Much Ado About Nothing

It was that time of the month again and Mrs. S hobbled feebly into my office. She was 95 years old and we had been through alot together: three hospitalizations, a heart attack, congestive heart failure, atrial fibrilation, spinal stenosis, and pneumonia. Yet, she looked remarkably good for her 95 years. She lived alone in a three story house and somehow managed. Her husband died over 30 years ago and she had no children or other living family. She was alone.

While Mrs. S fought a brave fight, she now was being challenged by a disease that I knew I couldn’t fix. She was going blind. As her vision worsened, her ability to take care of herself faltered. We had long talks about this. It troubled me, as a physician, because I knew there was no recourse. She had gone to 6 different ophthalmologists in the last 6 months and all said the same thing.

I reviewed my notes on Mrs. S. My assessment and plan looked something like this:
1)cad/chf: stable on current lasix dose, chest pain free
2)atrial fibrillation: INR stable, re check in one month
3)spinal stenosis: stable
4)visual loss: follow up with ophthalmology

I was tortured by how little I could do for her. As I said goodbye, I suggested that she didn't need to return for 3 months, her medical issues were stable. She gave a weak smile.

How about next month?

*

As a new medical student I experienced my first care giver relationship. I volunteered for hospice and was given the name of an elderly gentleman dying of prostate cancer. His condo was close to mine, and I would walk over once a week to spend time with him. I did little things like cleaned around the house or occasionally wound run to the grocery store. Often, we would pass the hours just talking.

I call this my first care giver experience although many would argue that I wasn’t really delivering any medical care. I, in fact believe, that it is the exact opposite. As a first year medical student, I didn’t know much about medicine. It was before my mind was clouded by diagnosis and symptoms, drugs and pathophysiology. My lack of medical knowledge allowed me to get to the core of what this gentleman needed: An attentive listener, someone to say they were sorry for his condition, someone to be there.

As I moved along in my medical education I forgot the art of “just being there”. As a resident and young attending, I was always too busy making diagnosis, prescribing medications, and planning the next step. But every now and then I would get caught in a situation where I no longer had anything left to do. Where all the appropriate actions had been taken and yet the patient still wasn’t getting better. These situations used to bother me. As I get older they do so much less.

As with my hospice patient I knew there was very little I could do for Mrs. S. She would eventually lose her sight completely. But I started to go back to my premedical way of thinking and take a more optimistic look. I could continue to be there for Mrs. S. I could hold her hand and say I'm sorry that she is going through this. I could keep my door open and let her know that no matter what happens, I would support her. I would be in her corner if she needed a hand.
I know, sounds like alot of nothing. But sometimes “doing nothing” is some of the best medical care I give!

Moving Violations

For years I have driven the same path every morning. I mastered the twists and turns, ups and downs, long ago. Occasionally, as the sun rises, I hallucinate that the roads have become like a patient. The gravel echos in the harshness of a straining voice. The squealing tires mimic the high pitched wheeze of distant lung sounds. The billowing smoke stacks in my rear view mirror recall the pack of cigarettes carefully placed in the breast pocket of a barrel chest.

This morning as I drove down the lonely expressway, I noticed a blue SUV approaching rapidly. With panic, I realized that less then a mile away was a speed trap where a police car often waited to snare unsuspecting victims at a bend in the road. I quickly pulled into the left lane to cut off the oncoming SUV. I felt a sense of camraderie and wanted to protect this complete stranger. I was hoping I could slow him down just enough to avoid the inevitable.

The SUV charged forward within a car length, and then flashed his turn signal. Anticipating the move, I cautiously veered between both lanes knowing that the bend was coming. Unfortunately the SUV pulled around me and sped away.

Moments later, a flash of lights and sirens confirmed that my attempts had been unsuccessful. I continued down the road and took the next exit to my office.

*

The oncologists voice seemed so far away over the telephone line.

I saw your patient today. The cat scan showed that despite chemotherapy the lung cancer has progressed.

I winced and stared down at the ground. I absentmindedly kicked at the side of the desk as I tried to concentrate on the computer screen and listen to the phone at the same time. I felt powerless. My voice, barely above a whisper, came out unsteadily.

So what can we do for him now?

The oncologist paused.

Hospice. That is, unless you can go back thirty years ago and stop him from smoking in the first place.

*

Sometimes I see a moving violation before it happens. Yet often I am helpless nonetheless.

I recall countless conversations about quitting.

But when you get to a certain point, inevitability sets in.

You can no longer undo whats already been done.

Society's Debt

When he was a child, Darren once accompanied his father to a patients home. He sat on a rickety chair in the corner and watched as his dad administered to an elderly woman buried in a mound of blankets. His father's stethoscope disappeared into the amorphous pulsating mass, his eyes averted as he squinted to listen. He spoke a few quiet words, and left a bottle of pills on the night stand. Upon entering the foyer, a young woman rushed forward with a loaf of freshly baked bread and a cherry pie wrapped in tin foil. Although they returned home with empty pockets, they ate well that night.

The summer after his second year of high school, Darren volunteered at the local hospital. He delivered newspapers and flowers to each room. Occasionally he stared out the corridor windows and watched his friends playing football on the adjacent field.

In his first year of medical school, Darren stood in a crowded room with hundreds of physicians and students. His white coat was overstartched and slightly to large for his shoulders. The name of his medical school was emblazoned on the chest in neat cursive writing. He recited the Oath Of Geneva with the rest of his colleagues and pledged to consecrate his life to the service of humanity.

During residency, Darren sacrificed sleep as well as his youth to an apprenticeship forged in minimal wages. During electives he accompanied the younger attendings to a clinic for the under served. Payment was considered a smile, handshake, or a pat on the back.

And when Darren opened his new clinic, he refused to turn away those who couldn't afford his care. His schedule usually had space, and his medicine cabinet was continuously stocked. Even when overhead costs skyrocketed and medicaid payments were months late, Darren stood by his principles.

So when the bank called one morning looking for payment, and the landlord could no longer wait for overdue rent, Darren figured he deserved some leniency.

A month later, without office space and mired in bankruptcy, he realized that most people weren't like him.

And most professionals don't bother to take such lofty oaths.

Jordan Grumet On Fame

In our continuing interview series, I discuss with infamous blogger Jordan Grumet the pitfalls of fame.

Me: Jordan, parking on your street was rough and I noticed a number of people milling about with cameras. What gives? Paparazzi?

JG: The girl next door is having her fourth birthday party. She's quite popular!

Me: all joking aside, you recently were interviewed for MDigitalLife and were mentioned in a Medpage article. How did you feel about that?

JG: I was honored to have my work noticed. Greg (Matthews) and Kristina (Fiore) did a wonderful job and helped get my message to a broader audience.

I sit down to write because I have a burning need to express myself, to get something off my chest. It is only later that I realize that others will read and digest what I have said. Each new comment on the blog surprises me.

Me: Speaking of comments, what affect has the reaction to your blog had on your writing process?

JG: I remember my first comment on IMHO (In My Humble Opinion). At first I was baffled by the text.

Get Viagra Cheap!

Yet post after post, Viagra has been one of my most consistant responders. I hope to meet him/her one day.

Me: I noticed that you have a stat counter. Do you check your numbers regularly?

JG:I used to get carried away and check every few minutes or so. Now I'm much better. I only look at that thing 10-20 times per day! I have to say that it's quite thrilling to see the numbers go up. In fact some guy named Googlebot checks my site at least 3-4 times per day. Where ever you are Googlebot-thanks for reading!

Me: Have you ever been recognized in public?

JG: No!

Me: Get asked for an autograph?

JG: No.

Me: What audiences do you think you need to reach out to?

JG: I have a fairly poor readership among non Internet users, and children to young to read.

Me: What was the last email you got about your blog.

JG: My mom wrote to tell me she liked my last post.

Me: What about the one before that.

JG: The same.

Me: Well, I want to thank you for taking the time to talk to us.

JG: Of course. Would you like a signed photograph.

Me: Um...er...I think I already have one.

Losing Battles

Would I not thrash against the rails of the hospital bed?

An uncovered leg protruding below the disheveled sheets is brazenly exposed by a skimpy gown. Arms are blackened and bruised from losing battles with phlebotomists and IV lines.

Eyes squint as faceless bodies in gray fabric roughly flip on light switches at varying hours of the night. The pressure rises as blood vessels are squeezed tightly and released. A thermometer is momentarily inserted and then removed.

Medicines are delivered in tiny paper cups and thrust forward with minimal explanation and large glasses of water. Family members gather by the door, in the waiting room, and outside the lobby. Doctors hurry in hoping the chairs surrounding the bed will be empty.

Days are measured in seconds. A tireless parade of anonymous drones poking, prodding, reporting, and then disappearing. A patient lies flat waiting for an infusion to finish, a fever to decline, or a laboratory value to normalize.

The tears of a child re frame the question and squelch the quips of futility oozing from the doctors lips.

And every time, I leave your room, the same questions echo through my head.

Would I listen to me?

If I was in your shoes?

Resistance is Futile?

It's not that I don't like the idea of it. I envision roaming tribes of doctors scattered amongst hospital floors rounding on patients. Everyone is polite, all opinions are counted, and decisions are made by consensus. Medical care is exact and parsimonious. The economy is saved and we all live happily ever after. Why not?

Group think has already solved all our problems. Look at congress! We don't need a conductor to lead the orchestra-we need a bunch of conductors. Why have a commander in chief when you can have a think tank instead? In fact, haven't most of the great inventions and discoveries throughout history come from the collective? Let me think: the light bulb, the telephone, penicillin. And haven't the great artistic and musical accomplishments of the last few centuries been produced by groups and not individuals?

So the next time my pager wakes me up in the middle of the night to report on my chf'er becoming hypotensive, I'll conference in the cardiologist, intensivist, and nephrologist and we'll make a decision. Although, most likely I will be the only one on the phone who actually knows the patient. I'll probably get some hodge podge of call coverage with bleary eyed specialists.

No. In reality, the road to expertism is a lonely one. Each individuals pathway to mastery is unique. We all develop our own off centered approach to that which we are good at. This is what separates the brilliant from mediocre. Attempts to sublimate such instincts to the group can only lead to bland homogenization.

The policy wonks have lost themselves in an orgy of false hope. Joining the Borg is not the answer. Collaboration is important, but won't solve all our problems.

Sometimes, the orchestra just needs a conductor.

The Doctor-Patient Relationship Can Be Difficult

I walked down the hospital corridor listlessly. My feet dragged as they fought each attempt to lift off the ground. My body was tired and achy. The phone calls the night before had been relentless. Each stolen moment of sleep was interrupted before a deep, restful state was reached. It was Monday morning.

I sat at the nursing station flipping through charts. A colleague across the table was staring intently at his computer screen. He previously had been a private practitioner like myself, but he shuttered his practice to become a hospitalist. He glanced over at me appraisingly, taking in my disheveled hair and unshaven face.

Hard night?

I nodded in his direction, and looked up from the progress note I was struggling to complete. I wasn't making much headway.

So why did you leave your practice anyway?

A look of pity came over his face as he stared down at a coffee stain on my wrinkled gray lab coat.

I was tired!

He went on to explain that it was not physical but rather emotional fatigue that spurred his decision. He was tired of fighting with his patients.

*

As I exited the hospital and walked a few hundred feet to my building, I pondered my patient interactions over the the last week.

A healthy thirty five year old woman called my office daily for a benign upper respiratory tract infection. During each conversation she demanded an antibiotic, and each time I explained how it was inappropriate. I cited studies, explained the possible harm to herself as well as society, and gave a number of recommendations for alleviating symptoms. She responded by saying that all her friends doctors gave them antibiotics. Eventually she decided to leave my practice and find care elsewhere.

A hundred year old demented woman was placed in a nursing home after a devastating stroke which left her completely unconscious. Her previous doctor had dutifully ordered a feeding tube and transferred her to the nursing home for further care. Last week her kidneys began to fail, and her son demanded that we initiate hemodialysis. I invited the family to the nursing home and spent an hour discussing futile care and it's consequences. We talked about how hundred year olds don't tolerate dialysis well, and that her quality of life was already low. After becoming very emotional, the son stormed out of the room and accused me of trying to kill his mother.

A 60 year old woman with chronic back pain came to my office for a refill of a narcotic prescribed by her orthopaedist. I talked to her about the pain ad nauseum, and described how narcotics are not affective for long term control of musculoskeletal pain. I looked her up on the Illinois prescription monitor, and my eyes popped as I calculated that she received over 250 hydrocodone pills from three different doctors over the last week. When I refused to write another, she stormed out of the office and threatened to call the local medical board.

*

The doctor-patient relationship can be difficult. At it's best, it is a mutual, symbiotic connection between client and consultant. Sometimes, however, being a physician is like trying to parent two thousand teenagers. Although there is great affection on both sides of the examining table, the perspective is markedly different.

I admit that I can never know exactly what my patients are feeling, I haven't walked a day in their shoes. On the other hand, I have years of experience treating just the sort of complaints they come to my door seeking help with.

There are days when I fervently wish they would let me use this experience to help them.

And there are days when I wonder if I should have ever decided become a parent in the first place.

Reinterpreting Death

He looked across the shadowy haze, death's mirage a shimmer in the space that interceded between his sickly body and my outstretched hands.

How long do I have?

His words were expected but no less difficult. I took a deep breath and cradled my thoughts before leaning over to speak.

A few days.

His lips parted and attempted to rise above his teeth. He was trying to smile.

I wondered why.

*
The lung specialist thought decades. His capacity had diminished, but the pulmonary function tests were adequate. If he used his inhalers, he may need steroids from time to time, but he would live to breath another day.

The heart doctor said it could be years. The catheterization showed the blockages were nearly complete, but wouldn't kill him. The sharp pain radiating through his chest could be ignored. He just shouldn't exert himself. Better to take it easy.

The bug doctor had stopped visiting weeks ago. His last consultation noted that all infections had resolved.

And the oncologist refused to give numbers. He optimistically ordered the next round of chemo with assurances that experimental protocols had been promising. He wrote each order with a certain flourish.

*

A week later, I imagined him smirking as I watched the nurse pull the sheet over his head and prepare for the trip to the morgue. I heard his voice bounce through my mind as if his mouth was still capable of chuckling.

Only you, my own doctor, sold me short. I told you you I'd make it more then a few days.

I couldn't help but smiling as they wheeled him away. He had set out to prove me wrong.

And indeed, he had.

Consequences

There are days when you're not your best. Everybody has them. The editor misses a typo. The accountant forgets an extra deduction. No one expects perfection. We are human after all. Our bodies are wired to expertly sort through the morass of physical and emotional data and develop a game plan.

We do this all the time. The subtlety of human thought and judgement touch on such banalities as which shirt will go with which shoes, which turn will avoid the morning rush hour traffic.

So many thousands of crossroads heaped on the pile of our daily decision making process. And unlike computers, we are prone to lapses. The consequences are usually minor. One may suffer a fashion emergency or get scolded for sauntering into work a few minutes late. One may even lose their job.

No one looks forward to these events, but they are recoverable.

Sometimes there are periods of darkness. When the lapses seem to be less the exception and more the rule. The decision process leaves the realm of the unconscious and becomes a screaming adversary that pummels us at every turn.

As a physician, I face these times with great uncertainty. Because unlike the editor or the accountant, my decisions have life altering consequences. On the good days, I accept my own fallibility as an occupational hazard. I suspect the benefit of my efforts far out weigh the harms.

But the devil is often in the details. I sometimes choke, sputter, and gag on the noxious fumes that fill the office. Sometimes the diagnosis is wrong, the brain is addled, or the hand is clumsy.

It's at these times, I pray to follow the great dictum and "do no harm".

And I hunker down and brace myself to deal with the consequences,

come what may.

Don't Worry About Them, They're Stable

I stared at the computer screen blankly as I tried to remember what I was typing. The medical floor was humming with various rings, dings, and shufflings. A maintenance person was cleaning the floors with a mini Zamboni like contraption that made more noise then a mack truck. It was six o'clock in the morning.

As I tried to center myself, I realized that what was really causing my blood pressure to rise was a series of alarms coming from the telemetry bank in the corner of the nursing station. Apparently multiple patients hearts were not behaving as they should, and the mass of wires and circuits was sputtering repeatedly for attention.

I watched as nurses and techs walked to and fro without paying an ounce of attention to the alarms. At one point, I stopped a nurse to see if she could turn the volume down.

No, we can't do that.

When I asked if anyone was attending to the patients with the concerning heart rhythms, I got an equally unsatisfying answer.

Oh, don't worry about them, they're stable.

My blood was starting to boil.

So why in God's name do we have alarms notifying us of stable conditions?

She shrugged her shoulders and moved on.

*

Health care is suffering from a complete failure of signal processing and differentiation. Overwhelmed by a morass of competing alarms, buzzers, and notifications, medical workers are unable to separate forest from trees, tress from branches, and branches from leaves.

Physicians have especially learned how to modify their work flow. We ignore the warnings that pop up every time we type in our emr. We click through the reminders that accompany each patient chart. We sign thousands of papers a day with only giving the most superficial glance at what we are putting our name on. We skim through each others note's trying to wade through the gelatinous mess and extirpate the crucial sentence or two.

And where does the fault lie for such bloated systems? We have become slaves to our government, slaves to regulation, and slaves to the technology folk who created our systems but have no idea the effect of information overload.

When alarms, notifications, and paperwork become so abundant, they lose the ability to inform us appropriately.

Let me say this again. More is not always better. We have lost our way in medicine.

We have no idea how to communicate that which is most important.

House Of Cards

Very few people knew that Jed had studied architecture before medical school. They also didn't realize that his trip to Europe after residency was less leisure and more scouting structural gems in various locales.

No, Jed was known as a brilliant general surgeon. And he was OK with that. But sometimes his curiosity and prior education got the best of him.

One morning, while rushing to get to the office after rounding on post op patients, Jed huddled in the corner on 4S to tie his shoe. He balanced his weight on one knee, while he reached out for the laces dangling from the other extremity. To his great surprise, before his grasp was successful, he clumsily fell forward and landed on outstretched hands. As he moved to the corner and braced against the wall, he completed the task absentmindedly. His brain was lost in thought.

He knew he had superb balance. He rarely fell in even the most treacherous situations. By the time he finished, he was convinced that the floor was not level. He rose and ducked into a supply closet where he looked for a round object. He quickly settled on a tiger top blood tube and made his way back to the hallway.

After looking to make sure both directions were clear, he placed the tube on the ground and pushed it due west. It meandered down the large hallway for a few moments and then slowly veered south. Jed followed it into the corner and was surprised to find that at the intersection of the very south and west walls of the building, a collection of round objects had formed.

There were tubes, marbles, and a series of coins. Someone had even apparently lost a tennis ball. Jed was now convinced that there was a material defect in the building. He stared up at the ceiling and then back at the floor. Within moments, his pager buzzed and he glanced down at his watch. The mystery would have to wait till the end of clinic.

*

Over the next few days, Jed conveniently found reasons to be on each of the hospital's eight floors. He was not surprised to find that every time, a pile of odds and ends had collected in the building's southwest corner. He envisioned an imperfection in the bracing or support. Something had to be done.

Jed decided to call the engineering department and discuss his concerns with the hospital staff. After a number of transfers and accidental hang ups, he eventually was able to reach the head of the department. As he accompanied the gentleman to the southwest corner of the building on the second floor, he explained what he had found.

The structural engineer seemed unfazed. He cleared the debris from the corner with his right leg as he looked at the wall.

It's just settling son, nothing to worry about.

Jed could see that he wasn't going to get anywhere with the man, so he thanked him and returned to the work of being a surgeon. But as the hours passed, he again felt a nagging sense of impending doom.

Jed's last option was to call the head of surgery and plead the case to his boss. Unfortunately, the conversation ended with a promise to bring it up again with the engineering department. Jed doubted very much that that would really happen.

*

Days turned into weeks, yet Jed couldn't stop the unnerving, demanding thoughts that ran through his mind. The building was insecure and needed to be corrected. The lives of countless patients and staff depended on it.

One night after waking up in a cold sweat, Jed decided he had enough. He threw on a pair of scrubs and drove to the hospital. At three in the morning, the halls were quiet, and he had no problem slipping undetected into the maintenance elevator.

He pushed the button marked SB for sub basement and waited till the doors opened. As he exited, he was cautious to avoid being seen. It only took a few moments to find the southwest edge of the building.

Upon turning the corner, he was surprised to find a door that lead to a dirt covered room with a low ceiling. As he closed the door behind him, Jed realized that for all intents and purposes he was outside the building. Looking up, he calculated that he must be standing directly under the front steps to the main entrance of the hospital. He could hear the occasional distant thumping of shoes overhead.

The room was roughly twenty feet by twenty feet, and it was barren except for hole jutting into the ground at the southern most edge. Jed stepped over to inspect and found a thin steel ladder plunging downward. He grabbed tightly and shook the metal structure before he climbed into the hole and started the descent into the earth.

Although he could barley see, he felt his way forward with his hands and feet. After what seemed like hundreds of steps, he finally came to the end of the ladder and his legs rested on flat ground. He grasped for the penlight clipped into the breast pocket of his scrubs.

By the faint illumination, he could see what lay at the bottom of the rabbit hole. The very southwest edge of the building was being propped up by something. He bent to look closer and blinked his eyes multiple times unconvinced of their accuracy. The mortar was balanced on top of two playing cards that were bridged together by a third. Jed squinted to see that the top card was facing up. The foundation came to a point and impaled the chest of a laughing joker as if amused by his own impotence.

Jed's head started to spin. A rush of memories and seemingly unrelated thoughts popped into his mind. Had not his medical school listed in a similar direction? Hadn't his clinic also felt slightly off balance?

As Jed began the long ascent back up the ladder, he felt queasy. It was not just the hospital but the whole kit and caboodle.

The whole healthcare system was built on a house of cards.

Wait

Wait.

No one had ever told her that such a great deal of parenthood would be waiting. Initially, there was the nine months in utero. Then, a never ending series of hoops to jump through: first full night of sleep, first steps, first day of kindergarten, etc. Although she couldn't quite put the sentiment into words at the time, she had a hunch that it wasn't the milestones themselves, but the time in between where life was lived.

She crossed her legs and shifted on the park bench where she waited for her youngest son to exit the school. Any moment his exuberant brown eyes would come rushing out the door in a sea of humanity like a mini running of the bulls.

She smiled briefly and then her mouth twisted into a frown. Last night he had talked about being a doctor again, just like his dad. She swallowed hard as she thought about his chances now that he was diagnosed with a learning disability.

It's not that he wasn't smart. The IQ testing had placed him in the appropriate quartile. But when school progressed to the point of learning how to read and write, it became clear something was wrong.

She had hired a series of tutors who were working with him closely, but progress was slow. She didn't have the heart to tell him that he likely would never become a physician. How could she crush his dreams at such a young age?

As he bravely sprinted across the school yard to her park bench, she decided that he was perfect the way he was. And only time would tell what he was meant to be. For now she would say nothing and love him the best she could.


*

Years later, that boy grew into a man and realized his dreams. Immersed in the problems of others, he married and had his own children. When his heart ached for his son, he began to understand the turmoil his mother must have felt.

He watched as life formed hurtles. Sometimes his son was lithe and agile; others slow and clumsy.

From time to time there were disappointments both great and small. He would pull those little boy hands and legs into his chest and wrap his arms around them protectively as hope fervently blasted through his soul.

And he would wait.

Social Media As An Amplifier

I'm not an early adopter. I certainly wouldn't call myself a tech geek. In fact, I'm usually the last one on the block to buy the new gadget. Email, mobile phones, and Facebook were basically forced on me. I'm chronically behind the times.

So when I read the words of many of those I admire at the forefront of the social media movement, I often struggle to keep pace. The terms and technologies far surpass my level of expertise. Yet here I am reading their blogs and tweets.

You may wonder how I got here.

The Internet is a platform. But like any stage, it is often difficult to differentiate the millions of users who inhabit the same space. Good social media, on the other hand, is like an amplifier. It takes lonely end users like me, and magnifies, nay multiplies the signal. Like any good amplifier, it reproduces the initial sound with greater strength but similar fidelity. In other words, if you put garbage in, you get garbage out. And not only will people not listen to you, they'll get annoyed.

On the other hand, if what you produce speaks to a specific audience, the volume rises. When momentum builds an idea reaches critical mass, and boom-your in the stratosphere.

I started to blog years ago when the profundity of everyday life became overwhelming. My experiences as a physician, as a person, burned deep holes in my soul and cried for expression.

In my writing, I found a place to express the truest version of myself. Unprotected by the false prophesy of appearances, I allowed my words to speak for themselves.

But years into the journey, I found my signal degraded quickly over the vast ether. My words bounced off the wall and echoed back into my own ears. The move to Facebook and Twitter has carried me farther. I've found groups of people to admire and share with. We form a symbiotic existence, the fabric of the social media universe.

So if you happen upon these words as you spin the internet dial: sit back, tune in, take a load off for awhile. I hope you find something here of value.

If not, keep looking.

And thanks for stopping by.

The Art Of Medicine

I don't like doctors!

It was always the same with Ronald. After years of absence, he would appear at my doorstep with some particular problem that had progressed to alarming proportions. Once, it was the abscess that seemed to swallow up his whole back. The next time, it was a hernia that had grown to the size of a grapefruit hanging out of his undergarments. But today was different. In fact, when I asked what was wrong, he told me that he was feeling fine.

Doc, I had a funny dream last night. At least I think it was a dream.

The night before, Ronald woke up to a gentle nudging on his left arm. When his eyes opened, he almost fell to the floor. His teenage daughter, who died decades earlier, was standing above him. She called out to him like she had when she was alive.

Papa...Papa, your not breathing right. Go to the doctor.

*

Ronald tried to convince himself that it was just a dream. He tried to ignore his daughter's words, but her voice paralyzed him. He walked in to my office cautiously as if embarrassed by an urge that he couldn't explain.

While I was skeptical to say the least, there was something about Ronald's story that moved me. There is a time when clinicians drop algorithms and guidelines and work from the gut.

I felt it would be reasonable to obtain basic lab tests and a chest Xray. I also informed him that given the lack of indications, medicare wouldn't pay for any of it. He took my referrals and left the office. I suspected that he would eventually think better, and decide not to go for testing.

I was wrong.

*

Three years later Ronald is disease free. The lung cancer found coincidentally on Xray was early stage, and was surgically cured. The thoracic surgeon marvels that if Ronald had waited any longer, he wouldn't be alive today.

Ronald did end up paying a few extra hundred dollars for the tests, but he now feels it was money well worth spending.

And I am left to wonder about the future of medicine. As guideline based care pervades health care reform, I fear that something will be inexplicably lost.

You may call it Divine intervention. It might be described as having a hunch. Or one could lay this gift on the doorstep of lady luck.

But if you ask me, I call it something completely different.

The art of medicine.

Nothing Has Changed

I have several lab coats. I usually buy a few each year; some gray, some white. I prefer the kind with multiple pockets. The breast is reserved for pens while the side pockets hold my stethoscope, prescription pad, reflex hammer, and various other tools of the trade.

These jackets tend to age quickly. They carry around the residue of my day. Frequently they get caught in car doors, spattered with body fluids, or trampled on. None of these are problems frequent washing and dry cleaning can't fix.

But what really bothers me is the pockets. Maybe its the heft or sharpness of the contents. Whatever the reason, the fabric frays at the edges and holes form. My first indication is when a pen or reflex hammer falls to the ground right after placing it in my coat. I look down cautiously as I hear the plink of the object crashing to the floor.

Of course I learn to adapt. I shuffle the contents from one location to another. However, as more rips occur, I find myself running out of options. I clip my pens to the top of the fabric in order to keep them fastened to my body.

I often marvel at my geriatric patients and their similarities to my old coats. Continuously shifting the contents, they often struggle to maintain the fidelity of an imperfect covering. Some defects we repair, others are ignored. And sometimes we mourn an irrevocable loss.

Is it possible that I'm just projecting? Maybe it's not my patients, but I who more closely resembles these war torn garments. The holes in the breast pocket are more reflective of my internal milieu. I ignore the tears and scars and carry on wounded but still somehow functional.

Until the lab jacket becomes so unusable that I discard it and buy a new one.

And months later as I race through the hospital I hear a plink and turn to find my reflex hammer has again fallen to the ground.

I absentmindedly place my hand over my chest and realize that internally nothing has changed.

What Might Have Been

I never questioned why Julie was childless. After watching her mother and sister die suddenly, I figured she was reticent to pass on such flawed genes. She walked the earth with the lightness of fatalism. When premature death is a given, one loses the fear of the inevitable.

To say Julie had no children was not to say that she wasn't a parent. She guided each student who passed through her classroom as if they were her own. Unencumbered by the filial noose, she taught life's lessons without the subjective fear of tainted blood.

Julie was a counselor. She was a teacher. She was a beacon of light and hope to the unmolded clay of childhood.

*

I admired her immensely. I longed for the moral certitude woven into the fabric of Julie's life as I struggled with my own professional fall from grace. There was no gray zone. There was only black and white.

When we talked of her family history, Julie listened politely. I explained the implications of disease mapping as well as cardiac testing. Arrhythmia was high on my list. I lined up a genetic counselor and a first rate electrophysiologist.

Days progressed into months, and it became clear that Julie had no interest in obtaining any further consultations. I eventually caught up with her on her mobile, she told me she wasn't interested in living life that way.

Like so many patients, I said goodbye to Julie when I moved my practice. My fears assuaged by the siren song of the ages: time.

*

Years later, I would unexpectedly come across Julie's obituary when thumbing through the local newspaper. Her husband found her lying quietly on the couch with a handful of student essays splayed across her chest. Her last moments were spent alone with a fire roaring in the fireplace and a glass of wine untouched on the side table.

When I'm asked what it's like to be a physician, Julie's face often comes to mind.

It's a profession filled with hope and fear, triumph and devastation. We live for the great save.

And we are tormented by what might have been.

How It Feels To Be Young Again

It had been a long day. I watched the waves of the pacific crash against the deserted beach from my table in the ocean front restaurant. The remnants of dinner waited patiently to be cleared from our plates. My son fingered the shark tooth necklace he had bought the day before as my daughter struggled to keep her eyes open. She slipped out of her chair and crawled onto my lap, placing her head on my chest.

A light breeze caused the the muscles of my arm to shiver. I enfolded my daughter and lowered my face into her hair. I inhaled deeply and took in the fragrance of shampoo from her pre dinner bath. The brand from the hotel was different than the one we used at home.

Within seconds, long forgotten memories came flooding into my consciousness. For a moment I could touch the textures, taste the flavors, and feel the vibrant emotions long passed.

I was young again.

*

For an eleven year old, the allure of sleep away camp was not the sports nor the freedom of being parentless for a month. It was the nights. Each evening, the camp counselors would turn off the lights and tuck the campers into bunk beds before leaving. And each night, the campers plotted their escape route.

We called ourselves "raiders" and danced among the trees and shrubs to avoid the few unlucky counselors who were assigned to patrol duty. If we were caught, we risked being placed on stable duty and shoveling manure left behind by various animals. But if we were successful, we crossed the open field to an identical set of cabins and stole a few moments with our counterparts from the opposite sex.

On one such evening, a group of us snuck into the girls cabin and convinced them to accompany us for a midnight stroll. Heather had just gotten out of the shower and was reticent to come along. I hadn't yet professed my feelings and usually could barley look her in the eye. But this time, the adrenaline bolstered my confidence.

Come on Heather, it wouldn't be the same without you!

Moments later we were running through a pitch black field hand in hand. As a light flashed over head, we jumped into the bushes and huddled together to keep still. My face pressed close to hers, I inhaled the sweet smell of her breath. The fragrance of her hair filled my nostrils.

A harsh voice crackled from an adjacent tree. The lights passed across our faces. We were caught.

*

The child experiences seconds as if they are minutes. Lives minutes as if they are days. There is no contemplation of aging because life is limitless.

I imagine there will be a time when my body is old and decrepit. My routine will no longer have external goals but will become a purpose unto itself.

I'll look forward to the young woman who comes to help me with my pills and lowers me into the bath against the will of my body. And the smell of her hair will no longer remind me of Heather, or those lost moments at camp. Instead I will revel in the memory of a trip to Mexico where my daughter curled up on my lap after a long day and a brief dinner.

I will spend the rest of the day lost in contemplation,

remembering how it feels to be young again.

The Fallacy Of Technology

Since the computer was open anyway, I clicked the EMR icon and waited to connect to the database thousands of miles away. The sun was setting on the pacific and a half empty Corona sat on the table next to my pool chair. My mind was relaxed. The kids splashed in and out of the water as a Mariachi band played in the background.

Within moments, the idyllic surroundings faded and I was back in my office. The inbox was full and I scrolled through the messages. Mrs. Jones was having urinary symptoms again. I rattled off a note to my medical assistant and eprescribed Cipro to her pharmacy.

Apparently Mr. Thomas was in the hospital. A few more clicks and I was perusing the inpatient chart. He ran out of meds again and forgot to fill the diuretic. I scrolled over his med list. Just as I expected, no one restarted his Digoxin. I jumped into the physician order entry page and added the medication. I shot a quick email to my partner to let him know that I had been in the chart.

I spent the next thirty minutes taking care of patients from a distant beach in Mexico. I placed phone calls, ordered CT's, and prescribed medications.

And for a moment I pictured the perfect life. Plying my trade with the latest technology from paradise. All I needed was my knowledge, and internet connection, a mobile phone, and a highly developed electronic medical record.

Ofcourse, unlike so many involved in the transformation of healthcare, I knew that this notion was just a fantasy. The bells and whistles may make the delivery of care more convenient, but they are not an end unto themselves.

We can measure quality based on clicks and ticks. We can denigrate whole systems based on their ability to comply, to meaningfully use the technology that is foisted upon them.

Or we can accept that healing takes place face to face, hand to hand, when the computer screen is ignored,

and we start listening to our patients.