Just A Small Town Girl

Just a small town girl.

Livin' in a lonely world.

It's funny how your mind can be in two places at once.  The boat is bouncing up and down off the coast of Puerto Vallarta.  The music blares from the speaker above my head.  My daughter is face down on a towel.  She writhes back and forth complaining about her stomach and the rocking motion of the ocean. 

I am a world away.  Sitting in my brother's room on a brown bean bag listening to the Journey album that he just purchased.  It's the eighties, and I probably am no more than ten years old.  We listen to the song over and over again as I commit the words to memory. 

She took the midnight train goin' anywhere.

It would be the first song that I memorized all the way through.  I daydreamed that I was on stage singing to a crowd of adoring fans (mostly girls).  Of course, my dreams never came true.  I never became famous.  Yet the song stuck with me through all those years.

Just a city boy.

My daughter looks up at me quizzically.  She no longer has the grimace of discomfort on her face.  Daddy, you used to sing this song to me!  Indeed, she is right.  When she was two years old she had so much trouble falling asleep.  So I would sing to her.  Horribly out of tune since I have no sense of tempo or melody.  And this was one of the few songs that I knew all the words to. This is the first time that she is hearing the original version instead off my warped, poorly executed warble.

All of the sudden, I feel such a strange sense of wholeness.  In a foreign land in the middle of the ocean.  My daydreams of singing this song to an adoring audience in a sense came true.  The lines of my life have twisted and turned but somehow tied these moments together over the decades.

And my dreams are nothing like what I had imagined when I was just a few years older than my daughter is now.  Yet I can't help but feel that everything happened exactly the way it was supposed to.  That indeed all those disparate and disconnected moments somehow have been woven into the pattern of my life.

Looking down into the soft sparkling eyes of my daughter, I feel great calm.  And I try so hard to hold on to the feeling,

because I know, in a moment or two, that it will dissipate. 

Almost Everything

Everything is beautiful in Puerto Vallarta. Almost everything.

The kids have left a half finished virgin strawberry daiquiri on the small lounge table next to us on the beach. I sit with a book lilting in my hands in the mid afternoon sun. The bugs come and go. A bee sniffs around the opening of the glass. He hovers ever so gently above the sugary brew unaware that he is about to falter. He lands nonchalantly on the froth but flutters his wings frantically when he realizes that he is stuck.

And I think that this death.

One moment you are parading your freedom in search of what ever drives a little bee's mind and the next you have cancer, are in a car wreck, or tangled in death's grip disguised as a froo froo girly drink sin alcohol.

My brother is a little less jaded than I. He reaches over, grabs a straw, and gently lifts the debilitated creature from the quicksand. He places it on the table. Although its wings are fluttering maniacally, the hind legs are weighed down by cherry red globs of liquid delight. He limps along forward unable to take off, unable to escape the horror that has befallen him. My brother, chiropractor turned surgeon, dips the straw in a glass of water and holds his thumb over the top. He sprinkles the sticky stuff off the bee's legs delicately with his make shift dropper careful not to inundate the poor creature.

Slowly but surely, his nursing pays off. The limping evolves into tentative walking. The bee crawls past me leaving a trail of red stuff on the table cloth that reminds me of blood. Eventually he makes his way back to the daiquiri cup, and I'll be damned if he doesn't start to climb back up. He inches past the base and heaves himself forward over the thickest portion in the middle. His strength is building, his confidence is growing.

And then he flies away.

But in my world, in my world he hoists himself up with his last bit of strength and falls over the ledge to certain peril. 

In my world, the temptation is just too great.

It's Time To Land This Bird

I have been doing a lot of travelling lately. Each trip begins in the planning phase. Usually there is a burst of energy. An idea flowers. Road blocks form and are hurdled over. This is the most critical moment. It only takes a light wind to blow us off course, to decide that the whole idea is a farce. How many jaunts have spanned the mind only to stumble when pen reaches for paper, when concrete overtakes the ephemeral.

But once the wheels have left the ground, once a comfortable cruising altitude is reached, a transition takes place. Now the journey has indeed started. The initial gusto gives way to a much calmer period. The view from ten thousand feet is grand and distant. Feet haven't hit the soil. Our mind creates and modifies a future that is not yet reality. Although there is no turning back, the eyes strain to see the shimmering land below.

There is a moment in every journey, however, as the plane breaks through the clouds. There is a jarring of turbulence and then suddenly the horizon appears. After all this time, details become clear. Below are cars and building, people and roads. It is our first view of what the destination really looks like. We had an inkling before, but is was a mere apparition of a hopeful mind.

I announced almost one year ago that I was leaving my current position to start a home based concierge medical practice. The original surge of inspiration gave way to a long period of planning. And indeed, I was cruising above the clouds for so long that I often wondered if I would ever land. I broke through the clouds today. I always thought I knew what the future looked like. Now I am watching the ground rapidly approach as I begin my descent.

I will go back to the beginning. Doctor and patient. One human being trying to connect with another.

The landing gear has engaged. The flight attendants are in position.

It's time to land this bird.

Cognitive Dissonance

I am in love with the old ways.

The wheels of my car struggle to grip the powdery snow of the unplowed highway. The sun's absence attests to the premature beginning of my Saturday morning. My wife and children are asleep quietly in their beds. Most of the world is in fact sleeping. Already, my dance card is full. Between two hospitals and three nursing homes, a number of crises are brewing. By the mornings end, I will sit by the bedside as one patient dies. I will have family meetings, make critical decisions, review labs and talk to specialists.

Unlike many of my colleagues, I still practice in the office, nursing home, and hospital. Even on the weekend. Whether on call or not. I will wake up in the middle of the night. I will go to sleep too late and rise far to early. My fatigue will be interrupted by flashes of wondrous energy. Day in and day out. I have found no other way.

I consider myself a modern man.

My wife and children form the nucleus of my daily activities. I try to be as involved as possible. Dinners at home, violin practice, nightly homework all interrupted by the nagging mistress hanging on my belt loop, the wanting mobile infidel.

I write, I blog, I tweet. I use the latest in EMR technology.

I don't know how to weather the changes that are coming quickly upon us. Once I bowed at the alter of diagnostic accuracy. Now, I realize that there are many parts to effective doctoring. Shared experience, understanding, and lasting bonds are often what I think most are in search of. These things take time. Time often given during nontraditional hours. Time when one should be with their family, sleeping, or even having fun.

I don't know how to choose the way forward. I don't know how to be a guide down roads that I have never travelled. For now I will continue to make my early morning trips, my tires trampling through the unplowed snow...

Making paths where none yet exist.

Silly Rules Made In Ivory Towers

Why must everything be so difficult?

Soni pushed her mother quickly into the building from the parking lot, she wore a strained look on her face.  The wheel chair appeared preposterously large for the aged figure cowering under the haggle of blankets.  They were enjoying the brisk air, taking a walk around the facility, when the elderly woman called out.  Her lips curled and she moaned deeply.

Now Soni's mother had stopped talking months ago, but the devoted daughter had become adept and interpreting the grunts and groans.  The sound her mother was presently making, however, was different, alarming.  Her one arm was dead, lifeless from the stroke, but her other hand clenched her abdomen.  She winced in pain.

Soni had a bad feeling.  Something horrible was happening.  She beckoned to a CNA who helped her mother into bed.  I walked in moments later, completing my rounds at the nursing home.  I bent over the bedside and examined my patient.  Her abdomen was rock hard.  Her brow was furrowed.  Her breath left her mouth guardedly and fluttered before escaping.  She was suffering.

I explained that indeed, something catastrophic had happened: a bad appendix, a perforated bowl, a ruptured aneurysm.  Soni nodded at me as she held her mother's hand.  There would be no hospital.  There would be no emergency room huddle.  Soni wanted her mom to die quietly in her nursing home bed.  The years post stroke had been difficult and fraught with misery and dementia.  Nature was asserting itself, taking back what had been forfeited prematurely.

And this was something that I was trained to do.  I ordered a sublingual form of morphine, called roxanol.   But of course the nurse and I both knew that it was not that simple.  The miracle drug meant to keep people like Soni's mom comfortable, can no longer be given just by doctor's order.  Even though the vial was sitting in the lock box at the nursing station, the dying woman writhing in pain had to wait.  First a prescription had to be written and signed by hand, faxed to the pharmacy, the pharmacist than had to release the medication and issue an authorization number.  It took ten minutes in all.  Ten wasted minutes while someone suffered.

When confused, agitated, and in pain, the poor woman started to clench her teeth.  I knew that my only choice was to go to an Intravenous formulation.  An IV was already in place.  But again a new prescription needed to be written, faxed, processed by the pharmacist, and a new authorization given.  This time, unfortunately, I delineated the number of milligrams instead of milliliters of solution.  The pharmacist made me rewrite the prescription and start the process all over again.  Another half an hour was lost.

Agonizing over the unnecessary pain my patient was suffering, I begged the pharmacist to hurry up.  He responded the way they always respond now a days...sorry, federal regulation!

Soni's mother died quietly in bed a few hours later.  Once the medicine was released, I was able to bring her the comfort she so desperately needed at the end of her life.   I wish I could have been even faster.

There is a troubling trend in the regulatory atmosphere of healthcare.  Nonsensical rules are binding the hands of caregivers.  We are facing ever steeper barriers to basic common sense care.  Regulations meant to protect the populace are becoming an agent of harm.

Unintended consequences of silly rules, made by naive administrators, living in ivory towers.  

#DOTMED13 Wrap Up

The truth is, I feel almost embarrassed about talking at medical conferences.  I feel bad for those who invite me to come and lecture, and pay my travel and expenses.  In reality, I think I get more out of these trips than anyone else.  Maybe I should be paying them? #DOTMED13 was no different. On the eve of my departure from Dublin, I find myself leaving with loads more than I came.  Let me first recap by talking about my fellow speakers.

@berci opened with his talk on medical futurism.  He, of course, wowed the crowds with examples of mind boggling technology.  What struck me, however, was between the the cracks of his technospeak was a fervent wish to enhance the experience of students and patients alike.  In his own measured and careful way, his passion clearly shone through. For various reasons, he describes himself as "in the process" of becoming a medical futurist.  Maybe the thing that keeps him in the present, is that age old wish to use one's talents to ease the suffering and solve the problems of others.  Sounds anything but futuristic to me.

@amcunningham followed with a discussion of the benefits of twitter.  Obviously, when talking of the other speakers, she was preaching to the crowd.  But what her lecture really showed me is how social media allows some of us to not only amplify our content but also our personalities into the ether.  In real life, Ann Marie is every bit as bubbly, sparkly, confrontational, and intelligent as her twitter feed would suggest.  This ability to digitize her essence means that people around the world benefit from her kindness and knowledge.  And they also consider her a friend.  I certainly do.

@alancorbett8 and Mahmood Mirza teamed up to talk about social media and the doctor in training.  Again, they didn't have to do much convincing from my view point.  In many ways, they represent the changing of the guard.  Us "old guys" who grew up in a world without twitter and blogging had to adapt.  This new generation has come of age already having acquired these skills natively.  Yet the changes they will face in the future will probably mirror ours.  No one really knows what disruption is lurking around the corner.  Interacting with these two at the conference, I had no doubt that their generation is smarter and more prepared than I was.

My one sadness of the conference was that @lucienengelen was prohibited by weather from coming.  Of course, we were able to conference him in.  His talk went nicely with @Berci's.  He stunned the crowd by using google glass technology to take a picture of the conference room.  I hope to meet him in person one day.

I was lucky enough to spend some time with @Doctor_V.  Brian talked of the emergence of the public physician.  What I loved about his talk was not only is he a world class speaker (in terms of style and technique) but he is truly a "thought leader".  He takes disparate and underdeveloped ideas that have been swirling around my head disjointedly, and pulls them together in a coherent and clean package.  I get the feeling that he is often a few blocks ahead of me in his thought process, yet he is always kind enough to wait for me to catch up.

@ArtsPractica is unique.  A non clinician by trade, she devotes her time to helping physicians deal with misdiagnosis and burn out by studying art work.  Her lecture had the crowd riveted for the full hour (which is no small feet since she was the second to last speaker).  And believe it or not, I think most of us were just getting started.  We wanted more.  None of this surprises me. Alexa, in real life, is much like her lecture.  As you get to know her, each layer pulled back reveals something even more interesting.  I feel lucky to have met her.

There are no words to describe Ed Gavagan's talk.  I suggest you look it up on YouTube or TedMed.  My description wouldn't do it justice.  What I can say is that he has a warm personality and a beautiful family.  And one more thing.  We tend to attribute his abilities and talents to the horrific and tragic events that befell him.  On the contrary, I suspect Ed was always super talented.  These events just happened to bring him to us.

In conclusion, I got so much from #DOTMED13.  While sometimes we spoke of different subjects: technology, social media, art, and story telling.  We all were trying to use our unique passions to bridge the gap with our fellow humans, to take better care of each other.

I can't think of a better way to spend a Friday afternoon.

I have tons to say about @RonanTKavanagh and @muirishouston who hosted the event but I fear it would take to long.  I will have to save it for another blog post.

Once Again, The Pound Of fat Comes From The Primary Care Physician

My dear medicare patients.  The government has just screwed you.  Did you know it?  Probably not, probably you have no idea about what the government is proposing to do.  But it is going to have profound effects on the quality of the care you are about to receive.  You are confused? You are surprised?  Let me explain.

The government is proposing to change the way it pays doctors for outpatients visits. According to modern healthcare, medicare intends to pay physicians a flat rate for each visit.  That's right, a healthy sixty five year old with a cold will lead to physician charges that are the same for a ninety five year old with congestive heart failure, emphysema, and out of control diabetes.

Accordingly, the complexity of the visit will no longer figure into the amount of reimbursement for the physicians.  What does this mean?  Physicians, fatigued and overwhelmed with patient care, will be much more likely to avoid sickly seniors.  It pays the same, why not select for the most healthy of the medicare population?

If you are old, sick, or have a complex medical problem, expect physicians to avoid you like the plague. You're care will cost us more, and lead to lower reimbursements.  For those of us in private practice, I expect that this will be the death knell.  You might as well sign up to a hospital based large medical group now, no one else will be able to afford to take care of you.

The reason why this is happening?  Apparently medicare believes that physicians are over coding.  The pound of fat for healthcare reform is going to be born by those who healthcare needs the most, primary care physicians.  It is the primary who handles the broadest, most complex, most multi system problems.  These problems take time, deep thought, and advanced planning.  These were things that medicare used to pay for.  Apparently no more.

This is a sentinel moment, a tipping point,

By the time I reach medicare age, will there be any physicians left?

Do Mechanics Have More Freedom Than Doctors?

So a guy has his car towed to the mechanic. All four tires are slashed. He has a simple request.

Please replace the tires.

But this is one of those comprehensive care mechanics. He not only examines the tires, he does a full once over. He pops the hood and immediately knows that the engine is shot. It's fried. The cost of fixing the engine is more than the value of the car. It's a zero sum game. The owner shouldn't replace the tires, he shouldn't work on the engine, this car belongs in the scrap heap. He saunters out to the waiting room, and delivers the bad news to his eager customer. The mechanic is utterly stunned by what he hears next.

Please replace the tires.

The mechanic, being a kind and gentle sort, assumes that he has been misunderstood. He sits down quietly next to his fellow human being. He again explains, more slowly this time, how the cars value is minimal. He draws a diagram to demonstrate why the engine won't function. He reiterates the futility of changing the tires on such a car. It is not only a waste of money, it is a waste of precious time.

The customer turns his back to the mechanic, pulls out his mobile phone, and dials furtively. He hands the mechanic the phone. It's the customers insurance agent.

Please replace the tires. We will cover it.

The office is full, the cars are piling up in the lot, and yet the mechanic patiently tries to explain the situation again. Again he tells how the engine is nonfunctional. Again he outlines the price of possible fixes and how they are completely cost prohibitive. The tires are just the icing on the cake. They are not the problem, and fixing them will solve nothing.

The customer snatches the mobile out of his hand and dials yet another number. He pushes the phone back without saying a word. This time it is a lawyer. He demands that the mechanic fix the tires unless he wants to face a lawsuit.

So the mechanic bills the insurance company. He replaces all four tires. He drops the car in the lot and gives the customer the keys. The customer thanks him, walks out to the car, gets in, and puts the keys in the ignition. Nothing happens. He gives it another try. Nothing happens. He walks back into the shop and approaches the mechanic with one more question.

How much will you charge me to tow this thing to the junk yard?

In reality, no mechanic would have been expected to fix the tires. No insurance company would have paid the bill. And no lawyer would have taken a case they so clearly couldn't win.

Yet doctors are expected to put dying patients on dialysis, give fourth line chemotherapy when the first three lines (which actually have some clinical benefit) fail, and refuse to turn off the battery of defibrillators in bed bound, obtunded, dementia patients.

We don't do this because we want to.

Unlike the mechanic, we have been denied the basic logic of futility.

I Am Not A Mark

I am not a disease.

Although when I enter your hospital, or office, or outpatient center, you may refer to me as one. You may lump me together with an odd set of symptoms, or signs. You will define me with those antiquated terms. You will pretend that you will know how I, my body, will react when placed under certain stressors. You will prescribe treatments for my disease, and yet leave me out of the equation.

You know, me, the me that the rest of the world sees when I am outside the obtuse boarders you have created. Only a milifraction of my life occurs in your realm. The labels you give, the actions you take, have consequences. They may determine my physiologic or economic well being.

Are you listening?

I am not a checklist.

You may use one when deciding whether my treatments are covered. You may question my doctor, read him the riot act. You will say that I don't fit your algorithms. I do not adhere to your guidelines.

Diseases follow a pattern, unlike every other aspect of human behavior, they are quite predictable. Why should I be different from any other? Why should my pain and suffering be unique? Require unique solutions?

I am not a mark.

My suffering was not meant for your exploitation. I see your commercials on television. People with my disease run through angelic fields with smiles on their faces. I don not live here. I do not run when my body aches and my mind is numb.

You ride in like a saviour and ride out with my wallet strapped on your back. You offer false prophesies. Some of your drugs, injections, and sprays truly save lives. Others are crap.

Must you treat them as one and the same? Just to make money?

I am a human being.

My disease is part, not the whole of me.

Lift your eyes from your tired misconceptions, your white washed guidelines, and your market driven economies.

And look at me.

Colleagues

Roger struggled with various maladies that came with growing older.  His blood was occasionally too sweet, his pressure stumbled upwards, at times perilously.  But it was the colon cancer that gave him pause.  It started rather innocently.  At first he noticed a little blood on the toilet paper, later, a touch of abdominal pain.  He put off the appointment for a few weeks, but eventually he showed up in my examining room.

We talked about the pros and cons of colonoscopy. Roger liked to think deeply about his medical problems.  A few days later, he underwent the procedure.  The cancer was localized. We picked a surgeon that seemed to fit his personality.  He scheduled a visit with me right after his consultation to talk over the options.  Would it surprise to you consider that he thought of doing nothing?

Roger eventually had the surgery.  His recovery was rocky.  I visited him in the hospital every day. When his temperature spiked, I put him on antibiotics for pneumonia.  There was a short nursing home stay.  To see Roger ambling through the hallways of the extended care facility was quite a sight.  A place he said he would never go, he seemed like a king sitting atop his thrown.

I discharged him home when he was strong enough to handle the apartment on his own.  There was quite a bit of discussion, he actually left a little earlier than I preferred.  What could I say?  He made some good points.

I bumped into Roger while walking down the street the other day.  He was chatting affably with an acquaintance.  He greeted me with a warm handshake, and we stood silent for a moment. Then he turned to the gentleman standing quietly next to him, and apologized for not introducing us.

"I almost forgot," He paused, and smiled broadly, "this is my colleague, Dr. Grumet."

Colleague.  I thought about Roger's words later that night while daydreaming in front of my computer. He was right.  The word patient didn't really make sense.  There was no paternalism.  A light went off in my head that day, and I haven't used the term patient since.

In the job of safeguarding Roger's well being, we were partners, workmates, collaborators.

Colleagues.

Are We Waiting For Godot?

Ten reasons I feel pessimism about our current healthcare environment (in brief):

Process vs Product

Computers are just machines.  I repeat, they are just tools.  Health information technology is a shell which houses knowledge and human ability.  It is nothing more .  Electronic medical records may either streamline our thought processes or make them more cluttered.  They will not, however, lead to better or more perfect care.  They haven't yet, and they won't in the future. And they are prone to be adulterated by commercial intentions.  Looking for an answer to our complex healthcare problems here is like waiting for Godot.  You can wait and wait, but no one is coming.

Role Confusion

Physicians, nurses, and therapists are some of the most educated, expensive cogs in the healthcare machine.  Forcing them to become secretaries, scribes, and box checkers is both inefficient and redundant.  Furthermore, it doesn't take a physician to make sure a patient has had a flu shot, colonoscopy, or pap smear.  These are roles for nonclinical, low payed employees.  Take them of the clinicians plate.  Let doctors be doctors, nurses be nurses, and physical (and occupational) therapists do what they are trained to do.

Call It Courage

Until physicians have the courage to practice sound medicine and are willing to deny inappropriate antibiotics, narcotics and futile care, we are lost.  Until politicians are willing to forgo the electoral advantage, and vote for what is sound, we are handicapped.  Until patients are willing to own up to their own unsavory habits and practice will and self control, our medicines are impotent.

In Data We Trust

Data is being collected on the backs of physicians and nurses who have no reason to insure its fidelity, and have almost every reason to fudge their answers to move on to the herculean task of treating their patients.  Garbage in, garbage out.  The medical decisions of a generation will be based on crappy, nonsensical, inaccurate information.

Right Or Privilege

Either healthcare is a right or it is a privilege.  If it is the former, tax the American people more (like we do for roads and such) and implement a single payer system.  If it is latter, then let the market have at it, and accept that the have nots will have not.  This is how we do it in America.  Somebody has got to choose.

In Government We Trust

Can anyone out there say healthcare.gov? Need I say more?

Anti Intellectualism

Few would call the care of the human body a simple matter.  Some would argue that it is remarkably harder than, oh let's say, setting up a web site for a healthcare marketplace.  So why ever would we consider shortening medical school, truncating residency, or replacing MDs with less trained practitioners?  Anyone?  Anyone?

The Sands Of The Hour Glass

My belief is that the number one determinant of quality healthcare is the amount of time your clinician spends thinking about you.  In other words, most practitioners are relatively smart and caring.  Mistakes are made when the amount of time relegated to the task is insufficient.  Yet we add more and more trivial chores to each encounter without expanding the allotted time.  Something has got to give.

It's Futile

We offer dialysis to centenarians, physical therapy to end stage lung cancer patients, and a bevy of harmful and costly treatments inappropriately.  The main reason, of course, is that there is no such thing as futility in American medicine.  We are so busy charging up the hill, that we fail to see that the apex is a ledge that we are about to fall right back off.

The Foxes Are Guarding The Hen House

Do we really think that pharmacy run clinics are going to be the saviour of our access problem?  Are we to trust expert opinions from specialists when their suggestions are both self serving and run counter to what our best data tells us?  Should politicians wield so much legislative power when they receive financial support from pharmaceutical companies, insurers, and the device industry?  Why do we have so much faith on those who have their hands in the cookie jar?

If we want to meaningfully reform our healthcare system we have to take a hard and difficult look at ourselves.

I'm willing to own up to my professions role in this horrible debacle, are you?

Introducing The Palliative Care ICU

I think we are overly limited by our descriptive terms.  We throw around concepts like hospice and palliative care, but in reality the medicine I practice is much more a hybrid.  Many of my patients are elderly, demented, and plagued by metastatic disease.  Often when one of them becomes ill, it is unclear if they are merely treading water, or about to drown.  The problem with our modern definitions is that they leave little room to pivot.  Pivoting, it turns out, is critical to delivering humane, dignified, high quality care.  And our patients don't want  to be pigeonholed.  They want aggressive doctoring when it will be helpful, and hospice when chances are slim.  Unfortunately our crystal ball rarely provides the answers we are looking for.

With these ideas in mind, I would like to introduce the concept of the Palliative Care ICU (PCU).  Less an actual place than a state of mind, the PCU is a philosophy of doctoring that allows physicians to treat both aggressively and palliatively at the same time.  In other words, short term, intense, pain neutral interventions are carried out acutely with an eye on pivoting to hospice vs aggressive care depending on short term response.

In order to illustrate, lets consider Tom, an eighty five year old in a nursing home with metastatic lung cancer.  Although he is getting weaker, he still is able to ambulate and enjoy time with his wife and daughters.  One evening he develops fever and somnolence.

Tom has a fairly limited prognosis based on his aggressive malignancy.  On the other hand, his family has been enjoying visiting with him, and would hate for him to die prematurely from a treatable infection.  The patient himself has resisted hospice because he wants to continue getting chemotherapy.

If this is Tom's time to die, all parties agree to make him comfortable, and let him go.  On the other hand, if medical intervention could prolong his life and maintain a semblance of quality, no one would argue with intervening.

What is Tom's physician to do?

PCU Concept 1: Shelter In Place

Tom will die soon from his cancer regardless of the outcome of the current infection.  The last thing his family wants is for him to spend his last moments in an ICU being poked and prodded by strangers wearing isolation gowns.  Thankfully, there really is no reason to move him out of the comfort of his nursing home bed.  Given today's current medical climate, high level care can be delivered not only in extended care facilities but also in people's homes.  IV's can be placed, antibiotics given, and pain levels monitored.  If Tom were at home he could be attended to by an home health company or palliative care program.

Maintaining Tom's location is critical to the PCU concept.  It allows humane, dignified medicine without the trauma of escalating the place of care.  When possible, home patients stay at home, nursing home residents remain in the nursing home, and floor patients remain on the floor and avoid the ICU.

Tom's family and doctor decided to sign a do not hospitalize form and manage the current crisis in the comfort of his own room.

PCU Concept 2: Pain Neutral Interventions

Because Tom's quality of life was still reasonable, his physician and family felt that drawing blood tests, placing an IV, and beginning intravenous antibiotics was reasonable.

Each intervention was discussed amongst all parties and decided that the amount of discomfort was minimal compared to the possible benefit.  CPR and artificial ventilation and feeding, however, would clearly be painful and therefore were forbidden.

Although Tom continued to decompensate, he appeared comfortable and no worse for the wear given the current levels of treatment.

PCU Concept 3: Pivot, Pivot, Pivot 

Tom's physician reviewed the lab results with the family the next morning.  The kidneys were shutting down, the liver tests were abnormal, and Tom hadn't shown any signs of waking up.  He started to moan occasionally during the night and morphine was started.  The nurse carefully placed a few milliliters of medicine under his tongue every few hours, and he quickly became peaceful.

During a family meeting, Tom's wife and daughters understood clearly that recovery was unlikely and that little benefit would come from hospitalization.  Hospice was consulted.

Tom died quietly, surrounded by his family and friends, a few days later.

Conclusion

Conversely, if Tom had a limited infection like a UTI, he may have responded quickly to antibiotics and recovered uneventfully in the nursing home.  Either way, he was given high quality, judicious care that allowed nature to declare itself.

The future of healthcare is here.

We have to learn to drop our preconceived labels and adapt more hybridized models.

With this intention,

I introduce the Palliative Care ICU.

The Return Of The Prodigal Daughter

When I was in training, I had the mistaken belief that disease was treatable. I felt human weakness resided in the inability of the physician. If a patient deteriorated, if a battle was lost, it was because we weren't skilled enough. I studied with every extra moment. I followed the gurus and hung on each word of wisdom that flowed from their eloquent lips. I embraced the wonderful naivete, hoping against hope, that illness was curable and human fallibility could be scrubbed from our pristine souls.

There was a time after residency when I lost faith in medicine.  I kneeled at the steps of a broken shrine. In the great war against nature, we physicians waged an imperfect and often losing battle.  We flung our minuscule pebbles against the three headed dragon of cancer, cerebrovascular disease, and infection.  The darkness of night was set afire by noncompliance, resistance, and futility.

Many wars were lost, few were won.

Yet battle warn and beleaguered, humility, the prodigal daughter, returned to re stake her claim.  And I learned that being engaged is a gift that each physician can give.  When we listen, when we care, we provide a salve more precious than our impotent pills.  Our hands can be more adept than scalpels.

I've ended at the beginning.

The science of the novice has been tempered by the wisdom of humility.

I continually strive to use both.

Is The Doctor-Patient Relationship Like A Marriage?

It was like we were breaking up.

She stared at the ground longingly, and lifted her eyes from time to time as she spoke. She valued my care of her mother. She would never forget how I stood at the bedside during those last moments. And then there was her own health crisis. The emergency surgery was made more bearable by my familiar face in the emergency room explaining what would happen step by step.

She couldn't afford my new practice model. She crunched the numbers, and it just wasn't feasible. She didn't blame me. She understood that like any relationship, sometimes things just don't work out. Even businessmen and service providers have the right to raise their prices. She wouldn't argue with such innate American principles.

She was going to miss me, and I, her. The doctor-patient relationship can be like a marriage. Somewhere between the pointing and clicking, the arguing with insurance companies, and the struggles with preauthorizations, a true bond forms. We were two people, thrust together by unfortunate circumstances, who stood side by side for a portion of life's uncomfortable winding pathway.

Now our roads were diverging. For better or worse, we would go our separate ways. Many will look at me and point the finger of responsibility.

I will not deny my role in this unfortunate travesty.

But how many are facing similar circumstances forced by our current crumbling healthcare system? How many breakups are happening each day? How many primary care doctors are going concierge? How many internists are becoming hospitalists? How many pcps are being dropped from insurance panels as insurers respond to health care reform? How many physicians are refusing to take the new exchange coverage? And how many aging doctors are choosing retirement over meaningful use?

Marriages are being dissolved.

Relationships are being broken.

Who is paying the ultimate price?

Somebody's Doctor

You won't at first.

I mean you will try.  But eventually the poor gentleman cowering in bed will just become the homeless guy in room 114.  New admissions will cease to be opportunities to heal or learn.  You will dread the extra work.  Blood on your hands will no longer be the ephemeral pulsating evidence of life recently passed, but instead will be the muck mixed with excrement that you mercilessly scrape from your soiled hands.

And in those lonesome times when you're well rested enough to surface from the meandering haze of responsibility and fear, you'll scoff at the refection in the mirror.  A mere shadow of your premedical self, you will feel nothing but disgust.

Who am I? What have I become?

Many will scold me for saying that it is inevitable.  Am I too callus?  The soft supple character that leads us to medicine becomes quickly incompatible with the harshness of having one's hands intertwined in the bowels of the dying.  We all are mangled by the inevitable gears that grind daily on the smooth surface of our psyches.

If you are lucky, you will hold on to your humanity when it is safe.  You will cry unnervingly at the end of a movie so much so that others will look on awkwardly.  You will seek pleasures, whether carnal or gastronomic.  You may decide to exercise more, run a marathon.

In those moments when the sweat drips from your brow and the muscles in your calfs strain, you will feel alive.  Maybe more than you ever did in the hospital.  This will calm the unnerving emptiness you sometimes feel at work.

Life will not always be so smooth.  Friends will tell you that you are distant.  Lovers will say that you can be cold.

But with time the joy you so carefully cultivate outside the examining room can inch it's way inward. You may not connect with every patient, but you will learn to hold a hand, touch a shoulder, shed a tear.  You will no longer be soft or naive, however, that is gone for good.

Maybe you will be wise. Kind. An old soul.

And life will pass before your eyes.

And one day, perhaps, you'll become a husband or wife.

A parent.

Somebody's doctor.

Credit Due

I once mistakenly believed I knew nothing. Then after many years, with great hubris, I assumed a false sense of mastery over all that lay at my feet. It was only the wisdom of experience that taught me the truth lies somewhere in the vast in between.

It was nothing really, at least to me. I was in the midst of a busy, contentious, office meeting when my mobile began to buzz. I answered with the bitter taste of annoyance whipping from my tongue. It was a nurse from the skilled facility. My patient was declining. Frazzled by my surroundings and emotionally invested, I found just about every excuse for why she was wrong.

I looked at my watch impatiently as I calculated the time till finishing the meeting and the distance to the nursing home. It would be at least an hour. Mentally frozen by my preoccupation, the director of nursing jumped onto the line.

Dr. Grumet, we need to transfer him to the hospital.

A flash of anger rose red from my chest. Who was she anyway to question my judgement? Who does she think she is? But thankfully, the force of my own response made me pause. Indeed, she was the head nurse of the facility. Unlike me, she was currently staring at the patient as she had all day.

The fire in my belly cooled, the rage ebbed. I agreed to send the patient to the emergency room.

Hours later, I charted quietly at the nursing station. The director walked by and paused. I looked up and smiled humbly. I've learned over the years to give credit to people when they make good decisions.

You know you were right! Thanks for being forceful. I was too emotionally invested.

Her face lit up and she slipped away to her office.

I could tell that my admission had made an impact.

I guess doctors don't often give nurses credit when they are right.

And frankly, I think that's a shame.

Cancer And Baseball

Drip. Drip. Drip.

I would eventually come to recognize the sound of lives sliding down the drain. The life of a physician would allow me a front row seat to the horrors of disease, premature death, and total financial destruction. But my earliest memories were of the small bathroom in the back of that little antiques store. The leaking faucet was just one of the many signs of the decrepit and decaying building.

Downtrodden as it was, the storefront housed a certain vitality that attracted young and sometimes lonely preteens like myself. The owner, on a fluke one morning, decided to sell his old collection of baseball cards beside his bevy of antique trinkets and refurbished armoires. His first customer, a know it all teen, quickly bought his best cards at a ridiculous discount. The owner, impressed by the young man's knowledge, quickly hired him.

The baseball business took over. Before he knew it, the owner was bringing in more on cards than antiques. The market was certainly there, kids came from all over the neighborhood. They congregated at the back of the store by the glass counter with eyes wide. They bought packs, opening them as fast as their little fingers would permit, and stuffed the free piece of gum into their mouths with one fell swoop.

But it wasn't just the cards, the kids were also drawn to the owner. He was both congenial and authoritative. A buddy when you needed one, he was also the perfect source of fatherly advice.

Still spinning from the death of my dad at such a young age, I found an oasis of comfort in the back of that little antiques store. It was located centrally between my school and the bus stop. Every day I would race out of class and blast through the door with my back pack in tow. During the summer, I spent countless days sorting through cards, hoping to hit the jackpot.

A group of us became friends in those safe confines. Many, like me, were awkward and struggling with social interaction. When the teenage employee went to college, the owner chose one of my friends to take his place. At first I was quite jealous. Years later, I realize that my friend was struggling in ways more profound than I. The owner was wise enough to extend the olive branch to someone who really needed a break.

Years passed. I transitioned to high school, changed districts, and my interest in baseball cards wained. I still stopped into the shop from time to time. The owner was struggling. He had been diagnosed with cancer and was undergoing treatment. Luckily, he would survive the cancer.

But his business wouldn't. He was just sick enough from chemo that he had to ask others to watch the shop for him. Without his electric personality, the baseball card business dried up. So did the antiques.

I came back from college one year to see that my beloved store had closed. A beading shop called Bedazzled took it's place. I heard that the owner had gone to work for one of the big card shops a few towns over.

And a small part of my childhood disappeared, like that. I would never find that place again.

I realize, however, that I was the lucky one. The owner, faced with the horror of cancer, survived only to find that the house he had so lovingly built had evaporated.

This kind, gentle, wonderful man.

I guess cancer doesn't take such things into account.

Who Is Responsible?

But doctor, ultimately it is your responsibility.

I can hear the case coordinator clicking her fingernails against the desk through the telephone line. I admit, I forgot to specify to the nurse, when she called me ten minutes before midnight, that this was a full admission and not an observation. In the absence of my order, a nurse manager reviewed the chart and decided that the ninety five year old woman with congestive heart failure and positive cardiac markers was appropriate for observation status. Of course the order can be changed, but one day will be lost. She will have to stay in the hospital an extra night in order to qualify for the nursing home.

But doctor, ultimately it is your responsibility.

The physician on the line doesn't actually practice medicine. He gets payed by the insurance company to sit behind a computer all day and talk to clinicians like me. I wonder if he knows what it feels like to push on a belly and suspect catastrophe. I do. And occasionally I order a stat cat scan on a patient who is writhing on my examining table to rule out such horrible things. Apparently I should have done a plain film first before moving to a cat scan. Maybe then the CT would be paid for?

But doctor, ultimately it is your responsibility.

The coding and compliance people are reviewing a dozen of my outpatient charts. Some are over coded, some under coded. Occasionally my ICD's are all wrong. It's funny how the quality of care means next to nothing. The dictates are quite clear. Follow these inane and often opaque rules, or get fined. Or god forbid even worse, you might just find yourself in jail!

It's no wonder, I slink out of the office most days with my head hanging low.

For me, medicine is oxygen. It is the bread that I nourish myself with, the draught that quenches my thirst. I have dedicated myself to no other master with such faithful resilience. I have stood on the mountain of knowledge and suffocated on the precipice of my own incompetence. Slept for minutes instead of hours. I battered and bruised my body in the most unhealthy ways. I have been cowed by the humility and shear fear it takes to be responsible for the lives of my patients.

But nothing, nothing is as utterly demoralizing as being told, day in and day out, how irresponsible I am.

I Will Come To The Water

When I was young, I stumbled up the mountain in search of knowledge. Years later, I descended to the water when knowing no longer quenched my thirst.

I took the news poorly even though I barely knew the woman. We had talked on the phone a few times, over the years, regarding shared patients. I heard that she loved to swim.

They found her car parked in the lot adjacent to the beach. It was rumored that she was far too strong a swimmer for this to be an accident. But later there were whispers that she swallowed a bevy of pills before striding confidently into the waves that early morning. They fished her body out of the water hours later.

And I wondered about this lonely profession that we share. I have said multiple times that physicians are like islands floating in the vast sea. We may interact with others from time to time, but we are mostly on our own. There is no one with us in the middle of the night as we answer persistent phone calls. We carry the weight of the consequences of these decisions largely in solitary.

I heard that she was embroiled in a law suit, someone mentioned a federal investigation into illegally purchasing chemotherapeutic agents to offer to her patients at a discount. I highly doubt most of it.

I imagine that she was enamored with the water. We return our dead to the land for the most part, but maybe burial at sea is more appropriate. Our bodies are water after all. Her plasma mixing with the unimaginable vastness, maybe she no longer felt alone.

I kind of wish they had left her body where they found it.

As sad as I am by her passing, she made her own decision. I continue to mourn, however, for the rest of us. The pressure of practicing medicine is enough, dealing with the rules and regulations is becoming unbearable. And we are all still stuck in our sad, broken silos.

In a world of loneliness, we still haven't found a way to wither these tumultuous seas together.

I am sorry that I didn't get the chance to know her better,

I hope she found the peace that she was looking for.

Have Physicians Lost Their Backbone?

What ever happened to courage?

Jim came through the choleycystectomy beautifully. In fact, he did so well that in no time he was back on the basketball court. Three weeks later he was in my office with a sore, swollen leg. He thought it was from twisting his ankle the day before. And indeed, it had all the appearances of a sports injury. I examined the extremity carefully, and decided to get a venous doppler to evaluate for DVT given the recent surgery.

My suspicions were confirmed when the technician called to tell me that he had found a clot in the deep veins of the thigh. Shortly after hanging up, my phone started to ring again. Jim was calling on his mobile. He was having chest pain when taking deep breaths, and his heart was racing. He was struggling to catch his breath. Certain that he was having a pulmonary embolism, I instructed him to walk down the stairs from the doppler suite to the emergency room.

I phoned ahead and talked to the ER doc on shift for the evening. I let him know of the positive study and my suspicion of a pulmonary embolism. We needed to start anticoagulation and admit overnight. He informed me that the ER was full, and likely it would be late evening before a bed was assigned.

I fell asleep early, awaiting the call from the floor nurse to give admitting orders. It never came.

I woke up the next morning disoriented and rushed to the hospital. Apparently Jim was accidentally admitted to the hospitalist on call. After reading the chart, I started to feel the blood rise to my forehead. The hospitalist ordered a cat scan of the chest as well as hypercoaguability studies. I was seething.

Why ever would he needlessly expose my patient to the radiation of a cat scan when the diagnosis of a pulmonary embolism was all but certain given the positive lower extremity doppler? And why would anyone order hypercoaguability studies when we had two perfectly good reasons for a clot to form: recent surgery and a sports related injury?

The cat scan showed a pulmonary embolism and the hypercoaguability studies were negative. Duh! I called the hospitalist to ask why he ordered such expensive and possibly dangerous studies on my patient when they weren't necessary. After much bickering back and forth, it became clear that although the diagnosis was certain, he didn't feel comfortable without having proof. The hypercoaguability studies were done "just to be extra careful".

I was pissed!

Now more then ever, in this time of economic upheaval and floundering medical quality, we physicians have to have the courage to practice responsible, parsimonious medicine. We can no longer offer costly or dangerous medical care just to "reassure" ourselves. We have to make the tough decisions.

We must have the courage to not treat minor bronchitis with antibiotics.

We must have the courage to not use narcotics for run of the mill back pain.

We must have the courage to use palliative care and hospice effectively when appropriate.

We spent years developing the knowledge and skill to efficiently and effectively treat our patients in a sound and thoughtful manner.

When will we develop the backbone?

Selfish Empathy

Forgive me.

I went to a funeral today. I listened intently as various friends and family of the deceased regaled in what is and what was. The rabbi at the lectern was somber. His voice floated through the room both melancholy and hopeful. As he cleared his throat to begin the Mourner's Kaddish, I was again dragged back to childhood.

Yit'gadal v'yit'kadash sh'mei raba...

This chant, this prayer, this island of familiar in a sea of horrific will always remind me of my dad. His death is my earliest remembrance of these foreign but comforting words. I listened as a child intently at his funeral. Then, year after year, in synagogue, my mom would bring us to remember on his yahrzeit.

And it is through these shattered lenses; through this prism that I experience grief.

When my patients die, when I hold their families hands, I am remembering. When I attend a funeral, or pat a shoulder gently and sigh, I am reliving. Not the beauty and wonder of the life before me, because I will never feel as profoundly as the poor husband, child, or sibling. But the epic loss that pervades my existence.

In your father, I see my father. In you, I see myself. Forgive me if my grief is divided.

I empathize with your pain.

And your grief brings me back,

to my own.

Death And Privilege

When I say it's a privilege I see your eyes go cross. You think I'm daft. You reason that you are to young too talk about such things, or old but healthy, or that the cancer has spread but you want to remain optimistic. And I shake my head and think of my father.

He never had the luxury.

At the age of forty, he left early one morning to round at the hospital and never came back. A small blood vessel burst in his brain causing irreparable havoc. By the time we arrived, he was connected to all the appropriate machines. Back then, there was no talk of such things as preexisting wishes. The neurosurgeon, my father's colleague, told us he was gone and the ventilator was removed. His body quickly caught up with his severely damaged brain. He died.

You see, my father passed way before he was afforded the privilege we are discussing today; the privilege of seeing death as a shimmery mirage somewhere in the distant future.

The privilege of having a modicum of control over that which you fear the most is a gift. I humbly offer this to you.

Please take some time to think about your code status and advanced directives.

IRL

(This would be the start of a great #hcsm joke)

@hjluks walks into the lobby of a posh New York athletic club. I am sitting by the elevators. While he approches, I marvel at how easily I recognize him. It's not that he looks so much like his twitter avatar, I just feel like I've met him before. We shake hands and embrace.

The conversation begins as if we we starting where we left off last time. But there was no last time. We exchange pleasantries and go right to substance. I look over at the elevator bank wondering if we should go up to the conference room, or just stand in the walkway. And talk forever.

Eventually we make our way to the tenth floor. Over bagels and fruit we welcome each participant as they arrive. Some of us have met before, others have not. Our content, however, belays a sense of commonality. We may be diverse in experience and profession, but we share certain ties.

The meeting has it's ebb and flow. I am beginning to form archetypes in my mind of the participants. To my right is @dlschermd. He lends me his marker from time to time (mine is barely functional).

@dlschermd reminds me of the brilliant professor that we all had in college, but better. He's neither bumbling nor arrogant. His generosity of thought far outweighs his freedom with writing utensils. Measured and insightful, the room becomes silent when he speaks.

Across from me sits @joshuaschwimmer. I can feels his gaze upon me when I speak. He is concentrating, dissecting. When he raises his voice to reply, I am completely sure that the first sentence will have the word "app" in it. And I'm right, but what comes next is often brilliant and throws my opinions completely on their side. Sometimes he says something and I think he is completely off base, till I realize that he is about ten steps ahead of me and I hadn't thought it out completely yet.

@PhilBaumann is calm and collected. He forgives me multiple times for interrupting without so much as making a grimace. He waits until there is a lull in the conversation and then proceeds forward. Although I have no basis for my opinion, I get the feeling that below the surface there is a ferocity. Controlled, tamed, but deadly when necessary. I wouldn't want to be on the wrong side of a heated argument with him.

Through @nickdawson (and @PhilBaumann)I can feel the patient advocacy shine through. @nickdawson is one of those rare people who speaks of ACOs and value based purchasing not with the grime of consumerism dripping from his lips, but with a zeal for providing more services for less cost for those in need. He later told me that as a hospital administrator he would sit in various places in his facility with a laptop and observe. I bet no one ever asked him to do this.

@hjluks sits towards the front. Calm. Engaged. He talks exactly the way he blogs. Disparate ideas become cohesive thoughts, wrapped in a bow and presented to us in such orderly fashion that one wonders if the problems of the world are really so unsolvable.

And all these fine gentleman tolerate my verbose and often repetitive opinions. They are confident in who they are.

The meeting ends and I lament that I have to say goodbye to Howard, David, Joshua, Phil, and Nick. It's been such a gratifying conversation.

I'm hoping I'll be lucky enough to get to drop the @ sign again soon.

There Is No I In Team

I was spiking a fever.

It was as if someone flipped a light switch inside my body. I could feel the sensation rise through the chest, and trample the dazed contents of my skull. Light, however, was a poor, lazy metaphor. There was no heat, only stimulation.

My belly ached from the repetitive heaving that preceded the fever. I envisioned the sandwich I had eaten that afternoon. I pictured small bacteria crowding into the generous dollop of mayonnaise wantonly placed by the store clerk. It was food poisoning. I was sure of it.

I cautiously sipped from the glass of water on the bedside table. My mouth, parched and yearning, was ignoring the revulsion in my mid section. I celebrated the brief ecstasy of quenching the abominable thirst before my belly began to swirl. I got up and ran to the bathroom.

Collapsing back in bed, I looked glassy eyed at my mobile phone which had just begun to ring. I mustered my strength, and picked it up.

Dr. G, It's Lisa at the nursing home, Mr. W's pain is out of control again. I tried the five of roxanol with little effect. His family is getting anxious!

I took a deep breath, and gave a few orders. I then fell back into bed. I had a long night ahead of me.

In fact, my sleepless night came at the end of a long weekend. Not being on call, my family and I treated ourselves to a few days in the city. We swam, we rode bikes, we deserted at Ghiradelli's. Carefree fun in the sun, right?

Well, not exactly. My hour long bike ride was interrupted by three phone calls. While swimming, I had to keep my mobile close in a dry and safe place. And even a hot fudge Sunday couldn't be eaten without some medical question or another needing to be answered. All of this, on my weekend off.

It has become popular to describe my breed of physician as outdated; to say that we have a hero complex, and can't adapt to today's team based mentality. If we would just loosen the reins and hand off some of the responsibility. Groups think better than individuals!

Unfortunately, I have found it all but impossible to "hand off" large numbers of debilitated nursing home patients. The care is too complex, too involved. On the aforementioned weekend, during my little vacation, I had a patient die (expected), and another develop multiple pulmonary emboli. Not to mention the diagnosis and treatment of a slew of new infections as well as a minor fracture.

All of this was managed in the nursing home, with close coordination between staff and families.

When physicians unfamiliar with these kind of patients try to cover, bad things happen. Hospice patients get sent to the emergency room. Demented people get inappropriately put on antibiotics for nonexistent urinary tract infections. The quality of care goes down.

So when I get sick, or take a weekend off, you better believe that I am going to answer that phone call. Because many of those patients are suffering far worse than I. It's not that I am trying to be a hero.

I'm hoping to become the kind of physician that I would want to care for my loved ones.

Are You Listening?

He was an expert in healthcare policy.  He wrote nationally lauded papers on such things as evidence based medicine.  He spent half his time in Washington advising one governmental agency or another, the other tucked away quietly at the VA.  Originally he attended at the University, but that didn't last long.

We residents avoided him at all costs.  Not only did he piss away our precious time with verbose and often tangentially related lectures, he was down right dangerous.  The head of internal medicine knew it; our chief resident knew it.  So schedules were shuffled, teams were adjusted.  Often the strongest housestaff were pulled to work on his team, and clean up the mess he made.

Years later, I now realize, that a number of poor unsuspecting veterans likely suffered by his clumsy hands.  Thankfully, someone of authority usually stepped in before irreversible damage occurred.  It was not that he didn't understand pathophysiology or differential diagnosis.  His deficit was far more worrisome,  he completely lacked in the art of medicine.  When a patient zigged, he zagged.  He flawlessly applied inappropriate and poorly timed algorithms in a rigid and ineffectual manner.

And worst of all, buoyed by all the back patting in Washington, he was utterly confident in his abilities.

Occasionally I still hear about him from time to time.  Prancing through political circles or spouting off on CNN.  His smile is wide and confident, but I will always remember his frown as a patient circled the drain, a victim of his misapplied "science".

And I shudder, shudder to think that the politicians who currently shape our healthcare policy are listening to him intently.

I Call Bullshit

I am hard on myself. I'm the first one to point the finger inward. Every patient that dies, every adverse outcome, I study my decisions in excruciating detail. I have high standards. I don't sugar-coat the abilities of myself or my colleagues.

As the owner of my own medical practice, director of a nursing home, expert witness, and associate director for a hospice and palliative care company, I have vast experience dealing with the pitfalls of our medical system. After seeing thousands of patients, in almost every setting over the last seventeen years, I strongly question what I have been recently reading on my twitter feed.

According to a new study in The Journal of Patient Safety, preventable adverse events (PAEs) account for over 440,000 deaths a year in hospitals making medical error the third leading cause of mortality in the United States.

I call bullshit!

In my experience patients die of metastatic cancer, end stage dementia, coronary artery disease, stroke, and sepsis. Of the thousands of patients I have watched die, only a handful, at most, were complicated by preventable adverse events. And most of these happened in patients with highly involved, already terminal diseases, where the pure number of physicians and treatments multiplied the complexity.

I'm not saying that medical error doesn't occur. I'm not saying that we shouldn't have a robust bevy of researchers and experts studying the issue. None of us should rest knowing that our patients lives are at risk.

But I have to think that the extrapolations that led to this data set are faulty.

It just doesn't match what most of us are seeing in the trenches.

Death Is A Period Occuring At The End Of A Sentence

You are dying.

I have reviewed the Cat Scans, spoken to the specialists, and studied the labs. There are many possible treatments that could be offered, but I fear they will not stem the course of all that is happening already. The tumor is too advanced, the metastases, too malignant.

I know there are many questions about chemotherapy, radiation, and feeding tubes. I would caution you to think of death as the inevitable endpoint. There are many things we can do between now and that endpoint. Some will increase your life expectancy, and some will cause pain and discomfort. The trick is to decide what is more important to you: quantity vs quality. Many life prolonging treatments come at a price. Chemotherapy causes nausea and fatigue. Radiation has many untoward effects. Feeding tubes get infected and accidentally pulled out.

You must feel like all hope is gone. But I want you to know that I have great hope. Let me explain. In my experience every person, young and old, healthy and diseased, wakes up each morning with a plan for the day. Although sometimes those plans are unreachable (you will not be able to make that last trip to Florida), others are quite possible. You should expect to spend each day with your pain controlled and in a safe environs. My goal is for you to experience pleasure, no matter how small. This, I can do for you.

I do not know when you are going to die. Doctors are poor at estimating such things. But I would like to help you focus on the life each day occurring around you. Death is a period at the end of a sentence, not a parenthesis or quotation mark.

Although my role in "curing" is over, I will by no means abandon you. In fact, I will be even more engaged. You need me more now than you did when I was treating your high blood pressure and colds. We will travel this road together.

And on the day when death finally comes. You will be cared for, likely pain free,

And surrounded by love.

Buyer Beware

Gertrude wasn't able tell me herself. She was ninety years old and moderately demented. It was her daughter who called. She pleasantly greeted me as I picked up the phone.

We had a good working relationship, Gertrude's daughter and I. We navigated a heart attack and stroke, multiple hospitalizations, and many discussions concerning end of life care. Gertrude was well taken care of. She was lucky enough to have a group of helpers who were under the doting, watchful eyes of her daughter.

In fact, the last pneumonia and urinary tract infection were both treated successfully at home without need for hospitalization. I guess I took it for granted that Gertrude would be a part of my new practice. I had no doubt she could afford it. So I assumed that this would be a phone call about some pressing issue or another.

But I was wrong.

Gertrude's daughter called to thank me for my service, and inform me that her mother was moving to another office. Her voice was smooth and confident with a tinge of pride as she gushed about the first visit that occurred earlier that morning. Although saddened by the realization that I would never see Gertrude's warm if not vacant smile, I tried my best to be gracious. I offered to have my staff forward the medical records, and wished them well.

A few days later, I received a letter from Gertrude's new doctor. He thanked me for the referral, and enclosed a copy of his note. My hands started to shake as I read the assessment and plan.

Gertrude, my ninety year old demented woman, was referred for a screening mammogram and a colonoscopy. To add injury to insult, he ordered full lab work including a cholesterol panel.

No matter how depressed I am at this unbelievably inappropriate care, I can't complain. It was I who changed things up on Gertrude. I have no right to be indignant. But I would like to offer a word of warning for all those out there looking for new doctors.

Buyer Beware!

You can no longer be a passive force in your own medical care. Before you race into the bosom of a new provider, do the research. After each visit, question each new prescription and lab order.

And above all else,

Verify. Verify. Verify.

Oasis

There was nothing wrong with Sarah's vocal cords. Her tumor had spread throughout the abdomen, but her voice was unaffected. Yet minutes after learning of the voraciousness of her metastases, she pursed her lips and began to communicate with head nods and hand gestures only.

I met her for the first time in the nursing home. I sat down quietly at her bedside on a Sunday morning. I was in the midst of a weekend call rotation that would last fourteen days. Then, because of a scheduling snafu, I would have a few evenings off before starting my next two week stint. Only one weekend to rest all month.

We communicated in the most rudimentary fashion. I asking open ended questions, and she nodding from time to time. Her body was growing weak. Her belly had become progressively distended, and she was no longer eating. I called her closest relative, a sister half way across the country. We talked of hospice and palliative care.

When I spoke of dying, Sarah would close her eyes. Complex coversations were reduced to the most basic. It took almost a week to establish her wish to be DNR, and a few more days to get consent for hospice. All the while juggling multiple crises at once, my sleep schedule was interrupted on a nightly basis. There were other patients drowning in a sea of disease and frailty. And I, muscles overwhelmed with lactic acid, was trying to row a lifeboat to each lonely oasis.

When Sarah began to die in earnest, I called her sister and bayed her to come. After hours of travel, she arrived at the bedside late Friday evening. Relaxing on the couch in preparation for my sparingly precious days of rest, the mobile rang at my side. It was my answering service.

Dr. Grumet, I know you're off this weekend, but the nursing home called and said that it was an absolute emergency.

Indeed it was. Sarah was dying. Her sister was petrified and wanted me to come to the bedside. My partner on call knew nothing about the case, and the hospice team hadn't arrived yet.

And this is what's so difficult about doctoring. Our patients and their families so desperately need us to be engaged and present. Yet being there is often inconvenient, exhausting, and ultimately unhealthy. We delay sleep, impose on our spouses, and deny our children.

We met briefly the next morning. My wife and kids ate breakfast at the Panera next door as I sat with the two sisters whose hands layed intertwined on the bed. Although Sarah was fading quickly, she had just enough strength to lift her head. I barely recognized the soft syllables that tumbled tentatively from her lips.

Thank You!

They were the first and last words I ever heard her say. I nodded my head graciously,

and ambled next door to join my family for breakfast.

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 thirty scattered amongst the oncology floors. We had ten admissions a day, and the same number of discharges. On average one patient died every shift.

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 but I was too busy: scurrying after labs, running codes, and 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 twelve hours a day, every day, for a month. My time at home, in-between shifts, was surreal. I would sleep, eat, have conversations. They were 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

Blood On Our Hands

I have blood on my hands.

No matter how hard I scrub, the fingers retain their burnt hue.

Many cannot see what I see; They cannot feel what I feel. They look at me with my crisp white coat, picturesque family, and all the trappings of middle class success. I am a doctor. I am to be envied. How dare I suggest that the profession that has buoyed me through this tumultuous economy is flawed? I should be thankful.

And indeed, I am, on those days when I see past the red. For there is a dark secret bouncing in an out of the minds of those who took this oath. None of us escape. Not even the ones who no longer "touch" patients. The pathologist has the image seared on his brain of the slide with neglected cells. The radiologist spies a lesion in every chest to make up for the one that was missed.

Those of us with our fingers deeply enmeshed in the bowels of human suffering have more tangible remindings of our shortcomings. How many decisions were made with the best intentions but faulty logic? How many lives were taken? I'm not talking about malpractice here. That's too easy. I'm referring to climbing out on the branches of thousands of small decision trees with simple yes or no answers but dyer consequences.

How many of the rest of you live with the fallout of these type of decisions?

How many of you can track the fatherless child, the husbandless wife, or mourning sibling to a choice that you were in charge of making?

I can.

No one told me that no matter how many lives I saved, there would be scars, wounds that would never heal. No one told me that like the most base of murderers, I too would have blood on my hands.

This is my privilege. This is my envy.

I grew up without a father. I understand the pain of premature death. I am fully aware of the consequences of my decisions.

I would not choose this profession for my children.

The pure act of doctoring is enough to give merit to the sacrifice. But today we practice a bastardized art. The power of touch has been overtaken by expensive machines. A knowing glance and kind smile have been reserved for the computer screen.

And true love and empathy have been replaced by fear of a tort system that accuses and a government.

A government bent on destroying a profession we hold most sacred.

Worrier In Chief

Saul couldn't have been a nicer guy. The story behind his arrival to the nursing home was long and sorted. But now we had a black gangrenous foot to deal with. The culprit, not the toe ulcer that brought him in to the hospital in the first place, but small thrombosed blood vessels from heparin induced thrombosis and thrombocytopenia, a reaction to a medication given as a precaution.

The vascular surgeon was equivocal, amputation versus watchful waiting. Toes can autonecrose (self amputate), but when the black tide of dead tissue spread towards the ankle our options became limited. As the white count began to rise, I had the wound care nurse unwrap the limb. Fluffs of inflammatory transudate soaked the dressing but no signs of active infection.

The leukocytosis (high infection count) was bothersome. Although the course of vancomycin had been long finished, the specter of clostridium difficile remained. And of course there was the polycythemia to deal with. A bone marrow disorder, the white count could shoot up for almost any reason, especially since he had been taken of the hydrea (treatment for polycythemia) as a precaution while treating the bowel infection.

So there were multiple possibilities: inflammatory reaction to necrotic tissue, C Diff, polycythemia, other infection? When the diarrhea began it was almost a relief. Cultures were resent, vancomycin and flagyl started, and daily INR's to track the interaction between coumadin (started to allay the risk of clotting with untreated polycythemia-hydrea on hold because of C Diff) and antibiotics.

Saul, though, had no fever, no abdominal pain, and the diarrhea slowed within days of starting antibiotics. But the white count (infection) was now heading towards thirty and the platelets were over a million. I tracked down the infectious disease specialist while in the hospital and briefly discussed oral antibiotics vs intravenous Tygacil. I paged the hematologist and we debated restarting hydrea in case this was just a noninfectious leukamoid reaction.

When cases are starting to get out of control, I like to sit and talk to the patient. Saul, bless his heart, was probably too demented to understand the complexities. His daughter, however, was involved and interested. We discussed the upcoming surgery. We talked of my clinical impasse between infection and inflammation. She was more concerned with her dad's comfort than prolonging his life.

And Saul was as happy as a lark. His functional abilities were declining, but his biggest complaint was being stuck in the room due to isolation from his infection.

Ultimately I decided to give the antibiotics a little more time. I held off on hydrea, and gambled that the high white count was more a reaction to the foot necrosis and less so infection. I watched tentatively at his bedside, visiting the nursing home daily.

Saul's dilemma bubbled up in my mind, even at home. Occasionally waking in the middle of the night with a startle, I wondered if I was missing something.

With time the white and platelet count started to abate. The diarrhea disappeared. A surgical date was set and another flurry of calls was made to figure out the anticoagulation. Coumadin needed to be stopped, lovenox was risky given the HITT syndrome, and no one wanted to put him in the hospital for agatroban. The hematologist thought that Arixtra would do, and be a nice middle ground.

Saul is by no means out of the woods, but there are signs of improvement.

***

When people ask what an Internist does, I sometimes have to pause. Unlike common perception, our job is much more complex then treating colds. We are not just followers of our specialists directions. What always surprises medical students is that when the lab results come back, or the phone rings in the middle of the night, the specialists are long gone. Often I have to take all the information I have gleaned over time, and make the call.

Hydrea or no hydrea.
Infection or inflammation.
Aggressive treatment or palliative care.

I guess I would say that my job is to think deeply, build consensus, and help families plan. I do this for a few in the hospital, seventy in the nursing home, and two thousand outpatients.

Everyday.

Call me an Internist, a primary care doctor, or a flea. The sign on my office door will tell you how I feel about it.

Worrier In Chief

The Anatomy Of A Hospital Admission

If Hattie had but one flaw, it was that she held her doctors in too high esteem. It was not unusual for an eighty year old woman of her culture to want to please her cardiologist. So when her blood pressure came up a little high, she was too embarrassed to admit that she had forgotten to pick up the toprol and hadn't taken it in over a week. The cardiologist hemmed and hawed, he buried his head in the computer, and eventually wrote for norvasc, a new blood pressure medication. What he didn't do was ask about whether she had regularly taken her pills. He also forgot to tell her that leg swelling is a side effect of the medication

But Hattie wanted to be a good patient. She squinted her eyes tightly and bowed her torso respectfully.

So you want me to take both the toprol and norvasc?

The cardiologist shook his head vigorously in affirmation as he reached for the door knob. He looked back, half his body already out of the room, and asked if there was anything else. By the time Hattie tried to lift her voice to answer, he was long gone. The waiting room was full and surely he didn't have time to stay around for her.

The next week, Hattie arrived at her primary care doctor's office for a diabetes check. After arriving thirty minutes late, he reviewed her chart. Although he read the cardiologist's note, the eleven page novel was so dense that he missed the part about the new prescription. He spent the majority of the visit clicking away at his computer, and making sure Hattie was up to date with her Hgb a1c and lipid monitoring. When he was about to zoom on to his next patient, she leaped up to catch his attention.

But the swelling in my feet, what is causing the swelling in my feet?

Befuddled by his computer, rushing to get to the next patient, and thoroughly annoyed by trying to address an issue other than diabetes, he sat back down and scrathced his forehead. The blood pressure was low and the legs were indeed swollen. Under intense pressure, he quickly reasoned that this must be an exacerbation of her congestive heart failure. He looked up at the clock and then down at the patient. He didn't re review the patient's medications. He didn't get on the phone and call Hattie's cardiologist. These precautions would have taken too much time. Instead he wrote her for a prescription of lasix ( a diuretic which would lower her blood pressure further) and ordered an echocardiogram.

Two days later, Hattie showed up to the emergency room dizzy and short of breath after lifting heavy boxes in ninety degree weather. She was dehydrated and had low blood pressure. This is exactly what would be expected to happen to an elderly woman who:

1.Inappropriately was put on an extra blood pressure pill because her cardiologist was too busy to ask about whether she was compliant with her medications.
2.Inappropriately was diagnosed with congestive heart failure instead of norvasc induced lower extremity edema because her primary care physician failed to illicit the history of a new medication or call her cardiologist.
3. Was exposed to high ambient temperatures.

And what happened in the emergency room? The ER doc read the history in the electronic medical record of congestive heart failure, examined the patient and saw the lower extremity edema, and incorrectly gave Hattie IV diuretic.

It was only hours later, when the hospitalist sat down at Hattie's bedside, that the tale of her woes came clearly to light. He ordered IV hydration, stopped the lasix and norvasc, and restarted the toprol the next day when the blood pressure came back up. Then he sent her home.

Now you may read this diatribe and think that my point is to trump the benefits of hospitalists or talk about the terrible diagnostic abilities of outpatient physicians.

But what I really want to say is that good doctoring takes time and concentration.

Both are commodities that most well intentioned clinicians caught in the dictates of our flawed healthcare system,

no longer have the luxury of.

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!