Tuesday, January 31, 2012
When I die, people will walk on me?
Even at the age of four, she knows that the dead are buried in the ground. More questions follow rapidly. She thinks that if a grandparent doesn't show up to pick up her classmate from school one day, he must have died. The same if someone goes on vacation for a week.
Her statements are crude but yet shockingly honest. Unfettered by the complexities of the adult mind, she is free to explore unencumbered. There is no guilt or embarrassment in her voice. Our conversations lack the fear and angst that so often cloud this kind of discussion amongst grown ups.
She is curious.
Was I dead before you had me?
In some ways, my daughters fascination with death will not likely evolve as she grows older. She will lose the innocence as she forgets the mechanics and begins to contemplate deeper meaning.
What happens to our soul?
The pang of love that shatters our hearts, does it just disappear?
And I will tell her that I don't know. I have helplessly watched life slip away countless times, but I am no closer to the answer.
I have both battled death as the enemy and humbly welcomed her mercy. I have travelled her paths and attempted to veer away at every turn. I no longer see friend nor foe, more a quiet mistress who waits patiently in the wings.
Like my daughter, we are all just children. Bobbing and floating in the vast ocean, our minds turn yet we have no control over the direction of the tide.
My daughters voice pulls me back to the little bed in her quiet room.
Daddy, what does it feel like to die?
I draw her close and hold tightly.
My sweet child,
I'm still trying to figure out what it feels like to live.
Posted by Jordan Grumet at 5:15 AM
Sunday, January 29, 2012
Eight months ago he stared at the gleaming instrument. For the first few weeks he practiced his plucking. Then, in no time, he was bowing. Now he plays a plethora of songs and learns something new each lesson.
The sounds coming from his violin are becoming less squeaky. The melodies are more constant and the clarity of each note is beginning to shine.
But more remarkable than his technical acumen, is the joy that is growing in his heart. He has started to smile as he plays. His lips curl upwards despite the furrowed brow of concentration.
Yesterday, toward the end of practice, he came to one of his favorite pieces. As he played his legs bent slightly, and his eyes began to close. Instead of the rigid stance so often practiced, his shoulders began to sway. For just a moment, his body and the notes dancing off the violin had become one.
It was pure ecstasy.
Unlike many other endeavors, music allowed my son to reach this moment without mastery. Only a novice, the feeling and emotion transcended his abilities. It will be years before his technical skills will match the expression of his body.
But we all have witnessed someone who's abilities and training match the emotion of the instant and reach "the sway". I am reminded of watching Michael Jordan dominate during a championship series, or Barack Obama deliver a speech. There is a point when years of education meld with thousands of hours of practice to produce a sum that is greater then the parts. This can't be taught. It is cultivated over back breaking effort and indomitable will.
Mastery is often difficult to quantitate.
There is a time when physicians also reach "the sway". It is usually after ten or fifteen years of practice when the doctor-patient relationship loses the rigidity and transforms into an elegant dance. Diagnosis and treatment are not only cogitated but also felt.
As a conductor, the doctor learns to anticipate the vibration of the instrument as well as sense the emotions of the musician.
Anyone who has been lucky enough to interact with a clinician during this period, will recognize how powerful the relationship can be.
It is a time of grace.
I worry about what is happening in medicine. We are losing our physicians at the prime of their careers. They are leaving clinical medicine for greener pastures. They are pulling back, abandoning the hospital, and cloistering their abilities behind the veil of increasingly specialized offerings.
Those clinicians who are choosing to continue are finding that they have to trade in their dancing shoes for boxing gloves. We fight with insurance. We fight with pharmaceutical companies. We fight with the government for the right to trust our instincts.
"The sway" is becoming fractured and labored.
That which has been lost,
may never be retrieved.
Posted by Jordan Grumet at 4:50 PM
Saturday, January 28, 2012
Claim denied due to duplication of care. Services payed already to emergency physician.
I shook my head in disbelief.
The notification that John was in the emergency room came blinking across my screen. Of course, he hadn't called me to say anything was wrong. I looked down at my watch. I could be out of the office and in the emergency room in five minutes.
I ran down the steps and pushed my way between pedestrians as I crossed the hall entering the emergency room. The morning rush had yet to materialize. John was one of the only patients.
I scanned through the nursing notes and the emergency physician's impressions. A cat scan of the chest was already ordered. When I entered the room, John was sleepy from a dose of morphine. We discussed his chest pain. Although he felt a little worse then usual, it was the same pain that had been present for years. I palpated his right rib cage and he yelped in pain.
His labs, EKG, and chest X-ray were normal. When I perused the medical record further, I found that the same emergency physician had scanned his chest the month before when he showed up with a similar complaint. In fact, He received five CTs in the last year. Surprisingly, none of them showed a pulmonary embolism.
It took a few moments to find the ER Attending. When I questioned her about the need for another cat scan, she looked at me appraising.
He said he never had chest pain before.
I gently reminded her that she saw John recently for the same complaint, and she started to blush.
I discharged John with a diagnosis of costochondritis and a prescription for a non steroidal anti-inflammatory. By the time he followed up a few days later, his pain was gone.
As I see it, I saved John an unnecessary dose of radiation and IV dye. I relieved the emergency room physician by doing her job for her. And I reduced the cost to the insurance company by hundreds of dollars.
Apparently the pittance I bill for my services,
is asking too much.
Posted by Jordan Grumet at 6:43 PM
Friday, January 27, 2012
He took me out of pity. The meager sums I saved were nothing near his average client. I was well below his minimum. But we had a common friend. And he liked me and my wife. We were his kind of people. Bargain shoppers. We bought low and sold high.
Over the years we talked every few months. He would take my wife and I out to dinner in the early days. Later, he would come to the house and entertain my children before we could chase them off to bed and talk financials.
It was a working relationship. But certainly he was the type of guy I would be friends with anyway. He invited us to his house many times to meet his wife and kids. We always had some reason to decline. There was usually something going on. We never had enough time.
We eventually learned his story and he ours. About how he met his wife in India. About how he didn't think he would marry and Indian girl. And about his children and the various activities they were involved in.
Occasionally there was turbulence. After all, the market was doing horribly. But we still came to him for advice; sometimes about money, sometimes about life.
He was kind and considerate. He was patient and calm. He always had a smile on his face.
Awhile back he called to tell me he had excepted a job with a new firm. I was proud that instead of expressing dismay or concern about my own financial well being, the first thing I said to him was "Congrats...I'm happy for you!"
He was surprised. I was the only client who had congratulated him. Later, we talked about how we would move our funds over to his new firm. I could care less who he worked for, it was his advice I was interested in.
A week later I called for a brief question about funds transfer. He was in the middle of a meeting, but took the time to answer me anyway. Little did I know that those were the last words I would ever speak to him. Thirty minutes later he collapsed in his office. In a few days he was gone. He never woke up.
My wife and I went to his funeral. As I watched his children, I flashed back to my own father's death. He died the same way. I approached the casket and mumbled condolences to his family. And there he was. His face edematous and puffy. Unrecognizable compared to the handsome smiling facade imprinted on my memory.
During the ceremony family and friends spoke about his affect on their lives. His clients were especially vocal. A widow talked of how he had promised to take care of her finances after her husband's death. And he had. An older man spoke of how he had traveled with him to India to guide him in search of his parents ancestry and to spread their ashes. He called him his son. There was no blood relation.
Then there was me. The fool that I was, I had thought that this gentle human being was brought into my life to teach me about money. Money! Useless money!
In reality his lessons were much more valuable. He demonstrated compassion,joy, and love. All these things he gently taught, quietly, and in his own humble way.
And I think of his distorted face and body lying in the casket. They were not a true window into his soul, but more an unkind reflection of what I had become.
One last lesson taught by a masterful teacher.
I wonder If I deserved as much.
Posted by Jordan Grumet at 6:44 AM
Wednesday, January 25, 2012
My dial is set to 91.5, national public radio. There's something about the reporting style, the ebb and flow, that draws me in. The content is superb; the stories informative. My car becomes a haven of calm and warmth in the midst of the frigid Chicago winter.
So when I heard the name of my hospital role gently off the lips of the voice on the other side of the speaker, my ears perked up. It appears a celebrity was admitted overnight. Someone who garners a lot more attention than any of the poor souls who mistakenly end up in my office.
As the story continued, I was gratified to hear the reporter specifically mention that the patients "primary care" doctor attended to him in the hospital and even accompanied the ambulance to the tertiary medical center for further care.
She didn't say surgeon. She didn't say neurologist. She said primary care. For once someone, a newscaster nonetheless, was giving credit to my beleaguered and haggard choice of specialty.
But who was this brave soul? Who was this role model for the next generation of internists and pediatricians? My heart sank as I got the answer, it was a local cardiologist. He was not an internist, not a family practitioner. He was a cardiologist.
Now don't get me wrong. He's an excellent physician who over the years has done his share of general medicine. But I couldn't help but feel a little let down. How are we going to get young physicians interested in primary care if the only time it's cool to be one is when your are a specialist taking care of a celebrity patient?
God forbid, don't leave such an important case to an ordinary primary care doctor with so little training.
One day you'll look and we'll all be gone.
Will anybody care?
Posted by Jordan Grumet at 6:01 PM
Tuesday, January 24, 2012
Geraldine fidgeted on the exam table with her purse in her lap. Her porcelain skin and quaffed hair were betrayed by hands that carried the wear and tear of eight decades. Her eyes bounced back and forth between my face and the handbag. Eventually she produced a series of aged photographs and handed them over one by one.
The man staring back at me in the first photo was wearing a soldier's uniform. He was handsome and tall with broad shoulders. The edges of the paper were worn and had frayed over years of handling. The second picture showed a young couple and was marked "tenth anniversary".
As I fingered through the pile, the faces became wrinkled and the postures stooped forward. In just a few moments, I witnessed the evolution of a love affair. Young feverish lust became life long companionship.
When he died in 2000, I didn't know what I was going to do.
She was now prim and proper again. Her back straightened against the pull of osteoporosis. I studied her face. The makeup was applied a bit too liberally. But looking back at her photos, that was obviously a lifelong habit. Her feet were swaying back and forth slowly. Every time our eyes met, she would look down quickly.
Her husband died suddenly. Healthy into his mid seventies, she woke up one morning to find his body lying next to her; his soul had departed. The doctors told her that it was likely a heart attack, or a stroke.
After his death, Geraldine tried to maintain the household just how he left it. But over the years the strain became too great. Her daughter swooped into town one weekend and helped her pack. The majority of her belongings would land in storage, but her husband's pictures, framed with a loving hand, would accompany her to the assisted living.
I still wake up every morning and stare into his eyes.
Fifteen minutes into the appointment, I was starting to get a little antsy. I waited for a lull in her soliloquy and then jumped in.
So what exactly brings you in today?
Her face turned a deep shade of pink and again she batted her eyes down toward the ground. Her words were almost inaudible.
I was wondering if you could prescribe some Viagra for my new boyfriend.
Posted by Jordan Grumet at 12:05 PM
Monday, January 23, 2012
When I heard the words, a strange memory popped into my head. My wife and I had just been married and were sitting on an airplane. As we prepared for the flight, a family of five bungled by and occupied the seats directly behind us. I gave my wife a knowing look. There were three children and the eldest appeared to be about seven.
I sunk down in my seat, and placed the headphones over my ears to no avail. The next few hours were filled with screaming, crying, and pushing on the back of my chair. I was livid.
I couldn't understand how adults could have so little control over their children. That is, until I became a parent myself and had to negotiate the perils of travel.
There are just some things you have to experience to understand.
Mrs Jones was dying. After years of dementia, she suffered a catastrophic stroke. Instead of rushing her to the hospital by ambulance, I asked the family to meet me at the nursing home to discuss her situation.
I entered the room and marveled at the number of family members stacked like sardines into such a small space. I introduced myself, and shook their hands individually. Mrs Jones daughter stood at the front of the crowd, and faced me as I began to talk.
I explained the prognosis was particularly poor for someone who was in the end stages of dementia. Heads shook in agreement as I continued. I discussed the different options and finished with my personal opinion.
If this was my mother, I would opt for comfort care only.
Upon hearing the last sentence, I sensed a change in the daughter's stance. Her lips pursed and her shoulders hunched forward in anger. She turned and talked to her family for a moment, and then calmly asked if I would speak to her outside the room.
Has your mother ever died? Because if not, you may not want to recommend withdrawing care so strongly.
I took a moment to think about what she just said. Although I had watched many patients pass over the years, I have never once walked in their loved ones shoes. Of course, my father and grandparents died. But each relationship is special and unique.
And in this way, empathy has its limits. I can't truly know what it feels like as they preside over such difficult situations. All I can do is remind the family that I have accompanied many patients and families through similar situations.
Often the acknowledgement of my own inabilities,
provides comfort in itself.
Posted by Jordan Grumet at 5:24 AM
Saturday, January 21, 2012
I hung up and took a moment to clear my head before making the phone call. It was the middle of the night and my eyes felt as if they were sown shut. I hobbled into the bathroom and stared at my cell.
I was about to make a call that would forever change someones life. Right now, they were tucked away in their beds sleeping quietly. In a few moments there would be chaos. I felt uncomfortable conveying such information over the phone, but I had no choice. I couldn't just wait till morning.
I listened to the ringing and thought about the nature of being a physician. It always made me sad to know that I become aware of such profoundly intimate news before the family. A few moments later a sleepy voice picked up.
I try not to mince words when giving notification. It's not something I practice, but I make sure to use the word "death" or "died" in order to be absolutely clear.
I apologize for waking you up. But early this morning your dad's heart stopped. The nurses and physicians performed CPR but were unsuccessful. Your father died. I'm so sorry.
I never know what the reaction will be on the other side of the line. Often there is grief, sometimes anger, occasionally relief. On this particular night there was silence. The static of my phone connection was interrupted by rapid staccato breaths. She was hyperventilating.
Unable to hang up and certain that my words would be unhelpful, I held the receiver to my ear and waited. In those fleeting moments my mind began to drift back to childhood.
I thought of my father.
I knew that my dad was sick, but at the age of seven it hadn't quite sunk in. The week before, I was pulled out of school and brought to the hospital. I sat with my mother in the ICU waiting room, and played with crayons and blocks. I had no idea that he was already dead. A brain aneurysm had ruptured and the damage was done. His physiologic functioning was now dependent on machines that could fill his lungs and help his heart beat. But nothing could replace the brain tissue that was lost.
The next Monday I went to school as normal. But upon returning, the living room was full of relatives. In the center stood my mom. She was crying. She took me in her arms and whispered in my ear.
I sat on the couch next to my brother. As I looked around the room the faces were sullen and glum. I wasn't quite sure the significance of everything that was happening.
It was only later that I realized how permanently my life had changed.
My seven year old son is more emotionally mature then I was at his age. Occasionally while sitting in his bed, before he falls asleep, he'll ask me about my father. He questions me about death and what It feels like. I tell him I don't know.
He wonders what will happen to him if I die.
I start to say that he will be okay and that his mother will take care of him, but stop mid sentence. I look into his melancholy brown eyes.
If ever someone comes to tell you that I have died, I want you to remember how my face looks right now. I want you to think about how happy I am and how much I love you. No matter what happens,
both you and I will be just fine.
Posted by Jordan Grumet at 4:50 AM
Friday, January 20, 2012
You don't remember, do you?
By now my embarrassment was replaced by curiosity. He proceeded to explain that he had seen me as a patient ten years ago in my previous office. I marveled at the idea of time passed. A decade younger, I had just married and my kids weren't even born yet.
I was a recent graduate then. Wet under the ears and fresh out of training, medicine was more like a space odyssey; a trip to the moon. I marveled at each new patient, each diagnosis. The unflappable professional cynicism had not yet mushroomed into the all consuming giant that it eventually would.
As my reverie cleared, I began to populate the electronic medical record at a rapid pace. I discussed the intricacies of his medical history and paused occasionally to tease out details. His previous diagnosis of ehrlichia intrigued me. A tick born illness, known to cause fever and rash, that is notoriously difficult to diagnose. I probed further.
Tell me about how your ehrlichia was diagnosed?
His face broke into a grin and he started to laugh. He thought I was kidding, but then realized I was serious and cleared his throat.
It was you. After two emergency rooms and one primary care doctor missed it, you put me on medication, and everything got better.
I was stunned. Not only had I forgotten the patient, I had lost all memory of making the appropriate diagnosis. I had only seen a few cases of this disease in my life, you would think that I would remember each one.
The next day, I scoured the medical records department for the old paper chart. As I read through the hand written pages, I couldn't believe my eyes. My admitting note mentioned ehrlichia as a probable diagnosis, and I started the appropriate antibiotics immediately.
Years later, I am often stunned by how much medicine I have learned and forgotten over time. If the same case presented to me today, would I divine the right diagnosis?
The practice of medicine blinds us with the haze of familiarity. New attendings remember their recent residency training and often are up to date on even the most obscure diseases. But as time goes by, what we gain in experience we lose in knowledge of the long tail.
It has been said that physicians spend the majority of their career learning.
For me, it's remembering that proves to be so difficult.
Posted by Jordan Grumet at 7:33 AM
Thursday, January 19, 2012
As the political climate changed, Dr. Lake became more distressed concerning his situation. His overhead was increasing and the regulatory culture was expanding. Laboring under the strain of advanced technology, the time for patient care diminished.
Looking in the mirror one morning, Dr.Lake decided that this wasn't the job that he trained for. He shuttered his doors, and signed a contract with the hospital owned medical group. At least now he would be able to ply his trade and leave the regulations to someone else.
Dr. Lake used to be a hospitalist. Trained in the care of the complex ailing individual, he enjoyed rounding at the hospital between appointments in the office. The bonds formed with each patient were strengthened by being available in times of greatest need. He took pleasure in seeing the nurses and consulting physicians on a daily basis. It was a community.
So when the administrators started to enforce the rule about using the medical groups hospitalist program, Dr. Lake felt a certain sense of loss. It was true, however, that unencumbered by those troublesome phone calls and travel time, he could see many more patients in the office.
Dr. Lake used to be a kind of emergency room. Often the sickest patients would walk through the door needing immediate treatment or triage. The phone lines were always open, and there was always enough space to fit someone into the schedule.
But as the onslaught of physicals, well patient visits, and followups increased, Dr. Lake found it easier to refer to the Emergency Room. After all, he couldn't just sit on the patient with abdominal pain for 24 hours while he tried to find a space in his schedule. And what if they needed a cat scan?
Similarly, the patients who wanted to be seen for colds and flu had to be scheduled a week in advance. Dr. Lake occasionally resorted to suggesting pharmacy clinics to lighten his load.
Dr. Lake used to be a master diagnostician. His skill was honed over years of experience and reading. Unlike his specialist friends, he was able to see the patient as a whole. While his knowledge was not as deep, his range was far greater. There was nothing more satisfying than making a difficult diagnosis.
If only there was enough time to use his clinical acumen. Dr. Lake was to busy with an overbooked schedule, and checklists and boxes to fill on his brand new electronic medical record. If he worked up each patient appropriately, he would have to keep his office open till midnight. A good thing his specialist friends were salivating to take his referrals.
Dr Lake used to be a physician. But one day an administrator from the medical group called to say his position was being filled by a nurse practitioner, PA, or a medical assistant. A person of his pay grade and education was no longer appropriate for the job.
As he packed up his office, he wondered what the future would hold. His best employment opportunity was to work as a consultant for a pharmaceutical company.
In a moment of clarity, Dr. Lake divined that he had been sold down the river.
He also realized, that he had done quite a bit of paddling on his own.
Posted by Jordan Grumet at 4:57 AM
Tuesday, January 17, 2012
I wouldn't get too close if I were you. She kicked the CNA in the chest
I entered the room to find Myrna pinned to the bed by her middle aged son. Russian curses spewed from her mouth intermixed with deeply accented English. Her legs kicked and her arms tried to flail against human flesh. The fatigue on her son's face showed as he let her go and sprung back to stand beside me.
Myrna was delirious. Her brain encumbered by plaques and tangles was unable to stave off the ill effects of fever and dehydration. Her usually calm demeanor was replaced by demonic screaming and unwieldy thrashing. Her ninety year old body was suddenly strong and agile.
Myrna looked up at us from the bed like a tiger ready to pounce. Her eyes rested on her son's face and then moved in my direction. My muscles tensed reflexively awaiting the possible onslaught. Her face softened.
The baby girl. How's the baby girl?
And then she smiled and looked at me knowingly as if we shared an intimate secret that no one else was aware of.
Even through the thick foliage of delirium,
I reclined in the chair and placed my legs on the desk in front of me. Just one more patient before lunch, and then I was done. My wife was thirty eight weeks pregnant and I looked forward to another weekend of peace before the new baby complicated our quiet lives.
My cell phone began to buzz and ring loudly. I almost fell out of my seat as I yanked my legs off the desk and dove into my pocket. Moments later, I listened as my wife spoke quickly on the other end of the line.
The ultrasound showed a problem. The doctor wanted her in the obstetrics ward immediately to be induced. My wife's voice was calm but firm.
Come home now!
I threw my lab coat on the chair and grabbed my jacket. I ran down the hall with one arm pulled through the sleeve and the other dangling out. As I passed my office manager, I spit out directions to cancel my last appointment and clear the next week.
The secretary and medical assistants huddled in the doorway and wished me good luck as I flew out of the office onto the landing, and jumped down the stairs in groupings of two. When I arrived at the bottom, I bumped into Myrna and her son who were making their way up to the office for an appointment.
They looked at me questioningly. I turned briefly and exhaled an explanation as I gasped for breath. Myrna shook her head and smiled. Even with her deep accent, I caught her words while racing out the door and into the parking lot.
It will be OK!
And it was.
Four years later, this memory came back to me as I sat with Myrna in her hospital room. Although her sensorium had not completely cleared, she was calm now. In time her fever would break and her mind would return.
I often marvel at how as a physician I am present during critical moments in my patients lives. I witness birth and death. I fight alongside them when it is time to fight, and console them when it's time to stop.
But every once in awhile a patient bears witness to one of my moments. And it is only then that true intimacy occurs.
Because between Myrna and I,
it was a two way street.
Posted by Jordan Grumet at 5:19 PM
Monday, January 16, 2012
The roles and expectations are set in a frigid stone of familiarity. I will point, prognosticate, and occasionally shame you. You will listen, cower, and shake your head in agreement.
Often my voice will be strong and confident. For one who has never smoked, it is easy to rail about the evils of tobacco. No longer having the time or taste for alcohol, convictions will drip convincingly from my lips.
But other times, I will squirm and struggle to keep my voice steady. I will tell you that three hundred pounds is too much, yet secretly I lust for the jelly donut waiting in the break room. Have I never medicated with food?
I counsel on exercise, but my brand new running shoes have not yet left the closet.
If you only knew my addiction. The secret I carry in my belly.
I'm strung out. Strung out on stress like the rest of my physician colleagues. I imbibe it first thing in the morning with bleary eyes and queasy belly. I inhale it on quick breaks in back allies between patients and hospital rounds. I chew it, and hock the disgusting byproducts into a used coke can during late night phone calls.
Would my own foibles and humility strengthen the conversation? Would it help you to know that I struggle also? Could we become comrades instead of teacher and student?
More importantly, could I convince you that between horrendous and perfect there is a place called "good enough"? Because I feel fairly certain that if you exercise a little more and eat a little less, things will be better. For my part, I'll work on the stress.
Do we have a deal?
Posted by Jordan Grumet at 4:57 PM
Sunday, January 15, 2012
At the time, it hadn't sunken in yet how much our solitary lives were changing. The nurses swept the baby away for routine testing and measuring. I settled into the chair and reclined for a few minutes before the the first signs of morning.
I didn't wake up for hours. Overwhelmed and exhausted, my body stumbled into deep sleep. My dreams were vivid and startling. And they brought back memories locked away and guarded with a key.
Any student rotating through the obstetrics department can tell you the stories. Every academic center has them. At my hospital, it was the cardiothoracic surgeon whose wife was delivering her third child and had an amniotic embolism. My attending shook as he told me how he heard the screams for help coming from the delivery room.
When you hear a guy like that, an experienced surgeon who has seen just about everything, yell with panic in his voice...
The attending stopped and looked up as if trying to question the Divine himself. After a long pause, he turned his attention back to me and changed the subject. I later found out that the poor woman was rushed to the operating room and her chest was cracked. It was futile.
I couldn't shake the image of an unfazable surgeon walking into his home alone with a new baby to face his other two children.
During my pediatrics rotation, as a student, I held a little girl in my arms in much the same way as I would eventually hold my own child. She was a few months old when her father brought her into the pediatrics clinic. He stared at the ground lifelessly as I examined his daughter. Occasionally he would grunt in response to my questions.
The first thing I noticed was that unlike most of the Hispanic baby girls brought into the clinic, her ears were unpierced. I unsuccessfully tried to question, but my pigeon Spanish failed me. I wondered why her father came to the clinic alone.
As I flipped through the chart the answers became clear.
The mother died during childbirth.
Last week, my wife was out of town and left me alone with the children. Every morning, I would wake up early before the kids started to stir in their beds.
Later, I sat with my four year old daughter and stared blankly at a closet full of clothes. We both looked at each other and started to giggle. I agonized over finding a suitable outfit. When we were done, I stood in front of the mirror with her small brush and hair clips.
After multiple failed attempts, I reached into the drawer and pulled out a head band. My daughter guided my hands as we affixed it properly. She looked appraisingly at my reflection in the mirror and spoke softly.
A good thing we have mommy!
If only she knew how simple hair and clothes are compared to everything else.
Yes. Good thing we have mommy.
Posted by Jordan Grumet at 5:09 PM
Friday, January 13, 2012
A: Ya, I get that alot!
Q: Um...OK. Moving on. I notice that you write a new blog post on most days. How are you so prolific?
A: I have been writing my whole life. As a child I was greatly impacted by the death of my father, and growing up with a learning disability. Living through these experiences made me think deeply about my surroundings. I learned to search for the profound in every day life.
I categorized my thoughts, one by one, in the recesses of my brain. The actually placing pen to paper (hand to keyboard if you will) only occurred later as I developed the requisite vocabulary to do justice to my observations.
I try not to think too much about my blog posts, otherwise I may stifle the creativity that bubbles up.
Q: Taken as a whole, what is your blog about? What are the major themes?
A: If you asked me this question a few years ago, I would have said that my blog is a love letter to my patients. As I grow wiser, I realize that it is more accurately a love letter to my father.
When my father (a prominent oncologist) died, I was seven years old. As silly as it sounds, I spent a great deal of my childhood and young adult years trying to forgive myself for his death. Even though I knew I wasn't responsible for his aneurysm, I struggled with issues of being worthy of love.
As I read my own writing, I'm struck by the parallels. I fight to be protect my patients and lead them through the dying process, much in the way I wish I could have done for my father.
Q: I have noticed that you can be a harsh critic of yourself as well as other health care providers.
A: As with any love letter, My words are filled with angst, self deprecation, and remorse. I pine for the unrecoverable loss. My father is never coming back.
When I'm critical of other physicians, I am also criticizing myself and the foibles of our profession.
Q: So if this blog centers around personal issues and your father, why make it public? Why Facebook and Twitter?
I think there's value in the conversation. Although my inner creative process may stem from personal issues, the themes of my writing have broader applicability. Through my blog I attempt to record the epic battle fought by physicians between maintaining their humanity and protecting themselves from the atrocities of everyday practice.
We are both flawed and scared, as well as brilliant and steadfast. Physicians bleed when they are cut, just like everybody else.
If we don't let the public know who we are, how will we ever move toward equality and intimacy?
Q: So your saying that the doctor-patient relationship needs to be a two way street.
A: Exactly, I couldn't have said it better myself. As health care reform progresses, there will be a power struggle as resources become scarce. The sooner we open the door to our patients, the better we will survive the tumultuous future.
We need to build a partnership based on trust and common understanding.
Q: Any last thoughts before we end this interview?
A: No, other then to say that I enjoyed this conversation immensely. You really are superb!
Q: Thank You.
Posted by Jordan Grumet at 1:16 PM
Thursday, January 12, 2012
The nurses were dispersed in groups of two huddling around computers and signing out to each other. The ancient ritual of the changing of shift had modernized by technological necessity. Quiet voices recounted patient histories and recent lab tests. Occasionally my ears would perk up when a nurse placed special emphasis and her voice catapulted above the hum of the crowd.
A middle aged woman stood with her back to me with tattered blue scrubs and a stance of authority. She spoke melodically with occasional stops and starts. The young woman receiving her soliloquy was petite and outfitted in pink. Her scrubs were freshly pressed and free of biologic spatter or remnants of a hastily eaten meal.
I couldn't help but listen to the conversation as blue scrubs spoke.
Mr. Slip presented to his local pharmacy clinic with chest pain and shortness of breath.
I almost fell out of my chair. Who in their right mind would go to a "quickie" clinic with such complaints? I imagined the chaos as an ambulance pulled up to the local pharmacy. I craned my head to listen closely as blue scrubs continued.
An EKG was done at the clinic and was noted to be abnormal. So the patient was directed to the ER.
Again I was incredulous. They do EKG's at these places? Are they capable of interpreting them? I imagined a sign in bright colors with a beautiful, young, athletic woman smiling back at me.
We now do EKG's. Get one today at your yearly physical in the pharmacy department. By the way, did we mention we sell aspirin?
Pink scrubs looked as confused as I. Although she didn't interrupt her senior partner, her lips pursed and she flipped curls of hair out of her face in mock frustration. Blue scrubs was not finished:
After returning home to walk the dog, the patient arrived in the ER and was found to have S-T elevations in leads II, III, AVF. His blood pressure on admission was 80/50.
She went on to describe the rest of the sordid hospital stay. By the time I finished my own charting, my head was swimming. How did we get to this place?
It's like I always tell my patients:
If you have a medical problem that will go away on it's own without intervention, go to a pharmacy clinic.
For just about everything else,
Posted by Jordan Grumet at 7:40 AM
Tuesday, January 10, 2012
The leader was an elderly gentleman with a thick creole accent. He learned the Voodoo art during his first assignment at Charity hospital in New Orleans. Since then, he had taught thousands of custodial assistants the refined art of patient healing. His eyes became large and hands moved in an animated sweeping motion as he described to the group the ancient technique.
For centuries, doctors and nurses felt that the surgeries and medicines they provided were curing their patients, but the truth was an underground group of custodial healers was actually saving the day. They would sneak into the room and perform their sweeping rituals before it was too late.
At this point the old man grabbed his broom tightly and looked out at the crowd.
Why do you think so many people die in the ICU? It's because we have limited access.
He then placed his broom on the floor and demonstrated the ten cardinal techniques and their appropriate application. Leandro scribbled on a scrap of progress note paper as the demonstration continued. The presentation ended with the circular method. This method, only for the most dyer situations, began with a twisting motion in the middle of the room, and worked its way out to the far corners.
Although Leandro was skeptical, he honed his skills late at night in dark hallways of the hospital where patients slept soundly or were to ill to notice the lowly janitor cleaning their room. With time and practice, his skills improved.
And low and behold, the majority of the patients got better. They awoke from comas. They withstood chemotherapy. They conquered pneumonia.
Six months later, Leandro had perfected his technique. Each morning he would round on his recently treated patients before signing out of the night shift and going home to his family. He felt invigorated and connected. The patients and doctors may not know about the important service he was delivering, but he could live with that.
At the end of his shift, he tucked his trusty broom under his coat and left the hospital. He couldn't leave such a valuable and powerful tool sitting around for just anyone to use!
Upon arriving home one morning, Leandro found his wife cowering in bed. She had been vomiting and having diarrhea all night, and the baby was at his mother in laws. When Leandro looked down at his ailing wife, his clinical skills took over. Her face was pale and her skin was dry. He put his hand on her head and felt her temperature. She was hot! His intuition told him something was very wrong.
Leandro panicked. Even after all he had seen in the last six months, he packed her into the car and brought her to the doctor. When they arrived, they sat in the waiting room for what seemed like hours.
Eventually they were ushered back to the examining room. The doctor walked in and without introducing himself, began asking questions. He sat with his head buried in a lap top computer and his eyes never left the screen.
After a hasty examination, the doctor declared that his wife had a viral gastroenteritis that would resolve over the next few days. Leandro couldn't believe his ears. He started to explain that his wife had never gotten sick like this before.
The doctor looked at Leandro, and then up at the clock above his head. He was already an hour behind and had to return to the hospital to do rounds. He could either take the time to explain to the agitated man and his wife, or he could give them a prescription to placate them.
Leandro took the prescription to the pharmacy and ushered his wife back home to bed. He gave her the first dose, and then waited till she fell asleep. When the room was absolutely quiet, he snuck into the closet and pulled out his trusty broom.
He knew that this was a situation which called for the circular technique. As his wife snored in the background, Leandro performed the centuries old ritual. He stopped when he had successfully cleared each corner of the room.
Five hours later his wife awoke refreshed and feeling healthy again. Although she praised the doctor and antibiotic, Leandro knew what was really responsible for his wife's miraculous recovery.
After all, both Leandro and the doctor had their own form of medical Voodoo.
But at the end of the day, Leandro's method had one major advantage over the physicians.
At least the floor got cleaned.
Posted by Jordan Grumet at 5:08 AM
Monday, January 9, 2012
I sat comfortably at the desk and opened my computer in preparation to start the physical. Leslie swayed back and forth in her chair slowly, and I sensed that something was bothering her.
Because she was a new patient, we chatted about her current health and past medical problems. I asked gentle probing questions to tease out the source of her discomfort. Although I had finished all the requisite social and family history, I still found myself searching
I opened the cabinet above the desk and pulled out a gown in preparation for the physical exam. At the sight of the white flimsy covering, Leslie's face became a bright shade of pink, and she turned in embarrassment. I was surprised by this kind of reaction from such a strong, confident appearing woman.
Is something wrong?
Leslie turn to face me again, and paused as she mentally rehearsed the next sentence.
You see Dr Grumet...I thought you were a woman....and I didn't shave my...
Her words trailed off as we both started to laugh. I offered her an appointment with my female partner, but instead she decided to return and finish the exam the next week when she was better prepared for the visit.
I sat in my office and giggled as I looked out the window and watched Leslie gracefully lower herself into the driver seat of her car.
And then I remembered something.
The morning rhythm of the ICU greeted my ears as I walked through the doors. The sound of shuffling feet, blowing ventilators, and beeping machines formed a raucous chorus. I stopped at the computer bank and looked at my patients labs and vitals.
She was much to young to be in this setting. Her twenty five year old body was stronger and more resilient then the average ICU patient. But the effects of chemo had taken their tole. Her immune system damaged and short handed, couldn't fight off the bacteria that plunged into her respiratory system.
Things were looking up. The chemo had finished. The ventilator was removed and life was beginning again. A bed was ready in the step down unit and hopefully she would go home soon. We chatted for a few moments before I started my examination. The lungs were clear; the heart was normal.
As I went to examine the legs for edema, my patient threw back her covers to reveal newly manicured toes with a bold shade of red polish. I looked up to the head of the bed to see her smiling.
She had been waiting all morning to spring this on me.
It becomes very easy in medicine to shun vanity. We looked past the dirty, unkempt, disease ridden bodies of our patients as a matter of course. We somehow picture ourselves too much above the fray to stoop to such banality.
But one thing I've learned from my patients is that dignity transcends sickness and health. That caught in the middle of a health care system that focuses on depersonalization, it takes courage to maintain ownership.
These women were trying to remind me that they are not just patients.
They are people: flawed, vain, courageous, and awe inspiring.
Posted by Jordan Grumet at 5:32 AM
Saturday, January 7, 2012
He was a business guy. And it didn't take long to ascertain that he saw me as an asset. I was a widget; an interchangeable part. If one physician wasn't on board, find another. I imagined that somewhere in his slick briefcase there was a list with each physician's name and two columns. Check marks were neatly penciled in to demarcate the doctor's status. Pens were never used because they were not erasable.
The majority of the conversation was like a Peanuts cartoon where most of the words sounded like distorted rubbish. Occasionally my ears would perk up as a phrase caught my attention.
Blah blah blah, blah blah ACO blah blah blah ICD-10. Blah blah blah blah healthcare reform blah blah ACA.
When are we going to stop talking of Armageddon? We treat private practice as the red headed step child, and not the predominant mode of physician organization. We huddle in the corner of dark alleys and wait for the boogey man that never comes.
And we jump ship the minute the going gets tough, and become employed physicians. It's what happened in the era of HMO's and it's whats happening now. The scramble to escape the unknown becomes more important then thinking about self interest.
We try to forget that we are staunchly independent professionals who don't like being told what to do. Certainly we can submerge our needs for a time, but eventually our true nature bursts forward. And when it does, we break through the chains of employed existence and venture out on our own.
It has happened in the past, and it will happen again
I have worked for hospital owned medical practices. They stand on the backs of their laboring assets. Physician sweat leads to profits that exsanguinate through administrative fluff and overblown salaries. Economies of scale give way to inconsistency and bloat.
The government is sadly mistaken if it thinks that ACA will lead to a tenable solution by placing the power and money in the hands of greedy hospital systems loaded with administrators and oozing with self interest.
You want to see who's running the tightest ship in the business? Find the little guy; the few physician practice that lives or dies by its own ingenuity. There are no unnecessary administrators, no burdensome policies, no political flotsam.
The consultants say that the ACA will end private practice. They say that ICD-10 and the new regulations will make small practice untenable.
I say let's look at history.
The reports of our demise are frequent and uncompromising.
They're also greatly exaggerated.
Posted by Jordan Grumet at 9:03 PM
Friday, January 6, 2012
I hope you sleep well tonight knowing that you tortured this poor lady in her last moments before death.
I could hear the sounds of CPR in the background as the nurse paused to digest what I said. I imagined strong arms pushing against the cracked ribs of a frail, demented, elderly woman whose quality of life had been minimal for the last few years. Even though I spent months trying to convince the family, they had only agreed to the Do Not Resuscitate order a few days prior. I dutifully placed the paperwork in the hospital chart, but apparently it meant nothing till the power of attorney signed the form.
Days later, as my patient was coding, it was noticed that the order had never been signed by the family. The nurse was unapologetic.
We've got liability issues doc. No order....No DNR!
I slammed the phone down in anger. I hoped the sting of my words would at least convince the code team to move in slow motion.
I grew up the youngest of three boys. I was shy and withdrawn. I spent a good deal of my youth afraid of my own shadow. I was soft and supple, pliant. By the time I reached medical school, it was safe to say that I had never raised my voice to anyone.
It is impossible to explain the deluge of medical education to someone that is unexposed. Students and residents learn to fight for scarce resources. In an attempt to advocate for patients, voices are often raised, threats are made.
I learned quickly that in order to protect those under my care, I either had to become a master of confrontation or get trampled. For the first time, I used cruelty and anger to force the unwilling hand.
And it worked: the X-ray tech would schedule the MRI early, the specialist would leave a full clinic to meet me at the bedside. The more voracious my attitude, the more I could accomplish.
A few minutes later my thoughts were interrupted by the jolly ringtone of my cell phone. It was the nurse again. The code was over. I took a deep breath and began to apologize for my inexcusable behavior. She interrupted me.
It's okay Doc! If it was me on that table, I would've wanted someone like you as my doctor!
I thanked her for being gracious.
I hung up the phone.
And then I wept.
It's only now that I realize that the anger of training wasn't about advocacy or about getting the job done.
It was about grief.
We fought so many unwinable battles that we grasped at any form of control that was available to us. We may not be able to cure the disease, but we certainly could get our patient to the front of the line.
We yelled, we threw things, we were cunning and underhanded because that was better then crying.
Ten years out of training, I realize that I've seen enough suffering for a lifetime.
And it has changed me.
Often in ways that I'm not proud of.
Posted by Jordan Grumet at 1:01 PM
Thursday, January 5, 2012
We talked a few moments before I tackled the supplement issue. I could picture a cigarette dangling from his brown stained fingers. His belly protruded over his waist and struggled to conform to his undersized pants.
He was working too hard, eating poorly, and spending little time with his family. He felt too nervous to quite smoking, but too lethargic to stop imbibing energy drinks. His business teetered from complete destruction to overwhelming success on any given day
Doc...why do I feel so bad?
Again he glanced over at the pill containers sitting on the table. While I knew the answer, I could tell that I wouldn't make much headway till I addressed the passion of his wandering eye. I reached over to the counter.
So what do we have here?
I mentally read through the list while I tapped away at my computer: Ginseng, vitamin E, Vitamin D, Vitamin C, Multivitamin, folic acid, St Johns's wart, fish oil, aspirin, and chondroitin. It was a myriad off supplements costing hundreds of dollars a month.
I picked up each bottle as I explained why it was inappropriate. Vitamin E had never shown to be beneficial for almost anything. Vitamin D was unnecessary in a person who had healthy bones and was not deficient. Folic acid could be harmful. Aspirin was ridiculous in a thirty year old with no heart history regardless of some risk factors. He stared at me impatiently as I droned on about one pill after another. Eventually he interrupted before I could spit out the last words of my prolonged run on sentence.
But if I stop those, what are you going to give me to take their place?
I paused. I could either go with the hard sell or the soft sell. I wondered which would work.
You want to feel better?
Stop all pills.
Quit smoking and energy drinks.
Exercise, lose weight, and sleep better.
Spend more time with your family.
His head slumped down towards the ground and for the first time during the visit, his legs stop shaking. He looked up and our eyes met. For a brief moment, I thought that I connected. But then he opened his mouth.
Isn't there some pill I can take instead?
Posted by Jordan Grumet at 7:47 AM
Wednesday, January 4, 2012
I studied my own face. Had it been a full decade? My features were softer, my hair thicker. I glowed with an innocence that has long since faded. As I contemplated my growth as a physician, I struggled to remember her name. My face burned with embarrassment and then settled with a heavy sense of guilt.
So much had been gained over the last couple of years, and so much lost.
I have watched hundreds of patients die. I start each journey with a full emotional tank of gas. But as time passes, complications arise, and fuel is consumed at an ever rapid pace. As we reach the finish line, I often feel like I'm existing on fumes.
And when the death certificate is signed, and condolences are given to the family, I run on empty. Of course the tank refills with each and every new patient that walks through the door. But the truth is, my endurance is limited to one fill per customer.
So as time goes by, I often forget details. Names and diagnosis slip through my clenched hands like sands in the hour glass. But themes remain. Love, fear, rapture, joy, and connectedness permeate my soul and affect the person that I have become.
When I look at the decade old picture, I realize that my patient was giving me one last gift before she died. As the memories flood back the details become more concrete.
I may not remember her name, but I can tell her story.
I can tell their stories.
Posted by Jordan Grumet at 5:59 AM
Monday, January 2, 2012
The officer moved at a glacial pace. I imagined him tapping away at his computer similar to how a physician does as he enters a patients room. The flashing lights reflected in my rear view, blinding me. My feet shook nervously as I waited.
It was a hell of a welcome back from vacation. The night before my partner called to tell me that Mrs. Silver was in the ICU. As I listened to his report, I couldn't help but feel guilty.
Mrs. Silver was a charming eighty five year old with her share of chronic medical conditions. For some reason, I doted over her like she was my long lost grandmother. There was something about her essence that brightened my spirit every time she entered the exam room. She was like a whirlwind. Before she left each appointment, she had my nurses and medical assistants pealing with laughter.
The day I left for vacation, Mrs. Silver was admitted to the hospital for pneumonia. My partner examined her and started antibiotics. Although she originally began to improve, she suddenly developed chest pain and severe shortness of breath. She was placed on a ventilator and her cat scan revealed a large pulmonary embolus.
Days later she was dying. Her blood pressure was dropping and her kidneys were failing. The family had gathered at the bedside and were waiting for me to arrive to turn off the the ventilator.
After the dismal report from my partner the night before, I barley slept. I sprinted out of bed five minutes before the alarm went off and hurried through my morning routine. Although I couldn't verbalize why I was in such a hurry, I knew I needed to see Mrs. Silver one last time before she died.
The officer eventually strode out of his car and walked up to my door. I rolled down the window and started to speak, but he interrupted me.
Are you OK?
It is only years later that I realize that my face must have been a pale shade of gray. My eyes were bulging and the sweat was starting to form on my forehead. Afraid, confused, and worried, I said the first thing that came to mind.
My favorite patient is dying!
His stared at me intently and then his gaze turned to the passenger seat where my lab coat rested comfortably. His voice was steady and commanding.
As he walked back to his cruiser, I put the car in gear and pressed down cautiously on the gas petal.
It wasn't the first time a police officer would show me a simple act of kindness,and it wouldn't be the last.
I arrived in the Intensive Care Unit minutes later.
Mrs. Silver passed quietly.
Posted by Jordan Grumet at 6:06 PM
Sunday, January 1, 2012
Afterwards, looking into mirror the reflection was anything but transformed; older, but not measurably more wise.
I have seen the question in your eyes as you stare blankly at the pathology report held inches from your face. You read the word "leukemia", but shock rearranges the letters as if you are at home playing a game of Scrabble with your youngest son. Your wife holds your other hand, and you both sit silently. You haven't yet begun to process the difficult and possibly fruitless battle that lies ahead.
Until now, denial had been your shameful bedfellow. It whispered in your ear countless times like a forgotten lover.
Just wait. The shortness of breath is only allergies. It will pass.
Your friends noted how the pallor of your face changed. Your wife fretted over gasping breaths when you walked up a few stairs to the bedroom.
I have listened to your voice beckon and coax during the silence. Your husband smiles as he sits next to you, oblivious. He laughs one minute and cries the next. His memory is like an annoying fly that buzzes back and forth, but always is barely out of reach.
Your partner has become an innocent. You lead him back and forth about the house as if he is one of the children of your children. Moments and details are lost and replaced with sinister plots.
Someone has been in the bedroom and stolen my glasses!
He sits in a haze of plaques and tangles. He inhabits a world in which you no longer belong. You fill the same space, but he is not your companion.
I have interpreted the rise and fall of your syllables as your look longingly toward your son. The beast of mania, swollen and bloated, becomes as sad as the depression. His twenty five year old body is strong and agile, but guided by a brain that is no longer nimble.
You heave on the bile of his physical vitality as it mocks you. You survived the fear and uncertainty of childhood to land here. You talk of your friends, the empty nesters, and how they complain about free time and unused bedrooms.
You long to have space that is yours alone.
And as I look back at my four year old daughter who has fallen asleep on the way home from the airport with her hand intertwined with my seven year old son's, I can't help but choke on the irony. How can the world hold such sweet and passionate hope alongside the desperate, crushing pain.
As a physician, I thought I would have developed answers to such riddles. But as I grow older, I realize that my training has been more about answering "how". Such banal descriptions of cells and physiology rarely satiate the hungry. The answers to the fundamentally pressing questions are left to philosophers and clergy.
So you'll have to forgive me. When I thought I was learning secrets, I couldn't have been more wrong.
And besides my empathy, I have little else to ease your suffereing.
I don't know why.
Posted by Jordan Grumet at 12:51 PM