Back To Life

I usually think of it as a positive the sign.  A patient is depressed, mourning, or just doing poorly.  Then they show up on my schedule for a physical.  It's the small efforts that start to change the tide: being sure to remember to brush the teeth in the morning, having that piece of fruit after lunch, going for an evening jog.  When one pushes the body to do healthy things, the mind often follows albeit unwillingly.

And this doctor thing can be quite tricky.  We strive to both create and break barriers.  We must ensure a level of trust to allow our patients to divulge the sensitive parts.  But we also maintain a certain amount of coldness, it is sometimes the art of being aloof that coaxes the truth from reticent lips. We draw them in and push them away. 

Draw them in and push them away.

It's an artificially crafted dance that for the most part serves the profession well.  The trick is to know when it's time to let go and stop being a doctor.

*

Johnny had no one.  Years before, his girlfriend had convinced him to move to Chicago after graduate school.  He packed his belongings and left his family and friends without much thought.  He was in love.  Their relationship went swimmingly, and during our last visit we discussed his wedding plans.  The deal was sealed and the date was secured.

So it was with great surprise, that I watched Johnny amble into my office for his annual with his head hanging low.  According to my calculations, his wedding should have taken place a few weeks ago.  But it didn't,  she left him at the altar.  The wedding was cancelled.  The engagement was called off.

Johnny was alone.  His former fiancee had packed her belongings and left the apartment.  His family was hundreds of miles away.  Most of his Chicago friends were actually hers.  He contemplated leaving his job and moving, but it was his one source of pleasure.  He didn't have the strength.

We talked briefly, and I examined him.  His body was listless.  His eyes focused on the floor and he spoke in a monotone. A single tear fell from each eye.  Although Johnny was only a decade younger than I, I felt like a father looking upon his wounded son.  As I finished my notes, I stared at the screen and tried to think of a way to comfort him.  I was at a loss.

Johnny and I both stood at the end of the appointment.  All the sudden I knew what I had to do, although I felt self conscious and awkward.  I ignored those feelings.

Looking him in the eye, I took a step closer.  I put my head down.

Then I embraced him.

His body became tense and then relaxed.  He wept.  I'm not sure how long we stood in place.  Eventually I handed him Kleenex and he walked out the office.

I saw Johnny again yesterday.  Years later, he still lives in Chicago.  At the end of our visit he showed me a picture of his newborn.  He is married and happy.

*

As physicians we learn to use all our senses.  We rely on our eyes and ears in addition to our minds.  But sometimes human beings require something more primal in times of great need.

Like a great defibrillating shock,

the power of touch can also bring us back to life.

Are You Trying Hard Enough?

I have had many mentors over the years.  I learned from countless teachers: family, friends, and colleagues.  But there has been one influence that has trumped all others.

I remember high school.  When my mother remarried, we moved to a new district.  My first day of classes, I knew no one.  Shy by nature, I spent weeks in the lunch room eating by myself.  Everyday I went to the gym and played basketball.  It was on the court that I began to make my first friends. 

I always loved basketball.  I tried out for the team in middle school, but was never good enough to make the cut.  The summer before freshman year, I hit the court every single day.  I practiced my shots, dribbling, and overall endurance.  I vowed that I would make the team. 

As the summer months passed and I actually started school, I realized that this could be the key to making friends.  If only I was successful, I would have an instant group to belong to. 

It seemed like hundreds of kids showed up on the first day.  The coaches put us through drills and then we scrimmaged.  By the end of the first tryout, I thought I was doing pretty well.  But as the days passed, I became anxious about the consequences.  In every sense of the word, I choked.  My jump shot fell short, my passes were off, and my dribbling was awkward.

I wasn't surprised, on the final practice, when the coach sat a few of us down to talk.  I was cut on the last day.  I was devastated.

Strangely, it is moments like these that I now look on with the most pride.  I was beaten that day.  I failed.  It was one of a series of failures that plagued my childhood: academically, physically, and emotionally.  It seemed that success was a distant shore that I could never quite swim to.

The funny thing about failure, however, is that it can either sink you or lift you up.  It wasn't that my lack of success created a raging fire in my belly, it was quite opposite.  I was so used to falling short, that the possibility no longer hindered me from trying.  I started to think:

Why not give it a try?  The worst that can happen is that I can fail.  I've been there before and it's no big deal!

I never did play on the high school basketball team.  But it was those early failures that provided the greatest opportunity to learn about myself and my abilities.  As an adult, I now find success to be the norm. And the skills I learned as a child, are enormously helpful as a physician.

While disease and illness do not neatly lend themselves to such terms as success and failure, it is in those times when outcomes are most poor that I dig in and investigate even more thoroughly.  Every mistake, incorrect calculation, or unexpected turn becomes a data point to improve on.  There is no time to bury ones head in the sand, quality improvement must be continuous and real time.

If you want to know what makes a great physician, it is someone who learns from each and every misstep.

Have you failed at anything recently?

If not, maybe you're not trying hard enough.

The O.K. Corral

I had already decided that I wasn't going to be a pediatrician.  So my third year rotation ended on a high note.  I was working in the cardiac care unit.  Most of the admissions were short stays, teenagers with a history of congenital heart disease coming in for their annual cardiac catheterizations.  They were healthy.  They stayed for a few days of intensive testing, and then were discharged back to their normal lives.  Occasionally we would take care of a sick kid, but the majority was routine.

My days were filled with conferences.  I enjoyed the banter between the pediatric cardiothoracic surgeons and the interventional cardiologists.  The room was alight with spirit and bravado.  Later in the morning we rounded on the new admissions.  Lastly, I would see our only frequent flier

Jeremy was a twelve year old with end stage congestive heart failure.  From the outside, he looked like your average pre-teen.  But if you watched him walk down the hall, you would notice his face turn blue and his respirations increase.  He basically lived in the hospital.  Waiting for a heart transplant, he was confined to the cardiac unit and tethered to his IV pole with life saving infusions continuously dripping into his veins. 

No one knew exactly how long he had been confined.  He often stood at the nursing station and chatted with young nurses and the secretary.  He sometimes followed behind the medical students as one of the attendings gave an interesting lecture on the pathophysiology of disease. 

He was a funny kid who was beloved by all.  More than one staff member said a prayer each night while kneeling in front of their beds hoping he would receive the heart he so badly needed.

My last weekend on call, I arrived to the floor Saturday morning to find that Jeremy was gone.  A poor family's tragedy became his possible triumph.  The report from the OR was that they were sewing up his chest with a perfectly viable, beating heart. 

Later that night I accompanied fellow doctors, secretaries, and nurses to visit him in the ICU.  His angelic face was swollen, and his mouth was distorted by a breathing tube.  But his vitals were stable.  We all felt sure that he would make it through just fine.

I beamed with pride upon leaving the room.  I was beginning the journey into the profound profession of medicine.  I, like the brave cardiothoracic surgeon, would deliver life saving care.  I would make people whole again.

Years later, I realize that such pride is very common in medical students.  It's a time before reality sets in.  A time before we willingly jump into the meat grinder that is our modern day health care system.  It's spits us out rough, haggard, and much less idealistic.   Many will say that it is the training process that beats the spirit out of us. 

I think this view is much too simplistic.

How often are we wounded when a loved one or family member dies?  How deep does the dagger cut?  How long before the wound heals?

The problem with being a physician is that we are sliced and diced every single day.  We fight so many battles that from the outset can never be won.  We watch helplessly as death stakes it's claim, and try haplessly to deal with the remnants of destroyed life. 

Over and over again.  Year after year.  We are marked by the tragedy that we witness.  We carry the extra burden of culpability and responsibility.  And we ruthlessly try to wash the blood from our own hands.  Victories are transient and far in between.

And patients wonder why their doctor is distant.  They wonder why in desperation they reach out to the stone cold figure that stands distractedly in front of them.  They become angry, suspicious, and sometimes downright accusatory.  The net effect is that the wounded doctor crawls further into his shell of protection.  Facing an angry public and afraid of litigation, the isolation becomes greater.

Once again we are stuck with a doctor-patient relationship that is dysfunctional.

It's like we're both gunslingers at the O.K. Corral.  As we stand with our guns pointed at each others chests, we realize the silliness.  We need deep, meaningful communication so badly, we just don't know how.  But in order to avert grave misfortune, one of us has to be brave enough to re holster his weapon first.

Can you see what I'm trying to do here?

I'm trying to lay down my gun.

A Slippery Slope

Dr. Sisk shifted uncomfortably in his chair.  He stared at the computer screen in front of him as he once again tried to plead with the elderly woman and her husband sitting quietly in the exam room.  The treatment being offered was futile.  The cancer had spread to too many organs. It was time to consider hospice.

The couple listened patiently but again expressed their wish to continue forward.  If the oncologist was offering, they were taking.  They weren't quitters after all. Dr. Sisk took another deep exasperated breath.  He wiped the sweat from his forehead before speaking. 

Well then, I'm going to have to ask you to find another doctor.

He looked down as he said the words.  He couldn't bare to peer into the eyes of the grandmotherly figure sitting in front of him. But, he felt he had no choice.  The chemotherapy cycle called for new injections every two weeks. No doubt, debilitated as she was, she would land in the hospital shortly thereafter.That would mean two admissions in less than the allowed thirty day period.  He couldn't take the risk that medicare would refuse to pay him.  The new rules had burned him countless times already  She was too high risk.

The couple left the office dejected.  Faced with the fight of their lives, the abandonment of their long time physician was just another hurdle in a series of impossible challenges.

Dr. Sisk returned to his office and pulled up the schedule.   The next appointment was a new patient with congestive heart failure.  He grabbed the phone and dialed his secretary.

Marge, this new guy with CHF, did you do a hospital check before accepting him.

He typed furiously at the hospital EMR as he waited for an answer.  Just as he suspected!  Three admissions in the last two months.  Someone was trying to sneak this guy past him.  He spit into the receiver before his secretary could respond.

Marge!  You want us to go bankrupt? Get that guy off my schedule. 

Don't you dare check him in!

Trial By Fire

I could feel her holding her breath as I continued the phone conversation with the oncologist. She sat in the floral upholstered chair next to the desk in my office.  Her short white coat was a touch to clean to belong to a student entrenched in hospital warfare.  A second year medical student with little clinical experience, she asked to shadow me a few days earlier. 

Half way through my morning, we had only encountered the simple bread and butter issues: upper respiratory infections, blood pressure follow ups, etc. She followed dutifully from room to to room, writing notes in a small pad that she slipped gently into her front pocket from time to time before retrieving again as need be.

She was young.  Inexperienced.  Her exuberance was evident in her overly self conscious nature and her precise preoccupation with detail.  I tried to be patient and kind.  Remembering my own student days, I knew that a young persons field of study was often determined by the quality of their experiences and not the day to day content.

As I hung up the phone, I paused for the comment that I sensed waiting to burst forth from her lips.  She spoke with surprising conviction.

That's why I want to be an Internist.  Oncologists have to deal with death all the time!

Almost falling off my chair, I bit my lip so hard, I drew blood.  I stood like a statue trying to mentally compose myself.  There were so many things I wanted to say.

My dear child.  Today you will walk in my shoes.  You will wake at 4:30 AM and drive to the nursing home and pronounce the old man dead right in front of his wife and daughter.  You will express your condolences and sorrow before you excuse yourself to round at the hospital.  Your first patient will be a seventy year old with widely metastatic lung cancer who has finally agreed to hospice.  Her time is limited.  But so is yours, so you will rush to see the other patients and then return to your office for a few minutes of paperwork.  The message on your desk to greet you will be a notice that a middle aged man you once took care of collapsed unexpectedly on vacation.  The funeral will be over the weekend.  It's is 7:30 AM and your first office visit will be arriving soon. 

In the few short hours you've been awake, death has already consumed you.

But instead, I leave the soliloquy in the realm of my thoughts where it belongs.  I look down at the computer screen and search for the next patient: a thirty five year old who is losing his battle with leukemia. I beckon her to follow.  I needn't say a word.

Experience will be a far better teacher than I.

The Rise And Fall Of Consequence

She hobbled into my exam room, pausing half way to lean on the walker and take a deep breath.  A year to the day, we had placed her husband in hospice.  He died shortly there after.  Seven decades of marriage over in the shuddering of a heart beat.  She now roamed the empty halls of her home.  She kept active with cooking and cleaning, chasing after her adult grandchildren, and other assorted hobbies.  It wasn't that she was unhappy, she was grieving.

The exam room was thick with the memory of what had been.  They always came to their appointments together.  I made pleasant conversation as we released ourselves to the puppeteer of familiarity.  She lifted the back of her shirt without being asked and took deep breaths without cue. 

We talked about her kids.  Her face lit up and choked back the tears of sorrow.  She was in her nineties.  At the end of the appointment I discussed having her return in a few months.  Her eyes sparkled as she answered.

If I'm still here!

I almost laughed in answer.

You probably will be.

The irony of being young. 

We spend every moment trying to prolong the minutes, wishing to turn back the calender.  But for her, minutes were hours, hours days, and days like millenia.  She was counting the moments till returning to her beloved.  And although their time apart will pale in comparison to the seventy some odd years together, she can't wait for it to be over.

And it made me think how small my thoughts and fears are: whether my next patient will be on time, if I do a good job and make a successful living, or if anyone reads this blog.  The brain busies itself with countless worries that raise the blood pressure. 

Maybe none of it matters.

Maybe we are all just specks, mere flecks in the vast universe, waiting for the next indifferent gust of wind to blow us asunder.

Skin In The Game

Ricky and I were the same age.  We both were struggling with the ins and outs of new parenthood.  I had a boy, he a girl.  Yet my gray coat hid the mildly protuberant abdomen, while his belly bulged into his t-shirt and formed a barrier between us.  He was at least a hundred pounds over weight.  And I, as his physician, wasn't going to pas up the opportunity to counsel on healthy living. 

Once a year, Ricky waltzed into my office for his annual.  Over time, I had noticed how his height stayed the same, but his weight kept growing.  He now fell into the category of morbidly obese.  I breached the subject of diets.  He preferred Atkins,  I preferred Weight Watchers. We discussed different methods of keeping active.  I suggested family walks with the little one in a stroller.

As the conversation progressed, I couldn't help but feel a dysphoric twinge in the pit of my stomach.  I shifted my weight in the chair.  My size thirty six pants were starting to get a little too tight. I absentmindedly wiped the edges of my mouth in order to make sure no remnants of the fast food I ate for lunch were left in plain view.

I was a hypocrite.  My girth had ballooned since medical school.  My eating habits were poor, and I lived a sedentary lifestyle.  Why ever should Ricky listen to me?  I decided to try a different angle.  I cleared my throat before speaking.

You know what?  I could do this better too.  Why don't we work together?

We put our heads down, and a few minutes later had a plan that we could live by.  Ricky would join Weight Watchers and swim three times a week, and I would cut out the fast food and walk every day.  The office visit ended with a sense of camaraderie and shared mission.

*

My son will turn eight in October.  I have no idea what came of Ricky.  The last time I saw him, he had lost over seventy five pounds.  His blood pressure was better, and he stopped all his diabetes medications.  I lost track of him after he moved to another city.

And me?  I dropped twenty pounds and now sport a comfortable size thirty two waist.  I walk everyday.

Ricky taught me so much about the practice of medicine without even knowing it.  I now know that to talk the talk, you have to walk the walk.

More importantly, over the years I've learned one essential truth.  For this doctor-patient relationship thing to work,

we have to all be in it together.

The Customer Is Always Right

You may have met him. I like to call him Dr.Patient Pleaser.  In fact, who knows, he may even be your doctor.  He is quite an agreeable chap.  Most requests are answered with an affirmative without giving it much thought.

If Dr. Pleaser knows the most current guidelines, he certainly doesn't show it.  His guidelines are based on patient preference. They line up day and night to fill every spot in his schedule.  They walk in with reams of papers copied from the Internet, or their brother in laws advice to start an antibiotic right away.

He thinks of his patients as customers. 

The customer is always right!

His clients love him.  They greedily gobble down scripts for antibiotics.  They rush to the hospital to get the stat cat scan.  They chase down every incidentaloma.  Ravenously pursuing each new test and biopsy until they are emotionally exhausted and their insurance company bankrupt. And when the workup finally comes back negative, they rejoice and sing the praises of their brave and insightful doctor.

Don't forget the drug seekers.  They all have his office speed dialed into their phones.  Maybe they have his private mobile number.  The hypochondriacs too.

It's not clear why Dr. Pleaser does it.  Certainly he has no problem paying the bills.  But it's deeper than that.  He doesn't want to be disagreeable.  He avoids confrontation because it's difficult.  For instance, he never tells a patient that they are dying. Better, he thinks, to create hope-even if it's false. 

He's just as destructive as our PR Problem or the Administrator.

But unlike those other villains,

he has the full support of the American Public.

Dogma Bites

I like to laugh at cardiologists.  They always seem to be pushing some new treatment, especially vitamins.  One only has to look at the Vitamin E, Folic Acid, or  the Vitamin D fads.  But all joking aside, while the field of cardiology may jump the gun from time to time, they are experts at scientific method.  That's why as each of these miracle treatments have been studied and shown to be non beneficial, the recommendations changed.  It's really straight forward: generate hypothesis, test, and draw conclusions.  The rest of the scientific community should take notice.

Yet, there are times in medicine when we fail to adhere to such basic principles.  One only has to look as far as the doctor's exam table. Now a days, perched upon it, is a computer screen in place of a paper chart.  Is there proof that electronic medical records are better?  We know that they are more expensive.

Now don't get me wrong, I've been using EMR's since 2003.  I learned five different systems over the years, and use Epic, Misys-Allscripts, and Cerner currently.  I adapted, and no longer find them an impediment to care.  But the truth is, I would go back to pen and paper in a heart beat.  I can't tell you how many times I've seen user generated errors cause harm to patients.  Recently, I witnessed the quality of care spiral in a local hospital as physicians and nurses scurried to negotiate a new system. 

When a patient is transferred to the nursing home from a hospital with an EMR, it takes untold hours to traverse the useless minutia and mine the important data. 

But all this would be worthwhile if there was one iota of proof that the large expenditures improve quality, cut costs, or increase patient satisfaction.  Please, anyone, show me the data!  Instead, we have a series of suppositions made by administrators, politicians, and starry eyed physicians who no longer get their hands dirty with actual clinical care. 

What we have is dogma.

And the problem with dogma is that it doesn't bend to science.  We run, like herded cattle, oblivious to the cliff in front of us.

Of course,  reality won't be so dramatic.  Maybe we creep towards a mild and continuous decline.  Either way, the results will generally be the same.

Prepare for the abyss.

Peaks and Valleys

We all have a nemesis.  For some it's a particular mental or physical challenge, for others it's a person. Every two years I meet my nemesis in the form of the climbing wall at Estes Park.  Mind you, it's a small novice climb that can be scaled by some of the older children.  But for me, it's a test.  Will there come a time when I am too weak to reach the top?  Am I in worse shape than the last time?

Two years ago, I faced the challenge bravely.  The wall has three sides: easy, hard, and harder.  Of course, I immediately lined up on the expert side.  As the carabiner was snapped on my waist, I called out "on belay" and waited for the retort, "belay on".  My muscles began to stretch.

"Climbing!"

I climbed up the face of the wall.  My feet slipped from time to time as I reached for the next hand hold. A few minutes later, I hung from the top.  I floated downward, kicking my feet against the structure, I gently landed on the ground.  I admired the tautness of my burning muscles.

Two years later, the wall looked much larger.  I scaled up much like before.  But coming down, I felt more winded.  I bent over and held my knees as I worked to catch my breath. 

My pride at success, however, was short lived.  Although I had conquered the the hardest side, I had climbed up the middle.  If  I limited myself to the right edge, the level of difficulty became much greater.  Jutting out was a stair like structure with two hand holds on the bottom, and then a few on top.  The problem was that I would have to hoist myself without concrete footing for my legs.

With only minutes left in our session, I saddled back into the harness.  The first few steps were like butter.  I grabbed both arms below the jutting structure and shot my right hand onto the area above.  Then with all my might, I pulled upward and hoisted my left hand, just barely catching the hold at the last minute.  But now I came to the tough part.  Hanging from both arms, there was no where to put my feet. I heard the guide yelling from below.  My only chance was to wedge my knees against the wood structure and pull up hard.

With my feet collapsed into my waste, I thrust my knees against the grain of the solid structure.  It began to slip and scrape my skin.  I  flailed forward, my hands catching the rubbery hold above.  Gingerly I lifted my foot and placed it into the hold my hand had just left.  Then I did the same on the other side.
I stood a few moments to steady my breathing.  My chest heaved back and forth trying to hold onto what little oxygen it could capture from the high altitude.  I was home free.  Half way up, I was past the hardest part of the climb.   

In some ways, this physical triumph made me reminisce about other challenges in my past: growing up with a learning disability, the death of my father, and a ruthless medical education.  How many times had I been stuck in a bad spot with my knees scraping against the mishaps of life?

And more importantly, how many patients have I watched mercilessly work their way through hardship.  They struggle on the right edge of the climbing wall hoisting themselves past surgery, chemotherapy, or cardiac catheterization.

Much like my climb, getting through the roughest patch is not always the end of the journey.  Even after all I had accomplished, two thirds of the way up, my leg reached out a little too far and cramped.  My feet slipped, and there I hung from the safety rope.  Failure.

For my patients, almost is not an option.  They not only suffer through the challenges, but also the nerve racking moments in between. 

There is no pinnacle or a raucous dance of joy.

There are only peaks and valleys.

Honoring The Past

As we turned into Estes Park, I couldn't help but feel nostalgic.  The problem with ritual is that it brings the past into such clear focus.  We started making these trips four years ago-my parents, four siblings, and a gaggle of children.  And in such a short span of time, so much has changed.  My face has become thinner and more gaunt, my hair line is receding.  Next year, I will be the last of the siblings to enter our forties.  The babies have grown into school children.  Their physical needs lessen as their emotional ones become primary.

My step grandmother came on our first trip. Well into her nineties, her body occasionally faltered but her mind was crystal clear.  I remember staying behind with her one evening when the rest of the group went for a camp fire.  We sat in the living room alone in a pair of chairs that faced each other. We talked for an hour, probably the only hour I ever spent alone with her.

I asked question after question.  She told me about her childhood and how she met my step grandfather.  We talked of the greatest generation and the difference from today's adults.  It was an intimate and honest conversation.  By the time the rest of the family returned, I felt a bond that spanned generations and the decades that separated us.

We returned to Estes Park two years later, shortly after her passing, to make new memories and mourn that which could never be lived again.

Sometimes when I see the kids running and playing together, I think of my own childhood.  I imagine that instead of our offspring, it is actually me and my brothers again.  Without a care, we scamper back and forth searching for the next great conquest. 

But clearly I am no longer a child.  And on this third family reunion in Colorado, I struggle more than ever in the art of balance.

I try to mirror the wisdom of the child in rejoicing in the present,

while honoring the memory of the past.

The Advocate

I remember the first time I heard the song.  It was some type of music awards show. The driving rhythm juxtaposed with melodic lyrics captured my attention immediately.  It was only after listening over and over again that I realized the beauty of the words.  But what did they mean?

It's empty in the valley of your heart
The sun, it rises slowly as you walk
Away from all the fears and all the faults
You've left behind

It was only later that I realized that it made me think of you.  I have known you for years.  Well...not exactly.  I have known of you.  I heard your story way back when, when browsing a web site or maybe as a human interest piece on television.  I always wondered how you survived such a tragedy.  How did you not lie down on that hospital room floor and never get up?  Certainly that's what I would have done.

Then one day you comment on my blog or follow me on twitter.  And finding you here, I realize the agonizing pain has not beaten you.  It's turned you into an advocate.

So tie me to a post and block my ears
I can see widows and orphans through my tears
I know my call despite my faults
And despite my growing fears

I said recently in a blog post that the indignity of death is that memories fade.  But you, you have done the exact opposite.  The power of your suffering has brought your loved one into even greater focus.

Physicians fear advocacy.  We demure when exposed to the prying public eye. Your persistence opens our eyes and returns us to the primary goal.  We must not make the same mistakes over and over again.


But I will hold on hope
And I won't let you choke
On the noose around your neck
And I'll find strength in pain
And I will change my ways
I'll know my name as it's called again

To lift up.
To protect
To advocate.

You change the conversation.



Words and lyrics from The Cave, Mumford and Sons.

Our New Reality

Our new reality.

Dr Thomas: Hi Dr. Grumet.  I was calling in regards to Mr. Chest Pain on 2N.

Me: Oh...hey are you the new guy with Cardiology Physicians, welcome!

Dr Thomas: No.  I work with a company called EMR Consultants.  We were hired by your hospital to review inpatient hospital stays.

Me: Ok.

Dr. Thomas: Getting back to Mr. Chest Pain, I see that you deemed his symptoms to be non cardiac.

Me: Correct.  He has muscle wall pain from coughing.

Dr. Thomas: So you will be discharging him today?

Me: Well, his cat scan showed bronchiectasis and bronchitis, and his lungs are very tight.  I thought he would benefit from steroids and antibiotics.  He is ninety years old after all!

Dr. Thomas: Well you put him on oral antibiotics and oral steroids.  Could he not get these at home?

Me:  Let me ask you this Dr. Thomas.  What did you think of Mr. Chest Pain's lung exam this morning?

Dr. Thomas: Of course, I did not examine him.  We do chart review only.

Me: Well did it say in his chart that he has to be able to negotiate two flights of stairs to get into his walk up apartment.  Or did it mention his wife Rosa?

Dr. Thomas: Well...um...

Me: Probably not since Rosa died six months ago.  Dr. Thomas, would it be too presumptuous to ask what kind of doctor you are you anyway?

Dr. Thomas: The last time I practiced, I was a pediatrician.

Me: When was that?

Dr. Thomas: Residency...but your missing the point.  You and I are the same.  I have flow charts, and algorithms, and guidelines that direct appropriate care.  Just like you.

Me: Sorry.  We're not the same.  I spend my days trying to master the science and art of expert patient care.

You, you make phone calls.

Is Social Media The New Doctor's Lounge?

It happened exactly one week ago today.  I was sleepily putting my phone down to take a shower after a long night of call.  I can't explain the exact sequence of events, but in the blink of an eye my mobile fell into a full sink of water.  I grabbed it with lightning fast reflexes and blotted it dry with a towel.  As I expected, it was dead.

After an extensive search of the Internet, I eventually settled on the rice method.  I filled a zip lock with rice and submerged the battery and receiver inside, and then sealed it tightly.  Seventy two hours later It emerged just as dysfunctional as before.

So I finally bit the bullet and took it to a mobile repair shop.  The technician explained the multi day process that included exposure to drying agents such as alcohol.  Leaving the store, I realized that it would be millenia before I would be able to use my device again.

I activated a cheap flip phone in the meantime.  Although the battery life is worlds better, it has none of the smart capabilities I am used to having available at the touch of a screen.  That's right, for the last week I have been almost absent on Facebook and Twitter.  Of course I can use my lap top or IPad, but the feel is just not the same.  The speed is slower.  This is not how I like to do social media.

The absence of social media has left me feeling like something is missing.  Gone is the witty banter and sarcasm of my physician friends.  More importantly, my speed of absorbing new and real time information has slowed drastically.  I feel left out.  It's like I've lost my community.

And in some ways, I think, as physicians, we are enduring a similar crisis.  It's been quite some time since the hub of physician social life and activism was centered around the doctor's lounge.   Academic centers are moving away from educational meetings and grand rounds, and starting to focus on productivity.  Independent physicians are feeling disenfranchised from hospital systems and are becoming the worker bees of the system. 

We no longer congregate.  We have become silos.

This loss of group identity is increasingly apparent in our organizations.  The great advocacy of the past has fallen prey to a failure to launch.  Confronted with members (and nonmembers) who are too busy and no longer feel a sense of coherence, the physician's interests are largely being neglected on the national stage.

It is no wonder that when it comes to policy making in Washington, doctors have not been asked to the table.

We, in fact, have become one of the entrees.

Could it be that our vehicles of advocacy are stuck in the twentieth century?  I, a lonely blogger, can tweet my ideas to thousands.  But if the content is good, it may be re tweeted to hundreds of thousands. 

This could be an organic community with grass roots origins.  It is stronger and more cohesive than any lobbying agency that we have used to date.  Most importantly, it is inclusive and moves at warp speed.  Social media could allow us to negotiate in real time and react accordingly.  It could be a hot bed of activism, the doctor's lounge of the twenty first century.

It's time we pulled our chairs back up to the table with good ideas, fresh optimism, and our newly repaired smart phones in hand. 

Don't Worry, It's Just Anxiety

I've sworn off caffeine-many times.  The most serious effort started a year ago.  I went cold turkey for six months.  But then it started to creep back into my diet.  I'd splurge on a Diet Coke from time to time.  My real problem is that excess caffeine gives me stomach aches and migraines. 

Last month, I bit the bullet and stopped completely.

I'm sure my intake is not absolutely zero.  I enjoy a decaf coffee a few times a week.  We all know that it isn't completely decaffeinated.  Life is too short for such slavish detail.

*

I'm generally a calm person.  I get antsy about time, but I wouldn't call myself anxious.  So when I felt my heart start to race this morning, it took me by surprise.  I felt like I was flying uncontrollably, butterflies fluttered in my stomach, and a horrible sense of dysphoria overtook me. 

I sat at my desk as the world closed in.  I listened to the phone ring, my patients chat in the waiting room, and my medical assistant speak softly into the telephone.

It took only a minute to realize what happened.  My coffee tasted funny this morning, a bit too bitter and harsh.  I gulped it down allowing my fears to be settled by the richness of the cream and sugar.  Sitting in my chair with my heart racing and the sweat forming on my brow, I was certain that I had mainlined an unadulterated dose of pure caffeine.

Newly unaccustomed to the stimulant, I buzzed around the office all day.  The feeling was quite uncomfortable.  I thought I might explode at any moment.  The only mitigating factor was that I knew the cause, and figured the it would end eventually..

*

I often tell my patients that I can't walk a day in their shoes.  I can only imagine the pain of appendicitis or the fear of cancer.  Fate will eventually deal me my hand of cards, both good and bad, but for now I can only learn from helping others through their tribulations. 

In one of those strange coincidences, multiple patients on the schedule were struggling with anxiety today.  I spent countless minutes counseling on something that I was feeling at the moment (to much lesser extent).

And I felt almost embarrassed.  How many times had I been insensitive.

Don't worry. Your not having a heart attack.  It just anxiety!

That just anxiety kicked my butt this morning.  What if I thought it would never go away?

I have come to think the true meaning of empathy is seeing your own suffering in another person's eyes.

That's what happened to me today.

Sorry, That's Unacceptable

Actual conversation, the details have been slightly altered.

Me: Hi, I'm calling in an emergency narcotic prescription for my nursing home patient, Terminal Cancer.

Pharmacist: Which facility?

Me: The Local Nursing Home, Lake Forest.

Pharmacist: What do you need?

Me: Terminal is a hospice patient.  He's in alot of pain tonight.  I would like to increase his dilaudid PCA from his current continuous dose of 0.7mg to 0.9mg per hour.

Pharmacist: Have you called in an emergency prescription  for dilaudid before?

Me: Yes, the DEA number on the script the hospital sent a few days ago was wrong, so I had to phone in the original dose.

Pharmacist: Unfortunately government rules state that you can only call an emergency dose once for a  patient and a given medication.  You could fax us a hard copy though.

Me: But it's three in the morning, and I don't have a fax machine at home.  Where am I going to find one at this hour? Could I scan and email you a script?

Pharmacist: Sorry, that's unacceptable.  You could give an order for a different medication.  Would you like to change the PCA to morphine?  We would fill that.

Me: The patient didn't get enough relief with morphine in the past.  That's why he was put on dilaudid in the first place.

Pharmacist: I'm sorry doctor.  That's all I can do.  Unfortunately the new government rules on narcotics are making everybody's life more difficult, especially the patients.

I pause in shear frustration.

Pharmacist: Maybe you should just send him to the emergency room.  That's what everybody else does!

Like A Moth To The Flame

The admissions director was waiting for me on the line.  The fact that she called, as opposed to one of the nurses, meant that my new patient was anything but straight forward.

Bob's on a PCA pump.  His bone marrow transplant failed.

I gulped.  Patient controlled anesthesia?  In the nursing home?  She continued to deliver the bad news.

A percutaneous gastrostomy tube was placed yesterday.  He's a full code.  His next chemo is scheduled for a few weeks.

I marveled that such a patient could be transferred to the nursing home without a courtesy phone call from the discharging physician.  Even a thorough review of the medical records would not convey the nuances of dealing with this amplitude of complexity.  Before entering Bob's room, I tried to connect with his oncologist.  The nurse kindly informed me that he was out of town and unreachable.

It took only moment's to realize that Bob was dying.  His young frame was battered by the ravages of cancer and multiple unsuccessful medical treatments.  The only evidence of his youth remained in the sparkle of his eyes.  I pulled a chair close to his bed and we talked.

We talked of his hopes and dreams.  We discussed futility and the risks of over treatment.  We lamented that he had no family members to comfort him.  I told Bob, in no uncertain terms, that he was dying, and that the price of prolongation of life would be quality.  I said these things as I had done so often before.  My voice was strong and unwavering.  I watched the emotions pass across his face. They were a mix of anger, sadness, and acceptance.

By the time I left, Bob had signed a DNR form and agreed to avoid hospitalization.  The hospice team would see him soon.  I titrated his narcotic dose generously.

Bob died a few days later.  His passing was peaceful and quiet.

Sometimes I wonder why I don't turn away from the sadness like so many other physicians.  I have never been adept and building such walls.  Instead, I watch as the flames engulf my defenseless skin and leave gaping welts.

There are weeks like these when I feel I have become an angel of death.  But in my heart,

I hope I'm more like an angel of mercy.

So Be It

I never had that much of an audience.  When I started my first blog in 2006, I would be overjoyed if my site meter counted over ten visits a day.  So I was used to being a quiet, if not lonely, small voice in the vast Internet.  Occasionally a kind word was proffered, criticism was rare.  From time to time, I would publish on a controversial topic, and then the fangs would come out.  A series of posts on physician assistants and nurse practitioners received a number of lowbrow assaults on my character.  But I accepted this as part of the process.  Sometimes there are casualties in the war of ideas.

When I started utilizing twitter, there was an uptick in my following.  I got even more attention when my posts were reprinted on KevinMD.  I realized quickly that along with exposure comes an increase in criticism.  Again, being a mature adult this was nothing that I couldn't handle.

I have said in the past that I live in a world of words, but actually I was inaccurate.  In reality, I live in a world of ideas.  Ideas that often come so fast that I am rushing to place pencil on page (fingertips on keyboard).  Translating emotion and the world of imagination to physical form is awkward.  Ideas are transient, the markings on the computer screen are more or less permanent. 

I have never professed myself to be grammarian or a spelling bee wizard.  So when I started to get blog comments correcting my posts, I took little notice.  You can assume that if it was missed by the spell checker, it was missed by me.  No harm, no foul.

Recently a commenter on one of my posts on KevinMD wrote:

I don't want to seem rude or condescending, but is this post a joke? A physician wrote this borderline illiterate and inaccurate essay? Typos happen and are just human. But this is egregious. Publishing a piece like this, riddled with the most elementary spelling errors ( "vane" instead of vein, "message" instead of massage, "bored" instead of board) and ridiculously mixed metaphors ("And like a blind man whose cataracts had just been removed, I once was lost but now couldsee.")seriously diminishes the credibility of this otherwise wonderful website.

I take this statement personally.  I thought about trying to explain how I am a full time doctor, father, husband, and owner of a number of small businesses.  Or tell of how I only have an hour to write each day.

These are just excuses.

I could write less frequently and spend more time editing.  Or maybe writing for the public is just an act of futility in the first place.  I could stop.

But that wouldn't make me happy.

I write this way because the maddening stream of emotion, jubilation, anger, and hurt come so fast that I fear pausing will result in a missed opportunity.

A commenter once noted that my spelling errors will detract from my message.  He lamented that many would stumble on semantics and miss the importance of the post.

My reply is simple.  I am who I am.  When you read my blog posts you see me: scars, blemishes, misspellings, awkward analogies and all.  I'm far from perfect.

If that makes you want to close your browser and never return to my blog again,

so be it.