Tuesday, July 29, 2014

Doctors Behaving Badly?

A dozen set of eyes stared upwards.  The nurses ate their pizza and glanced back and forth between me and the dry erase board that I had recently filled with incomprehensible scrawl.  I had given this lecture many times; said the words over and over again.  And yet the response was always surprising.

Why do you think physicians get angry and annoyed when you call?

A simple question.  Every day clinicians yell at nurses.  They bully, they prod, they rush off the phone before fully answering questions.  I have done it many times myself.  The phenomena is so common that most nurses and secretaries accept it as part of the job.  That doesn't mean that it doesn't hurt.  It doesn't mean that they won't cower the next time they have to call that physician again.

I waited patiently for the audience to venture a guess.  In all the times I have asked this very same question, I have never had any one volunteer an answer.  And this befuddles me.  Because most physicians go into the profession to help others.   Most truly want to be there for those in need.  So why when the cards are on the table, when a nurse or patient calls in crisis, is the response so negative?

I threw out a few possible answers myself: they're tired, had a bad day, didn't get enough sleep last night?  I few half hearted nods from the crowd.  All possible explanations, but I could tell that no one was really buying it.  Slices of pizza were now frozen halfway between plates and mouths as the audience waited attentively.

Maybe because they are afraid?  Don't know what to do?

A look of astonishment and then understanding flashed across a dozen faces.  It was like a weight was lifted off their overburdened shoulders.  Faced with difficult and life changing decisions, physicians often react with anger and annoyance due to frustration.  It rarely has anything to do with the nurses themselves.

This reaction is neither professional or acceptable.  And I try to modify my own behavior accordingly.  Some days I am more successful than others.

But at least today, a good day, a handful of caring people left the lecture room with full bellies

and a sense of well deserved vindication.

Tuesday, July 22, 2014

Come And Knock On My Door

The house was getting cold.  My wife and kids snuggled in their blankets as I crept out of bed and checked the thermostat.  The subzero winter air howled as a blustery morning took shape outside our windows.   I looked at the digital display with disbelief and manually tapped the screen with my finger, hoping that the jarring motion would loosen the exact faulty screw leading to our frigid state.  No luck.  The thermostat was working just fine.  The problem was much more sinister.  I covered myself with a blanket and ran to the basement.   I paused for a full minute to listen.  Not a peep.  The furnace was absolutely silent.

A few hours and a hefty credit card charge later, a workman strolled into our house.  His bag overflowed with a  gaggle of steel and electronic tools salivating at a chance to sink their jaws into our machinery.  After much tinkering, adjusting electrodes, and forehead scratching, a pronouncement was made.  A few pieces of equipment were procured from the van and adjustments were made.  To our relief, the sweet hum of air passing through vents once again filled our house.  We  sat underneath the counter top, and bathed in the heated air rising from the bowels of the house.

Until, of course, an hour later when a loud clanking sound announced the end of our geyser of contentment.  The temperature plummeted.  Phone calls were made.  And the process started all over again.  Two weeks, various repairmen, and multiple diagnostic tests later, we were no closer to an answer.  The heater would spit and sputter, work for a few hours, and then shut down ominously.

Finally, one of the workers noticed that our air intake valve was pointed in the exact same direction as the exhaust.  Hot air was leaving the exhaust, entering the intake valve, and overheating the system.  It took him seconds to adjust.  The problem never reoccurred.

Years later, as I ponder this cold episode in my families life, I am flabbergasted that a supercomputer didn't exist that could have been hooked up to our furnace and immediately diagnosed the problem.  It appears that heater repairmen are unlikely to be put out of business by the vast expertise of technology.  And they are not alone.

As of this time, no one has created the technology to replace lawyers, accountants, or airline pilots yet either. Sure there is quickbooks, and auto pilot, and legal zoom.  But when push comes to shove, the technology to overthrow these fleshy human beings is just not agile or savvy enough.

Yet time and again, technophiles dream of a world in which Dr. Watson or Dr. Google takes the place of our stethoscoped brethren.  They say that instead of diagnosticians, physicians will be trained to be experts in empathy.  They will be culled from film schools, and broad liberal arts educations.  They will recite poetry instead of treatment plans.

I can't help but think that maybe these oracles, these technologists, need to refocus.  Shouldn't we concentrate on logical systems with finite variables to practice on first?

Figure out how to replace auto mechanics and appliance repairmen.  Then maybe, maybe you should knock on my door.

Monday, July 14, 2014

The Novice

It's a strange thing to be driving about in your car in the middle of the day.  For one who has spent the majority of his professional life sheltered in dark offices and aseptic hospitals, the summer sun and fresh breeze is quite lovely.  One almost begins to approach humanness.  Normal.  This must have been what it felt like before immersion into the tribe of medicine.

Sometimes I have trouble remembering my premedical days.  The divide seems vast.  It is not only the effects of age but an emotional chasm that has formed over the years.  The optimist says I was naive, inexperienced.  The more harsh reality is that I have developed a cynicism, a coarseness which permeates all aspects of life.   I am a person, I am a doctor.  The two mangled halves rarely come together to approach a whole.

But my new reality has begun to unravel the protective coating super glued to my insides.  My clinical encounters are but small punctuations in a day filled en route from location to location.  Homes, hospitals, nursing homes.  I spend more time in the car than anywhere else, and when I am there,  I roll down the windows.  I turn the radio up.  And I am just another guy, speeding down the expressway or caught in traffic.

This feeling like a regular person has had profound affects.  It's helped me look at the world through what seems like an ancient lens: that of a human being first and a doctor second.

I was cruising down a side street the other day when I came to a backup.  I cursed as I slowly progressed through the line of cars.  It took twenty minutes to traverse a single city block.  When I came to the head, I witnessed a macabre scene.  An ambulance was pulled over and a couple of paramedics were performing CPR on a shirtless man on the sidewalk.  His arms were splayed to the side and his chest flailed with each compression.

Within seconds I was moving again, and the the ambulance was barely visible in my rear view mirror.  A lump stuck in my throat and I took a deep breath.  I have watched hundreds of people die, I have performed CPR countless times, but this was somehow different.

For just a moment, I had escaped the curse of all those years of training and experience, and was able to just feel.

I am hoping to carry this with me from patient to patient.  To use all my knowledge and experience to diagnose and treat, but to care for my patients like the uninitiated.

The novice.

Monday, July 7, 2014

We Can Barely Dream In The Place That Empathy Dies

It was a vulnerable time.

The man sitting next to me in the car shifted gently.  His arthritic hands curled into a bow and rested on his lap.  He melted into the seat as if all those years working on automobiles had somehow strangely made him part of one.  I self conscioussly placed the key in the ignition and glided out of the parking spot.  I could feel his gaze upon my shoulder as we both strained to listen.

After the accident, almost the whole body needed to be repaired.  I marveled at the clean finish and drove home overjoyed to forget all that had just happened in the last few weeks.  The shell, however, often betrays that which dwells within.  It only took a few miles before I noticed the knocking coming from somewhere behind the left rear wheel well.

So I drove a few miles with the elderly man from the body repair shop in my passengers seat to see if we could tease out the problem.  I marveled at how uncomfortable I was with this stranger in my personal space.  I was aware of my every movement, my every breath.  For him, this was routine.  How many times had he ridden in the car with a complete stranger trying to diagnose a bump or squeak?  But for me, secretly shattered and struggling with my confidence after an unexpected car accident, my skin bristled with every displacement of the intervening air.

I couldn't help but think of my patients.  Their presence, the exchanging of secrets, the caress of skin, all so familiar.  So familiar for me, the doctor.  The apprenticeship of medicine teaches not only the ad nauseum details of disease but also the physical and emotional closeness.  One learns how to face tragedy not as the event changing moment in another's life, but as a part of ones daily routine.

Yet it occurred to me that sitting in that car, what I most needed at the moment, was to be told that it would all be okay.  The big it (not the knock in the wheel well).   I was so vulnerable.  I needed to be reassured that my confidence would come back, that my heart would stop racing every time I merged onto the highway.  But why would this kindly gentleman know that?  He was just an auto body repair man coming to work, taking a ride to diagnose a problem.  You know, routine.

And I struggle with how to professionally not become the body repair man.  Because indeed cancer, and infections, and heart disease, and death and dying are the fare served up on my daily menu.  My repeated exposure to such things, the nightmares of the general populous, changes how I experience.  Changes how I feel and perceive. The exact qualities that make us master diagnosticians, i.e. repeated exposure, make us lousy human beings.

Those of us steeped in the difficult, have lost the ability to break out of our practiced shell.  We have lost the ability to experience as the novice.  Yet as physicians, it is exactly the novice who we have dedicated our lives and careers to.

It is no wonder there is a disconnect.  Our patients come to us desperately needing our skills and knowledge.  Yet in the process of obtaining these skills, we lose the ability to see the ensuing landscape through the same unaware lens.  We can no longer experience what our patients experience.  Nay, we can barely dream in the place that empathy dies.

The patient is thankful for the help but sometimes just wants to be told that everything will be okay.  The doctor is confused about why physically treating the problem doesn't bring about full resolution.

It turns out we were never able to reproduce the troublesome noise the car made that day.  As I thanked the gentleman for his help, I hung my head sheepishly feeling the weight of yet another humiliation.  He looked me square in the eye, and I could feel the warmth in his grip as he grasped for my hand.

Any time.

His shoulders stooped and his back bent as he walked away.

Any time.