Parachutes

We all wear one.  Maybe you can't see it under our lab jacket.  But if you look closely, you'll spy the outline of a bulge on our backs.  If not physically, you'll notice the weight metaphorically.  Shoulders bend forward as if craning under a satchel of bricks.  Maneuvering becomes anything but effortless.

And we fly through our days, careening between sickness and health.  The obstacles in our path are many, and the detours are often unexpected.  Occasionally a frightening gust knocks us off course.  We swear this time we're going down.  We finger the ejection button and grab for the cord on our pack.

Yes, we all have a parachute.  The dirty secret we tell ourselves when the darkness gets too great.  The voices are always bubbling under the surface.

I can leave this place. I can leave!

The bottom of our desperate pit is lined with hope.  Physicians can do many things besides practice medicine: research, consulting, chart review.

Go ahead, pull the cord.

Yet often when we are in greatest peril, our motion is sluggish.  We spin into a nose dive as we pull up on the controls.  The ground accelerates even as we move our hands away from our packs and cover our faces.

We do not eject.  We do not save ourselves.  We do not deploy our parachutes.

Instead we crash to the ground, our bodies and souls shattered.  We pick up the pieces one by one, recreating a likeness, a shadow of what use to be.  And we return to the cockpit.

Hollow.

Broken.

A Review Of @louiseAronson A History of the Present Illness

I mean, she says it right there in A Medical Story on page 240:


Doctors, you see, aren't so different from patients. Every day we hope someone will see past our elaborate and very impressive window display to the jumble of expired products weighing down the shelves and choking the aisles of our psyches.

But let me digress for just a moment.

If your in search of fantastic literature (Yes, I said literature and not a series of stories told by a physician) than A History of the Present Illness is a must read. Does Louise really have time to doctor? If her writing wasn't fraught with such an accurate and profound understanding of what I have experienced, I would surely question whether one who has spent an inordinate amount of time learning how to be an MD could emote so eloquently.

There is so much good here.

The characters explode with humility and complexity like Quingshan in Snapshots From An Institution, who loyally protects his ailing wife and yet adapts to the ways of his son and their new country.

Like in the stories title, Heart Failure, we gasp for air with Marta stuck between the death of a father and the blinding pain of parenthood.

And don't let me get started on language and imagery. Go to Twenty-Five Things I know About My Husband's Mother and read number twenty five.

OK...now breath.

But let me return to the quote that I started with. Louise, in A Medical Story, talks about the process of writing the book:

For my sake, I have to downplay some aspects of my professional and personal lives. The heartbreak and incredible sex, for example, but also the joy. In real life, there was more of it. In real life, if you're as lucky as I have been-with work that is long on characters, drama, and significance-there's always more joy.

This is where I actually disagree. Because even in the dark corners of this collection there is much joy. Many of the physicians are flawed: the psychiatrist's wife who tries to deaden her insides and her clinical husband, or the great Dr. Bautista and those nagging fears that he refuses to acknowledge.

But in that imperfection, in that diseased part of ourselves we become closer not only to our patients but also the kind of doctor we were before life and medical school tried to obliterate the luxurious softness.

Every day we hope someone will see past...

I have come to believe that joy is shared imperfection.

Joy is the "inappropriate" kiss that the brave "Dr Chitra" gave Maurice before he died in Soup or Sex.

Louise Aronson played a funny joke.

I had no idea the title of the book referred to me.

A Tale Of Two Cities

It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity

The woman lying on the gurney was motionless.  Her chest moved up and down with a timid but halting regularity.  The calmness of her face was in sharp contrast to the panicked despair of the man sitting next to her.  He clutched at her brow as he mumbled into the phone incoherently to his a son who was waiting in line at the airport.

The ER physician entered the room and waved away the phlebotomist who had been maniacally tenderizing the poor patients arm looking for a new IV sight.  A crash cart stood ideally in the corner waiting for an overzealous hand to break the seal of the intubation kit.

The young doctor pulled up a chair and waited for the frantic man to hang up the phone.  The CT showed that the cancer had spread into the lungs, and possibly invaded the precious pericardial sack surrounding the heart.  Surprisingly, it was even worse then the scan done just one month ago.

The man looked lovingly at his ninety year old wife.  Their doctor had said that maybe if she could gain a little weight and lift herself out of bed...

We have an experimental chemotherapy that has shown much promise.

No one ever mentioned supportive or palliative care.  No one talked about DNR.

*

It was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair

The man lying on the bed seemed unaffected by the morning light flowing in through the bedroom window.  His skin was ashen and his mouth remained open as the air barely rushed past.  He was in no pain.  His arms were clean and unburdened by the scars of medical care.

His family and friends gathered in the living room.  His children and grandchildren had flown in a few days before.  FMLA papers had been signed and submitted. 

It wasn't  a surprise.  Weight loss and weakness accompanied months of conversations.  The doctor set up family meetings.  The man had spoken his mind for all to hear.

No tests.  No hospitals.  Just make me comfortable.

For some, eighty years isn't old.  For others, it's a lifetime.  The doctor seemed unconcerned with the lack of a diagnosis.  With the specter of procedures and cat scans on the horizon, a patient took a stand and made a decision.

The important people were notified.  Plans were made.  Hospice was consulted.  And a life, a proud life, slipped away quietly on sunny winter morning.

We had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way

In short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only.

The Alzheimer's Repeat

Doctor, doctor?

The elderly woman stands in front of the barrier that separates the dementia unit from the nursing station.  She accosts me repeatedly after our short conversation and exam.  I have ten charts piled in a stack on the desk in front of me.  Each time I try to concentrate the voice yanks me to attention. 

At first I am zealously accommodating.  I answer over and over again.  But eventually, even I become a victim of the Alzheimer's repeat.  No matter how many times I respond, she will be back again.  I turn my head to look for a nurse or CNA to distract so I can finish. 

The hallway is desolate leaving just me and the needy patient that I am ruthlessly ignoring.

Doctor, doctor?

The young secretary behind the counter jumps as I walk through the door.  My blue tooth is engaged, and I am finishing a conversation with a floor nurse when the call waiting goes off.  My first patient is already in a room.  I need at least ten minutes to take off my coat and hat, and boot the EMR. 

She has some urgent issue or another.  A question about an overbook or perhaps a patient waiting for a script.  Overwhelmed by too much input, I wave my hand in a nonsensical gesture that only a mind reader could interpret.

She races out from behind the desk to follow me to the office.  My pager starts to buzz as I hang up the phone and slip the blue tooth off my ear.  She pushes a tablet computer towards me and mumbles something about signing for drug samples.  The rep has been waiting for a half an hour.

Doctor, doctor?

My head is so buried into the computer that I almost don't hear the pleas coming from the exam table.  The damn eprescribe function is on the blink again, and the whole thing is frozen.  I look up and lock eyes with the agitated patient who is clearly more concerned with his abdominal pain than whether I meet meaningful use or not. 

I ditch the computer, sit back in my chair, and take a deep breath.

F**k meaningful use!

Daddy, daddy?

I breeze through the door and drop my bag at the entrance. 

All day my attention is being fought for. 

I transfer the call on my mobile to voicemail, and look up with the warmest smile I can muster without faking it.

Yes honey?

Who's Your Daddy Now?

I have nothing against the patient empowerment movement.  In fact, I think an informed and collaborative partnership is mutually beneficial.  But I can't help but laugh when I read some of these tweets.

Death to paternalistic medicine!
The age of paternalistic medicine is over!

True, the era of doctor knows best is long gone.  But it's a mistake to think think today's health care consumer has any more leverage than before.  It just seems that way.  The reason is that the strings are being pulled, and the levers are being switched in a slightly more diabolical way.

If you want to know the root of any modern problem, either follow the money or follow the power.  You think you have control over your health care decisions, but in reality, many are being made for you before you even step foot in the office.  You see, your options are being whittled long before the exam room door is breached.

Want to spend thirty minutes talking about end of life care?  Good luck.  The government has deemed that doctors shouldn't get paid for such conversations.  Guess who will try to avoid them at all costs?

Want a PSA test?  Well the USPSTF has deemed that they are not beneficial (which I agree with by the way), and eventually Medicare and private insurance will refuse to pay for them.  Most physicians will avoid offering such tests if they are going to be dinged on quality and cost efficiency metrics.

You just had a heart attack and your cardiologist thinks you need a defibrillator.  Not so quick.  You'll be offered a defibrillating vest first until you wait a certain number of months, unless your doctor wants to get investigated by the department of justice. 

It's not that I don't agree with some of these decisions.  Some make sense.  But don't think you have power to control your own destiny.  What once was the purview of your trained doctor has fallen to an array of nonclinical and barely clinical administrators in Medicare and private insurance.

So empowered patients of the world might just want to ask themselves a basic question.

Who's your daddy now?

Gifts Given And Taken Away

It was a striking piece of porcelain.  I admired the craftsmanship, and turned it in my hands as if the rotation could recreate the expertise of the potter's wheel.  I gently placed it back on the desk, and looked up at the women sitting on the exam table.  

She wanted to thank me for saving her husband's life.  I averted my eyes towards the floor and blushingly scolded her.  But we both knew it was a half hearted attempt. We both knew that I indeed had saved his life after a series of miscalculations by other physicians.

And I couldn't help but think of other offerings proffered by those who entrusted their care to me.  The various trinkets and bobbles during holidays, at the end of a long journey, or just to say thank you.  Could I not help but feel guilty?

Over the last year, I've cut my hours in half.  Yesterday, I directed my office manager to cancel all appointments on Thursdays.  I've decided I'm going to stop accepting new medicare patients.

It's not that I don't enjoy practicing medicine.  But it seems like I have become a puppet.  The puppeteer pushes gently on his wooden cross and my head turns away from the patient and is buried into an unforgiving electronic mistress.  I lift my arm and an invisible string stops it mid motion.

It is only when I abandon patient care that I am free from the ties that bind.  My skills are appreciated in other nonclinical realms.  Why would I stay?

I've worked hard at mastery.  I've spent years studying the appropriateness of care.  I do not check PSA tests.  I rarely give antibiotics for upper respiratory tract infections.  My patients die in hospice at home, not in hospitals.

Yet the brutality of health care reform does little to differentiate.  Those laws made to menace the inefficient effect both the best and the worst of us.  How many bystander causalities will we suffer?  Yet these same bodies that scold us have never even produced a sufficient method for conscientious individuals to measure against.   

Medicine is quickly losing its joy.  As the day of reckoning draws near,

who will be left?

The More Things Stay The Same

Yesterday morning as we were lounging around the house lazily, my wife had an epiphany.

Let's go ice skating!

The kids excitedly scurried around the mud room gathering gloves and scarves.  While confirming the open hours at the rink, she also reminded me that somewhere hiding in the house was an old pair of my father's skates that my mother gave to me a decade ago.  My father, now dead for over thirty years, loved ice skating.  Admittedly, I had once enjoyed the sport as a child.  But my skating days ended prematurely at the age of eight following his death. 

My own children have brought me back to the ice.  From time to time, we skate at a birthday party or other such event.  Until now, however, I had forgotten about the pair of figure skates that lay dormant somewhere in the house.  I spent the next thirty minutes searching high and low.  It was only after exhausting every last storage spot, that I peered into the crawl space in the basement and found them sticking out of an old frayed box.  I dragged them out and tried them on.  Of course, they fit perfectly.

Thirty minutes later, I gently glided onto the ice.  My shoulders tipped backwards and I almost fell.  The part of the body that physical therapists call the "core" is particularly underdeveloped in me.  Muscle memory finally kicked in, and I was swooshing at a better pace.

The irony wasn't lost on me.  The fact that my father's size ten skates fit me perfectly.  Nor that I entered the same profession that so defined him.  I live in a red brick house just like the one of my childhood.  In the same city, I skate on the same ice that he probably skated on some thirty odd years ago.

After all those youthful struggles to define my unique contribution to this world, one fact remains starkly clear.

I am my father's son.

My children skittered past with smiles on their faces and the wind blowing through their hair.

And maybe, that's exactly how it was meant to be.

Blink

I can almost hear the laughter in his eyes as the skin wrinkles into bunches around the cheeks, and his lips turn upward into a smile.

But you are so young!

Indeed, what is forty to an octogenarian?  One recalls the infantile wanderings of childhood.  Only the decades can mold experience into wisdom and understanding. The contrasting elasticity of the skin mocks the fine tuning of the senses.  I watch as my muscles grow limp, and my waste line bulges.  He remembers such foibles as firmity in comparison to the total loss of turgor.

I have a young man's thoughts and aspirations.  I bend to the folly of a young man's dreams.  For me, there is never enough time.  For him, his schedule may be uncluttered, but he is also a slave to the finite.  He moves slowly.  Talks slowly.  He pauses and thinks before opening his mouth.  He has experienced the worries that tumble through my mind.  He knows.

He knows.

Waltzing through the door after a busy day in the office, I pause in the entry way.  My son is building a tower of Legos clear to the ceiling.  He moves with the swiftness of youth.  His body lean and muscular, he learns mastery through physical dominance.  He notices me out of the corner of his eye.

Daddy, I'm going to make the largest building ever!

He is linear.  His exuberance is the fuel that powers the imagination.  If it can be thought, than it can be done. 

I shake my head and nod approvingly.  He tries to be an adult already.  I can't help but mouth the words so recently slung in my direction.

But you are so young.

I can still hear the old man's guffaws as he clanks out of my exam room with his walker.

Not for long my friend. 

Not for long!