Top Five Posts of 2011

Thank you for all your support, readership, and retweets on twitter. Here are my top five viewed posts from 2011. Happy New Year!

1.Saving Death
2.Sometimes We Are Doctors
3.Disclosure
4.Post Traumatic
5.Why I Write

Best for 2012!

I Know This Much Is True

I walked out the door and down the steps on a clear St. Louis morning. The air had a slight chill as the sun began to rise in preparation for the new morning. Spring had not yet transitioned into summer and the humidity was minimal.

As I had done on so many other days, I walked with my lab coat slung across my arm. My stethoscope would occasionally pop out of the pocket and dangle from a thread before I scooped it back up and placed it awkwardly into its temporary resting place. If the temperature dropped, I may slip the coat over my shoulders and wear the stethoscope around my neck.

When I arrived at the hospital, I walked through a side entrance and took the elevator to the medical wards. The resident's office was busier then usual. The interns awoke and left their adjacent call rooms to find that they were no longer on the bottom rung. The new interns, donning neatly pressed and clean white jackets, had arrived for their first day of work.

My fellow residents and I basked in the glow of our final day of training. We would stay for a few hours and hand off patients, help with rounds, and generally enjoy the absence of true responsibility.

We walked the floors as if we were kings. We strutted back and forth and chatted with the nurses.

A few hours later it was time to go.

We left the sheltered and protected existence of training and launched ourselves into the vast unknown.

And we never looked back.

*

There is a sense upon leaving residency that you know just about everything. That you've seen and done all that is important. You've cared for the sickest of the sick, and dealt with the poorest of the poor.

A list of dieases and procedures has been appropriately checked and checked off. An air of confidence lingers.

But I have to admit that the majority of doctoring, I learned after training. The ivory towers provided a good working knowledge of the arcane, but the day to day, bone on bone grinding of patient care was learned on the fly. Each encounter provided a new skill, a new fount of knowledge from which to draw from.

And I was often surprised at my own prior misconceptions. I would have never imagined that as an attending, I would sleep less and work harder then in residency. I couldn't comprehend the crushing responsibility of being the bottom line. No one prepared me for the three am call from the nurse when there was no one higher up on the food chain to call for advice.

Yet the hardest skill to achieve was not the science but the art. How to become a "healer" and not just a doctor. How to know when to place your hand gently on the shoulder of a mourning patient or to raise your voice to an unyielding family member.

I still struggle with how to remain humane and kind, as well as stay effective. Medical knowledge comes and go. Diseases are discovered and cured. But in the purest sense, the job of the physician is to be a beacon, a lighthouse, to guide each ship safely to land in the harshest of conditions.

This is what it is to be a doctor. After all these years of training and practice,

I know this much is true.

On Carrots And Sticks

Larry knew he had to make a doctor's appointment immediately. The searing chest pain almost stopped him in mid stride. For a moment he considered going to the emergency room and then thought better of it. He remembered the heart attack 10 years ago, this felt nothing like it.

The doctor's office answered on the first ring. He began to explain his predicament but the receptionist interrupted him.

Sir, you haven't been in the office for over a year. You better come in right away!

As Larry hung up the phone, he realized that he didn't mention the burning over his left rib cage. No matter, he thought, he would bring it up with the physician.

*

Later that day, Larry strode into the waiting room. He caught his breath in pain as he leaned up against the front desk. The receptionist took his insurance card and began to click on the computer screen.

Are you married?
What race are you?
Do you subscribe to any religion?

Larry answered each question cautiously, but wondered why he was being interrogated. The gum in the receptionists mouth cracked and popped as her eyes concentrated on the screen in front of her. As she looked up at Larry, she realized that he was losing patience. She focused on the screen as she mumbled in his direction.

New government requirements! If we don't ask, the doctor doesn't get paid.

When she finished with her questions, Larry was directed to sit in one of the flimsy chairs and wait. He placed his left hand over his heart and probed for the source of pain. He winced as if daggers were skewering him. The front desk person hadn't inquired about the reason for his visit either.

*

A few minutes later a nurse walked through the sliding glass doors and called his name. He shuffled gingerly into the exam room and waited as the nurse signed into the computer.

Boy Larry, you haven't been here for greater then a year. We have alot of work to do!

The nurse measured his weight, height, and waist circumference. She asked about domestic violence and gun use. As the minutes passed, Larry marveled at the detailed and often nonsensical material being covered.

To her credit, the nurse did ask Larry about pain. She even had him rate it on a scale from one to ten. But she didn't bother to ask any other details.

*

When the doctor finally walked into the room, Larry heaved a sigh of relief. He waited quietly for direction. The doctor shook his hand and sat down at the computer.

Wow! We haven't seen each other in a year.

He then preceded to stare silently at the computer for a few minutes. Larry watched as he clicked and typed from time to time. Moments later he was being motioned onto the table. The doctor examined him head to toe and then directed him back to the seat.

Everything looks good. We'll see you next year.

Larry was stunned. He stood to get the doctor's attention.

But what about my chest pain?

The doctor turned and removed his hand from the door knob, and glanced back at the computer.

That reminds me. With your history of heart disease, it says here that you're due for a stress test.

Without another word, he left the room.

Larry sat back in the chair and tried to put the pieces together. If the doctor had given him the chance, he would have explained that he tripped and slammed his chest against the book case. Did he really need a stress test?

When Larry made the appointment that morning, he was thinking more along the lines of an xray.

He figured he cracked a rib.

Evolution/Devolution

Sitting in my office, I tap the last words of the progress note on the keyboard as the student shifts in his seat. He looks up at me with all the innocence and naivete of one who is at the beginning of an arduous journey. I strain to hear his words.

So, how does it feel to be a doctor?

I'm taken aback by the sincerity of the question and the rawness in his quivering voice. I ponder carefully how to respond. A million cliches pop into my head, and I fight them off one by one.

This time will be different.

This time, I'll tell the truth.

*

I can't remember a time when I didn't want to be a doctor. In fact, my identity and profession have intermixed to such an extent that I often can't tell them apart. My internal image includes a lab coat and a stethoscope. It always did. Even as a child.

My voyage through medical education was powerful. Like a flower, the seeds of identity blossomed and became external reality. But I couldn't help feel a certain sense of unease. It was as if the more I learned, the less the burning embers of humanity would glow.

When you encounter death and destruction at every turn, such things lose their profundity. And patience and tolerance become the exception and nary the rule. Such a treacherous path for a wandering soul.

Once, while sitting in the exam room, I found myself staring at the clock while I talked to a patient about her recent cancer diagnosis. I listened to the barrage of questions, but secretly I was calculating how to end the appointment early to run errands.

As the patient left the office, I realized how far I had fallen. I promised myself that that would never happen again. But now my eyes were wide open.

After all these years in medicine, it wasn't the difficulty of diagnosis nor the desperation of disease. What I find myself continously struggling with is maintaining the beauty and humility that were present when I started this process. Because somewhere amongst the paperwork, fears of malpractice, sleepless nights, and unexpected outcomes, something broke.

How does one build armour strong enough to repel the demons of sickness and despair yet allow the skin to bask in the piercing barbs of humanity? How do I evolve as a physician without devolving as a person.

*

How does it feel to be a doctor?

Well, how does it feel to be a human being?

Mired in the morass of moral frailty, I struggle with my own imperfection.

The difference is, as a physician,

the affect is greatly magnified.

From Birth To Death

As luck would have it, she happened to die while I was in the room. I sat with her family as the last breath precariously left her lips. We waited for the next as if it was a forgone conclusion. It never came.

Walking toward the nursing station, my mind wandered back to medical school.

*

I tentatively followed behind the resident as we entered the birthing room. The patient writhed in bed and opened her mouth, but nothing came out. Her face tensed and then relaxed. The contraction had passed.

We stood quietly for a moment, and then the resident cleared her throat.

This is Doctor Grumet, he will be delivering your baby.

My back muscles tensed and I gritted my teeth. My mind bobbed back and forth between embarrassment at being referred to as a physician, and fear of performing the delivery myself. I looked over at my patient. After months of going to the residents free clinic, she learned to accept what she was being told without questioning.

Although she refused the epidural from the beginning, her sighs of pain made me wonder if she regretted it. The nurse and resident stood by her side bracing her legs. As she started to push, I looked down in anticipation.

A tuft of hair bounced in an out of the birth canal with every contraction. After a few minutes, the head broke free and I tentatively pushed down and delivered the anterior shoulder. I slipped my hand over the baby's neck hoping to gain traction as the posterior shoulder broke free. I caught the body clumsily with my other hand, and held the baby up for the mother to see.

After forceps were applied, the umbilical cord was cut. Minutes later I delivered the afterbirth and sutured a small lacertaion.

I left the room, and sat at a desk with the chart in front of me. I paused and looked down at my hands. Only moments before they had taken part in the ritualistic dance of childbirth.

It was a familiar dance.

One that had been performed over and over again since the beginning of time.

*

I often marvel at how similar birth and death feel. The ephemeral movements of the soul are difficult to diagram, but it is impossible to escape the feeling that as the last grain of sand slips free, the hour glass is just waiting to be flipped back over.

And we struggle to control that which occurs between bookends. Doctors and patients fight to write more pages to prolong introduction and ending. Yet sometimes I wonder If we miss the point.

I haven't delivered any babies since medical school, but I see my share of deaths. And each time, I can't help but hear the same words echo in my head.

This is how it's always been. This is how it always shall be.

There is nothing to fear

Dying Of The Old Guard

Millicent couldn't help but feel out of place. The sterile white sheets were anything but soft and downy. They rubbed against her feet like sand paper. She twisted herself into a ball and waited. The edges of her gown creased in the back exposing her derriere.

Millicent's histrionic nature plagued her from childhood to her mid seventies. Although she pictured herself waiting for death, more likely she would spend a few days in the hospital till the antibiotics eradicated the mucous in her lungs.

The nurse said that her personal physician would see her once she got settled on the floor. But it had been hours since she left the chaotic emergency department, and still no hide nor hair of Dr. Howard.

Milicent couldn't help but smile through her febrile haze. Dr. Howard was an "old fart" like herself. They had been together for decades. The graying of his hair reflected in the bowing of her spine. Of course he was probably in his fifties and she in her seventies, but that didn't stop Millicent from overestimating their equivalence.

*

Millicent dozed on and off. The much needed sleep was interrupted by occasional fits of barking cough. Each time she opened her eyes she glanced at the clock. Her IV dripped beside her bed, and beeped from time to time as if jealous of the silence.

The nurse came and went. Around midnight, she walked in and woke Millicent from a deep sleep.

Your doctor is at the nursing station. He will be in shortly.

Millicent sat and rearranged her hair. although she felt miserable, there was no reason to appear so to the handsome Doctor Howard. She glanced at the clock in the corner of the room and almost fell out of her bed. Midnight-why the heck was he rounding so late? Millicent briefly worried about poor Dr. Howard's wife before her reverie was interrupted by a knock at the door.

A young boy walked into the room wearing an over sized lab jacket and a stethoscope that twisted around his neck and likely got lost somewhere underneath his scrubs.

I'm Dr. Thomas. I will be taking care of you here at the hospital.

For a moment Millicent thought that she was still dreaming. She rubbed the sleep from her eyes and looked up at the young man questioningly.

There must be a mistake. Doctor Howard is my doctor!

*

Dr. Thomas sat at the bedside and quietly explained how Dr. Howard no longer came to the hospital. That instead, he use a group of physicians called hospitalists. Hospitalists were available twenty four hours a day to take care of people like herself. Times had changed and many physicians, like Dr. Howard, no longer felt able to see patients in the office and hospital.

Millicent couldn't believe her ears. After all those years.

So you will call Dr. Howard first thing in the morning?

By now Dr. Thomas was half way out the door. His beeper had gone off, and he looked like he was rushing out of the room to another emergency.

No, I will be gone in the morning. But one of my partners will come by tomorrow and he will call Dr. Howard.

As the door closed, Millicent found herself feeling very alone. The cough that had been a mere nuisance hours ago now exploded in her chest.

Being laid up in the hospital with pneumonia was bad enough.

But what really burned Millicent to the core,

was the feeling of abandonment.

Transfer Of Addictions

We danced around the subject. James wasn't going to ask me directly to increase his meds, but I knew that's what he wanted. My brain did a silent eye roll as I watched him hop around the room.

It was true that his foot looked swollen and bruised. But the xray was negative and there was no reason to expect a more sinister process. He stubbed his toe; no more, no less.

But James had a problem when it came to pain.

Or had he just become a victim of our medical system?

*

There was a time when James was not strung out on pharmaceuticals. Alcohol was his poison then. But he got into a car accident and suffered a knee injury. The DUI was the least of his problems.

The MRI of his knee was normal but his pain was excruciating. Visit after visit to his internist and orthopaedist left him with a medicine cabinet full of narcotics, which he felt good about because at least he was no longer drinking.

The custody agreement for his son required regular breathalyzer testing. But they couldn't fault him for taking the medications his doctor prescribed, could they?

By the time he came to see me, he was taking several norco and oxycontin a day without relief. I reviewed his MRI and lab tests skeptically. When I explained that in the absence of pathology I wouldn't accelerate his dosing, he almost fell out of his seat.

It never occurred to him that maybe the medicine wasn't helping. Our conversation went something like this:

What is your level of pain when on medication?
10/10
What is your level of pain without medication?
10/10

We argued back and forth, month after month. Each time I prescribed less pills.

*

Finally when the courts threatened to take his son away, James got serious about kicking his medication habit. He got admitted to the hospital and was treated for withdrawal.

The next few months were difficult. James struggled with daily activities. He found a job and spent more time with his son. I would be lying if I said that he didn't have pain. But he learned to use more mature coping mechanisms. He attended physical therapy, acupuncture, and biofeedback.

He was making significant progress, or so I thought.

And then he disappeared.

*

Six months later he waltzed through my door with a large medication list. As I silently read through the consult note, I felt my eyes popping out of my head. He had seen a pain specialist at the local university and was again using large doses of narcotics.

We were back to square one.

I buddy-taped his bruised toe and sent him on his way. I assumed shortly after leaving the office, he would be on the phone with his pain specialist.

*

We've created a nation of junkies. The tide began to turn when the government made pain the sixth vital sign. The miserable and wretched learned that they could stop cowering under illicit and costly activities. Now all they had to do was show up at the doctor's office where kindly nurses would check their blood pressure and pulse before serving up the perfect lob:

Are you in any pain today?
Why yes I am!

Instead of protecting the cancer ridden and orthopedicly adventurous, we have turned our offices into dispensaries.

Unfortunately we still haven't come to terms with the fact that narcotics do not treat psychic pain. Furthermore, they are particularly poor at relieving chronic orthopedic conditions.

So the treadmill continues. We use pain medication inappropriately. The human body becomes use to it and then needs more. Minor traumatic injuries become emergencies.

And as a nation, we transfer our addictions.

Educational Distress

I woke in a panic. My heart felt like it was thumping out of my chest. I sat up and waited for the blare of the alarm radio to wash out of my ears. The room was pitch black. I pushed the covers aside and crawled out of bed and inched my way to the bathroom. The cold morning air did nothing to soothe my nerves.

I showered, dressed, and locked the door behind me as I made my way to the garage. Although my stomach was growling, mild nausea overpowered my sense of hunger. I turned the key in the ignition and was met by the throaty voice of a public radio announcer.

By the time I hit the on ramp, I settled into my morning drive. I felt an overwhelming sense of unease as I remembered the dream that yanked me out of sleep.

*

It's the first day of high school, or maybe college, and I am sitting contentedly in class. As I look around the room a panic overtakes me.

I forgot to bring my class schedule!

I forage through my backpack without luck. It's a new semester and I have no idea where I need to be next. Without room numbers or building names, I am lost. I start to breath rapidly as the fear overtakes me. My head pounds and my eyes begin to water.

I feel a strange sense of doom about starting the year off this way. It's as if somehow by missing the first day of classes, I will suffer great harm. I will lose some essential piece of information that will be devastating. I will fail miserably.

I jump out of my seat and sprint to the door. I have to quickly get to the administration building to print up a new schedule. But when I exit the class, I can't seem to remember which way to go.

I walk back and forth aimlessly trying to reconstruct the correct path. With each failed attempt my mind races even further out of control. I feel like I just got punched in the gut. I glance repeatedly at my watch as if I could freeze time.

When I finally get to the front of the administration building, I heave a sigh of relief. I walk up the steps and approach the entrance.

The door is locked.

*

The fetid odor of cleaning products mixed with the refuse of human illness is the first thing that hits me as I enter the medical floor. I try not to breath out of my nose. A demented patient is lost somewhere in the jungles of Viet Nam and swings at his nurse. He just barely misses her.

It is six in the morning and the maintenance man walks past me pushing the floor cleaning machine. It sounds like a garbage truck and the noise disrupts the otherwise quiet hallway where sick patients try to get their rest.

I take a deep breath, and for the first time this morning, I feel the calm wash over me. My heart is no longer racing and the nausea is gone. I have finally shaken the stress of my nightmare.

Thank God I'm no longer a student!

Loyalty

I broke my stethoscope the other day. Or actually, the stethoscope broke, it really wasn’t my fault. A couple of weeks ago I noticed that the tubing was beginning to tear. As I am wont to do, I ignored the situation and tried to tape it up. Of course my temporary solution only worked for a short while. After multiple tapings, it finally broke. Imagine my embarrassment as I went to put the ear piece in my ears and it split in half, right in front of a patient. There I was wide eyed with half the stethoscope in one ear and the other ear piece dangling disconnected in my hand. As you can imagine it was quite a site.

So I threw my stethoscope in the garbage and borrowed a loner from a colleague. I ordered a new one and waited for it to come in the mail. A few weeks later I tried out my new model and it didn’t feel the same; maybe it was the way it fit in my ears, maybe the length of the tubing. Who knows? It just didn’t feel right. And then I started to think.

I threw out my stethoscope! The same stethoscope I bought with such pride on my first day of medical school. The stethoscope that had literally touched every single patient I had seen throughout my medical career (it had never broken before). And like an idiot I just tossed it aside. I didn't perform any ceremonies, no thank yous for a job well done, no tender thoughts of all we had been through together.

Sure my new stethoscope will likely be just as good. Hell, it probably will function better. But I guess that’s not the point. The point is that somehow down the line I lost my loyalty. I lost my respect for a relationship forged by closeness, shared experience, and yes years of time spent together.

I know what you’re saying:

it’s a stethoscope-an inanimate object!

But maybe there is some importance here we’re missing. Maybe our health care system is taking a turn for the worse. Maybe we are losing our loyalty in other places. Hospitals and doctors are becoming less friendly. Staff turnover is rampant and you no longer recognize the faces when you enter your doctor’s office. Physicians are moving, changing locations, or even swapping careers.

I got a letter from a patient the other day. We had been through so much together. She battled depression and a divorce. She survived a horrendous cancer and was still dealing with her diabetes. We knew each other for years.

I guess I didn’t take it personally that she was leaving. Her health insurance changed and I was no longer on her plan.

But as the tears well up in my eyes I can’t seem to stop thinking about that damn stethoscope.

How could I have just thrown it away?

Disclosure

Jack's youthful appearance and boyish eyes were betrayed by a body more fitting his grandfather. He hobbled into the office in his usual manner. His ambling gate was hampered by painful knee joints which creaked and crackled with every movement. His forty year old posture was marked by the cruelty of early onset rheumatoid arthritis.

His visit to the rheumatologist had been modestly fruitful. After injections to both knees, he was able to stop using the wheel chair. But joint replacement surgery was coming on the horizon. No matter how long he tried to prolong the inevitable, his day of reckoning was near.

He leaned back in his chair and tried to get comfortable. As he closed his eyes the sweat began to poor down his face. He reached over to the desk and helped himself to a tissue. He dabbed his forehead and looked in my direction.

If I knew how painful my forties would be, I would have had a lot more fun in my thirties!

We both laughed, but I knew that he was only partially joking. We spent alot of time in the exam room talking about what this disease was doing to his self image. The physical toll was matched, if not overcome, by the metal anguish of disability. Once a track star in college, he now considered himself a cripple.

As so often happens, I struggled to express comfort and understanding without being demeaning. How could I know what it felt like for Jack to not be able to ruff house with his kids;to not be able to pick up his crying daughter? I had no inkling of the painful stiffness he woke up with every mourning or the feeling of nausea brought on by his medications.

I found myself repeating familiar words.

I won't even pretend to know what it feels like to walk in your shoes because I haven't. But I've seen people in your situation and I know it is very difficult. Let's see if there are some things I can do to lessen your burden.

Jack sat quietly for a few moments absorbing my words. When he looked up, our eyes met and he started to speak. What he said next caught me completely by surprise.

I read your blog.

I felt a sense of doom arise from the pit of my stomach. I mentally scanned through my last few posts. Had I said anything inappropriate? Jack recognized the look of panic on my face and quickly reassured me.

I was really impressed! It would have never occurred to me that doctors think about such things.

As I listened to the squeaking of Jack's walker as he rolled toward the checkout counter, the weight of his words began to sink in.

Maybe our patients don't know that we suffer through difficult decisions. Maybe they don't realize that our insomniac brains toss and turn during sleepless nights where worry and fear become our dark companions.

And they likely don't realize that the pain and suffering we witness leaves disfiguring scars.

How could they?

Unless, of course, we tell them.

Post Traumatic

You'll have to excuse my pessimism.

I've bathed in death. The senescent skin cells fall into the basin and expose new facial wrinkles. My hair is thinning and strands of gray streak through the jet black landscape. The gulp of water streaming down the drain is the only interruption of a perfect mornings silence.

I've choked on grief. The tasteless globs of oatmeal stick in my throat. I barely awake from my reverie to notice the glass of juice sitting beside me. The windows reflect the last memories of undisturbed night.

I've exhaled desperation. The breaths escape and take form and then disappear into the air. The path from the parking lot to the hospital expands and contracts with the whim of my mood.

And I've stumbled on sadness. The land mines in the office are frequent and offer little space to negotiate in between.

So you'll have to forgive that I jump at the sound of an unexpected phone call or the pleading voice of my daughter.

She has woken up in the middle of the night.

It's probably just a headache.

Will It Hurt?

Will it hurt?

I am lying on the bed in my parent's room. My six year old legs fidget like a frog who has been pinned on his back. My father stands over me and opens a small box of tools by splaying the paper wrapping and spreading it across the night stand.

He gingerly unfolds two thin sheets of wax paper to reveal a set of sterile gloves. He grasps the first on the outer bent lip and pulls his arm through. Using his covered hand he scoops his fingers under the bend of the other glove.

As my father lifts the forceps out of the box a stream of sunlight catches the metal and bounces onto my face, blinding me.

Should I close my eyes yet?

He doesn't answer my question but commands me not to move. He takes a moment to survey the clean line of sutures above my right brow. As he pauses, I feel his breath caress my skin. The faint smell of mustard reminds me of the deli sandwiches we ate an hour before. It intermingles with the acrid perfume of alcohol being applied to my skin.

He squints through his glasses as he approaches my forehead with scissors in one hand and forceps in the other. I shut my lids tightly, waiting for the pain that is sure to come.

His shadow blocks the light from the window and I sense his body leaning over me even though my eyes are closed. He pulls at the edge of the suture with one hand and snips with the other. I feel a sharp sting as my skin leaps to meet the scissors.

Each suture is methodically cut and removed in similar fashion. Minutes later we are finished. I sit up on the bed and smile at my father. He is arranging his tools. He stops what he is doing and reaches up to my face. He cups my chin and gently pushes upward. He surveys his work.

Not bad!

Six months later I will fall and need stitches again. But by then, my father will be dead and I will have to go back to the doctor's office to have them removed.

This memory came flooding back to me the other day as I stood over my own patient with scissors and forceps in hand.

It had been so many years-I had forgotten.

Forgotten

I want a Diet Coke!

It was the first thing I thought as I woke up this morning. Although I had mostly kicked the addiction, occasionally the urge was strong. I recently relegated my caffeine drinking to availability. I refused to buy soda at the grocery store. I strutted past the vending machines as if they didn't exist.

Once in awhile, I allowed myself to partake: a drug lunch here, a sporting event there. If a Diet Coke was placed in front of my face, I would drink it. So it wasn't a complete surprise that I woke up with such cravings. After years of drinking six pack after six pack, I was convinced that my brain chemistry had been altered.

When I stopped by the office before rounding at the hospital, I rummaged through the refrigerator hoping to find buried treasure. No such luck! I knew that I would pass a bank of vending machines in the long hallway that led to the hospital, but I had sworn off such a willful solution to my lusting.

This morning, I would have to forgo my needs.

*

The hospital census was large and active. I worked my way through the telemetry and ICU floors. I stopped at each patent's bedside and then the nursing station to chart at a computer. There was a hodge-podge of bread and butter medical and surgical care.

I quietly entered the room of my last patient for the morning. Mrs. Brooks was nearly one hundred years old. Her dementia had progressed severely over the last few years, and she was admitted for a urinary tract infection. Her verbal ability was limited to the single word "yes".

Mrs Brooks, it's good to see you....yes.

Are you feeling better then yesterday...yes

Do you want to go back to the nursing home....yes

Mrs. Brooks had no children and the rest of her family had died or moved away. Her medical decisions were made by a distant nephew, who I had talked to on the phone, but never met in person.

After examining Mrs. Brooks, I turned to leave the room. Out of the corner of my eye I saw a glimmer of aluminum on the desk. I turned my head and my mouth started to water like one of Pavlov's dogs. Sitting on the table was a six pack of Diet Coke.

I couldn't resist the lure of the silver can enshrouded in a white label. Perverse thoughts ran through my head. I was Gollum from Lord of the rings stretching for my "precious".

She's demented! She'll never know!
Mrs. Brooks can I have a Diet Coke....yes.

*

As I reached for the can I had a shocking moment of clarity. It was if, all the sudden, someone turned on a spot light and pointed it in my direction. I was standing in a demented woman's hospital room stealing her Diet Coke.

I felt a great sense of shame. After all of these years learning and caring for the elderly I had stooped to this.

Mrs. Brooks had been forgotten. She was abandoned and relegated to the dark corners of a nursing home where society didn't have to acknowledge her.

It somehow escaped me this morning.

It was my job to protect her.

Sign Of The Times

No matter how hard I tried, I couldn't control Lisa's blood pressure. We experimented with countless combinations of medication with no luck. She was working on diet and exercise. I started to feel desperate. I imagined her confidence in my abilities was faltering although she hadn't said a word. Our weekly visits had been fruitless.

As she climbed up onto the exam table, I retrieved the blood pressure cuff from where it rested on the wall. I repeatedly squeezed the bulb until the meter read above 200. The cuff crackled on Lisa's arm. I released the air valve and became quiet. I held my breath in anticipation.

Please be lower. Be lower...

When the liquid past the 180 mark, the dreaded thumping pounded through my stethoscope. Lisa's blood pressure was no better.

I took the cuff off and settled back into my chair.

So tell me what's going on in your life?

Lisa stared blankly at the wall for a moment, and then a tear formed at the corner of her eye. I could barley hear her speak.

If debt was a cancer, my husband and I would have been ten feet under long ago.

As the words stumbled out of her mouth the image of her twelve year old twins flashed through my mind. I leaned over the desk and handed her a box of Kleenex. I had little in my bag of tricks to fix her situation.

We sat silently in the room for a few minutes. How much had changed with my patients over the last few years. The faltering of our countries financial health was being mirrored in the day to day ailments that crossed the threshold of my office doors. The illness was contagious.

I took out my prescription pad and started to write. Lisa glanced at me quizzically. She waited in anticipation for me to explain which new medication was being added.

Often the great difficulty of being a doctor is discovering what it is that each individual truly needs. Sometimes the answer is something that we as physicians are not trained to give.

Lisa read silently the scrawled glyphs on the paper that I handed to her. She looked up at me with confusion etched into her tear soaked face.

Whats this? She asked as she wiped her face with a tissue.

I waited until our eyes met.

It's the number of my accountant, he can do more for your blood pressure then I.

Saving Death

The orders came indirectly from the government.

Reduce hospital re admissions. Cut costs.

So the hospital contacted the local hospice/palliative care center and asked for help. Of course, overwhelmed with work and understaffed, the project was handed off to me.

My task sounded simple. Create a palliative care program at the nursing home. But as I gathered for the first meeting with the administrator, social worker, and clinical staff, I knew there would be resistance.

And, in fact, I had my own feelings of reticence. Although I had learned much over the years, I was not trained in palliative medicine. As I gazed around the room, I realized that neither were any of my colleagues.

*

I looked Nancy squarely in the eye as I explained my vision. Our beginnings would be simple and humble. Admissions would flag appropriate patients based on predefined criteria. Then social work would approach each patient and family within seventy hours and have "the talk".

When Nancy heard her profession mentioned her ears perked up and her face twisted in confusion.

What do you mean, "the talk"?

Ready for her question, I pulled out a POLST (physician orders for life sustaining treatment)form and passed it around the room. The two page document was a series of basic questions.

Do you want to be resuscitated if your heart stops?
Do you want to be hospitalized if your condition worsens?
If you are unable to eat on your own, would you want a feeding tube?
Can IV fluids or antibiotics be given?

Attached, on the back, was a series of questions I had created myself.

Do you have a religious affiliation?
Would you like to be visited by clergy or a therapist?
If you knew you were dying, would you rather pass at home, in a hospital, or in the nursing home?
What are your health care wishes for the next six months?
What is more important to you: quality or quantity of life?
*

I looked around the room as the participants read the form. Nancy was becoming more anxious.

Isn't this the doctor's responsibility?

I answered her with a tinge of melancholy.

Yes, it is the doctor's job. But it's also the nurse's, social worker's, and therapist's job also. It's all of our jobs.

*

We met each week. Nancy presented new patients, and then the nurses and I would discuss clinical issues and pain control. The difficult cases were referred to the associated palliative care doctor from the local center.

During the first few sessions, I continuously hammered Nancy on the POLST form. For each patient, I wanted to know the answer to all of the questions. At first she rolled her eyes, but as time went on she got the hang of it.

A transformation occured during our fourth meeting. We had ten people in the program. As Nancy presented each patient, I could sense a diference in the tone of her voice. She was now approaching the project with a new sense of zest and zeal.

At the end of the meeting, I asked her what was going on.

Well, you know Mr. Smith? He passed yesterday.

Mr Smith had end stage dementia. He was in the process of dying for months, but his physician had not bothered to talk to the family about end of life care.

His daughters and I completed the POLST form a few weeks ago. So when he started to die, we were all on the same page. He passed quietly in bed without ambulances, IVs, or CPR.

I could see the change in her posture. She got it. She now saw how powerful these conversations could be. I smiled and congratulated her on how well she was doing such an important job. She looked down embarrassed.

It's not like I saved his life.

Our eyes met.

No, you did something most doctors have forgotten how to do.

You saved his death!

Turning Tables

Dr. Borak's voice was uncharacteristically timid. The authoritative lull and crisp enunciation had receded into a awkward bucket of uncertain phrases. For a moment, I felt as if I was back in grade school discussing the object of his affection.

Did you talk to her? What did she say?

I could feel the intensity through the phone as if the mouth piece had arched upward and was staring me dead in the eye. I felt bad for poor Borak. He suffered greatly the last few months. Although he was dropped from the malpractice suit, the scars brought on by years of finger pointing remained.

Then, there was the dispute with hospital administration. When they formed their own oncology group, Borak's referrals dropped significantly. His years of experience and relationship building couldn't stem the tide of inevitable change.

It was not an opportune time to be part of the old guard.

*

It wasn't particularly notable when Borak's patient asked for a new oncologist. She had visited him once and felt like there was no connection. Hell, people left me all the time! So I offered up a few names and thought nothing of it.

When Borak called to discuss the situation, I was caught completely off guard. I stammered as I tried to explain why I had given her other names. It wasn't the accusatory nature of his questioning that rocked me off balance, it was the hurt and uncertainty in his voice.

Borak was fighting for his professional life, and apparently he was losing ground quickly.

My discussion with the wayward patient was unfruitful.

We just didn't click.

When I reported back to Borak, his anger had receded. With sad recognition he accepted the fact that he lost another patient. He always considered the grim reaper to be his greatest opponent, not his fellow colleagues.

*

Most people become physicians because they feel a calling to help their fellow human beings. For better or worse, doctors are also driven by their own primal wish to be needed.

Our perfectionism, our selflessness, and our ability to waltz in the room and save the day are all self created concepts. They justify our actions.

Rejection, to someone who has spent their whole life learning how to be needed, is a bitter pill to swallow.

In all fairness, I am very aware of how the actions and words of a physician can evoke pain and hurt in his client.

But I wonder if patients realize that they haven't cornered the market on suffering. Do they know that behind the emotionless facade, doctors are soft and pliant on the inside?

Sadness, fear, and rejection are another part of our daily existence.

And it hurts us just the same.

Of Apes And Men

There is a time for sitting in classrooms. When such heady topics as congestive heart failure are abstract and intangible. Discussion veers from myocytes to cardiac output and stroke volume.

The world, through the student's eyes, is inflamed with passion and opportunity. The reality of doctoring is a distant dream. Hope peals back layers of fear and loss of confidence. Reward is imagined as a handshake, a return to health, and gentle guidance and counseling.

And there is no better place to be.

*

There is a time for rounding in the hospital. Groups of students and pharmacists trail the blue coat tails of residency. Voices tinged with false authority scoff at the regurgitated nursery rhymes of biochemistry and pathophysiology.

Clinical reasoning becomes her majesty's bejeweled throne. The vagaries of the heart are enumerated in clean categories: systolic and diastolic, valvular and ischemic.

The world, through the resident's eyes, is a masterfully structured algorithm guided by skill and knowledge. An apprenticeship forged in sleepless nights and the cold, hard steel of the analytic process.

*

There is a time for taking phone calls at home. Your table is set for thanksgiving dinner.

Congestive heart failure, through the attending's eyes, is neither about biochemistry nor algorithms. It's about missing a night of sleep. It's about another admission for Mr. Miller who forgot to fill his lasix prescription and then ate three servings of salt coated mashed potatoes.

And as you lay down on the stiff couch in the living room, you think about your family. They will sleep quietly in their own beds and not be bothered by the pager and cell phone tethered loosely to your pajamas.

You smile as you remember those student days with a mix of fondness and melancholy.

As your mind drifts lightly off to sleep you wonder:

where has the magic gone?

Spoils of War

When asked about his breathing, George would puff out his chest and release his booming tenor. On good days it would seem to last for minutes; on bad, it would peter out in seconds.

If I noted the soars on his feet, he would reminisce about his infantry days. His eyes would sparkle as he described how the heal of his brand new army boots would develop holes after hours of marching through rough terrain.

And if I questioned him about his blood sugars, he sat quietly with a blank look on his face and held his arms up at his side. George was nearly blind. He couldn't read a glucometer or decipher the tiny markings on an insulin syringe.

*

George was alone. He had no living family or friends nor money to hire a caretaker. He spent his days in a small apartment that he rented after the death of his wife. His physical existence was limited by illness and geographic disability but his world was anything but small. His mind was alive with music and poetry. His heart was overflowing with memories of his beloved wife.

Every two weeks he ventured out of his apartment an hobbled over to my office. Each visit was filled with questions which he often answered obliquely with stories. I learned that his wife once worked in an exclusive club for Hugh Hefner. That to pass the time, in his younger days, he would take a twenty mile walk from city to suburbs and then back again.

As he left my office, I was keenly aware that the doctoring skills that I learned in medical school had no place here. I had metamorphasized from an advisor to a student. I had become a companion, George's last connection to the outside world.

*

When I told him that I was moving my practice, The smile vanished from George's face. He knew that he wouldn't be able to travel the thirty minutes to my new location.

With artificial enthusiasm, I promised that I would find a local doctor to take care of him. He looked more feeble than usual as he described how his next door neighbor had recently died of a heart attack. She was a year younger then George.

As I watched him amble out of the front door that day, I felt a deep pang in the pit of my stomach. I knew I was choosing my own well being over his.

It was at that moment that I decided I would take care of George at home. I could stop by his apartment a few times a month on my way to work.


*

When I called the next morning to break the good news, no one answered. A few hours later, I received a note from the local coroner.


George died the night before. The paramedics found him lying on his kitchen floor. The coroner believed that it was a natural death. When he examined the body, he found and old frayed photo clasped tightly in George's hand. It was a picture of a woman dressed in a playboy bunny uniform.

If there's a heaven, I'm sure that George has found it.

It probably looks like an upscale club with a large picture of Hugh Hefner in the corner.

And George is being served

by the prettiest woman in the room.

Pedagogy

People often ask how I write so consistently. They wonder how I have so many stories to tell. But for me, that's like asking why I breath. My answer is always the same.

How could I not?

I wouldn't describe writing as fluid. To capture the moment to moment drama played out in the confines of the exam room is anything but straightforward. I grasp at the straws of fluency and try to clarify through garbled grammar and awkward phrasing.

But what choice to do I have? How else can I integrate the hum drum reality of family dinners interrupted by phone calls regarding code status and withdrawing life support? How do I explain why I tear up at the end of a sad movie yet negotiate pain and suffering as if I was a weatherman announcing another sunny day in San Diego.

When I stop writing my soul shrivels behind a protectionist shell. I become a shadow of the husband and father that I used to be. I transform from a healer to a nameless, faceless physician. The kind you look up in the index of some health insurance guide book.

But maybe, just maybe, when you read my words you'll feel a little bit closer to understanding.

Physicians will nod their heads in a shared brotherhood of traumatic experiences.

And patients will know that someone is finally listening.

The Cost Of Closure

You know Mr Miller?

I adjusted the phone on my ear as I slipped out of bed and snuck into the bathroom. I tiptoed across the floor and winced as the old hardwood started to creek beneath my feet. I craned my head and listened for signs of stirring children.

Remembering the resident holding on the line, I whispered into the cell.

Yeah. What about him? He had a choleycystectomy this morning.

I waited impatiently. I suspected that Mr. Miller had spiked a fever or needed some changes in his pain medication. It was a naive moment. The moment before I was about to hear something awful.

He coded. We were unable to revive him!

The phone slipped from my shaking hand and crashed onto the floor.

Seconds later, my two year old daughter started to cry.

*

I immediately felt out of place as I entered the church. The suit clung uncomfortably and the tie was strangling. I meandered past the pews in the front, and found a seat in the rear of the room.

As the ceremony began, I marveled at how many people had shown up for Mr. Miller's funeral. I watched as men sat stoned face and women wept silently. I searched through the crowd, but couldn't find a single familiar face.

The preacher was standing at the lectern. I tried to concentrate on his words, but It was impossible. The sweat poured down my forehead and I started to tremble.

I couldn't shake the feeling that I let Mr. Miller down. That the medical community offered cure but delivered heartbreak instead.

How did we allow this healthy fifty year old to die?

I quietly extracted myself from the chair and left mid ceremony. A few heads turned as I walked down the center isle and exited through the ornate swinging doors.

*

Sadly, I've never attended another patients funeral. Mr Miller taught me that I don't have the emotional fortitude.

The covenant between doctor and patient is sacred. My commitment to my patients well being is absolute. I vow to stand by them in sickness and in health. I will support them when they are hurting and I will tend to them when they are broken.

And when they are dying, I will devotedly attempt to ease their pain and suffering. But then the commitment ends.

Sure, it would probably be more healthy to go to the funerals. It would be personally gratifying to mourn appropriately each and every time. But when you have a hundred people die a year, it can be emotionally exhausting.

Sometimes the cost of closure

is too great.

The Revolution Will Be Tweeted

The doctor/patient relationship is like a conversation. Physicians have been quiet for so long that patients feel like they are talking to themselves. But there is great import in what the doctor didn't say.

It's time you heard the view from the other side of the stethoscope.

*

I am not the government. I am not a politician. I did not choose your insurance for you.

When I accept an invitation to lunch or covet a plastic writing utensil, I am not suckling on the teet of big pharma. Chances are, I'm either hungry or need something to write with.

If you left my office with a referral for an xray, cat scan, or mri it was not given to pad my wallet. You will not see me standing in the parking lot of the imaging center high fiveing a radiologist. It is more likely that I had a clinical question that I couldn't answer with history and exam alone.

I am not sadistic. I withhold antibiotics because it is the right thing to do. Not because I want your Thanksgiving, or flight, or 20Th high school reunion to be miserable. My life would be much easier if I was less of a stickler.

When my treatment plan is unorthodox and doesn't follow protocol, it's because I saw something that doesn't fit. I am trying to balance the art and science. I do not make such decisions lightly.

And when you enter the office and I seem hurried or distracted, it's not because I don't care. Sometimes I am preoccupied with worry and fear over another one of my patients.

*

You will not hear these words on the TV. You will not see groups of physicians clad in lab coats march on Washington or leave the hospital on strike.

We vote on our feet. Doctors retire early or move to non clinical careers. Primary care becomes extinct and goes the way of the dinosaur. Hours are reduced and lifestyle is chosen over commitment.

But, If you're attuned to social media you'll catch the whispers. The discontent oozes from our keyboards and smart phones.

Because we want things to change. We want to remain physicians. Secretly we hope our words will waft into your ears and be the flint that sparks revolution.

Fundamental change is coming. The question is whether it will be for better or worse.

This revolution will not be televised.

It will be blogged.

It will be tweeted.

A Cutter's Diary

The neon lights of the hospital corridor boldly contrast the bland gray of the morning mist creeping through over sized windows. My feet shuffle and then stumble as I absentmindedly propel myself toward the ICU. My eyes shudder, deflecting remnants of last nights sleep.

At this early hour, the hallway feels like a forgotten graveyard. My reverie is interrupted by a flurry of activity. Transport personnel wheel their patients in front of the door well that leads to the operating room. Family members scurry to give one last hug, say one last goodbye, before their loved ones are pushed through the swinging doors and into the unknown.

I can't help but stare at each face as they pass by. I recognize the strange mix of terror, hope, and desperation brought on by powerlessness.

*

If Dagny Taggart existed in real life she would have been a surgeon.

Josie is standing in a circle of men who don't usually take direction from a woman. They belong to an era of medicine that has long past. Like in the days of the giants, they stalk through the hospital indifferent to their surroundings. They are cardiothoracic surgeons.

Josie presents patients like a machine gun. Each diagnosis and vital sign sprays forth in rhythmic staccato. The appearance of her torso is lengthened by her unorthodox posture; one leg is a stilt while the other folds into a triangle. Her hair is slightly disheveled from missing a night of sleep.

I watch from the corner of the room with the other medical students. Josie is pretty but not in the classical sense. Her jaw juts forward and her body is sleek and thin. As she finishes her conversation with the attendings, she strides effortlessly in my direction.

Come with me. We're opening Mr. Simpson's chest.

*

Mr. Simpson is dying. His blood pressure is dropping and his anemia is worsening. His emergent coronary artery bypass, the night before, has kept Josie busy till daybreak.

She leans over her patient in the cardiothoracic ICU. He is too sick to take to the OR, so Josie scrubs and steriley drapes him in his room. She is on the front lines of a battlefield and has created MASH unit.

She expertly removes the sternal wires and opens the chest cavity. Her eyes survey the operative site. I watch from the corner mesmerized. Her hands move with ease and fluidity. She performs a complicated dance with the attending who is functioning as her first assist. They communicate through movement without the exchange of words.

The blood pressure stabilizes. The anesthesiologist transfuses another few units. Josie closes up and takes off her gown. Their are other patients to tend to.

*

I can't help but feel a touch of anxiety as I pass by the operating room doors every morning. Sometimes there is a rush of fear as if I am the one kissing my wife and saying goodbye.

But no patient enters this solemn and sterile world alone. They are accompanied by a surgeon like Josie. Someone who has sworn to protect and cure with the precision of a scalpel.

Surgeons have been called butchers and carpenters. They have been mythologized as goons and thugs.

But, if you ask me, It takes guts to willingly put another person's life in your hands. It takes skill and mastery.

I think we owe them a debt of grattitude.

Anatomy Of Dying

Two weeks ago I told a man that he was dying. We sat together in the mid afternoon haze. Puffs of snow meandered by the hospital window and wended their way down to the ground. The sun was lost behind winter's never ending clouds.

The tempo of my voice was steady, lacking variation in tenor and pitch. I clung to my lab coat as if I was floating outside the window and being blasted by the inclement conditions.

I waited coldly for a response. At first, he stared at me quizzically. His eyes asked so many questions but his lips remained still. He shook his head and sighed. I glanced above him at the ticking clock.


You're wrong. It's not my time yet!

*

Two days ago I entered the same room. I watched as my patients chest heaved up and down slowly. His laborious breathing like spikes piercing the insides of his family members. They sat somberly around his bed in a circle.

It won't be long now.

As the words slithered out, I realized that I failed to convey the proper warmth. My voice box robotic and stale. The phrase lost in a haze of familiarity.

*

Two minutes ago I pronounced him dead. The room still heavy with doubt and false expectations. The social workers and case managers huddle around the family as funeral plans are made.

And in two days, I will call his wife. I will express my condolences and ask if there is anything I can do.

Then, most likely, I will never speak to her again.

*

Two weeks from now I will tell a man he is going to die. He will sit calmly in my exam room as he shifts his weight from side to side. Although his hair has grayed and his body has weakened, his face will sparkle with youth and vibrance.

He'll stare deeply into my eyes and I'll detect a hint of mirth.

We're all dying my friend.

He will draw in a deep breath and put his hand on my shoulder.

The trick is learning how to live!

Is It Just Me?

I use the words "death" and "dying" so often that I sometimes forget that the majority of my life's work is focused on avoiding such things. In a geriatric population like mine, end of life issues are a part of everyday practice. Lately, however, there seems to be a rent in the fabric of my reality.

Where previously these conversations were nurturing and beneficial, recently they've turned quite negative. As hospice and palliative care are moving forward at a breakneck pace nationally, on the ground, there's more resistance than ever.

I'm finding that my relationships with patients and colleagues are souring around such issues. No one wants to acknowledge the elephant in the room.

Or is it just me?

*

I really hated you that day!

I see the anger migrate through her face as Agnes looks at her elderly parent. Her eyes soften when she walks over to the bed and gently combs her fingers through her mother's hair.

She is referring to when I told her that the dementia had progressed and that death was near. The evidence was incontrovertible. Her mother hadn't spoken in weeks. She wasn't eating and her weight had dropped significantly. Now her breaths were prolonged and erratic.

But the neurologist said she could live for years!

Tears drop slowly from Agnes's eyes and cling to her cheeks to avoid the perilous pull of gravity. I can see the question in her posture before her lips part to vocalize. I interrupt her softly.

A feeding tube would provide more harm then good.

Agnes stops mid sentence and her head bobs down toward the floor. Could I tell her that I don't agree with her neurologist? Should I explain that his reputation is to flog his patients well past the point of no return?

Maybe we should call the neurologist again. He says we should put in a feeding tube.

The same neurologist crucified me on the phone the week before for signing the DNR order.

*

Eventually Agnes sent her mother to the hospital for a feeding tube against my objections.

A few days later it fell out.

When her mother's heart eventually stopped, an ambulance was called.

CPR was performed to no avail.

Someone's Gettin Scoped! A Farce

Icicles shot down Lisa's back and into her left calf. Standing out in the cold, waiting in line, wasn't the best place for someone with severe sciatica. But this is how Black Friday had become. At least she could stand.

The police had just carted away a belligerent man and his wheel chair bound daughter. There had been a kerfuffle with a young couple standing in front of them. It had been whispered among the crowd that the girl had some sort of brain tumor.

The gold slips for the brain MRI's were going fast. Lisa was lucky. Her spine films were not in such great demand. Although she was easily the hundredth person in line, she would likely limp away with the coveted referral form.

*

Everything had changed since the great healthcare reform. No one had dreamed that hospitals would profit so handsomely. But the provision that allowed billing for uncovered services had unintended consequences.

Fettered by poor reimbursements from medicare and private insurance, the market took over. Every other commercial on the TV was hocking some uncovered medical procedure.

Mercy Hospital is going out of business. Everything must go! MRI's half off, CT-thirty percent discount, elective choleys starting at $5000.

Black Friday was the biggest day of all. The people would crawl out of their beds early Thanksgiving morning and push, wheel, or be carried to the nearest medical outlet to stand in line and hope for a bargain. Sure insurance covered many essential procedures, but like Lisa, the panel often denied basic requests. She knew her back surgery would never be payed for unless she obtained the MRI on her own. Once the results came back, it would be a gamble to see if the panel would OK her procedure. If not, the neurosurgeons down the street were having a buy one get one free sale for Christmas. Of course, Lisa would have to hire a lawyer to make the legal arrangements to find and share costs with a complete stranger (anyone no someone trustworthy looking for back surgery?).

Lisa sighed as she crept toward the front entrance. Her chances were good. She wondered if poor John was having as much luck.

*

John couldn't help but salivate as he watched Lisa and the kids slurp down turkey and stuffing for breakfast. Unlike his wife who would receive a referral to have her MRI at a later date, if John was successful he would be whisked off immediately for the procedure. And, of course, you couldn't eat the morning of an endoscopy.

After breakfast, Lisa's parents arrived to watch the kids and it was off to the races. Lisa dropped John at the GI suites, and then rushed to the radiology center. Luckily the parking lot was not yet full when she arrived.

Twelve hours later Lisa left the facility with her hand greedily clutching the thick gold referral form. She sent a quick text to John, but no answer. She hadn't heard from him in hours.

She clicked the Facebook Application on her smart phone. Amidst the pictures of Thanksgiving feasts and newly purchased flat screen TVs was a mobile upload from John.

He was siting on a gurney dressed in a skimpy gown with his black socks covering his dangling feet. He had a large smile on his face and was holding his thumbs up in mock triumph.

Lisa couldn't help but laugh out loud and exclaim to no one in particular.

Someone's gettin scoped!

Thankful

As I pull out of the hospital parking lot, I feel nothing but gratitude. The cold Chicago morning has transformed from blustery to pleasantly sunny. I become acutely aware of the gifts bestowed upon me.

I have a mind to think, a body to work, and a heart to love.

*

I walk into the house to find my four year old daughter singing along to an old Squeeze CD.

Tempted by the fruit of another..

She hops back and forth as her button dress flies through the air. My wife stands over the stove, and the smell of Ghiradelli's brownies wafts through the kitchen. My son's face is stained red from the seeds of a pomegranate that he greedily grasps between his fingers.

I will answer phone calls tonight but how can I complain? I will round at the hospital tomorrow, but it is a small price to bear witness to humanity. To experience such profundity on a regular basis that I am often unable to choke out the words to describe my experiences. Instead I write to clumsily record that which I fail to express by other means.

*

And it is you my dear reader.

You have allowed my words to seep out of your computer or cell phone. You have followed me on facebook, twitter, or read my blog. You, who has given me the greatest honor and pleasure to awkwardly juxtapose my thoughts and phrases into something that pleases.

It is for you reading these words at this moment that I am thankful.

Happy Thanksgiving!

Missing The Boat

Arthur's voice rattled as if small bits of gravel were stuck in his throat. His words resonated over the phone and felt more like commandments then questions.

Lillie's coming back home?

By home, he was referring to the assisted living that they both had inhabited for the last few years. But Lillie developed a severe case of shingles and was transferred first to the emergency room and then to the nursing home.

She was like many of the other patients in the dementia unit. Her complaints of pain were both persistent and monotonous. When it was explained that her belly discomfort came form shingles, she would calm down and become quiet. Moments later, however, she would forget the explanation and start to moan all over again.

As the weeks passed, Arthur would call from time to time. The nurses rumored that he was abusive and controlling. Lillie's son mentioned that having them apart was not necessarily a bad idea.

*

So when Arthur made plans to move into the nursing home and sleep in a bed alongside his wife, there was a general uproar. The nurses scurried in and out nervously expecting his arrival. The administrator paced back and forth in her office. Lillie's son sat quietly in the room with his mom.

When Arthur arrived I was surprised that the small thin frame belonged to such a powerful voice. He barraged the staff with a series of demands. They shook their heads but dared not disobey.

The months passed and a routine was established. Every now and then Arthur would spew forth another unreasonable request. The nurses felt less trepidation and grew bold over time. They began to understand that his bark was much worse then his bite.

*

I walked into their room this morning for my monthly visit. Lillie was perched low in her wheel chair and Artur was stooped over her, sitting on his bed. The TV was on and they were holding hands.

I flipped through the chart as I talked to them. Lillie's use of pain medication had dropped seventy five percent since her husbands arrival. I asked Arthur about her tremor.

When her hands start to shake, I reach out and hold them. She then stops within a few seconds.

There was no signs of being overbearing here. There were no accusations of alleged abuse.

*

There is no doubt that as health care practitioners we need to make decisions based on slivers of information. We become like cameras. We store a series of snapshots and use them to tell a story.

Yet clearly we occupy such a small portion of our patients life. We miss 99.99% of their existence. But sometimes it is in those miniscule moments, when doors are shut, that we see a true window into their souls.

If we are lucky, we may get a chance to be a part one of those moments.

If we are not-we might just miss the boat.

Concussion

The thud vibrated through my body as the pipe refused to budge against the sudden upward force. Damn crawl space! My eyes closed and bright shards of light shot through my visual field. I struggled out into the open and put my hand on my scalp. I could feel the lump beginning to form.

The vague pain in my head and neck lingered. I payed little attention as I continued to inspect the house. My thoughts limped forward as if caught in a deep haze. When I was finished, I slid into the passenger seat of the car and my wife began the long drive home.

My eyes felt heavy and my head woozy. A spasm of nausea started in my abdomen and worked its way up my throat. The saliva spilled into my mouth as I gulped to keep from vomiting.

*

It's just a concussion. It's just a concussion.

I kept repeating as I crawled into bed. The nausea abating only in complete stillness. My head was pulsating. My eyes felt heavy as they rotated to survey my surroundings.

I fell asleep hoping that I would feel well enough to make the long drive to work the next morning. Every few hours I awoke and choked back the uncomfortable feeling in my belly.

As morning came, I arose and walked down the stairs to get a Tylenol. I stumbled over the ledge. I felt like each step was another turn on a roller coaster. I walked past the bathroom but thought better and turned back quickly.

As I lay on the ground in front of the toilet my body heaved and convulsed rhythmically. Each wretch sent spasms of pain up my spine and down my forehead. After a few minutes I was able to get up and flush the toilet. I wandered up the stairs and woke up my wife. It was time to go to the emergency room.

*

The ER is such a different place seen through the eyes of a patient. I slumped in the chair at the front desk as the intake person took my insurance information. As she asked me questions, I tried my best to control the war that was raging in my abdomen.

I was walked quickly back to a bed. The gown was cold and the bed had neither sheets nor pillow. I laid flat and moved as little as possible. A nurse came in and placed an IV. The blood trickled down my arm as she applied pressure.

Sorry we hit a bleeder!

Zofran and ativan were pushed through my IV. The nurse dutifully scanned my wrist band after each new medication as If I was a box of cereal being checked out of the grocery.

The attending came in and checked me over. I fidgeted at the thought of the radiation of the suggested cat scan, but I felt too sick to argue. This is what I would have suggested for my patient.

*

The cat scan was negative and I was sent home with an anti emetic. After sleeping most of the day I finally feel well enough to sit up and write this blog.

Tomorrow I will return to work and forget this day as if nothing happened.

But maybe I'll be just a little bit more understanding of what it's like to be sent to the emergency room.

Maybe, from now on I'll avoid crawl spaces.

False Intimacy

When I saw the name pop up on my schedule, I sighed deeply enough that the nurse and secretary both turned to stare. I ducked into my office. Mrs. Lange had just been double booked into my last opening of the day. I quickly perused my calender. The likelihood that I would make it on time to parent teacher conferences just plunged to zero.

Mrs. Lange was an old, crotchety, lady that belonged to my partner who was currently out of town. The cracks and crevices in her face formed chasms that only seem to deepen with each visit. Each clinical note began with same mirthful statement.

The patient is a ninety year old Caucasian female appearing older then her stated age.

*

As the day progressed, I felt a sense of dread in the pit of my stomach. Each visit with Mrs. Lange ended exactly the same. After a mind numbingly difficult history and physical, I would shoo her out of my office with a set of referrals and no likely explanations for her miriad symptoms.

Her testing always came back negative. By then her complaints were replaced by a new set of maladies.

And we danced this peculiar dance. Like fencers we sparred relentlessly. Each jab defended and countered in short order. Each match ending without the delivery of a fatal blow.

Mrs. Lange evoked in me the most difficult emotions as a doctor: anger, pity, frustration, and helplessness. She made me feel like a prisoner trapped behind the cold metal bars imposed by the exam room.

I left every appointment feeling beaten down and hopeless.

*

And this appointment was no different. I struggled through a dizzying list of nonsensical symptoms and signs. She spouted forth a complaint and I shot back an answer. Finally I convinced her to climb onto the examining table.

Her vital signs were normal. Her lungs and heart were regular. I lifted her sleeve to examine her elbow. My hands shook as I peered down at a patch of skin I hand never seen before.

Below her elbow, on her forearm, was a faded series of numbers. My heart fell into my abdomen as I realized that this was the branding of life's atrocities.

I must have been too hurried in the past to elicit a detailed social history.

She was a Holocaust survivor.

*

As physicans we suffer from false intimacy. We are given a pass to delve into the most delicate parts of people's lives. We see the best and worst of human nature.

But in reality, how well do we really know the innocents that sit before us? How often do we make snap decisions and judgements based on faulty and incomplete information?

Mrs. Lange taught me alot about making assumptions.

Every time I feel my temper rising and my patience ebbing I picture her ancient face.

And then I remember her arm.

Complexity

As I opened the chart on the computer screen, my eyes glazed over. It was the third case of shortness of breath in a row. I combed through the records of yet another octogenarian: stress test (check), xray (check), echo (check), pulmonary function tests(check).

It wasn't even lunch time yet. I sat down quietly at my desk. The screen blinked reminding me that a patient was ready for assessment. The overhead pager system was calling my name. My cell phone started to ring.

I laid my head down on a stack of papers.

When did life become so complex?

*

I push the mop and bucket out behind the counter and move slowly as not to spill. Inching toward the smaller of the two dining areas, I stop at the entrance and remove the garbage can. As I dip the mop into the bucket of soapy water, I listen to a group of girls giggling at a table a few feet away. They look my age, maybe fifteen.

I glide from one end of the room to the next. Pausing to place the mop back in the bucket, I push a row of tables onto the newly mopped floor, before starting the process over again. My arms relax and contract and my hands grip tightly around the handle.

I enjoy this work. My thoughts are free to wander. I calculate how to complete my task more efficiently as I bounce to the music overhead. I think about my life, school, and work. My mind hums like a machine. It jumps from thought to thought without pause or interruption. The sweat roles down my back and the white ice cream parlor uniform clings to my sides.

My muscles ache from physical labor intermixed with occasional jaunts to the equipment room where the teenage employees do pull ups on an old rusted pipe. I am youthful and proud.

I finish the small dining room, and move a garbage can to block the entrance to the large one. I will sweep and mop. Then the bathroom, break room, and equipment room await me.

*

I leave the exam room with more questions then answers. Maybe it's just a bad case of sleep apnea, anxiety, or deconditioning.

I think back fondly to those days in the ice cream parlor. When, at the end of day, I could look out and see all that I had accomplished. I could peruse, contemplate, and record my inconsistencies.

But as time went on, life changed. With education comes complexity.

And as a physician, I spend most of my day flopping in a sea of the abstruse. There is so rarely a finite beginning and end. My work product is subjective and ephemeral.

But sometimes I dream of dropping it all, leaving my profession, and donning the apron once again.

I'm sure I would enjoy myself immensely,

for about a few hours!

Empathy

As Sylvia swept through the door into the waiting room, the receptionist called out from behind the counter.

Dr. Kris, Dr. Kris, Mrs. Beckwith is on the phone. She's having back pain again!

Sylvia paused, the bag carrying her laptop propelled forward and then snapped back on the shoulder straps. Her laboratory jacket was folded neatly across one arm and the adjacent hand held a cell phone. She was about to call the Nanny. She pushed the power button on the phone and glanced at the display.

Technically, it's after four. Give it to Dr. Short, he's on call!

The secretary opened her mouth to explain that the covering physician wasn't familiar with Mrs. Beckwith, but then thought better of it.

It wouldn't have mattered anyway, the front door of the office had already slammed shut.

Sylvia was gone.

*

The choice of practices was perfect. Sylvia could work a full schedule and still have time to cart the kids back and forth to their various activities. Hospitalists had taken over the inpatient responsibilities. Call duties were light and spread among a large group of physicians. The clinic closed at four.

Sylvia congratulated herself on finding the perfect post residency job. The work-life balance was exactly what she and her classmates were looking for. At first, she had been worried about being able to handle the more difficult patients. But she quickley realized that there were always specialists to refer to, and she could send the sick ones to the ER. And when the clock struck four, they were someone elses problem.

As Sylvia bent down to place her bag into the passenger seat, she felt a faint twinge of pain radiate down her stomach and into her pelvis.

I wonder what that was?

She quickly walked around the side of the car and got into the driver seat. Her son would be finishing soccer practice soon, and she didn't want to be late.

*

Upon awakening, it took a moment for Sylvia to realize that she was about to vomit. As she jumped out of bed, she felt a sharp stabbing pain emanate from her epigastrium and spread into her chest. At first her mouth watered, and then she heaved violently. Her body spasmed over and over again until she had completely emptied the contents of her intestines.

She crawled back to bed and fumbled with the phone.

Hello...hello...I need to talk to Dr. Phillips immediately.

She silently prayed that her personal physician could give her some guidance. She felt alone in the large bed left absent by her traveling husband.

Dr. Stone is on call for Dr. Phillips. Please call back If you don't hear from him within the next half an hour.

Each minute seemed like an eternity. As Sylvia watched the clock desperately, she wondered if the phone would ever ring. When she walked into the bathroom to rinse her mouth, she was taken aback by her own reflection. The whites of her eyes had turned yellow.

*

Sylvia watched the nurses bustle back and forth in the emergency room. The dose of dilaudid had calmed her abdominal pain, but not her anxiety. She was all alone. Her husband was thousands of miles away. Her parents were sleeping in her guest room next to the children.

She reached over to the table to check her cell phone. Maybe Dr. Phillips had returned her call. Maybe he would walk through the exam room doors like Marcus Welby, and grasp her hand and tell her that everything would be okay.

Unfortunately, the only one who came was the Surgical PA. He explained in an emotionless tone that the ultrasound showed choleycystitis. In a matter of moments the antibiotic would finish running and then it was time for surgery.

Dr. Carson is on the way. The anesthesiologist will explain everything and then we'll put you under.

Sylvia grasped for words as she felt a sense of terror rise from her belly.

But don't I at least get to meet my surgeon.

The PA's back was turned and he was moving quickly toward the door.

Sure. After the procedure.

*

As the anesthesiologist placed the mask on Sylvia's face, her mind raced. First she thought of her husband and children. She wished that they were by her side.

Then she thought of her parents and how they used to comfort her as a child.

But as the intense feeling of fatigue washed over her body and she started to lose consciousness, she conjured up the face of poor Mrs. Beckwith. She imagined her sitting alone in a cold room with her arm retro flexed and her hand grasping her painful flank.

She recognized the fleeting sensation of empathy.

It was something she hadn't felt recently.

Not since the early days of medical school.

Having Your Story Told

Mrs. Fitz clasped her husbands dangling hand as her son and daughter sat in the empty chairs next to the examining table. The children had brilliant black hair with the beginning of gray streaks at the edges. The family waited quietly while I maneuvered the stool into the corner so I could interact with each member without craning my head. The daughter cleared her throat to speak and looked affectionately towards her father's wheel chair.

Since you are going to help my father die, we thought you should know his story.

*

The mustang glided easily under Captain Fitz's steady hand. The World War II era fighter was reserved for only the most advanced fliers. He was finishing a successful mission in enemy territory, when he noticed a flash out of the corner of his right eye. The staccato sound of gunfire was brief but ended in a large thudding sensation that he felt in his fingertips as he struggled to control the flubbing aircraft.

Seconds later he felt a heave of pressure on his chest as the cabin rolled. He fell into a tailspin. His body hurdled violently toward the ground as the unbearable g-forces lead to a loss of consciousness. As his eyes closed for what he believed to be the last time, he pictured the pale face of his fiancee waiting innocently for his return.

Like a bird suffering from a heart attack in midair, he tumbled lifelessly out of the sky. He later calculated that he fell at least forty thousand feet. He awoke expecting to meet his maker at the pearly gates.

Instead, his first recollection was searing pain coming from his right leg. He looked down to see the bottom half of his lower extremity shattered and bent disfiguringly under his thigh.

Three men stood above him speaking in a foreign tongue. One pointed a rifle in his direction and gesticulated wildly. The other two walked calmly over to the captain and lifted him onto a stretcher.

On the thirtieth anniversary of the crash, Captain Fitz would return to the exact site and be reunited with the three men who had had every intention of killing him. But in a strange twist of fate the men decided it would be a bad omen to kill a man who had survived such an incredible fall.

*

Captain Fitz was taken to a POW camp where a fellow prisoner happened to be an orthopaedic surgeon. His leg was meticulously cleaned and splinted. His extremity was spared but his luck was brief.

The Captain refused to speak of what happened in the camp. But he survived years of torture and forced labor. When the war was over he limped back across enemy lines.

He came home to find a fiancee who had already attended his funeral. Within months they were married and soon were expecting their first child. Captain Fitz became a proud father.

He returned to school and earned a PhD. His research would eventually have profound effects on modern medicine and biology. He would educate the next generation of researchers and physicians.

As he entered his eighties, the miracles would run out. Captain Fitz developed a progressive neurological disease that first stole his words and then his thoughts. Relegated to a wheel chair, his body failed in the same manner as his mind.

As Captain Fitz sat silently in front of me on that day, his daughter's eyes brimmed with tears. His son put his arm gently around his mother's shoulder.

I took a moment to enjoy the silence. We were all lost in thought.

Captain Fitz died a few months later. None of my subsequent visits were nearly as profound.

*

Sometimes part of dying is having your story told.

Sometimes being a healer is less about talking and more about listening.

Medicare has no way of measuring such things. There are no ICD-10 or CPT codes for this kind of interaction.

But ask anyone who spends their life taking care of others.

This is where the healing takes place.

If I Die Young

It's funny how a few words, a phrase, or music can bring back buried memories.

If I die young, bury me in satin
Lay me down on a, bed of roses
Sink me in the river, at dawn
Send me away with the words of a love song

The sharp knife of a short life, oh well
I've had just enough time

I heard this song on the radio this morning. A rush of memories flooded my brain in the form of the smiling face of a beautiful little girl.

*

Hola Flaco!

Hola Flaca!

A peel of giggles erupted from the small figure enveloped by the hospital bed. Her frame was lithe and frail but her eyes were large and luminous. Sparkles of light and fire shot forth when she honored me with her melodic laugh.

I was a third year medical student and unaccustomed to the wall building that accompanies most medical education. I had been assigned to the case because I was the only medical student on the team who spoke passable Spanish.

Although we sometimes had trouble communicating, the relationship had attained a certain level of fluidity. The family called me "flaco", the Spanish word for skinny, because I had started to work out during the rotation and lost ten pounds. My clothes were hanging uncomfortably off my body and my pants were barely held up by my overextended belt.

Although the miniature girl in the hospital bed was alive with passion and spirit, her body was dying. In better times, I referred to her as "flaca", the female version of my nickname. But, as the days passed, I became leery as she lost more weight and her illness progressed. Her rampant giggling reprimanded me for my political correctness and reminded me that it was just a small intimacy between inconvenient friends.

*

Flaca was struggling. Her energy was waining and her laboratory values told the story of a fairy tale that was coming to an end. Her body could no longer sustain the repeated insults of medication and dialysis.

One night toward the end of my pediatrics rotation, she spiked a fever. The nurses hurried to administer Tylenol and draw blood cultures but they were unsuccessful. As I walked into the room with a tourniquet and butterfly needle, Flaca's eyes turned cold.

I fumbled with words in both Spanish and English to explain why I needed to draw her blood. My resident stood above me tapping her foot in disapproval because she felt there was no time for explanations.

Flaca pulled her arm away from me and spit in anger. The fear in her parents eyes was overcome by determination. They nodded at the nurse who walked over and pinned Flaca's arm down against her struggling torso. I quickly grabbed the needle and jabbed her arm. As the blood flowed, we all gasped a sigh of relief.

*

Flaca would never speak to me again. When I entered the room she would turn her head in disapproval. The frailty of her body was betrayed by the unending strength of her anger. It was as if my face had become the form of all the hurt and sadness brought on by her terrible illness.

She died a few days later. And along with her a small part of myself.

I will always hold the greatest respect for those who take care of our ill and dying children.

But I could no longer be one of them.

Practice

My son plays his violin. He practices every day. He attends group and private lessons multiple times a week. Occasionally he learns new pieces. Mostly he plays the same music over and over again. There are days when the music seems to glide sweetly from his hands with little effort. There are also days when screeching mangled notes seem more the norm.

It's a tiring process. Day after day and week after week, he struggles. He concentrates on his posture and fingering. He battles to hold the instrument in just the right manner. His fingers bend and contort. His hands cramp. His progress is measured in small increments.

And if he is lucky and persistent, he will improve. His practice will pay off. His notes will be more melodic and pleasing to the ear. He will graduate from one set of pieces and move to the next. The complexity and pace will increase.

Each time he studies a new composition, he will need extra hours of training. His arms will learn the exact twists and turns. He will repeat over and over until his mind no longer thinks of each separate movement, but learns to play as a whole.

But the violin is knowable. While there are some minor differences to each instrument, he will expect roughly the same sound from any violin he picks up. There are a finite number of sounds and notes to learn.

After countless years and thousands of hours of practice, he will approach mastery. Likely this will take decades of both persistence and luck. It is definitely possible. There are no short cuts. Some will reach mastery faster than others. Some will not reach it at all. But every one will have to put in the appropriate time.

*

I don't understand how we think we can short circuit medical education. Under the rubric of reform we are undermining our training programs.

Residents are being told that they must work shorter shifts and take call less often. As they finish their programs, they are entering their profession with less accrued experience. Their knowledge base is lacking and they learn to consult often, order more tests, and refer to the emergency room.

Primary care physicians are being replaced with nurse practitioners and physicians assistants without requiring the same requisite hours of training. While basic care is surviving, the art of the differential diagnosis and the treatment of the complex patient is being punted to specialists.

Yet my son continues to practice. In order to obtain mastery, he will be expected to study more them most residents and medical students, more then nurse practitioners and physician assistants. And he will learn this tiny instrument. With its four strings and single bow. With its countable number of pieces that move in finite and measurable ways.

No one would expect him to reach his goal without putting in the appropriate time.

Why don't we expect the same out of our medical professionals?

Hubris

The clanking of the wheel chair destroyed my memory of Tim's last visit.

He was healthy then. His long torso sat on top of spindly legs. He strode into the exam room confidently. Although he described burning in his chest, his gait and demeanor were unhindered. He seemed reassured that the work up in the hospital was unrevealing.

The cardiologist's report from the outside facility said that he had clean coronaries. He showed me the bandage on his groin to prove it. Eventually he was given the label of gastroesophageal reflux or anxiety.

His chest pain was worse then ever, but he could manage as long as it wasn't life threatening. He grinned at me as I took out my stethoscope. His exam was normal. I thumbed through the hospital records. His cardiac catheterization, chest xray, ekg, and lab reports were normal.

We discussed different treatment options and finally decided on watchful waiting. As I ushered him out of the office, I had no inkling of the torment that would soon befall him.

Hours later, he collapsed in his living room.

*

Ya, I know he has chest pain!

The caller annoyed me. I just saw Tim in the office. Why was he in the ER now?

The last thing I expected to hear was that he suffered a devastating heart attack, and was being resuscitated. I rushed to the hospital to find him in the Intensive Care Unit on a ventilator.

His status wavered from day to day. His wife and I talked about the poor prognosis and the likelihood of death. But as the days passed, Tim got stronger. When sedation was weaned, we removed the ventilator.

Tim's mind was as sharp as ever. But he couldn't talk, and he was having trouble moving his right leg. The lack of oxygen during the initial days in the ICU took its toll. Tim had suffered a stroke.

I wrote his discharge orders with a heavy heart. He was transferring to a rehab facility and then a nursing home. I didn't have privileges at either location, and I would have to surrender his care to another set of physicians.

*

Months later, Tim was leaving the nursing home and returned to my office to reestablish care. His eyes rested on the ground as his wife pushed him into the room. This was one of his bad days. I could sense the depression before I even talked to him.

I felt a great compulsion to apologize. I wanted to say that I deeply regretted not sending him to the emergency room. I wanted to explain that even when all the protocols are followed correctly, the body is a fickle master. Even the bravest of lion tamers occasionally gets bitten.

I couldn't feel the ache of the tooth marks nor the restraint cast upon his soul. It is only with great hubris that the physician pretends to understand the reality of illness.

So I sat silently next to the wheel chair and put my hand in his. A promise to unlock the bodies secrets would neither be offered nor accepted. Instead I looked him in the eyes, and gave the only thing I had left.

I'll be right here.

You're not alone!