The Impatient Mistress

Leave him alone, he's talking about dying again!

My son gently pulls at one of my daughter's arms as she thrusts the other towards my face. Her delicate fingers are wrapped around a small tattered paperback book. She wants me to read to her. I squint and struggle to concentrate on the words coming from the mobile phone glued to my forehead. I make menacing looks hoping they will scare easily and run off. They stand their ground emboldened by experience. My children are all to familiar with these histrionic antics.

My son is right. I am talking about dying again. Five thirty in the evening is as good a time as any. My family is accustomed to me discussing such things: at dinner, on weekends, at their cousins birthday party.

Death is an impatient mistress.

And my patients are old and frail. They wallow in the tempest of disease and antiquity. Their bodies fail at the most inopportune moments, and I refuse to learn the venerable deception of unavailability. Which means that death infuses even my most private occasions.

Yet the fault lines of our lives can also shift in sudden and cataclysmic ways. Once the growth plate fuses, the child's bones will expand no further. Missed opportunities become memories of inconsequence.

Father, husband, physician...physician, husband, father.

Moments lost.

Pedestrian

I've experienced much loss in my life, both personal and professional. It's no secret that as a physician people come and go often without warning. And I worry about my patients. Not just about diseases and diagnoses, but I think about their well being. Are they happy? Do they have enough support? Are they in pain?

The doctor-patient relationship is a bidirectional investment. Over years of visits, I have become intimately familiar with the people who inhabit my exam room. I ask about their families and hobbies, not to be a more avid physician, but to be a better human being. I am not just pedestrian. Making the right diagnosis is a joy but doesn't sustain, becoming part of the intricate stitching of the quilt of another's life is ultimately what pulls me out of bed every morning. When a patient dies, or moves, or leaves to see another physician, the effect can be devastating.

I accept the inevitability of my career choice. I hear the sound of the door closing most every time a new patient enters my office. I will journey with them, maybe for days, maybe years. I will give of myself freely and try to take sparingly. It is a familiar cycle. Seasons change.

People come and go.

When I decided to convert to a concierge practice, I hoped to retain ten percent of my patients. I fully realized that, in a sense, I was closing the door on the other ninety percent. I planned carefully. I sent my letters six months early to help people land on their feet. As the months have passed, jubilation has given way to harsh reality.

I now have to help plan for the mass exodus of many people I have spent the last ten years worrying about. I stressed over their heart attacks and strokes as well as their colds and gout attacks. I have held hands, mourned losses, and celebrated triumphant victories.

I knew intellectually what I was in for when I made this decision.

But right here, right now, in the midst of it I can't help but pause.

This humongous, cataclysmic, overwhelming loss

is nothing less then suffocating.

Girls, Fast Cars, And Healthcare

It wasn't that I was so enamored with the girl herself. But as an awkward teenager, when a member of the opposite sex takes an interest, you tend to notice. We had gone on a couple of dates; spent some time together. So it took milliseconds to accept the invitation to join her and a friend for a ride in her new white Volkswagen Jetta. I slid into the back, and tried to nonchalantly fasten the seat belt. She hopped into the drivers seat with her best friend by her side.

Moments later, we were off.

The radio blared and the windows were open. My hair flew spastically in a multitude of directions. I patted the wayward tendrils and keened forward to listen. The conversation in front was lost in the rhythmic trance of radio waves. Expecting the joy ride to be over soon, I held tightly to my seat cushion as the car swerved onto Lake Shore Drive.

The rush of air was just enough to totally ablate the wild and carefree screams of the young girls in the front. Picturing them now with animated but mute faces would surely give the pair heartburn to know that this was my lasting, silly impression. I watched with slight horror as the odometer began to climb.

40, 50, 75, 100mph

We weaved back and forth through traffic. I closed my eyes tightly as the near misses became more near and less misses. I braced myself for the imagined impact. With relief the car began to slow and pull over to the right. The music was abruptly stopped, and the sound of approaching sirens filled the air. The policeman sauntered out of the squad car, and rested his elbow on the open driver's seat window. He looked at the two crimson faces in the front, then smirked at my pale white facade.

Her license was suspended for a year.

As I grew older and more confident, I developed the ability to speak up and not get myself into such situations. But as a hormonal teenager, there was definite gain in remaining silent: being cool in front of the object of my affection.

Unfortunately, as adults, we are confronted with many similarly confusing and difficult situations. Being a doctor, my patients often ask for tests or treatments that I don't feel comfortable dispensing. Every day I am approached for antibiotics, narcotics, and cat scans, usually in the absence of medically reasonable indications.

And like the teenager, there are many gains to being silent and acquiescing. Happier patients refer their friends. Happy patients rarely sue their doctor. Happy patients score their physicians better on quality surveys.

Yet studies are beginning to show that contented patients cost our healthcare system more, and suffer greater morbidity and mortality.

I'm all for shared decision making. When reasonable options exist (including declining care), I believe our patients should be fully informed. But some in the ranks of healthcare reform opine that patients should always be the driver of care. They say that a well informed patient can make the right decision even if it is deemed by the physician as unnecessary or even harmful.

To me, that sounds alot like getting in the passenger seat of a car with a sixteen year old girl for a 100mph joy ride down Lake Shore Drive. It may sound appealing at first.

But in the end it's downright dangerous.

A Review of @danielleofri What Doctors Feel

When I started residency in July of 1999, I felt confident that I was doing my life’s work. I came to the hospital early the first morning. The chief physician brought me to the third-year resident who was covering the patients who would become mine. This was the resident’s last day of training. I will never forget the phrase my chief used when introducing him.

He said, “This is John. You’re taking his patients. Today is his last day of residency. He can’t be hurt anymore!”

My thoughts raced. What did he mean “can’t be hurt”? Who was hurting him? And why couldn’t he be hurt anymore? Unfortunately, I would eventually learn.

*

In What Doctors Feel:How Emotions Affect The Practice of Medicine Danielle Ofri plays us like a celebrated cello concerto.

Piano

In the beginning she caresses the strings softly, piano. Her fingers dance around the definition of empathy . Her stories (the rape victim and the cockroach, the patient with ulcers incompatible with life)are the vibrato giving color and nuance. The pace is still humble, andante, as she asks if we can build a better doctor. This is Danielle the scientist. She delves into notable clinicians and teachers, and touches on studies of how empathy affects patient care.

Mezzoforte

The volume grows as we enter the chapter "Scared Witless". Here we encounter the complexities of physicians as fallible human beings. She struggles with her first chance to run a code, stumbles over a forgotten psyche consult, and trembles at a missed life threatening diagnosis of a pulmonary embolism. She describes the fallout of medical errors:

There's no easy answer about how to proceed onward in daily medical life with the ongoing churn of anxiety and fear, and certainly no research to guide us. Each doctor has to come to terms with it and negotiate an individual emotional armistice.

Forte Fortissimo

The thrum becomes loudest and most persistent In a "Daily Dose of Death". Here we meet Eva and learn of her heartbreaking experiences as a pediatric resident. Ofri transitions from the calm cool scientist to the impassioned story teller. Although the narrative is always controlled, the reader is punched in the belly by the raw staccato jabs. She follows with "Drowning" where we see the poor coping mechanisms Joanne (and so many other physicians) use to deal with burnout.

Finale

In "Under The Microscope" we come full circle with a discussion of malpractice and the physician psyche. Both the scientist and story teller intertwine. Piano, fortissimo, vibrato. We at last learn of the ultimate outcome for Julia, the heart failure patient, whose story meandered through the chapters and set the overall tonality.

We end where we began, not doctor and patient, but two human beings traveling the same lonely road.

*

I only have a minor criticism for this wonderful book. My quip is that Ofri refuses (and this may be her true brilliance) to name the emotion that kept coming to mind as I read. She answers the question posed by the title with such words as fear, shame, grief and anger. Yet I can only imagine she purposefully uses pain sparingly.

Why?

As a physician, pain is the apparition that hides behind the closet door of my nightmares. Pain is what I felt when I told the three unsuspecting women that their father died knowing that I had fumbled in the ICU with the intubation. Pain is what drove my chief resident on my obstetrics rotation to break down after standing by helplessly as a mother stabbed in the neck, and her unborn baby, died. Pain is realizing that you are not the hero you hoped you would become, and that medicine is opaque, murky, and just plain messy at best.

The chief physician from my residency program had it all wrong.

I too felt at the end of my training that I couldn't be hurt anymore. I was drowning in the steely leather of self protectionism. But then in October of 2004 my world radically changed with the birth of my son. When I looked into his eyes looking back at me with complete trust, the barriers that I had erected since those horrible days of residency came down. I could cry again. I didn’t have to shield myself anymore. And I began to understand the meaning of empathy.

It is only when we allow the pain to flow through us unhindered and mix with the joy and awe, that we are truly free. Danielle realized this much earlier in her career then I did. Not only friendship and caring, but pain is the tie that bound her to her beloved patient with heart failure, Julia. In hurting she transcended the physical barrier and truly walked a mile in Julia's shoes. This may be the greatest gift that any doctor can give a patient. This is empathy, the jump that allows us to pass over "doctor" and become "healer"

*

You want to know what doctors feel?

You have kindly read my feeble opinions.

You want a more nuanced and articulate view?

Read the book!

Departures And Arrivals

Thomas should have died long ago if not for a secret weapon.  Neither faithful medicines nor dedicated physician could battle the ravages of age and disease with the simple clarity of the love of his daughter.  Indeed, congestive heart failure and general frailty were no match for Leslie's unbending will.  She nursed him back from all exacerbations.  She slept by his side during every nursing home stay.  And she prepared his home triumphantly for each return to health even though he was getting sicker.

Her father's debility was in stark contrast to Leslie's own vigor.  She visited me occasionally for random colds and work related physicals.  Our contact was mostly limited to planning for the various hurdles her father was working to stumble over at any given time.  When it came to doctoring, he was my patient, she was more like a casual acquaintance.  Yet, as I was rounding the corner to enter Thomas's hospital room, it made perfect sense that the ER would call me.

There had been a car accident.  Leslie was in the emergency room. Dead.

A lovely bit of purity deep inside became black and sullied in those few moments in which I told Thomas that Leslie was gone.  It is in times like these that even the most religious curse their beloved deity, the faithless beg for prayer, and the mighty stumble.

Thomas stumbled.

The blood drained from his face, and the butterfly of life fluttered away from the cocoon of his still moving body.  He continued to breath.  His heart continued it's marathon march.  But the runner had become shoeless.  He lost his soul.

I sat with Thomas many times over the next few days.  I had few words of solace. As I held his hands, I voiced the bizarre thought that kept charging through my mind.

This is just like Leslie.  She probably wanted to go first to make sure everything was prepared for your arrival. 

He chuckled.  It was the last sound I heard leave his lips.  He died in his sleep a few hours later.

I'm not sure I believe in such things as heaven and pearly gates, but I like to imagine Leslie was waiting there for Thomas with open arms.

Ready in death as she had been in life.

Welcoming him home.

Why Doctors Lie

The oncologist shook his head as he walked out of the room.  He still held a paper towel in his hand which he used to wipe the last remnants of soap and water.  He tossed it into the trash, and looked in my direction.  We talked for a few moments.  The cancer was more widespread than originally thought.  The surgery exposed a belly full of metastases.  The options for chemotherapy were thin.

I entered the room with a heavy heart.  I sat next to the bed, and listened before beginning with a litany of questions.  The post operative pain was well controlled.  The patient had been informed of the diagnosis but still felt lost.  Her family watched hopefully, and measured each word as it left my mouth.  Their chins moved up and down frantically when I was hopeful, and back and forth soberly when I was not.

Before long, the conversation turned to prognosis.  The patient bowed her head and prepared for the answer. Every ounce of my soul longed to tell her that everything would be okay.  If only human will were the issue, I would explain how we could eradicate each cancer cell one by one.

And in that moment, I chocked on the truth.  I wished to give her the gift of hope, even though I knew it was false. It was not because it was easier, not because I wanted to intentionally deceive. In reality, I couldn't face my own frailty as a physician.  So many times we ultimately lose to diseases that are far too advanced or ingenious for our rudimentary knowledge.

I discussed the prognosis truthfully.  After answering their queries, I left quietly.

But I understand why physicians lie, why they embellish.

Even harder than telling someone they are going to die,

is seeing oneself without distortion in the reflection of the mirror.

Sacred Ritual And Twitter, Some Thoughts On @nprscottsimon Live Tweeting His Mother's Death

It was another perfect Los Angeles day. My family and I sat on the veranda of the hotel as the midafternoon sun cascased gently onto the shoulders of the onlookers. We collected in rows of chairs that were covered in white linen. The music marched forward, and the wedding party assembled cleanly in pairs of twos. We all knew what was coming next. Of course there would be some variation, but most have been through enough weddings to be familiar with the routine.

We use rituals to mark our sacred events: beginnings and endings, birth and death, and even marriage. We gather our loved ones, our communities, to celebrate or mourn with us. But as the bride and groom waltzed down the aisle at the end of ceremony with smiles on their faces, I scanned the reaction of the spectators. A number of them were hunched over their mobile phones. No doubt facebooking and tweeting. And I couldn't help but think for a moment about Scott Simon.

Many know that Scott recently made a splash in the social media world by live tweeing the death of his mother. At first, being a physician involved in hospice and palliative care, I wasn't thrilled with the idea. His tweets were authentic and brilliant, but while reading them my first inclination was to wish that he would put down his phone and just be with his family.

This wedding reminded me how profoundly we have been altered by social media. It has become crystal clear that our digital communities are just as important as our traditional, filial, and geographic ones.

Scott turned to twitter to share this sacred moment with his friends, family, and yes, followers. The outpouring of love, respect, and well wishing he received is exactly what one would expect at a traditional funeral but was more consistant with his digital reality.

Scott, I'm sorry that I originally doubted you. I have a profoundly different understanding of community after reading your eloquent tweets.

My deepest and most heart felt condolences to you and your family.

Regression To The Menial

I was far ahead of my time.

The cachectic middle aged man had been admitted to the hospital fifty times in the last calender year. The other residents and I joked that new graduates only truly became interns after they had Leon on their service. He suffered a range of chronic illnesses, mostly respiratory, that were overwhelming to his mentally challenged mind. He often would walk off the floor with discharge instructions only to appear in the emergency room minutes later complaining of shortness of breath.

I liked Leon. He was soft and gentle. His lack of mental capabilities only made his kindness more endearing. He was anxious about the outside world and preferred the safety of the hospital confines. And I couldn't blame him, to a homeless man on the St. Louis streets, our institution must have looked quite welcoming.

After his third hospitalization in as many days, I decided to take action. I gathered the patient's pulmonologist, primary care doc, and a bevy of clinic nurses together in a room to hash out this difficult case.

The pulmonologist retrieved his cat scan, and outlined the nodules and signs of emphysema. The primary care physician reviewed his compliance record. The clinic social worker and nurses attested to his housing issues. We worked together as a team. The group consensus was that his lungs were benign, and the best plan of care relied heavily on social intervention.

I left the room feeling like, for once, Leon had a concrete plan of action. I discharged him the next day confident that we could stem the tide of hospitalizations. From time to time, over the next few months, I patted myself on the back in recognition of the fact that Leon seemed to be nowhere in sight.

While strolling through the halls of the clinic during my third year outpatient rotation, I bumped into Leon, and almost didn't recognize him. He had gained fifty pounds. His emaciated figure filled out into more normal proportions. He smiled as he walked by and waved. Moments later, Leon's primary physician filled me in on his progress.

It turns out that Leon left the hospital the day I discharged him, and walked across the city to the emergency room of a competing hospital. He was admitted, and the attending physician called our institution. This physician listened to the details of our work ups, and was informed about our team discussion. He then decided it was all bunk, sent Leon for a biopsy of his lung nodule, and diagnosed him with tuberculosis. Leon was sent to a state facility for six months for monitored medication administration.

Leon thrived. He gained weight, his breathing improved, and he had been living out in the community for six months without a single readmission.

Now I know what you are thinking. Another case of a doctor warning about the diagnostic traps of not taking a frequent flyer seriously. But my point of contention is actually more about team based care. Ahead of my contemporaries, I used the group model, now lauded by healthcare reformers, to try to "hot spot" Leon.

The problem with team based care, however, is there is often a regression to the menial. Ideas and diagnostic possibilities on the periphery are inevitably homogenized or coerced to the center by other members of the team. Extremes are reasoned out, and often those who think out of the box are marginalized.

Specialty groups have an altogether different issue. Tumor boards and such often make extreme options more palatable. Last ditch and low probability chemo is bolstered by like minded individuals with well meaning intentions but often little clinical evidence.

It turns out that what Leon needed was not a team at all. His savior was a lone internist, weighing the clinical evidence carefully, measuring the pros and cons, and not being clouded by the faint murmurings of ineffectual group think.