Gone Electric

Haven't written much in a while, but thought I'd throw in an off-topic post, just for the heck of it. A couple of months ago, I made a major change in my life: I traded in my old car, a 2004 BMW 530i and I went and got a Tesla Model S

Yep, I'm a proud member of what's been described as the "world's more expensive beta test."

I've had it now for almost exactly two months, and I thought I'd share my observations.

First of all: cost. Yes, it's an expensive car. No denying that. However, it's not quite as crazy expensive as the sticker price makes it seem. My default plan was to replace my old BMW with a new one, probably the 550. The Tesla actually specs out about the same in the cost department. There's 10% sales tax on the BMW, but my state has no tax on electric cars, and there's a $7500 federal tax credit, which helps narrow the gap quite a bit. Then, depending on the assumptions you make, the cost of fuel should actually make the Tesla cheaper over time than the BMW. I figure that over 100,000 miles (I put 130K on my old one), I'll spend about $22,000 on gas for the BMW. Electricity costs for the Tesla over the same time period should be about 10% of that figure, which could in theory make the Tesla substantially cheaper. A lot depends on the big unknown of the battery life. The one I got is warrantied to 100k miles, but the replacement cost and whether I should lay away costs towards a replacement at 100k miles is unclear. On the other hand, Tesla maintenance should be near zero. It has so few moving parts - pretty much brakes, tires and running gear; contrast that with replacing the clutch on my BMW which was over $3000. Just looking at cost of propulsion, so far I'm averaging about $0.028 per mile, compared to about $0.25 with the BMW. 

It's a pretty car. It's got a rear-focused profile which reminds me of the Jaguar XK8. I happened to get mine in something approximating a Jaguar green, which looks lovely in the sunlight but alas looks black in gray light (so in the cloudy Pac NW, it mostly looks black). The front styling looks a little like an Aston Martin, but the LED "eyebrow" lights around the headlights are distinctive and unique. 

I also like the layout. There's no engine, so the front hood hides a medium-sized trunk. I can carry my emergency supplies plus a suitcase or gym bag or groceries or lawn chairs, but it wouldn't handle a golf bag. The back is a hatch design and since I have 4 kids I got the jump seats:

The girls are sitting directly on top of the drive train, which is shockingly small. There are no gears to speak of, and no transmission. The engine revs from 0-30,000 RPM or something ludicrous like that, and is directly mated to the rear wheels. 

The interior is outfitted to match the price, easily comparable to the BMWs and Mercedes of my experience. Certainly consistent with a luxury car's expectation. I think I detect a little roughness in the fit & finish -- a little buzz from the inexact fit of the air vents, maybe. Nothing major. More puzzling is the spartan approach to storage and utility. The cupholders (there are only 2) are small and oddly placed behind the driver, and there is only one very small shelf useful for holding, say, a cell phone or some sunglasses or other doo-dads. Other than the glove compartment, there are no other storage compartments anywhere in the car. There is a lovely flat space in between the front seats (no drive train to create a floor hump) and I can toss my ipad or my wife's purse there. But it's not the same. 

The center console is a bright, sharp LCD:

The center number is your speed, and the left blue bar is an analog display of your speed. The right yellow bar is your instant power usage. Yellow means you are discharging the battery, and green means you are regenerating it. You can configure the side panels to show what you want; I have media on the left and energy stats on the right. In the right corner is a Lego figure my son made a few years back, which is the totem of my car. When you're in navigation mode, on the left is a perspective-style view of where you're to go, which is pretty intuitive and easy to follow without taking your eyes too far from the road. The center green bar is battery status and ideal range in miles. The display, as a whole, is exquisite. I'm super impressed with the design and the care that went into it and how easy it is to use. 

The big display in the center console has gotten a lot of press. It's a multifunction display which is very familiar to those of us with aviation backgrounds! It's also bright and sharp, but placed such that when you use it, your eyes are well off of the road. One very cool thing is that the rear view camera can be used while driving and supplants the rear view mirror to a large degree. The view out the rear hatch is not that great, so the fish-eye lens actually give better rear and blind spot awareness. The camera is super sharp and bright (it was raining when the above pic was taken, so it's a bit blurry). I leave it on most of the time. Below is the nav, which is powered by Google maps. You can swap out various functions or make them full screen. The media lets you choose between radio, internet radio, satellite (if you pay for it) or your local media, such as an iPhone or flash drive. The energy function lets you monitor your power usage and efficiency and is super addictive. I usually wind up trying to beat my "high score" for a given route. But that requires you to drive slow, so I turned it off. There is a browser window, which you CAN use while driving, if you're reckless enough. Fortunately (?) it's super slow, both the 3G internet and the browser itself, such that it is essentially useless, so there's little temptation there. Supposedly there's a 4G and wifi option in the works, which would make it more useful, but so far there's little risk of driving and surfing. Data is free for now, but we will probably have to pay up in the future. The phone app syncs your contacts, if you have a smartphone, and makes it super easy to call or navigate to anyone in your phone book. And unlike ANY other car I have ever used, the voice control functionality is actually pretty useful. As for the stereo:

It goes to eleven. 

The driving experience is pretty damn awesome. It's been said over and over again, but the acceleration of this thing is just sick. It's hard to describe what "instant" throttle response really feels like till you've experienced it. I've driven some really fast cars in my time and this car is quicker to respond to drive input than any I've experienced. The Porsche 911 does have more acceleration, but only by a bit, and even then it has the ups and downs of its power curve, while the Tesla has maximum torque from the moment you stab at the right pedal till you let off. While it's impressive off the line, it's almost more impressive when you're doing 40 and can still fling your head back against the rest as you punch it to 60.  I've had it as high as 110, and it still felt like it had plenty to give, though it's electronically limited to 125 mph.

Also unusual is the braking: you rarely touch the brake pedal. The moment you let up off the throttle, very strong regenerative braking begins, recharging the battery. You are actually thrown forward slightly if you let off the throttle at speed, and the brake lights come on. (They are controlled not by the brake pedal but by an accelerometer.) For someone used to a manual, it's you need to relearn how to drive, slightly. This car does not coast. 

The handling is good. This is in fact a very heavy car (4700 lbs curb weight) and it does feel that way when cornering and stopping. It takes corners very well and is more than competent at high speed. I am a bit spoiled from the stiff handling of my BMW, which I miss. The suspension and ride of the Tesla are distinctly softer, if perhaps more comfortable. 

One other odd experience is that you never turn the car on -- or off. You walk up with the key (which is shaped like a little matchbook Tesla) in your pocket. The door handles extend as you approach, you sit down, put it in drive, and go. No ignition, no parking brake, no "on" button, you just go. And when you get to your destination, you just put it in park, get up and walk away. It knows you have left, and applies the brake, locks the doors, and powers down. I'm always feeling like I have forgotten a step. 

Charging has been a non-issue so far. I had a standard 220-volt outlet (like a dryer outlet) put in my garage and I just plug the car in every night before I go to bed, as I do my cell phone. There are charging stations all over Puget Sound, but since I've 200-300 miles to play with I've never needed to charge outside of my garage. I get about 30 miles of charge per hour, so I can pretty much completely recharge overnight, even if fully drained. You can also set the car to charge during off-peak periods, when electricity is cheaper.

The rated range is 240 miles, and the ideal range is 300 miles. My experience is that I can count on the 240 miles pretty reliably. In order to get the ideal range, I'd need to drive a lot slower and also live somewhere flat, since hills really eat up the charge. But as I live at the top of a 7% grade, I accept that I will never get the ideal range. I can do road trips, but it takes a bit of planning to make sure that you can get there and that there are charging stations en route in case you need it. There are a number of good apps that tell you where to find charging stations, what sort they are, and whether they are free or charge (about 50/50, it seems). 

On the subject of apps, there is a Tesla app for the iPhone. Its main use, as far as I can tell, is to allow me to preheat the car at 2AM when I'm getting ready to leave the ER. It's nice to come out to a cozy preheated vehicle. It can also be useful for finding your car in a parking lot, or checking the state of charge. But it doesn't do much else. 

Overall, I love it. I love the fact that I never have to fill it with gas. That was a chore that I always hated and tended to make me late for work -- even later than is my norm. Now I've gone 2500 miles without setting foot at a gas station, which is pure heaven. Yeah, it's green, especially in the NW where almost all our energy is hydro. But that's not why I wanted this car. Frankly, I would still love it if it ran on ground-up puppy dogs. I'm not in this for moral superiority. I've done too many terrible, terrible things to claim that mantle. I love it because it's a hoot to drive, and because it's the coolest damn gadget I've ever seen: the über-gadget, if you will. And I am all about the gadgets. 

Mayor Bloomberg and Narcotics

I may be just a bit late in commenting on this, but last week (which was like ten years ago in Internet time) there was a bit of hue and cry regarding Mayor Bloomberg's report on the matter of prescription drug abuse and restrictions on new prescriptions for painkillers through the Emergency Department.

Initially, I was concerned. I completely agree with the comment from the linked article: “Here is my problem with legislative medicine,” said Dr. Alex Rosenau, president-elect of the American College of Emergency Physicians... “It prevents me from being a professional and using my judgment.” The verbiage used regarding the new rules was worrisome: restricted sharply... city policy ... will not be dispensed ... regulatory authority to impose, and the like.

I'm like most doctors in that even when I agree with the purpose of proposed rules, I quite object to interference in how I practice, to "the government coming between you and your doctor" as it was so memorably put in the past. And given that Bloomberg is getting something of a reputation for being a little dictator I was all ready to get my pitchfork and torches and head down to join the mob.

While I was getting my outrage machine up to operating temperature, I took a moment to read the official press release and the actual source document (PDF), though, and one word in the very first paragraph, notably absent from the press coverage of the proposal, jumped out at me:

VOLUNTARY

Well, that's a horse of a different color, isn't it? Doctors and hospitals are encouraged but not obligated to follow the new guidelines, and in individual cases, the doctor can freely exercise his or her judgement. I'm good with that. So what about the meat of the policy?

Key points that jumped out at me:

• A new/improved database for tracking narcotic prescriptions and making it available to prescribing doctors.
• Not prescribing more than a 3-day supply of most narcotics, and not at all prescribing oxycontin, fentanyl or methadone through the ER, and not refilling these meds
• All narcotics to be electronically prescribed (to limit forged prescriptions)
• Changing the defaults on EMRs to have lower amounts of tablets dispensed.

Frankly, these all seem reasonable, as long as physician discretion is preserved. If someone has a long-bone fracture and won't be into see ortho for a week, well then a week's worth of pain meds is reasonable, for example. In our state, we put forth some very similar guidelines in our "Seven best Practices" for reducing ER overuse and abuse.

The "guidelines" are particularly useful for a practicing doc in that it gives you permission to say "no." Currently, if I see a patient whom I suspect is "working me" for narcotics, but I don't have clear evidence to support that suspicion, I am in a bit of a bind. In such cases, there's no objective evidence of disease — back pain, neuropathy, etc — but that doesn't mean there isn't real pain. If I say no, I run the risk of patient complaints and a letter from the CEO. If I say yes, I then get bogged down in negotiations over how much and what drug. The guidelines offer a compromise: a limited supply of less potent meds. If the patient ups the ante or tries to demand more, I can point to the guidelines and explain that we have a policy, that it's not personal or judgmental, but is simply our "best practice." Even better is that there are clear guidelines against refills and treating of chronic non-cancer pain in the ER.  All this is meant to give doctors faced with a demand for narcotics the institutional backing to say no, and tacitly recognizes the fact that doctors have been complicit in creating the problem through excessive opiate use.

I note that endorsing the proposal in NYC was the New York chapter of ACEP, which is also heartening. The problem of ER abuse and prescription narcotic addiction/diversion is a real issue, and it is growing. We, as ER physicians, need to take ownership of the problem, as much as we can, and take leadership in developing measures to mitigate the problem. If we don't, then it is predictable that someone else, likely state governments, will come in and impose solutions on us -- and those "solutions" are likely to be heavy-handed, draconian, and probably ineffective.

So. from what I can tell, New York's approach seems very well-reasoned and hopefully pretty effective. I am also encouraged by an addendum that several private hospitals in the NYC area have announced that they are also going to follow these guidelines (which properly only apply to city-owned hospitals). I'm also particularly pleased that the process we went through in our state has begun to be used as a model for other states to follow!

Apparently I'm a pimp

I actually have no interest in responding to this. I decided some time ago that life is too damn short to waste it arguing with assholes on the internet. I've stuck to that reasonably well, and been happier for it. But since I have been personally named I suppose I should give it a perfunctory response. That's all it deserves. 

I wouldn't bother at all, in fact, if it weren't for the steaming mass of ad hominem attacks piled on top of it. But that's his style: he uses strawman arguments and personal insults to obscure fuzzy thinking. Apparently, in the minds of the free-market, anti-government zealots out there, if I support expanded government funding and regulation of health care insurance, which I long have and still do, then I may never ever criticize or disagree with anything the government does. 

That's the mindset of an ideologue: purity above all else. You are for the government or you are for the private market. It’s an either-or, absolutist position. You cannot logically have a nuanced view or a pragmatic approach: that’s unpossible! 

Clearly, there’s no point in discussing anything with this sort of person, so I won’t bother. But I will make one point — just one point — in rebuttal. The worst abuses I have encountered, thus far, have been by private, not governmental actors. Contracted Medicare carriers and insurance companies have been far more aggressive in trying to exploit the logical catch-22 in the medical necessity rules. For those who say they fear the government intruding into medical care, I agree it’s a fair point. But given their financial incentives and lack of ethics, I will always fear the private insurers even more.

Canadians can be funny

Who knew?


By Bowser and Blue

Merry Christmas!

From one godless atheist to your family. Hoping it's a great holiday for all of you.

Tis the Season

Grew up in a very big Irish Family in Chicago, and this pretty well encapsulates my experience of the holidays growing up:

My cousin Tom and I were the nephews designated Mischief and Mayhem...

(Only) human

Chatting with some med students, a good question was raised: how do we, as doctors, deal with the emotional baggage we encounter in our profession? It's high stress, we see disturbing things, and sometimes we make mistakes that can result in harm to patients. The pressure and responsibility can be very hard to handle.

These stresses, if unmanaged or poorly managed, can carry severe consequences for physicians. Burnout is rampant among docs (and trainees, too). Doctors have high rates of divorce, substance abuse and have the highest suicide rate of any profession.

A normal day at my job is hard: I'm running nonstop for 8-12 hours, I'm constantly interrupted, I have patients making demands of my attention and empathy, I'm saturated with information and need to make rapid decision without adequate information, and I know that if I make an error or miss some important piece of information, the human, professional and financial consequences can be disastrous. It's a pressure cooker.

And that's a day where things go well. A bad day can be very bad indeed. Sometimes it's just the emotional strain of dealing with particularly difficult patients. Maybe you go through a run of giving out terrible diagnoses. Maybe you deal with the death of a child. Or a patient who pulls at your heartstrings in some unique and personal way. Maybe someone dies on you unexpectedly. Worse, maybe someone dies on you and you're not sure if it was your fault or not. Perhaps you know you made an error, and that you're going to have to face accountability for it.

These are the days that drive physicians over the edge. I've had them, and I remember them so vividly even years later. There was the one lady with a gallbladder attack on Thanksgiving, many years ago. She had classic signs and I saw gallstones on my bedside ultrasound. She crashed and died right in front of me from a ruptured thoraco-abdominal aortic aneurysm. Her abdominal aorta had looked normal on my scan; the aneurysm was in the chest and ruptured into the thorax, which is very unusual. That didn't make it any easier to go home and sleep that night.

So I guess my take on the question is not how do we deal with the psychological stress but how should we? I am not an expert, but here are my thoughts.

The first step, which most practicing professionals have already accomplished, is to learn what is called "professional detachment." This is an unnatural skill in which you must suppress your innate sympathy for the suffering experienced by a fellow human being, pain which you may be personally inflicting. The first time you stick someone with a needle, it's probably as traumatic for you as for the patient. More advanced applications involve you ignoring someone's pain or personal tragedy while trying to figure out the hidden life threat. This is a necessary skill if you are to function in the medical environment.

Another way to think of the same skill is to maintain a sense of distance. Remember, an older teaching physician once told me, the patient is the one with the disease. This helps you remember that the patient's condition is not your doing (usually) and their outcome, if negative, is the result of their disease and not necessarily a reflection on your care.

While this detachment is useful and necessary, it can be maladaptive if taken to extremes. First of all, as a physician you do need to express empathy and compassion. It's part of the job. But the emotional demands will be overwhelming if not governed in some fashion; we have limited capacity for caring. My solution is to dole out my compassion and empathy in measured doses, as appropriate to the case and my own mental state. This is not a license to be callous and uncaring in other cases, but rather to be polite, professional and reserved, emotionally.

Furthermore, you need to understand that the professional reserve does not equate to repression of emotion. You suppress it, in the moment, set it aside to get the job done, but that doesn't mean it never happened. For minor stuff it probably is okay to suppress it & forget it.  But the bad things — they won't go away on their own, but will fester and bubble up at the most inopportune moments. You need to take some time, when appropriate, to unpack the experience and re-live the emotions to deal with them. Maybe it will be just turning the case over in your head the next day. Maybe it needs to be more immediate. We've sent docs home after bad pediatric arrests when it was clear they were so upset they needed some time. It's essential, in any case, to explore the disturbing feelings so you can come to a resolution and move on.

Many institutions will have formal critical incident debriefings for the entire team, for particularly awful events. While this doesn't need to be performed formally for routine events, it's a good idea to informally debrief with a trusted partner, superior or mentor. Talk through the case, review the medicine and the science, review your actions and outcomes, and your emotional response to the situation. It is helpful to do this with someone you respect, so he or she can give you valuable feedback. This can be over coffee or a beer or three; possibly better that way.

There can be a lot of shame involved when there was a bad case, even when well-handled, but especially so when you know that you made an error or may have. A lot of docs like to bury these as deep as possible. But these in particular are helpful to talk about, and the more publicly the better. This is not easy, but can be invaluable. We instinctively shy away from openly talking about our mistakes, but when you do you will probably receive a lot of support from your colleagues, many of whom have done the same or understand that "there but for the grace of god go I." An additional benefit is that your mistakes may have been due to a system error or a cognitive bias and by reframing the discussion in an educational light, by seeking out the root causes, you can improve the quality of your own care and that of your partners.

Keep a sense of perspective, and try to stay positive. When the job is really getting you down, take a break, go out to the ambulance bay, take a few deep breaths and try to remember the big picture. We have a great job. It's a privilege and an honor to be allowed to care for patients. We can sometimes make a huge difference in people's lives. We have respect and status in society, and are quite well paid for it. Many people would give their right arm to be where you are. Yes, seeing the 10th drug seeker of your shift is a drag, but damn, it's still better than sitting at a desk and moving numbers from column A to column B.

Sublimation is a defense technique that is particularly valuable in the ER. It is a form of displacement where the negative feelings are transformed into something positive, or at least more-or-less acceptable. The most common form it takes is "gallows humor." Tragedy and comedy are deeply linked, and a morbid witticism can provide a lot of relief of the emotional tension that builds up in a clinical setting. Others may channel these feelings into art or literature. To each their own. If this is not your thing, find an outlet. I practice karate, and there's nothing like pounding the hell out of the heavy bag — or a white belt —after a bad day.

Finally, and possibly most importantly, when you know you screwed up, when you know there was an error that harmed or may have harmed a patient: forgive yourself. You are human, as are we all, and we make mistakes. Take the time to understand it, do your best to learn from it, and forgive yourself. Let go of it, file it away, and move on. If you don't or can't, self-doubt and self-hate will paralyze you and in the end it will sink you.


One last thing: if you are really having trouble, get professional help. If you're self-medicating, or if you are bringing work home to the point it's affecting your family, be humble and realize that doctors can benefit as much as (or more than) any other patient from psychological counseling and support. Many hospitals have a confidential Physician Assistance Program, staffed by professional counselors trained to deal with the issues doctors struggle with. I've seen doctors torpedo their careers with behavior and substance issues, and I've seen programs like these successfully rehabilitate physicians who were in a downward spiral. Check with your medical staff office and use the resources that they offer.