An Act Of Submission

As I reached for the doorknob with my right hand, I had but one and only one impulse.

Run!  Turn around and run as fast as you can!

It's fair to say that being a physician requires a certain constitution.  When one deals in the currency of death, it becomes second nature to hold our heads high when others fall.  How else can we view the tortured realities of existence. The average life is chocked full of suffering.  People die tragically, unexpectedly.  Pain rips through the tender belly of humanity leaving us raw, and yet we stand our ground.

But sometimes it's different. Sometimes the guarded armour of the physician is pierced in just the right fashion to expose the glistening skin overlying the Achilles tendon.  We fall, mortally wounded but unable to close our eyes.  It is in these times we learn to hurt all over again.

It is in these times, you either shield yourself, or open the door and let the pain run right through you.

I choose to open the door.

The act of writing about what hurts usually soothes me.  It gives a morsel of control over that which is ultimately ephemeral.

Today, writing it is an act of submission.

As the raging waves of the ocean crash against the shores of my insides, the waters eventually calm and the tide recedes.

And I am empty once again

Do You Know?

Do you know?

I realize how I must sound.  Throwing around the word futility like a game of dominoes, I slam the last piece onto the table defiantly.  You glare.

She's not your mother!

I want to shake you.  Of course she is.  They are all my mothers, sisters, and brothers. My father who died when I was ten and my grandmother who waited for me to drive from St. Louis before drawing her last breath.

I won't escape unscathed.  My birthright is to experience the allotted measure of human grief.  But I'll lose your mother too, and thousands more.  Sadness will be my daily companion, collateral damage from the oath I so naively took all those years ago.

Sometimes I sit in bed after being awoken by your mother's nurse.  I stare at the ceiling and listen to the walls exhale deeply.  I dream that when I die the spirits of my deceased patients will come to greet me.  A parade of old and young, angelic and bruised.  They shake their hands over their heads, and I can't discern whether they are clenching their fists in anger, or signalling affably.

I know, for better or worse, the consequences of my actions.

Do you?

Do you know?

Jordan Grumet Interviews Himself, Again

I caught up with Jordan Grumet, physician, Internet entrepreneur, writer, and overall man of mystery in a secluded corner of Panera Bread Company.

Q: Jordan, this is the third in a series of self interviews over the last two years for this blog.  Tell me, is anyone else (present company excluded), interested in what your doing?

A: Actually, my life story was recently presented to a distinguished group just last week.

Q: And how was it received?

A: My son's second grade teacher said he did a really stellar job!

Q: Um...OK.  You recently were featured in Mike Sevilla's Family Medicine Rock's online radio show.  How did it feel to be interviewed by a social media legend?  And tell us about your new practice.

A:  Mike is the real thing.  His voice, his interview skills, it's like being on Oprah (I know you're out there O.  You haven't returned my calls yet!)

I'm really excited about the upcoming changes.  As of January 2014, I will no longer be seeing patients in the office.  Instead, for a about a tenth of my current population (250), I'll be doing comprehensive primary care from the comfort of their own home.  I'll charge members a yearly fee to allow myself to break the economic bonds forced by Medicare.

Q: What prompted you to make the change?

A: Medicare, healthcare reform, medicare, medicare, and healthcare reform

Q: Explain?

A: The delusional administrative and regulatory requirements by our governmental agencies are hampering basic medical care.  We our losing sight of our patients, and spending time and energy bowing to the electronic dictates of an insatiable monster.

Becoming a master diagnostician is an ideal that takes a hundred percent commitment.  Every click, form, and ridiculous constraint takes our eye off the ball.

By collecting the funds required to support myself completely outside the system, I will for once be free.  Medicare can do what it wants. 

C'est la vie!

Q: Is it true, that you are also starting an Internet business?  CrisisMD.com?

A: Yes.  What I enjoy most about being a physician is helping people make complex decisions.  As most of us know, our healthcare system has been so perverted that we can no longer count on our own personal doctor to guide us through medical care.  What with meaningful use, HIPAA, and completing yet another idiotic MOC (maintainence of certification requirement by the ABIM), who has time to spend hours with patients and their families making complex decisions?

CrisisMD does!  We provide healthcare coaching, advocacy, and interpretation.  We are not your doctor.  We don't diagnose, examine, or treat.  We translate.

Make no mistake.  When you arrive at the doctor's office or the hospital, you are entering a foreign land.  The language may sound familiar, but it's not what you speak at home!

Q: Wow!  With all these balls up in the air, how do you have time to sleep?

(A crash is heard, Jordan has dozed off and fallen forward into his lukewarm bowl of broccoli cheddar soup).

Q: That's a wrap.  Somebody get this poor slob a towel and clean him up.

An Open Letter To @kevinmd

I think this needs to be said. 

I have been writing a long time.  I have been blogging since 2005.  In all this time, I've learned much about social media. 

There is a problem with content.  No matter how important it is, and how good you are at creating it, it all means nothing if you can't find your readers. 

Content comes first, then amplification.

There are many amplifiers out there: Twitter, Facebook, etc. I have tried, succeeded, and failed at using many of them.  But by far, the most effective amplifier in the health care social media world is Kevin Pho and his awe inspiring website kevinmd.com.

I have been reading Kevin since my earliest dipping of toes in Internet based self expression.  I have watched his site morph from a personal blog to an open forum for today's opinion leaders to express their latest insights.  Never, I repeat never, has the information been stale or dated. 

Over the years, I have been lucky enough to have Kevin pick up and publish a number of my blog posts.  The opportunities afforded me through his attention have lead to media interviews, publications in major periodicals, and invitations to speak in exotic places (and get paid for it).

As his website proclaims, he truly is "Social media's leading physician voice".  He also appears to be a kind, down to earth, stand up sort of guy.

Kevin, you have paved the way for many of us in the heath care social media universe.  You continue to deliver day after day, year after year.

From the bottom of my heart,

Thank You!

CrisisMD Launches Soon: Guidance Through Uncertainty

When was the last time you were in a medical crisis?

When was the last time you had a health scare with a family member and felt you had no one to turn to?

The medical landscape is changing.  Healthcare reform, economics, and the modern agrahospital system are clouding basic personal care.  We no longer treat patients, we treat communities.  We no longer heal our patients, we manage their insurance companies, input their data into impersonal computer systems, and spit them out of the hospital with a nonsensical set of discharge instructions.  The doctor who performs your yearly physical is different from the doctor who triages you during an unplanned office visit or who oversees your hospital care.

Frankly, it's not surprising that patients and families with no medical training or experience are floundering under the weight of this awkward system.  How could you not?

I proudly announce the upcoming launch of CrisisMD. 

Visiting the hospital or doctor's office can feel like entering another country.  The terminology is unfamiliar and the process convoluted.  CrisisMD will help fill the gap.  We provide healthcare coaching, advocacy, and translational services to families in need.

Please support this venture by:

Following on twitter: @CrisisMD
Liking on Facebook: https://www.facebook.com/CrisisMD
Or visiting our website that will launch in the next few weeks: www.crisismd.com

Show Time

My daughter is surrounded by a gaggle of small girls. Half the cohort marches forward gingerly on their skates while others have learned to glide.  It is the first act of a two hour ice show at the local rink.  The little ones have been practicing every week for the last few months.  This is their first attempt at performance.

As the show progresses, the age and the skill set of the skaters improves. Those of us in the crowd can tell fairly quickly the talent of the soloists.  Some have the God given grace and bearing of performance, even though they have not yet mastered the intricate movements.  Others hit the jumps cleanly, but somehow struggle with the appropriate posture.

Then, then there are the ones who have it all.  We hold our breath as they speed by and effortlessly nail a series of complex moves.  It's almost easy to forget that years of practice have lead to this moment.  While their friends were clowning around on the weekend, these teens were in the rink sweating: before school, after school, on holidays. 

As my daughter waddles off the ice to the rousing applause of the audience, I wonder what her future will hold.  The same goes for my son and the violin.  Will these be just passing fancies or something more? 

It certainly never happened for me.

Growing up, there were no sports I excelled at, no instruments that bent nimbly under my fingers.  And I regret it.  I regret not becoming a gymnast or concert pianist. 

But I wouldn't say I wasted my youth.

I was in the library.  Locked in my bedroom, I poured over school books hour after hour.  knowing I wanted to be a doctor since preschool didn't make the subjects any easier.  I struggled.

While my friends in high school were cruising chicks at Northbrook Court, I was buried in algebra.  I spent countless Saturday mornings in the law library while the rest of my dorm was getting drunk at the football stadium.

I remember each test, each landmark: the SATs, The MCATS, Step 1, Step 2, Step 3, and the Internal Medicine boards.   How many little moments go into artistry?  I stumbled through the first patient encounter.  I tripped over diagnosis after diagnosis.  One day I was a resident, the next a full fledged attending. 

Although what I do may not always be pretty, I perform each and every office visit.  This is my art. 

This my triple axle. 

Sometimes I nail it.  Others, I fall on my rear.

Take away the computers and the annoying paperwork, it's just me and the patient sitting in the exam room.

I prepare my instrument and flex my calf muscles.

It's show time.

Jumping The Fence

It would be an understatement to say that things have been a little topsy-turvy.

I tossed and turned last night as the thunder cracked and sheets of rain slapped against the windowsill.  My body rose out of bed by habit, minutes before the alarm released it's throaty bellow.  I hunkered into my spring jacket and ducked out the door, through the backyard, and into the garage.  The drips of water fell off my brow as I climbed into the car.

Visibility was poor.  The entrance ramp was under a few inches of water, and my car lurched forward slowly.  Thankfully, the highway was clear.  Miles down the road and picking up speed, I saw the familiar line of break lights in the distance.  I slowed down cautiously before coming to a complete stop.  I was stuck.

At the end of a long line of cars with an impenetrable swamp obstructing my passage to the hospital, my options were sparse. I felt a sinking sense of doom.  Like a caged bull, I could butt my head against the bumper in front of me, but it would be an act of self flagellation.  There were patients waiting, but I couldn't get to them.

I craned my head in desperation, complete darkness.  Not a single vehicle on the road barreling toward me.  So I whipped into reverse, clicked on the blinkers, and drove the wrong way down the shoulder till I could exit off an entrance ramp.

Driving the wrong direction on the expressway is an odd feeling.  It's like being given special glasses to look directly at the sun.  Your mind can rationalize the action your body is initiating even as the muscles fight to maintain the status quo.

But at some point, you take the path that is given to you.

Many of us bulls are waiting till the door of the pen is flung open, and will run as directed into the arms of healthcare reform. 

I, for one, have chosen to jump the fence. 

And gallop the other way.

Aftermath

I have watched people die.  I have pounded on the chest of a teenager as the cerebrospinal fluid seeped out of his ears after being swiped by a truck on Lake Shore Drive.  I have told parents their child has died and children their parents.  I have stood at my father's grave before the end of my first decade. 

There is no light in premature death, no beauty, no joy, no optimism. 

Yet, there is solace in this wondrous profession.  I have opened my mouth to the great fire hose to have a small taste, even as the whiplash strained my neck.  I am scarred and worn. 

The only salve to heal these wounds is the opportunity to stem the tide of this all consuming blackness, to soften the blow.

What lies in the great divide between love and pain is basic humanity.  When religion, fundamentalism, or mental illness drags ideology outside this continuum, it is easy to lose faith.

It is becoming difficult to explain to my eight year old son why we are doing such a lousy job of protecting his peers.  And admittedly, I don't know how to find a middle ground with those who would unflinchingly commit such acts. How could we see eye to eye?

I will bury this terror with the humility of those who are left to deal with the aftermath. 

For every one of you there are millions of us. 

I may be clutching my children tightly now, but tomorrow the sun will rise.

And you'll be old news.

Deliverance

I've always kinda envied obstetricians.

I remember with my first child.  We laughed at the positive pregnancy test.  We went to the doctors visits together. So many milestones: the first heartbeat, the ultrasound, and the kicking.  The OB was like a guide walking through a foreign land.  She sauntered ahead of us merrily, advising gently but firmly.  Of course there were bumps in the road, there always are.

But the end points were knowable. She was not only our doctor, she was a mother herself.  And when the time came, she was by our side.  We journeyed together, teacher and students.  Our eyes bleary at 2:30 in the morning when the pushing, sweating, and clutching were interrupted by the sweet vocalizations of a little boy.

One phase of our lives over, another was about to begin.

***

I also journey with many of my patients.  The beginnings, however, are of a more bitter nature.  The voyage starts with an incomprehensible diagnosis, a lopsided prognosis.  And I, like Charon the ferryman, usher the lonely souls onto my boat.  I steer through the uncertain fog, my hands wrapped solidly around the oar. Belting through turbulent waters, the bumps jar even when expected.  The sign posts are few and hard to interpret.

I coo soothing words and hold hands, even with the realization that I am of limited experience.  No matter how often I make the trip, I only get so close to the opposing shore.

The time eventually comes.  We dock.  The family and I huddle while the courageous soul leaps out of the boat and onto the other side. 

We wave, heartbroken. 

Unlike that wondrous morning with my wife and precious child,

there is only silence. 

How Long Has It Been Since You Spent Quality Time With Your Doctor?

I'm going to be a little nondescript here.

The other day I saw a patient in the hospital.  I was covering for a partner.  The patient was gravely ill.  There were many decisions to be made, surgeries to be planned, and antibiotics to be given.  Of the fourteen days in the oncology unit, I may have be the rounding doc once or twice. 

As the situation worsened, the relationship between the patient, family, and medical staff had begun to decline.  Although I assessed the patient and wrote my billable note in the morning, I couldn't help but feel that there was much more to be done.  Decisions were being left open ended, and many of the realities of diagnosis and prognosis were ignored like that annoying friend that one never acknowledges in public. 

As luck would have it, a number of cancellations in my schedule left my afternoon completely free.  So I made a few phone calls and gathered the family.  I walked into the room and sat down comfortably on a chair, and looked up at all those anxious faces.

Tell me about it.

I didn't move for nearly two hours.  I waited patiently on phone calls, bathroom breaks, and pillow adjustments.  When I emerged from the room, the plan was completely different.  Surgeries were cancelled, antibiotics stopped, and a modicum of peace was restored to an otherwise hectic situation.  

The patient/family didn't need more medical care.  They didn't require an xray or a brain scan.  They needed an ear to listen, and an experienced voice to help guide them.

This type of interaction takes time.  It also saves the healthcare system a boat load of money.

Healthcare reform, meaningful use, quality reporting, etc, etc...what could possibly go wrong?

Well, how long has it been since you spent quality time with your doctor?

Fear Is Like Ice Cream

My mobile rings at least fifty times a day  My pager buzzes double that.  I'm stopped in the hall and accosted by doctors, nurses, patients and families.  And most of the questions are mundane: an adjustment of the coumadin dose, a formulary change for the antibiotic.  Thousands of daily decisions reasoned through years of experience and practice.  This is the life of the modern day Internist.

Yet, I can't help but admit that I'm always waiting for the other shoe to drop.  Each ring, each buzz, carries the possibility of disaster.  Will it be the ER with a hypotensive octogenarian, or the nursing home reporting a patient has been put on a nonrebreathing mask.  Or worst of all, a young person with real chest pain and shortness of breath.

I'd be lying if I said it didn't have an affect.  Fear, to me, is like ice cream.  No matter how often you taste it, you can't help but quiver each time the frozen tundra meets your lips.  Unfortunately, the Pavlovian nature of the human conscious can be quite indiscriminate.  Sometimes we react to the stimulus in the absence of need.  My body jumps awake to the vibrating pager clipped to my waste.  I yell into the phone at the poor nurse reporting a skin tear or fall. 

This reality can be tiring.  The over stimulation of the senses and lack of sleep mean that surprises at the end of the day can be particularly challenging.  So when my phone rang this afternoon while waiting for my daughter to finish her ice skating practice, I jerked to attention and fumbled to pick up.

It was Mrs. Morris calling for the third time to inquire about her husband's place on the transplant list.  I reflexively began to explain again how, as the internist, I had very little power to dictate how long it would be.  But she couldn't wait for my soliloquy to end and cut me short. 

Dr. Grumet, Dr Grumet...he got a liver.  He just left recovery!

For once, the sound of the other shoe dropping didn't startle me. 

It brought me joy. 

Heaven And Hell: Portraits Of An Alzheimer's Ward

The lanky gentleman propels himself forward in a wheel chair towards the nursing station.  Crumbles of food fall from his chin and land on his old tattered flannel shirt.  He stops, as he is wont to do, at the half door that is controlled by a keypad.  He peers over and spies a staff member sitting at the desk in front of an open chart.

I'm hungry, get me some food!

The staff member lifts his head for a moment and returns to his work.  If one witnessed this solitary reaction in isolation, it would be assumed that this is a cold and ineffectual haven for the misplaced.  But in view of the repetitive nature of this event, it starts to become more clear.  This is the fifth request that has been made in the last half hour.  The emergency stock of cookies and crackers has already been used up.  The wheel chair backs up for a moment and then pushes forward crashing into the door.  The series of epithets and racial slurs that follow is enough to make even the most staunch observer blush.

#%#*&#%%%%#!!

A string of panicked words in a foreign language fly out of the mouth of a ancient woman cloistered in a room a few doors away.

Ayudame, ayudame, ayudame, ayudame...ayudame, ayudame, ayudame.

The tone rises and falls.  Sometimes the lilt of the voice suggests a question.  Others, it's purely a statement of wrath.  Occasionally, a moment of silence interjects until the rabble starts over again.  It will go on like this all day.  So long in fact, that her voice will weaken and become raw. Silence will follow only with the sweet respite of sleep.

Half way down the hall a smallish man sits in a over sized chair placed between doorways.  His body limply melts into the cushion, and he weeps uncontrollably.  A tall thin Asian woman towers above him draped in over sized pink scrubs.  Her cart of medicines has been pushed to the side, and her hands gently reach out to his sorrowful cheeks.  She clucks like a mother hen, and gingerly wipes the tears from his eyes.

Oh Harry, Don't cry.  Don't cry

Day after day.  Year after year.

Only the faces will change.

Brinksmanship

I hate it when I think of the best retort ten minutes after the conversation has ended...

She had enough.  Her son said many times that he didn't want to live this way.  Intubated, disfigured with tubes and lines, and riddled with small satellites of cancer throughout his body, he was no longer recognizable. Her voice was unwavering.

Remove the tube.

It was the right decision even though there were signs of improvement.  The last vestiges of sepsis had pushed the kidneys into oblivion.  The lungs moaned against the ventilator and refused to open.  Yet the fever had resolved and the white count was trending back towards normal.

I huddled with the staff and prepared the orders for the morphine and ativan drips.  I finished my note and turning the corner, I almost ran smack into the oncologist. She had seen my charting on the EMR, and rushed over to talk to the mother.  She was hoping to convince her otherwise.  She addressed me before she entered the room.

How come we push people off the building with chemo and then pull away the safety net right as they are hurdling towards the ground and need us the most?  Withdraw care?  He is just starting to improve!

I was so stunned, I didn't know how to answer.  Minutes later the mother shook her head as she listened.  She reasoned out loud. 

So we pull him from the brink, what then?  How are you going to fix the rest?

The oncologist left the room and returned to her clinic, beaten but resigned.  The breathing tube would be removed despite her objections.

Sitting in my office moments later, I couldn't help but think the oncologist had it all wrong.  Dying from cancer can be like falling off a building.  Without interference, one dies instantaneously, no harm no foul.  But sometimes we doctors pull out our flimsy tarp at the last minute.

The canvas defies acceleration and hinders death briefly, but doesn't fully cushion the fall.  Bones break and vertebrate snap.

The miserable soul then lies prostrate for days on a ventilator in the ICU.

Awaiting the certainty of death,

 in the most inglorious fashion.

Healthcare's Dumping Ground?

I couldn't really blame the social worker.  He was just doing his job.  The SNF unit connected to the hospital was full of flailing patients.  So he thought he would ask for a palliative care consult (after getting an okay from the primary team).  It was his third request of the day.  He spoke slowly as he tried to untangle the twisted path the patient had taken.

Dr. X was managing poor old failure to thrive before he came to the hospital.  But then Dr. Y, the hospitalist, admitted him and treated the urinary tract infection.  Dr. Z was covering Dr. W on the cardiology side.  And of course Dr. S, the oncologist, was giving chemo before he landed here.

My head started to swirl as I waived him away and ambled back to the nursing station.  This was another complex patient with multiple doctors and few answers.  I reviewed the chart and then went to the room and began my exam.  He was an elderly, confused, chronically ill gentleman with labored breathing.  He was unable to communicate effectively. 

I left the room and called the daughter.  She hadn't spoken to any of the doctors in awhile.  She was hoping to meet later in the day to talk.  I hung up and paged the nurse practitioner who covered the hospitalist patients in the SNF.  Even a move down the hallway ended in a hand off to yet another provider. 

It was just as I expected.  Doctor X didn't come to the hospital.  Dr Y had finished his week as hospitalist and was now off for the next seven days.  Dr. Z and Dr. W signed off the case since the cardiomyopathy wasn't responding to maximal therapy.  And Dr. S, the oncologist said that the metastatic prostate cancer was the least of the patients problem. 

So it would be me, the newly consulted palliative care specialist, who would sit down and talk to the patient's family about end of life and futility.  I would start a little morphine, tweak a few medicines, and stop the ativan due to delirium.

I have to admit that it all left a sour taste in my mouth.  This is just one example of many.  Yes, this is what we are good at, but it also kind of makes me wonder.

Has palliative care become the last bastion of sanity in the dumping ground of today's disjointed and broken healthcare system?