The Sun Will Rise

My Daughter was afraid of the dark.  So she climbed in bed with my son and he read her a story.  As he closed the book, he realized that she had fallen asleep.  Like any sweet, kind older brother, he wandered off to her room and crawled into the unoccupied bed.

Chaos, of course, ensued at three in the morning when my daughter awoke in the wrong room, and grasped for her absent teddy bear and blanky.  It took Katie and I fifteen minutes to calm her down.  I barely closed my eyes before the alarm clock blared.

Four forty five on a Saturday morning. 

Thirty minutes later I was closing the door, and striding toward the garage.  Four admissions to three different nursing homes last night.  One of which was spiking a fever to 102.  Another patient tucked into the hospital yesterday afternoon.

The roads were less quiet than you would expect.  The sun had not yet risen, and most of the store fronts on Central Street were hidden in shadows.  I stopped for a red light at the same corner which I always seemed to time imperfectly.  To my left, a beacon of light emanated from the bakery.  Inside a middle aged man bustled to and fro directing four or five others. 

Every morning I marveled at the hurried flurry of activity.  The bakers and I, the only souls in the universe silly enough to be rushing around at such an hour.  The owner kneaded dough relentlessly while his workers lifted, carried, stacked, and arranged.  Although the light already turned green, I lingered a moment to watch before pressing down on the gas.

The patient at the nursing home had stabilized, her fever was gone.  On the way out, I grabbed a few pens and a reflex hammer for the kids.  They always enjoyed such little trinkets.  I stopped by the hospital and eventually landed in the office. 

Saturday morning clinic is refreshingly slow.

Sometime between patients, Katie called to tell me to meet her and the kids for lunch.  I finished my paperwork and shut down the computer.  The afternoon sun was a stark contrast to the somber morning haze.

Passing by the bakery on the way home was a different experience.  It failed to stand out under the glare of the sun.  The middle aged man was now helping customers.  The store was no longer clean and tidy.  The remnants of heavy foot traffic had brought in the dust and dirt.  The loaves of bread in the display counter were either absent or jarred to the extent that they no longer sat neatly in the case.

Time will pass, and the store owner will gray and his movements will slow.  Driving by from day to day, the changes will be so subtle that I'll probably not even notice. 

My children will grow up. 

In the brief moments alone before I park the car and jump out to meet my family, it hits me that this is a life. 

The sun will rise.
The bakers will bake.
And I will father.

And doctor.

In The Midst Of Tragedy

At first it's a little daunting.  A friend or colleague approaches you to take care of their parent. You pause for just a second before accepting.  Do you really want to get involved in this person's life?  But it is a compliment after all.  They are entrusting the well being of their loved one in your hands.

You tread lightly.  You spend extra time teasing out the symptoms.  You explain each diagnostic test and medication.  Days or years go by. Usually they get better, sometimes they don't.  But eventually tragedy ensues.

And you're calling your colleague or friend in the middle of the night.  You don't mince words, you tell them the end is near.  Physician to physician, friend to friend, there must be a level of truth and certainty. 

The appropriate orders are written.  Morphine and ativan.  Hopefully you can avoid the IV's and diagnostic tests.  While looking into the teary eyes of the family you again question whether you should have gotten involved.

The truth is, you will honor your friendship.  You will bath their relative in a cocoon of loving care.  Because you owe at least that much.  Because you will do it better than others.  Because you will be there to comfort and explain patiently in the midst of tragedy.

We do these things for acquaintances.

In fact, we do these things for complete strangers also.  Every patient eventually becomes like family.  We care for them as if their sons and daughters were our best friends.  We shower them with the best we have to offer because that is the covenant we make when we usher them through our exam room doors.

It's an intimate relationship between doctor and patient.

Even more intimate than with friends and colleagues.

Would You Do It All Again?

I suspect I would have changed anyway.  It's not just medicine, but life itself that distributes it's share of blows.  Battered and bruised, the body adapts. Unfortunately the mind also adjusts. The softer, more sensitive parts, are often the first victims.  We become hardened to the difficulties of reality.

There is no doubt that medical education is particularly aggressive.  The ego, like a scab picked over and over, maintains a solid exterior .  The skin becomes leathery and tough.  Our behavior subtlety changes.  A patient is quietly castigated or a child is allowed to whimper without the benefit of our empathic touch.  There is an attempt to assault the victim.  Instead of facing the difficulties and harsh realities of dumb luck, it's easier to cogitate blame. 

If they had just exercised more and eaten better!

There is an urge to cower and protect oneself.  In residency, many imagine that they are under siege.  They devise a plot where the world is out to get them.  The poor CHF'er in the emergency room on thanksgiving morning no longer becomes the wounded soul in need of healing, he becomes an agent of torture.

Those who read my writing will scoff.  They will say that I exaggerate, and point to the ideas expressed on this blog as proof. But I will counter.  Words on a page are much easier than real life. They are more safe and require less action.  I have known the coldness and bitterness that goes along with doctoring.  Accusations find their target on my chest from time to time.  And often they are deserved.

So it comes as little surprise that I paused when asked by the exuberant young college student if I would do it all again.  Her eyes scrunched together and her lips pursed in anticipation as she waited impatiently for my response.

Ultimately, the answer is yes.  But it's a calculated and often unsteady answer.  I would do it differently.

I would hold on to my idealism more tightly.

I would try not to protect myself so much.

Superman's Burden

I mean, your like superman.  You fly into the room with your white lab coat.  You might not bend steel, but you do something more important.  You save lives.  I wish I could do for a living what you do.

Superman. Hmm.  I guess it's been so long I forgot.  It use to feel like that!

Use to?  What happened?  Are you no longer a doctor?  You're a hero in my eyes.  There are so many people who wander around this planet aimlessly.  They bounce from job to job, firm to firm, and year after year they toil without making a shred of difference.  They touch not one life.  Their footprint is wiped away the minute they take the next step. 

It's funny how it stops feeling that way.  Sure, the first time you help someone, the first time you save a life there is a certain rush.  But you finish medical school and enter residency, and that rush disappears.  You may help hundreds, but it no longer feels special or different.  It just feels like your job.

Yet you become acutely aware of those times when you can't help, when your skills are not enough.  You suffer through every failure.  You remember every death until the day comes when there are so many that you can't possibly hold on any longer.  And then you forget.  The worst part is when a name disappears and all you have left is a face imprinted in the depths of your subconscious.

You don't blame yourself, do you?  You try your best.  What else can be expected of you?

The funny thing is that even superman doesn't feel like superman all the time.  I bet sometimes he wishes he were batman or wonder woman.  Sometimes he feels that there is a pile of kryptonite waiting around every corner.

And sometimes, he finds that helping an old lady cross the street is a heck of a lot more gratifying,

than the death defying acts of bravery that everybody expects of him.

Social Media's Fun House Mirror

I like to think that I would write like this anyway.  I like to think that the breath, depth, and quantity of my output would be the same regardless.  I always say that I do this for myself.  Of course, the occasional comment and retweet are gratifying.  Can you blame me for basking in the joy of being heard?   But there is a certain danger in notoriety.  When does hoopla replace the primacy of the writing process?

I have started and stopped a million times.  The record laid forward in my blog history is marked by periods of great productivity interspersed with vast deserts of low yielding crops.  The ebb and flow of my emotion crests and falls with motivation.  I write and write and write, then stop.  These dry periods can last days or years.  There's no way to tell.

Never in my life have I produced as consistently as in the last year.  Never have I blogged so much.  When I look back at the last three hundred posts, I feel great pride.  Some are better than others.  Some have barely been read.  But they all are an accurate reflection of who I have become (spelling errors and all).

I don't know how long this fruitful period will last.  Maybe I will push the publish button and disappear for a month, maybe not.  Your guess is as good as mine.

The one thing that is abundantly clear, is this period began when I linked my blog to Facebook and Twitter.  Is it a random coincidence?  Or has the process of social media altered me.

I look into social media's fun house mirror.

In the reflection, I see the writer I was so hoping to be.

But better.

Without Succor

If my car was ninety years old, I would have thrown it away a long time ago.

She speaks nonchalantly as she appraises the wrinkles that bunch together on the back of her hand and collect at the base of her knuckles.  The skin hangs from her once muscular biceps.  She is neither bitter nor sad.  Acceptance oozes from her brow like the drops of sweat that collected during her labored walk into the office.  She is tired.

We talk of her shortness of breath.  Even as I offer a plethora of tests to draw back nature's curtain,  she shakes her head quietly.  For her, the betrayal of the body is simply the unassailable progression of tempermant.  She would no more try to fight it, than attempt to manually disassemble the second hand of a clock. 

Time passes regardless of whether it is measured. 

She will slip away delicately.  Inch by inch, pound by pound she will succumb without succor.  There will be no protestations, and no proclamations.  One day the phone will ring and I will be informed that she is gone.  Likely, found cold in her bed by a neighbor who noticed the mail piling unnaturally at the front door.

And as she hobbles out of the office, I can't help but think there is some important lesson to be learned.  Why do some die angry, regretful deaths while others pass gently without fanfare? 

It is said that we die as we live.

And we live as we die.

Room 2413

I could've sworn the hospital operator said room 2413. But as I wandered the halls, a perplexing look came over my face.  I searched above each door: 2411..2412...2414.  I stopped a smartly dressed nurse rushing past with a cup full of pills.

Where's 2413?

She laughed, and called over her shoulder as an after thought.

There's no 2413, 3413, or 4413 for that matter!

I started to protest, but it was too late.  She was long gone.  And the truth was, I didn't need an explanation.  How many buildings skipped from the twelfth to the fourteenth floor?  How many room numbers had been intentionally changed?

It was a myth.  Superstition and folklore permeated even the most holy of scientific grails, the hospital.  As an institution we failed the most basic test of identity.  And I started to wonder what other myths pervade our culture.

This won't hurt a bit!

How often do we knowingly mislead or water down the truth? Furthermore, how do we justify this charade in light of the dictum "to do no harm"? 

Sadly, I think the answer reveals the worst kind of ugliness.  We would rather defer to ease, than accurately interpret the reflection in the mirror.

Don't worry, we'll do everything!

Because the truth is much more difficult.  Patients die regardless of the room number.  The procedures we perform are often hurtful. 

And "doing everything" can be more than just dangerous.

It can be cruel.

I Forgive You

Staring into the tiny mirror perched above the bathroom sink, he started his morning in the same fashion he had done every day for the past thirty years.  He winced from the splash of aftershave on his face, he straightened his bow tie one last time, and he studied his own steely gray eyes in the reflection in front of him.  His lips barely moved as he softly pronounced the words to no one in particular.

I forgive you!

The drive to the hospital took less than five minutes.  The walk from the doctor's parking lot to the physician's lounge was half that.  He picked up his lab coat from the hanger next to the mail boxes and rushed up the stairs to see his first young patient. 

Matt was just a teenager if calculated in years.  But in view of his multiple rounds of chemotherapy and failed bone marrow transplant, he had traversed several long and difficult lives.  And even in death, he evaded the immaturity and self centeredness of many of those his age.  He had one last request of the doctor who had navigated his medical care so expertly, to help explain his last decision to his parents. 

The family meeting lasted a full hour.  He left Matt curled with his mother and father on the hospital bed, and raced to the office.  The methodical pace of the clinic helped take his mind off the tragedy.  In each child's eyes he saw the pain that Matt suffered.  The pain he was still suffering.  And in each parental tone of concern he remembered the anguish of the two individuals whose hearts were breaking at the very moment.

By the end of the day, Matt's situation worsened.  Countless family members huddled at the bedside.  On the desk lay a school yearbook with signatures and well wishes written in bubbly and careless lettering.  He sat at a distance fingering his bow tie and clearing his throat from time to time.  Years of experience had taught him that it wasn't words that families sought at such difficult times,  it was the mere act of being present that brought comfort.

He ambled home at eight o'clock.  His wife had left dinner for him on the stove.  He sat quietly and picked at the food as he leafed through a throw away journal his beloved placed on the table.  He wasn't particularly hungry.

The call alerting him of Matt's death came in the early morning hours.  He fumbled while putting the phone back on the receiver in an attempt to spare his snoring wife from the inconvenience of her husband's chosen profession.  He woke up a few hours later without the benefit of an alarm clock.

He bounded out of bed.  He brushed his teeth, shaved, and took a shower in usual fashion.  He winced from the aftershave, and straightened his bow tie.

I forgive you!

A younger man may have been repenting for his own imperfections as a physician.  An angrier man may have been letting his patients off the hook for the intense frailty of the human condition.  But a wise man, he had long outgrown this type of immature frivolity

No.  He was absolving the universe of such random and abject cruelty.  He was purging all malice toward a higher being who could allow Matt and his parents to suffer so.

For him to continue, year after year, in a profession that inflicted deep wounds,

he had to lay his burden down.

It was a large heart with lots of hearts growing smaller inside, and piercing from the outside rim to the smallest heart was an arrow. Momma said, “Sister, that’s right pretty.” Then she turned back to the Store and resumed, “Glory, glory, hallelujah, when I lay my burden down.” *




*When I Lay My Burden Down , from I Know Why the Caged Bird Sings, Maya Angelou

A Day In The Life

My cup runneth over.  No, really, my cup runneth over, and over, and over!

I spent a few hours sitting in on a meeting for the board of directors of a local home health company.  I listened intently as the discussion turned to strategies for dealing with medicare's 2013 readmission rules.  Most home care companies are positioning themselves to woo local hospitals with promises of tighter care and lower rehospitalization rates. The discussion ended with an invitation to Las Vegas.  Vegas?   Who has time for Vegas?

Next, a stop at the nursing home for a pow wow on our palliative care program.  We have assembled a group of nurses, social workers, and recently added a psychologist.  While the program is up and running and serving our patients, what we really need is to codify the data.  What impact has the program had?  Are pain scores better? Is satisfaction higher?  And oh by the way, could I cover hospice consults at the local hospital next week?

After rounding on half a dozen patients and doing a few new palliative care consults, it was off to the post office to drop a copy of my book in the mail to someone who had bought it over the Internet.  Then I had a few minutes to start to prepare for my upcoming grand rounds at the Carolinas Medical Center on social media in October.

Did I mention that I had a blog post that was itching to be written?

I spent the afternoon seeing patients in the office.  It was a slow schedule-just a few late Friday stragglers.  But I felt a certain joy in the process.  I concentrated on each patient.  I took the time to address every concern and fear.  I made sure they walked out of the office satisfied.

What a great way to finish the week.  This is why I went into medicine.  The buzz of my pager reminded me that I had one more admit to see in dialysis,

before returning to my family and ushering in the long awaited weekend.

Fierce

She must have stood at least six feet tall.  Walking past me in the parking lot towards the breast center, I couldn't help but solicitously stare.  Her sinewy torso caused ripples in the abdomen of her t-shirt.  She was elegantly thin.  One would never have used the word gaunt.

Her jeans clung to her body like a glove.  Her strides were long and confident.  Maybe a touch of midriff was showing.  I dared not look too closely for fear of being discovered.  She was ageless.  At first I thought youngish, or possibly middle aged?  She defied classification.

She walked with the apathy of a model, and the decisiveness of a warrior.  There was no doubt her taut muscles were contracting towards battle.  She led with her chest, supporting the swan like elongation of her neck.  Her head was perfectly perched atop.  Her recently shorn scalp added to the sleekness of her sculpted facade.

The timber of my voice humbled, I mouthed the word in an anemic attempt to be heard.

Fierce.

This wasn't a woman to be crossed.

Certainly not by a self indulgent doctor,

nor some trifling cancer.

Efficiency, Value, And Unexpected Consequences

I bounded down the stairs of my office to the cafe on the first floor of the hospital owned building.  I could taste the early morning coffee before it even touched my lips.  I charged right to the front of the line, and handed over my credit card. Already familiar with my order, she swiped away and handed it back to me.  A few steps later, I was standing at the coffee station.

Something was strangely wrong.  The cascade of various sized cups was still resting by the beverage dispenser, but the sugar was all the way on the other side of the counter.  I shuffled over to get a few packets (which is always my first step).  I shook vigorously, than tore off the tops of three at once.  I gently shook downwards and waited.

Then it hit me.  The little hole in the granite for trash was gone, or at least covered up.  I crinkled the waste in my hand and secured it between my pinkie and ring finger.  Unperturbed, I reached my arm out for the half and half to no avail.  It took a few seconds of searching to realize that it was across the room in the refrigerated section.  I carried my cup in my left hand, my trash in my right, and paused as I tried to figure where to set my cup to pour from the decanter.  There was no flat surface.

Finally I walked back to the coffee station and pumped the nozzle.  Later, I fumbled with the sleeve which was stored in a particularly awkward place, and spilled my coffee on the counter when I reached up to grab the stir.  Lastly, I collected all the trash and walked around the corner to throw it away.

Thoroughly discombobulated, I sauntered back to the register and caught the woman's attention.

Who messed up the coffee station?

She stared at me for a moment, and then peered cautiously over both shoulders before speaking.

The hospital sent some kind of efficiency expert over yesterday.  He changed everything.

Although nonfunctional, apparently the display now looked more appetizing.  Plus, by making the cream and sugar less accessible, the cafe was expected to save thousands of dollars in supplies.  Ditto for the awkward placement of the stirs and cup sleeves.

As I walked towards the stairs, I looked one last time at the my beloved coffee station.  Trash had collected on the counter because there was no where to dispose of it.  Puddles of liquid had accumulated from knocked over drinks.  And a line of people had formed at the register, waiting for the poor employee who had left her counter to clean up the now unkemt beverage area.

I shook my head. I figured any money saved on sugar and cream was being lost on cleaning supplies and wasted napkins.

I settled into my morning routine, but couldn't shake the feeling that something was wrong.  I sipped on my coffee and enjoyed the pleasant taste and woody aroma.  I was seriously thinking of going to Starbucks next time instead.

I entered the exam room to find my first patient anxiously clenching the exam table.  Before I could open the chart, he began to sputter.

Doc, my chest is really hurting!

I half listened to his complaint through the fog of my disruptive EMR.  When I went to open his chart, an annoying pop up window wouldn't let me proceed.  I cursed my front desk employees for failing to follow the meaningful use questionnaire, and interrupted the patient as he was repeating himself in an even more forceful manner.

I'm sorry, I have to fill out this field before I am allowed to continue.  Could you just answer one quick question?

What race do you consider yourself?

9/11 Repost

My dream is always the same.

It’s just another day in hell. I stand on the Bone Marrow Transplant unit. There are no windows. Suddenly the building starts to shake. The ceiling cracks letting in rays of sunlight. The ground rumbles below.


Sadness, grief, and despair spew from the floor. They rise as black lava erupting from the innards of the building and drag me to the street. I am swept forward as black death encompasses the earth and moves to envelop the sun. It carries me to the east…..always to the east.

*

I've never thrown a punch. Never been in a fight or carried a gun. So if you ask me what it is like to do battle…I only have a limited set of experiences to draw from.

I did, however, catch a glimpse of the desperation of war during residency when I spent a month in the Bone Marrow Transplant unit. I felt continuously under fire, attacked from all sides, desperate. I experienced death every day.

It wasn't just the elderly...it was also the young. Mothers, fathers, children…no one was spared!

*

The Bone Marrow Transplant program during residency was large. There were fifty patients on the unit and then twenty to thirty scattered amongst the oncology floors.

We had ten admissions a day and the same number of discharges. On average one patient died every 24 hours.

The job of taking care of these patients fell on two fellows, two residents, one attending physician, and countless dedicated nurses.

There are many beautiful life affirming stories that occur on a Bone Marrow Transplant floor.

This is not one of those.

*

I remember my last day on the unit. I spent the morning avoiding ambush. There were no codes. All our patients survived the night.

I stepped into Mrs. P’s room gingerly. Mrs. P had been in the hospital for over 6 months. She had a stubborn lymphoma that persisted despite treatment. She knew that she would never return home.

She knitted every morning as she watched the news. As with so many patients, our conversation moved from cordial greetings to a discussion of world events. I went through the motions of my examination as she recounted the most recent atrocities. They were particularly horrible today.

We did this every morning. She telling me who recently died, or was killed, or robbed. And I feigning interest although in reality I had lost touch with life outside the unit. The world could fall apart around me but I was too busy…scurrying after labs, running codes, talking to family members. Secretly trying to protect myself from the death and destruction that surrounded me.

If you listened closely to the discussions that we had every morning the essence of what was said would sound something like this:

“Doctor, I watch TV and see that in the world things are happening, and I am still here”. And dutifully I would respond, “yes, yes, bad things are happening in the world and yet, thankfully, you are still here!”

Mrs. P’s days were limited. And my days on the unit were almost over. I worked 12 hours a day, every day, for a month. My time at home, in-between shifts, was surreal. I would sleep, eat, have conversations. Mostly exhausted bridges to my next stint on the unit.

I had become a robot, a zombie.

I was withdrawing.

*

It was just another day in hell.

I sat down for rounds that morning. Mrs. P was right...things were happening in the world and strangely I couldn't’t relate. The TV above us was blaring the latest news. My attending was sitting down with his daily Tab and being prepped by the other residents.

The hum of the nursing station had reached a fevered pitch. I glanced at my progress notes and realized that I forgot to add the date and time. I looked at the clock on my pager:

10:45 AM

09/11/01

The world had instantly changed.

And it would take a good deal of time and spiritual healing to realize that it wasn’t just another day..

of death and destruction on the unit

Is Your PCP A Palliative Care Practicioner?

I wouldn't call myself a palliative care expert.  I kind of happened into the job.  The nursing home had a need, and the local hospice/palliative care program didn't have the available staff.  I had always been good at handling end of life and pain issues, so I stepped up.  Of course, there are finer points that I could have learned in a fellowship program.  I don't want to pretend that my qualifications are anything other than what they are.

But one must beg the question.  Why aren't all internists and family physicians palliative care practiticioners?  Don't we strive each day to alleviate the pain and suffering that walks into our exam rooms?  Does it matter whether the cause is a broken arm or a metastatic cancer?  And since when do we farm out end of life discussions to someone else?  Someone who likely doesn't have a longstanding preexisting relationship the way we do. 

Primary care has become a conveyor belt.  We are no longer the chief operating officers.  We have become the chief test orderer, chief prescription writer, and chief specialist consulter. 

I don't think this is the way we planned it.  We never wanted to hand over our autonomy.  But difficult things take time.  Overrun by an ever decreasing portion of the financial pot, and consumed with the moment to moment needs of documentation, most PCPs learned to survive by increasing throughput.  Skimp.  Delegate.  Move'em in and move'em out.

We let someone else handle the time consuming difficult conversations because we couldn't afford to do it ourselves anymore.

So what is the most important job of a palliative care specialist?  In my opinion, it's spending time with patients and families.  Real time, where long drawn out conversations take place on ethereal topics such as quality of life, individual choices, and plans for the future.

And of course we also talk about management of pain.

I tell my patients that they have other doctors to worry about their heart failure, cancer, and COPD.  I come to discuss their hopes and fears.

I have no other interest than their well being,

regardless of our health care systems current state of disease.

An Act Of Anticipation

We are motion. Finger tapping, knees shaking, continuous motion.  The rhythmic beat of the marathon heart propels the legs in constant flux.  The intensity of modern life grabs us by the scruff of the neck and thrusts into each new day. We over eat, over exercise, over work.  Running in countless circles the path often leads back to the starting point.  But the voyage is anything but futile.  Futility is stillness. 

And stillness is death.  Except in the movies.  In the movies, dying is kinetic.  First laughing, then crying, some hugging, and a head falls to the side as the music begins. Boom, boom, boom, the curtain drops and the credits role.

But I have seen death in it's myriad shades and forms. More often than not, it is anything but quick.  Instead, bodies lie almost lifeless in dark rooms with family members gathered in a semicircle around the convalescent bed.  The second hand meanders as the visitors wait and are haunted by the slow, motionless, disturbing passage of time. 

We are befuddled by the absence of initiation.  So entrenched in the act of powering up, we become cataplectic at the unfolding of a life.  Sometimes days pass.  The barrel is loaded and griefs trigger is cocked.  Waiting for death is an act of anticipation. 

It is always this way.  The calm before the storm.  The stillness amidst turbulence. 

One last moment to surface and take a deep breath,

before submerging in the deep dark ocean

Catastrophe

I was thoroughly enjoying my Labor Day weekend before I got the phone call. 

Catastrophic failure.

That's the term my office manager used to describe what had become of our EMR.  Prompted by the on call physician, she dragged herself out of bed early Sunday morning and came to the office to sort things out.  After a few hours of phone calls to the emergency support hot line, one thing became glaringly clear.  For little guys in small private practices like ours, there is no cavalry.  Apparently tech people take vacation too.  There would be no solution till Tuesday morning. 

Ahh...Tuesday morning.  The highly anticipated prize for taking a long holiday weekend was a barrage of phone calls, "emergencies", and unhappy patients.  On top of everything else, our new physician was starting that morning.

So I snuck into the office at seven am, and took stock of my surroundings.  I sat as still as possible in my chair, and basked in the silence that soon would evaporate with the unbolting of our front door.  Then I grabbed a pen and paper and dug in.

Unhindered by the computer usually tethered to my arm, I felt a strange sense of lightness walking from room to room.  I greeted each patient with a warm smile and sat down at the desk.  I forgot how much easier it is to make eye contact when your not staring at a computer screen.  Sure, I was at a disadvantage without all the information at my fingertips, but the freedom to concentrate on something other than the electronic paraphernalia that cluttered the exam room was quite liberating.

An hour into my schedule, I recognized a certain joy that I hadn't felt since back in 2003 when I started using EMR's.  It was the joy of concentrating every ounce of attention on my intended and preferred topic: the patient.

Needless to say, the problem ended up being as simple as a memory issue.  Before I knew it, the computers where whizzing and purring again.  With resignation, I abandoned my archaic writing utensils and palmed my computer.  I had a few hours of charting to re do. 

Kind of makes you wounder whether the computer glitch was a catastrophic failure at all. 

Or was it a glimpse, a taste, of what could have been.

When Bayed To Come

She didn't know me.  She didn't even know my name.  Yet the stethoscope and gray coat somehow crashed through her tangled demented brain alerting her that I was a physician.  She sat enthroned in a wheel chair across from the charting station at the nursing home.  Her clothes were spattered with dried food, remnants of a half eaten breakfast. Like Medusa, her eyes shot daggers, petrifying me.

She waited anxiously for the nurse to leave the station before spewing her venom

Doctor!  Doctor!  Why don't you help me?

I looked at my watch.  It was only a few minutes before my clinic across town would be starting.  I had already entertained her complaints a number of times.  I had put down my chart, stooped next to her patiently while she harangued me with a series of questions having nothing to do with medical care.  She wanted to know where her daughter was.  She wanted to know who had stolen her car (she hadn't driven in decades).  She wanted to know why I hadn't visited her more often (she was not even my patient!).

Each time I explained slowly and quietly.  Each time she sighed and looked at me blankly.  But the moment I restarted my charting, she was at it again.

Doctor!  Doctor!

Eventually I turned and left, despite her shrieks following me into the elevator.  As the doors closed I felt an overwhelming sense of relief.

*

People often tell me that their doctors don't listen to them.  They say that they beg for attention and are ignored.

Yet I find that hard to believe.  Even the haggard, confused cries of a floridly demented octogenarian are enough to rip my heart out of my chest.

How does one not respond when bayed to come?

A Year Of Twitter

This month is an anniversary of sorts. About a year ago, I joined Twitter.  It started when I noticed that after a few of my blog posts were tweeted, my stats climbed.  Thinking I could build a larger readership, I jumped in. 

I took the first steps with trepidation. I signed up for NetworkedBlogs which simultaneously announced my posts on Twitter and Facebook upon publication. 

It took a few days to understand Twitter lingo. At first I struggled to re post others content, or to reply to a particularly poignant post.

As time went on, I found a group of people to follow.  And magically, some found me.  I continued to blog as before, but my audience had deepened.  Maybe I could reach a  few hundred, but a retweet from some well placed social media figure could expand the number by thousands.

I met some important people.  I scored a writing assignment.  I was interviewed. 

The changes were subtle.  I never wrote that sentinel post that made me famous nor learned the trick to having endless followers.  Although there were no publishers or consulting gigs waiting in the wings, my writing became more expansive and prolific.  I wrote about medicine, health care reform, and life.

I learned that my spelling is atrocious and my grammar sub par.  I also learned to forgive myself for such inadequacies.

The funny thing is that unexpectedly, twitter gave me so much more than I asked of it.  I should say that I have never felt a part of something greater.  Unswayed by religion, unmoved by high school spirit, and disconnected from university loyalty, I always pictured myself somewhat of a loner.  But all of the sudden, I became part of a community.

I belong to a helter-skelter group of physicians, nurses, therapists, advocates, pharmacists and others who fall under the big tent of health care social media. Some are writers, others commentators.  We are connected not by physical closeness but a tenuous electronic signal that whirrs through the ether and lands squarely on the face of our mobile phones.

We dig deeper and create content to share with each other, waiting for the next great idea to surface.  Sometimes we laugh, others we cry.  We scream our opinions into the vast echo chamber and rejoice that somewhere out there we are being heard.

Standing shoulder to shoulder with humanity on any given day, it took the intangible, ephemeral world of Twitter to convince me.

I am not alone.

Home

I'm sitting in front of the granite slab table in the kitchen.  The house is quiet.  My wife sleeps soundly in the bedroom upstairs and the kids are at their grandparents.  We went to a wedding last night.  The sort where you really don't know most of the participants.  Yet we left well past midnight. The sun is now rising and my restless body has dragged me into the shower and down the stairs to breakfast. A bowl of cold cereal sits to my left side, and I tap at my mobile, browsing through my twitter feed.  Even my tweeps are lethargic on this still Saturday morning.

Ten years ago I moved into this house.  Katie and I painted nearly every wall.  I remember when we brought Cameron home.  Three years later, almost to the day, Leila arrived.  Over the last decade we have filled the four bedrooms comfortably, finished a basement, and done countless repairs and upgrades.  And at some point the wood and concrete, plaster and metal became a part of me.  Our roots intertwined.

I never got over my childhood home.  The home in which my father lived and died.  We inhabited that space thirteen years before my mom remarried and we moved to an adjacent community. 

At the time, the sense of loss was overwhelming.  Not necessarily the change in friends or school, but the safety and familiarity of the walls that surrounded me.

Years after leaving, I had the most vivid dream.  I was back in my childhood home. I quickly became aware of the fact that it wasn't real.  I knew I was in the throws of a deep sleep and that I would awaken soon.  So I consciously resolved to wander the halls one last time.  I surveyed each room carefully trying to recapture the depth and breath of emotional that each space held.  And then I said goodbye, and awoke to my present reality.

That's when I realized that "home" is not a physical place, but better yet a construct unwittingly created in each of our minds.  Maybe like deja vu it is the fleeting sense of familiarity but also laced with an overwhelming dash of safety and remembrance.

But somehow sitting alone in the kitchen this morning as the sun rises, I realize that these artificial barriers help frame me.  My love, my children, my countless books and pictures.

I am home.