you BEFORE the crave kicks in on what is expected by end of day and a mindful coach to design and redesign do-able routines to keep a stress neutralizing routine on your daily accomplishments.  If I act as head-coach one to twice a year during your visits....I need these coaches in your back pocket with day to day/week to week motivation. 

Either way, if you are headed to and early coffin or worse, a label of "disabled" due to stent, numerous medications, physical pain or emotional imbalance has been adopted...someone has to design a template for lifestyle change.  In taking care of lowering blood sugar, I usually like to add psyllium (fiber), timing of meals, volume of meals, ingredients of meals and level of satiety (satisfying feeling of fullness).  In Toms story of lowering sugar, the odd thing is he gained weight since his last visit which doesn't make sense as his sugar level dropped down?!...  In the Q&A that ensued, I found out his sleep was being interrupted!!!  AH HA!!! but poor sleep would cause sugar to go up?  Then he revealed the answer.  Tom got a puppy and he has been the one caring for the new family member.  The little guy wakes Tom at 3 am to pee but even with this seemingly frustrating info...Tom was smiling while talking about his new best friend.  To me this is the typical result found when people participate in laughter yoga.  Small studies have been used to check pain tolerance during duchenne type laughter and it was speculated that there may be an endorphine mediated response that changed the way damage to the body was handled.  Being in love can cause the heart and mind to be bulletproof to damage / the opposite is true too.  Maximum stress can cause a normal heart to undergo anatomic changes resulting in the heart attack.

This is where my hypothesis on love and inflammation.  Tom gains weight=sugar goes higher.  Tom loses weight=sugar goes lower.  Tom finds happiness=metabolism changes.  Tom finds puppy=sugar lowers JUST LIKE HE LOST WEIGHT!!! and the test for my theory is his weight gain should have increased sugar but actually reversed it.  Now there is alot more to test, control for variables, check the lab reliability, scale accuracy...but who cares.  Tom found a friend, puppy found a home, doctor got a reason to blog, one less medicine the insurance has to pay for. 

LOL -click here to check you how laughing changes the world

Back to Business

The proverbial "waiting room"

When I was growing up in the 70's : (
... the waiting room was where dad's would wait while babies were being born. 
The stereotypical scene was several dad's pacing back and forth anticipating the
good news.  Now the dreaded waiting room associated with western medicine
is where you wait for hours, read outdated magazines (that sick people have leafed
through) with a sign that says no phone use.  In this culture of immediate reward,
it rubs everyone the wrong way to have to deal with waiting. 

So even before I see anyone in the exam room, an unsatisfactory review is brewing.
One wonder why a doctor would care about reading reviews when they all should be
focused on patient care ....but.... salaries are dependent on satisfaction.  The current
design structure for getting paid by a hospital has efficiency and patient satisfaction
built into the formula (RVU's).   It was started in the early millennium when large hospital
organizations had to be accountable to medical insurance payers to be efficient (and
not order too many expensive tests) but insurance companies also wanted their
clients to get the "best" health care.  One parameter of measurement was patient
satisfaction surveys.  Reviewing wasn't as hot a tool in 2000 as it is now.  Additionally around
1999...there were a still primary care doctors that owned their own medical practice paying
attention to utilities, salaries, billing, malpractice insurance...even answering their own
phones and pagers at night.  (I remember someone paging me at 2am just to say they
couldn't sleep!!!)  With medicare reimbursement decreasing back then about 3% every
year.....it was only a matter of time before being a small business owner of a medical practice
would cave in to being a salaried employee.

I left medicine totally disgusted in 2005 and moved from Illinois to Florida where I was
going to start over and just be a dad.  The last thing I remember was being told by
administration that the hospital paying my salary was changing and if I didn't get
on board with the new salary structure (less pay more hours because I wasn't producing
the same as other primary care docs in rest of the country) then I should leave.  But in theory I couldn't leave even if I wanted to, there was a restrictive covenant in place that would bar me
from opening my own practice within a 15 mile radius and I would have to pay for a malpractice
insurance "tail" to cover any potential law suits filed against me for the prior 10 yrs.
-most patients don't see primary care docs > 15 minutes from their homes
-tail coverage costs about $10,000-20,000 to be paid all at once
-new malpractice insurance would have cost me $50,000 before I even opened my doors
-electronic medical records were being pushed by the government as an attempt to decrease
paper waste and have efficient doctor to doctor communication (more like doctor to insurance billing efficiency)
-offering medical insurance to future employees as a small business owner was impossible to afford (and still is)

But I had work to pay mortgage, kids education, medical insurance.....(I didn't have medical insurance
for about 2 yrs as I couldn't afford it...prayed every day to stay injury free).  So I signed up to be an immediate care doc.  See patients that I didn't have attachment to, finish work right on time and hand
off the the next doc.  No phone calls middle of the night.  "Treat em and Street em" was the motto.  That was not why I stayed in school until the "21st grade"  (I am now on my 24th grade / year of study).  I was disillusioned from medicine due to the harsh words of an administrator saying that my practice style of medicine didn't make a difference in the community as compared to the national average "I was below average"....until the phone call.

I remember being okay with life in Florida, payed hourly for immediate care coughs colds sutures injuries....then I got a call from an old patient from Illinois.  They were looking for my help as all the docs they were assigned to didn't give many options. He was dying slowly of cancer.  With the acupuncture training I finished before leaving for Florida, I remember designing a few options no one else thought of.  He died eventually but I hope my suggestions gave a small sigh of relief for at least his family.  This is the part of the movie where the hero thinks back in time and pieces together the keys to conquering the the big Boss bad guy.  I re-awakened my core thinking ..."I wasn't below average and all the weird things I invested in -acupuncture, breath, yoga, nutrition, exercise...gave options no other doc was offering.  They made a difference to my old patients who looked across north America for me, they made a difference for me during the time I had no medical insurance, I had to make major lifestyle changes to stay out of the hospital!  So I came back albeit slow, I still worked my way back into private practice (kinda) still holding onto my style of medicine.

So how does this pertain to the waiting room?  I learned from Andy Weil, Herb Benson, Deepak Chopra and Joseph Helms that the answer to the disease manifestation is in the patient.  Getting the answer out will take more than a blood pressure reading, a throat swab or blood testing.  There is a gentle teasing out of information from the human sitting in the exam room with you.  An exam is not just a physical exam...it should be a bio, psycho, social, nutritional, educational, introspective  interaction between healer and patient.  Look at the word 'patient'....connoted the need to take time for healing.  Done properly, the time spent in close proximity to a good healer will reveal the most direct path to heal-ing.  When we truncate the time spent in planning out the journey on our path to being disease free, there is more chance for error.  Making a mistake means back tracking and starting again.  This time loop of only inquiring about the biggest symptom and then treating with a temporary medicine till another symptom pops up to be repeated again...doesn't get anyone (doctor or patient closer to "healthy".  In fact this stutter stepping pushes healing farther away and brings chronic suffering into younger ages.  The answer is in the patient, to know the patient inside and out will be the best way an architect can design change, empowering change will beat disease.

This take more than the standard 20 minute visit (15 minutes actually but I have 20 years of experience!!!) so when I run behind by 45+ minutes, it is usually to accommodate for the 20 minute slot given for a "wellness check up" that turned out to be a multi-system, multi-symptom chronic presentation that needs fixing now.  I'm not blaming patients, they don't know that the majority of medical insurance payers are following the state's reimbursement of 49.95 for the most complex of visits (that usually takes about 45-60 minutes of face to face time to listen to plan out and diagnose.  Tag that onto a 6-9 month turn around on payment receipt...how is a business supposed to survive? Then at the same time I have to make sure service is with a smile or I wont get my "potential" annual salary.  I am not embarrassed to say...I am getting the same salary I was paid during my first years of working for a hospital.  (in 1995)  I have the potential to make what the average primary care doc makes in the US but I would have to see more patient and practice medicine like everyone else...just contributing to the time loop, but I choose not to.

I know my body mind spirit won't tolerate practicing at this pace forever BUT for now:
-I take my salary as is (at least I have a job)
-continue to change lives (check my drricsaguil instagram posts)
-save up some money doing other things (like my youtube channel and maybe an acupuncture clinic on "days off")
-hit the lottery
-vote for change
-opt out of taking medical insurance BUT charge a reasonable fee
-continue to create a sense of calm in the "waiting room" so that patients are actually healing before I walk in to start the healing process.

My faith tells me if I provide the keys for people, the Universe will open the door for both of us.
Guess I have to take a seat in my own waiting room.