Monday, December 7, 2015
The daughter didn't know that I had watched this same nurse successfully perform CPR on a man the day before, and her quick thinking was one of the factors that save his life. She had once recognized a rare side effect of a medication, and solved a clinical mystery that had hounded doctors, hospitals, and pharmacists for months.
In my mind, she was the best that clinical medicine had to offer. Knowledgeable, kind, intuitive.
But this trend has been escalating over the last few years. Patients and families wagging their fingers and nodding their heads angrily in the direction of clinicians. Doctors, nurses, and therapists have been accused of being incompetent, lazy, or downright cruel.
There is a basic loss of faith in the ability of our healthcare practitioners.
I think that the Internet plays a role. The ability to Google one's symptoms and come up with a host of diagnoses has made the populace feel that medicine is easy. Furthermore, the lay press and some of our own physicians and administrators decry the system as befouled by errors. They say that we account for as much death and disability as heart disease and cancer.
While I believe that medicine requires a continuous and stringent effort to improve itself, I also think that the populace is becoming progressively fooled and brain washed.
Here is what I think the public should know:
1)People die, for the most part, because they are sick. Yes medical errors occur (even to healthy people). But medical errors happen more often in deathly ill, hospitalized patients, with poor prognoses to start with. The more ill the patient, the more complicated the care. More medicines. More tests. More risky procedures. More errors. This doesn't mean that we must not strive to do better. But all those articles about how "hospitals kill more patients than..." are ungenuine.
2)Complications are not errors. A small percentage of people who get colonoscopies will have the unfortunate complication of perforation. They may even die from it. This is expected. Same for post surgical deep venous thrombosis. Same for deadly side effects of medications. There is a cost/benefit ration. We can do our best to mitigate risk, but we can't avoid poor outcomes altogether. It's like a reverse lottery. The grand majority do just fine, but occasionally there is a big loser.
3)A text book presentation of a disease is very rare in clinical medicine. It happens infrequently.
4)Physicians are some of the most highly trained individuals in society. Our education is arduous and can span more than a decade.
5)Medicine is one of the most researched fields known to man. Billions are spent every year improving our clinical knowledge. Our ability to treat cancer, heart disease, and injury is far better than it was even a decade ago. Patient safety is, and has been, at the forefront of researchers minds for years. We are making great improvements. Think anesthesia, hospital acquired infections, and surgical check lists.
6)physicians have active and time consuming requirements for continuing medical education and board certification. Greater, I believe, than almost any profession.
7)The legal system holds physicians to a high standard and the penalties can be life altering for the involved clinician. The grand majority of physicians are sued at least once during their career.
In summary, medical practitioners are highly trained and skilled individuals who are plugged into an incredibly regulated and researched domain of human existence.
To treat them as if they are stupid or ignorant is unkind, to say the least.
Posted by Jordan Grumet at 12:03 PM
Wednesday, November 25, 2015
I visited him in the home.
We met eight months before his death. His wife, two daughters, and I. We discussed what dying looked like. We talked of dignity, and what decisions he would make if he had the ability to rationalize his current situation. We talked of dementia and how it eventually robbed it's victims of the ability to protect themselves from infection, aspiration, and bed soars.
They wanted him to continue seeing the oncologist and take the monthly shots that were possibly keeping the cancer at bay. They wanted antibiotics and blood tests, but agreed to look over the POLSTt form that I brought them. We discussed what would happened if his heart stopped, or he stopped breathing.
A few weeks later, I came back to look in on him. The daughters were not present but his wife handed me the completed POLST form. Heroic measures would not be necessary but antibiotics and lab tests were ok.
I examined my patient. He no longer recognized me, but answered my questions as he was able. His fingers had begun to contract, and there was the hint of a pressure sore on his back side. I educated his caregiver on positioning techniques and placed the POLST form on the refrigerator where all could see.
Five months before his death, he became more confused and his urine developed a foul smell. I came to his bedside and obtained his vitals. The blood pressure was strong but the heart rate had risen. We sat again, his family and I, in the living room and hashed out the details.
He had a urinary tract infection and was becoming septic. We reviewed the options and eventually it was decided to try oral antibiotics at home. Unlike his previous episodes, there would be no hospitalization this time.
Three months before his death his mental status became progressively worse. He refused to take his medications and would often pass on meals. He occasionally spit his food back at the caregiver.
Again we huddled in the living room. They were not emotionally ready for hospice but yet were reticent to send him back to the hospital or check more tests.
He somehow made it to one more oncology visit. His labs were strikingly normal. He even woke up for the trip and put on a good show for his doctor. But by this time he needed such extensive assistance to get out of bed and into the car, that even his daughter who was in quite a bit of denial about the current situation couldn't fail to see how far his state had progressed.
A few hours before his death his wife called to tell me he was having difficulty. She held the phone up so I could hear the undeniable rattle of Cheyne-Stokes breathing. I told her that he was dying. That she had to make a decision to call an ambulance or to let him go peacefully at home. I told her that this was what all our conversations had been building up to.
She hung up the phone and called her daughters. A few minutes later, they were all by his side. His daughters arrived in time to be present for his last breath. Calm, quiet, uneventful.
I certainly wish they had allowed me to get hospice involved early, to make sure that appropriate meds and training had taken place.
But that was not their wish.
And it all turned out okay in the end.
Posted by Jordan Grumet at 1:53 PM
Tuesday, November 17, 2015
It has occurred to me recently that such story telling does not only have to be reserved for interpreting the past. In fact, it is the present, and even the future that could also use a certain recalibration of lens.
I think that we, as human beings, struggle with happiness from day to day. We bounce from stress to joy to tragedy. We slog through our jobs, relationships, and financial issues and think little about how our own thoughts lead to even greater distress.
I have decided to try to take a different path, and become the protagonist.
When facing the hardships of life, I am going to reframe my vantage point. Like any good book or movie, most conflict can be distilled down (or blown up) into a battle between good and evil, right and wrong.
When you envision yourself the protagonist of this epic battle, you automatically view yourself in a different light. For instance, the protagonist, from the outset, is innately good and virtuous. It is the nature of the role even before any action takes place.
Furthermore, when you take on this persona, you hold yourself and your actions to a higher ethical standard.
No matter the outcome, win or lose, there is a certain glory in being the protagonist. Success, against the odds, is expected. And failure, even at it's worst, is filled with honor and humility.
The role of protagonist could embody our best and most virtuous intentions.
Posted by Jordan Grumet at 3:37 PM
Saturday, November 14, 2015
My father is standing besides my brothers. We’re all building. Putting the pieces together. But I’m stuck and no longer making progress. My mom stands besides me oblivious to my turmoil.
Does she know what I’m thinking? This must be a dream because we are grown up now, and dad died when I was eight years old.
Although everyone’s building, I can’t. I watch the way my father moves. Somehow, I know this will be my last chance to see him again. I’m afraid because over the decades his memory has faded so much.
But here he is in front of me. I try to distill his essence, but it hurts. I start to shake and bend over in pain. I weep.
Mom turns to me and glares. She’s the only one that notices.
”Tell him, tell him!” she urges and then turns away.
I crouch besides my dad while he continues to build. I whisper softly in his ear.
”I will miss you dearly when you are gone”
These are words an eight year old never knew how to say. But now, now I know
He turns around and smiles He then holds me.
”I love you” he says
But I am too overwhelmed to speak. Which really doesn’t matter. He understands.
I hear voices, spirits, coming to take him away. He holds my mom’s hand and she walks him to the door. My brothers and I continue building. But now we are joined by my wife and kids.
As we work, I tell them we have to stick together . We have to talk to each other. My son and daughter look up inquisitively and ask me if I am okay. I'm not a twenty two year old medical student anymore more but a forty two year old husband and father. Yet with complete certainty, I answer the same way.
I take a deep breath. Put my head down. Start all over.
And begin to build again.
Posted by Jordan Grumet at 8:10 PM
Tuesday, October 27, 2015
I have learned just about everything I know about empathy by being a husband and father. In no other relationship have I so acutely felt the joys and pains of another person. Triumph, despair, guilt, surprise. Each emotion transcending the flesh and glomming on to those in closest proximity.
But empathy, like parenting, is hard. You have little say over what befalls your children from day to day, yet feel each painful barb. The loss of control can be maddening for those practiced in manipulating their surroundings. You wear your heart on your sleeve unprotected. I suspect this is one of the main reasons many decide not to procreate.
So I find it rather ironic that we stress empathy as a character trait to idealize in our physicians. Few among us have the emotional fortitude to process such tumultuous emotions on a grand scale. I dare say the majority of human beings would be paralyzed by the difficult and frequently overwhelming nature of illness. Everyday. With every patient. All the time.
Empathy is an act of selflessness given as a gift to those we love most.
I think it is time to ask our doctors for what they are capable of.
Kindness, patience, humility.
And occasionally. Very occasionally.
Posted by Jordan Grumet at 3:53 PM
Tuesday, October 20, 2015
My shoes squeaked quietly down the hallway of the nursing home as I approached her room. I knocked gently trying to avoid any particular rhythm or dissonance.
Her voice was at once stern, and then followed by peels of laughter. She only saved such greetings for me. And I tried to trip her up. I varied my visits by time and pattern. Sometimes I knocked, and others I would call out in a distorted voice. She always knew.
She was recovering quickly and would be discharged soon.
The rest of my visits that day were not as positive. The gentleman next door was concerned with service issues. He decried the quality of the food, and demanded a faster response to his call light. I didn't have the heart to explain that as the physician, I had little control over these issues.
The woman on the floor above was dying a slow, uncivilized death due to Alzheimer's. I huddled with her family, and discussed the gruesome details. Her body was fading away much in the same way as her mind. She lost every ounce of extra weight. Her voice had diminished to a nonsensical whisper. She was no longer capable of making the difficult decisions that were left to her befuddled family. They signed the necessary paperwork with both hope and sadness. Hope that the end would ultimately be dignified, and sadness that her time was indeed near.
Cancer is an ugly term. But it was chemotherapy that sickened the young man at the end of the hall. He spent a week in the nursing home between hospitalizations. His family couldn't manage the vomiting and intravenous fluids. He peered through the window at the first ray of sunlight on a cold winter's day. He didn't feel much like talking.
I left the facility two hours after stepping foot into the front atrium. I felt as if I had already been working a full day. But there was a certain lightness nonetheless.
Because just before leaving, I crept up to her door, knocked yet one more time, and waited gleefully.
I paused for a moment and then joyously replied.
I could hear her laughter echo past me and through the hallway as I exited the building.
Posted by Jordan Grumet at 4:31 PM
Tuesday, October 13, 2015
I bit my tongue.
Which wouldn't have seemed so calamitous if it had not been one of many bodily malfunctions that had recently befallen me. A growth the size of a marble called a chalazion has grown under my eye lid. My hairline continues to recede. All of the sudden, out of nowhere, I have acne far surpassing that which befuddled me as a teenager.
My joints hurt every time I exercise. My ankle now makes a clicking noise while jogging. The connective tissue holding my abdomen in place has started to falter.
Time is passing. I am getting older. Yet my mind has thankfully lagged behind my body. I wake up each morning feeling like a much younger man. There are a thousand tasks to be performed, a thousand opportunities, and I chase after each one of them. Enthralled by the possibilities, I rarely stop running until the day is over and I collapse into bed. Six hours later the alarm sounds, and it starts again.
This makes me happy.
For the most part. The problem that comes with an awareness of the possibilities is the realization that time is finite. There are projects that I will never finish. Relationships that will never be rekindled. The past is gone and the future diminishes even as these precious moments pass.
And just when I seem to have gotten myself into lather, I feel a soft tugging on my shirtsleeve. I peer down into my daughter's soulful brown eyes.
Dad, dad, you're spacing out again.
My son is dancing a silent jig on the other side of me, listening to music that only he can hear.
They both need me so much right now.
Maybe it's time to give up on all this thinking.
And just be.
Posted by Jordan Grumet at 4:25 PM
Tuesday, October 6, 2015
Helplessness, powerlessness, impotence.
I struggle with these feelings daily. In the beginning of my career, they were spurred by the complexity of disease, the willfulness of bad luck. Battling the human condition was a long, difficult slog fraught with trap doors and missteps. Many patients improved, but others suffered. And I often suffered with them.
Years of practice brought a hard earned humility, the wisdom of acceptance. I learned to rejoice when interventions were beneficial, and comfort when a kind heart was all I had to offer. I felt great peace in this middle ground.
These were the battle scars that I carried proudly. My wariness was never a sign of failure, it was the toughness and patience developed by the skilled art of warfare. I wore my badge proudly.
Yet these feelings have returned, even more powerful than before.
My enemy, however, is no longer the thoughtful, wily adversary of the past. Instead of the foibles of humanity, I am hereangued with a litany of administrative tasks with no trace of nobility. Preauthorizations, face to face, peer to peer, meaningful use, ICD, CPT. The list goes on.
A long line of administrators, insurance employees, and government workers await my attention. They tell me that my care plans are incorrect. Improbable. Not covered. Out of the question.
And as my blood pressure rises and my temperature boils, I see no silver lining. No lesson learned.
I always expected that I would be bludgeoned by the awe-inspiring task of practicing medicine.
Not broken by a thousand, tiny, thoughtless insults.
Posted by Jordan Grumet at 3:56 PM
Tuesday, September 29, 2015
He glanced over at my tattered lab jacket without trying to seem obvious. I'd like to think that it was the gray color (as opposed to his white) that gave me away as an attending physician. More likely it was the telltale signs of aging that I have been doing my best not to notice. I slumped against the back wall and waited for the doors to open. My eyes flickered and closed for a moment, but opened quickly.
I was drawn to him. The energy emanated from his body, and pinned me into the deepest corners of the elevator. I couldn't decide whether to envy or pity him. A young intern, he was at the mere beginning of his medical journey. He couldn't yet fathom the degree of wonderment and heartbreak he would experience over the next few years. The joy and the guilt. The triumph and the disappointment.
There is a whole world ahead of him. A world I have become strangely accustomed to. Racing into the hospital on a Sunday morning is no longer novel or extraordinary. It is part of my weekly routine. I get up early and round at the hospital and nursing homes in order to be back home before the kids awake. There is no excitement.
Instead there is a gentle quietness. A certainly that comes from years of sparring with health and disease. An acceptance of both the hardships and joy involved in spending one's time contending with the human condition.
As the door opened, I awoke from my reverie, and sprung towards the hallway and the ICU. I patted him firmly on the shoulder as I passed by.
I caught one last glimpse of him as I turned the corner.
He was still standing in the elevator doorway,
his face a strange mix of confusion and pride.
Posted by Jordan Grumet at 4:10 PM
Tuesday, September 22, 2015
As I stared at the playground, a long buried memory percolated to the forefront of my consciousness. I must have been around 8 years old, a little after my father died. I am playing by myself on the jungle gym, and glance longingly at the street in front of me. I am overtaken by a great sense of loneliness. I want to run down the street. I want to go home.
"Home", at that time, was the building I lived in.
Many years later, my mom remarried and we moved from Evanston (the city I was born in) to the neighboring town of Winnetka. A mere 13 years old, feeling myself the center of the universe, I resisted the move wholeheartedly. For years I mourned the departure from my beloved city. Only a few miles apart, the emotional distance seemed immense.
I pined for my old neighborhood. I dreamed of riding my bike down the old streets to my favorite places. I was so in love, that years later, I returned to build a family.
"Home", at that time, was the town I was born in.
As I got older, I found solace not in places or things, but in people. My interest turned to the amorphous task of building relationships. Acquaintances, friends, lovers. People and personalities became a currency by which to measure happiness. I bathed in the luscious glow of humanity. I gave and I took.
"Home" became the people I surrounded myself with.
Recently, I have begun to believe that "home" is something much more personal, more internal. Maybe it is a construct based on those people, places, and things that make us feel most connected, most safe.
And driving by my childhood elementary school this sunny afternoon, on my way to the nursing facility, which will be followed by a jog with my wife, and then a walk to pick up the kids...
I feel as if, for possibly just this fleeting moment,
I have finally come home.
Posted by Jordan Grumet at 4:11 PM
Saturday, September 19, 2015
But as he haltingly entered the dark building at the end of an otherwise unexceptional suburban street, he felt more like a criminal than a scholar. His office was drab. Each room a glow with the artificial light provided by an incandescent bulb. He often wondered whether the lack of windows was to keep the light from piercing the imperturbable darkness or to trap the terror in.
He knew his place. He was the last stop on a frightful train line that ended in horror. There was no solace. His clients never dreamed of needing his services, and yet they came. Without fail, they averted their eyes to hide the excruciating pain and loss. He met them in life's basement. In a lonesome quagmire, he helped them wade through the morass.
In his younger years. his work clung to his back even outside the office. He awoke from nightmares of the vilest kind. Remnants of the day stuck to his clothing. He tried to scrub and scrub but they refused to fade away. A sort of blackness pervaded his waking hours.
It was in this acrid garden that a certain soullessness grew and flourished. He found that he could approach his clients with a coldness that became rather comforting. Empathy wouldn't pull them through the manure laden pit that they found themselves trapped in. His voice, certain and clinical, could.
As the years passed, his body bent and his haired thinned. Years of tumult left scars that were far passed the point of healing. From time to time he found himself wandering through the office on the weekends, or in the evening when no one in particular was scheduled to visit.
He sometimes felt lost amongst his family and friends. He occasionally had bouts of agoraphobia at home with all the light and windows.
He left the office cautiously everyday and found the outside world to be a place that was no longer black nor white but filled with incomprehensible shades of gray.
And that terrified him.
Most of all.
Posted by Jordan Grumet at 6:38 PM
Monday, August 31, 2015
Medicine, I explained, is still as noble a profession as ever. Every day I dip my toes tentatively into the current that swirls around me. Often I am pulled violently into the depths. My body bumps and sways in the mass of humanity. Our rhythms join at times and depart at others. Amongst the tumult my mind strains to unlock riddles, my hands reach forward pawing the Rubix Cube of disjointed anatomy laid bare on my table.
I am imperfect, and it is hard. Maddening. I sometimes curse my own feeble abilities. Yet this profession offers the opportunity to be with our fellow humans. Regardless of outcome. It offers the ability to reach an imperfect hand towards a suffering soul. Over and over again. On weekends, on holidays, in the middle of the night. When it's inconvenient. When it really matters.
You become the beacon of light to someone's darkness. The epitome of meaning, wrapped in a profession, crafted over years of practice.
There is nothing that I would rather due for a lifetime. No profession more worthy. No pastime more challenging. No calling more sacred.
We suffer today not from a failure of training nor a mighty profession gone astray, but from the greedy, lecherous, and diabolical distortion foisted upon us,
We suffer from a government so mired in special interests that often the most simplified and logical tasks become overly burdensome. Administrators with little knowledge of actual medical practice add layers of bureaucratic minutia on the backs of hapless workers. Computer systems are generated with the wrongheaded idea of Big Data collection as they further warp severely strained processes.
We suffer from big business, hospitals, and insurers bent on squeezing every last cent from a system where they produce nothing. They repackage the knowledge and ability of their clinicians, and slap a brand new inflated price tag.
And we suffer from ourselves. Our medical societies who pat our back with one hand while picking our pockets with the other. Our physicians who have lost their way, and traded in this holy art for a chance to feast on the leftovers from the carcass of their debilitated brethren.
The doctors who value bloat, cruelty, over-testing, and over-diagnosis to add to their wealth and not the health of their patients.
Medicine can still be noble and worthy.
If society allows it.
If we fight for it.
Posted by Jordan Grumet at 5:20 PM
Friday, August 21, 2015
Everyday I wake up to a schedule brimmed with purpose. The door of my office is a portal into the richness of the human experience. I become a thread in the tapestry of other's lives. I bear witness to the joy and pain, laughter and heartache, and mundane daily routine.
I spend my days bouncing between art and science. Paid to be the wily detective, my brain stumbles on detail. Some cases are typical, quickly resolved with an adjustment here or there. Others are more enduring, months are spent contemplating the possibilities until answers present themselves. The sick become healthy. The terminal are comforted and allowed a soft place to land.
A familiarity grows out of the wisdom of experience. An acceptance of the limits of human knowledge. Self acceptance soon follows. The connection between me and my fellow man is the bedrock of my professional existence. I help people solve problems.
I make a good living. My title still carries a certain amount of respect. Job security is a good bet. And my days are anything but boring.
Being your doctor is excruciating.
Everyday I stare into the abyss of humanity. I become a party to every patient's agony and despair. I have witnessed pain and loss that endure. My mind is scarred from an invisible emotional battle much like the physical ailments of an infantryman.
I am haunted by countless decisions that profoundly affect other's lives. The devil hides behind every dichotomy. Poking out it's steely head, waiting to attack the supple underbelly. I remember each battle lost, each face. Until the next horrific calamity erases the last. Over and over again.
I rarely sleep uninterrupted. My phone rings while I'm taking a jog, in the shower, or on the toilet. Occasionally a nursing home thinks my mobile is a fax number, and my phone rings over and over again in the middle of the night, waking my family.
I am constantly told that I am wrong by technicians, administrators, insurers, and the government. I often have to fill out the same paperwork over and over again. I sign thousands of papers a month for what appears to be no reason.
I often feel crushed by both the enormous responsibility and stupidity that the American healthcare system has placed on its doctors.
Being your doctor is...
Posted by Jordan Grumet at 7:36 PM
Friday, August 14, 2015
His parents and teachers recognized his talent early in childhood. Accordingly, he was afforded the luxury of the finest education. His ability grew with each class and workshop. He graduated college among the most gifted, and found work in one of the finest drawing shops in the country.
Here, surrounded by his friends and peers, he found his daily work to be anything but taxing. Every morning he would role up his sleeves, open the very same box of colored pencils, and draw from the early morning to the late evening. The time would pass by unnoticed as his mind wandered, and his hands dutifully followed suit.
Others would watch in astonishment as his creations took form. They came from far and wide to witness the miracle. Every drawing was lovingly produced for its exact purpose. He was an expert. A master whose skill was honed from countless years of repetition, innovation, and experience.
It was in this state that he toiled for many years, happily fulfilling his purpose, until the day the mandates started to roll in. His shop was bought by another, management changed. The first directive was annoying, but easy enough to comply with.
Straight lines were no longer acceptable. Zigzags, however, were allowed. So he substituted where he could. He found that if he worked slowly and laboriously, he could make such small lines that from afar his zigzags looked straight. A pain to say the least, but a fair approximation in the end.
Next came the war on green. His boss appeared at his desk one day and fingered through his box of pencils, removing anything with a greenish hue. Again, a work around was fashioned. Blues and yellows were carefully mixed to create the right effect. Some shades were easy, others could take hours to get just right.
As usual, the boy who had now become a man, refrained from raising his voice in defiance.
The directives flew out of the C-suite at a maddening pace. Some were perfectly reasonable, others were odd and senseless. All required an accelerating amount of time and concentration to be compliant, and yet still create a product that he could be proud of.
He no longer enjoyed his work. He often left the office past midnight, and refrained from whistling on his walk home. He even stopped drawing for fun. He didn't have the energy or interest in reading up on new techniques.
And the sad truth was that his drawings were technically flawless. They followed each directive expertly, but one couldn't help but notice that they had lost their purpose.
They had lost their heart.
His bosses shook their heads approvingly.
His customers turned their backs and mumbled,
and never returned to his office again.
Posted by Jordan Grumet at 6:21 PM
Monday, August 3, 2015
My favorite is the widowed war hero. His unrequited love for his deceased spouse pervades most visits. He writes poetry and can carry a note to operatic proportions. He is kind and humble. He lives lost in a world of dreams and sweet memories. He is both jovial and melancholy at the same time.
I have known many of these. Taken care of them. Watched them die. They do so with a grace and determination which is nothing less than dignified. They take their last breaths with a certainty and peace that I can't help but admire. Maybe they know that they are one last gasp away from their lover's arms.
And I often contemplate whether they are right.
Perhaps we physicians also have our archetypes. The arrogant and the too busy to be bothered. The hand-holder. The incompetent and the God-complex. The automaton.
Then there's me. I have seen myself in almost every archetype, good and bad. And as with our patients, these are poor constructs. Because even though our most glaring attributes fit well into cubby holes, the reality is that human beings are so much more sloppy.
Maybe a bit introspective.
The kind of guy who writes about being a doctor to no one in particular.
On the Internet.
Posted by Jordan Grumet at 6:33 PM
Sunday, July 12, 2015
Each day had brought improvements. The range of motion was returning. His strength was growing. His body balanced now with only the most minimal of assistive devices. What had once been disability had transformed to normal physiologic functioning.
In medicine we often talk in the most passive of manners. We say that the knee is improving, or the wound is closing. We talk as if healing is a mere act of God. A blessing that is bestowed on the weary from time to time in a somewhat whimsical manner.
And I am not a denier that randomness pervades our experience in hospitals and medical clinics. But I have been trying to be more cognizant of the role that human will plays in the rehabilitation of both body and soul. The force and strength, the sweat and tears, the physical act of becoming healthy.
So I said what was on my mind.
You know, I'm really proud of you!
Funny words coming from a middle aged doctor to his geriatric patient. But his face lit up, and I could see that he was thankful for the recognition of the difficult road he had travelled and barriers that still lay ahead. It wasn't condescending. It was a truthful moment that transcended the artificial barriers between doctor and patient. I was just an innocent bystander acknowledging the remarkable personal will it took to get better.
I feel both awe and pride, frequently, at the strength and endurance of those patients that fill my moment to moment existence.
From time to time, when appropriate, I try to let them know that.
Posted by Jordan Grumet at 7:27 PM
Friday, July 3, 2015
After we exchanged common pleasantries, we jumped into local politics. We were hungry for news. Battle worn and weary, we were searching for signs the tide was starting to turn. The gossip was mostly pessimistic, but I saw a glimmer in his eye as he abandoned his screen and turned to face me.
I bet you haven't heard about...(fill in the name of your favorite academic medical center).
He was exited now. The words came from his mouth faster than the keystrokes that disdainfully filled the electronic medical record that had become his slave master. An academic center had taken over a hospital, and felt that it had every right to bully the large allied medical group. The physicians, tired of being pushed around, silently vowed to steer their admissions to a local competitor. Months later, the academic center was on it's knees with empty beds and an angry community to boot.
We both basked in the glow momentarily before returning to our respective tasks. Although we wanted to go back home to our families, there remained a need to share a fleeting moment with someone who could relate. Someone who could understand.
And I imagine that conversations like these are taking place across the country where physicians congregate: hospitals, clinics, and doctor's lounges.
Meaningful Use, EHR, PQRS, ACA, ACO, Value, Quality, Patient centered Medical Home, Medicare Fraud, The Physician Sunshine Act.
A once humble profession is struggling desperately to find it's soul.
I find it rather disconcerting that a decade ago, colleagues used to revel in a recent save, discuss a difficult prognostic dilemma, or brag about a diagnosis of a rare ailment when happenstance caused their paths to cross in the middle of the night.
But now, now all we talk about is sticking it to the man.
And I wonder how those, at the moment, dying to find appropriate medical care,
are feeling about this.
Posted by Jordan Grumet at 6:56 AM
Monday, June 29, 2015
There is nothing truly original in the world.
I ease off the gas pedal of my already outdated hybrid Prius.
My job will eventually fall prey to a computer named Watson. My practice will be gobbled up by the nearest Goliath medical center as history scoffs at the arthritic physician bending over a doorbell with leather bag in hand.
There is no flash of glory here. No smart technology.
The echo vibrates through cracks in the sidewalk and drags me unwillingly forward to the unkempt house at the end of the block.
Adapt or perish.
I open the door without knocking and find a decrepit figure slumped into a reclining chair in front of the television. His car keys were long ago taken by some relative or another. He waits for nothing in particular. Scraps of food have been left on the side table by a home health aid.
There are memories of being gainfully employed. Road trips across barren lands and such. His son is now grown up and makes decisions on his behalf. A nursing home is a far safer environment than this empty old house.
My visits to the end of the road are numbered.
Old is replaced by new.
Utility and functionality apparently are relative terms.
And by and by something is lost.
Posted by Jordan Grumet at 5:59 PM
Tuesday, May 26, 2015
Conversations occurred that would be unthinkable if two strangers were to meet in the outside world. I learned of abuse and infidelity, pain and yearning, secret joys and countless regrets. I bore witness to the inner pain and struggles that often were hidden from one's closest friends and family.
People undressed. They replaced their clothes with unflattering gowns. They demonstrated their body parts unabashedly. Pointing to that which looked out of place. Wincing from pain induced by my clumsy touch.
The exam room became a safe zone. A place where judgement was replaced by support and understanding. A place where one's darkest secrets could be revealed but not allowed to consume them.
When I abandoned my traditional practice for home visits, I feared that something important would be lost. I often wondered if there was a certain element of depersonalization that came with such sterile environs. Maybe my patients revealed their inner needs and fears because the institutional setting of the exam room was a sufficient departure from normal life.
Then there was the question of my lab coat. The wizard's frock symbolized a certain otherness that separated me from the rest of society. Again I conjured up visions of a magnificent veil that allowed me special access of a most personal nature.
It's been almost two years now, and I have visited countless homes without the comfort of the exam room nor the lab coat to hide behind. My fears, of course, were completely unfounded.
My patients still tell me their triumphs and tragedies. They still pull their shirts up unashamedly to show me a rash or lump or bump.
And I have come to realize that it was never the sanctity of the exam room nor the long gray coat that droops from my shoulders.
With both great awe and humility,
I have come to the conclusion that it is me.
I am the safe zone.
Posted by Jordan Grumet at 3:59 PM
Friday, May 22, 2015
The television above us is playing Ferris Beuller's Day Off. The volume is muted and a radio blares When Doves Cry by Prince. A mother sits in front of us with her two teenage children. A boy and a girl. She mouths the words to the radio as her kids bury their heads in their mobile devices. Her face is animated, and her body sways with the music. I understand. Because that's exactly how my body responds when I am transported back to my childhood.
The woman and her kids leave, and a young college-aged couple takes their place. Their faces are fresh and soft. She blushes as she coyly looks into his eyes. He moves closer when they talk. Their bodies almost touch.
The music on the radio has now changed. Adam Levine is singing Lost Stars. One of my current favorites.
The burger is dressed with chipotle ketchup. The fries have more pepper than salt, and are served with blueberry mayonnaise. The flavors are different than what I grew up with. Yet I like them all the same.
The crowd is heterogeneous. A group of older ladies huddles against a counter in the corner. They talk softly and sip craft beers. My wife and children, sitting beside me, have stopped talking. They are too busy inhaling the delicious food in front of them. A few young kids chat amiably at tables dispersed among the other restaurant goers.
And I realize that I am neither retro or new. I am neither young nor old. I am caught somewhere in the middle.
In the great in-between.
Posted by Jordan Grumet at 5:35 PM
Thursday, May 21, 2015
Monday, May 18, 2015
What I remembered is that we had gone to high school together. We had grown up in the same city, in the same neighborhood, on the same block. We were never compatible socially. She was gregarious and popular, and I quiet and introspective. We may have nodded familiarly or said hello if we passed on the street, but nothing more. We were acquaintances by proximity.
We exchanged pleasantries in the school hallway for a few minutes. Our kids were of a similar age. She looked happy. Healthy. I glanced at my watch and prepared to enter my son's classroom when she stopped me, and asked the question that I assume hand been hanging on her lips the whole time.
You don't remember, do you?
She had come to my office nearly ten years prior for a routine physical. It was a mid-morning appointment, and as I listened to her heart I recognized the faint odor of alcohol poorly covered by breath mints. I waited patiently till the end of the appointment, and then gently discussed with her my suspicions.
She was drowning in new motherhood. Her job was taxing. She was fighting with her husband. The alcohol originally was meant to help her unwind at night. With time, however, she was consuming more and more. She was hiding her habits from her family and friends.
She was an alcoholic.
Her words cleared the cobwebs in the vaults of my distant memory. I remembered telling her that she wanted to face her alcoholism now for her children. That she wanted to be healthy when they grew up and needed her. I handed her a few brochures, gave her a few numbers, and scheduled up a follow up appointment.
I made her promise that she would get help.
As it turns out, she never came back to my office for the follow up. But that morning she began a long successful journey toward sobriety.
Now, a decade later, she was thanking me for saying the words that launched that journey.
Years into the practice of medicine, I have spoken millions of words in the exam room and forgotten the majority of them.
I humbley hope that some others have similarly hit the mark.
Posted by Jordan Grumet at 10:04 AM
Tuesday, May 12, 2015
I have to admit that I was nervous. I perused the records before he walked through the exam room door. These conversations were always difficult and felt out of place in the office. But I had looked at the numbers over and over again. There was a glaring deficiency that had to be corrected. I planned to jump in right away, but we got sidetracked..
He wanted to discuss blood pressure. His cholesterol numbers were slightly off, and we spent quite a few minutes discussing the difference between HDL and LDL. I readily counseled on diet and exercise as my mind drifted to the unpleasant conversation that only I knew was coming. I wondered if I would ever get to my agenda.
During a brief pause, I thought I found my opening.
Unfortunately, he was just building up the confidence to talk about erectile dysfunction, That's right, I was foiled by ED! Again, I waited patiently and listened as he described in detail his current situation. We discussed lifestyle modifications, medications, and finally the utility of blood tests for accurate diagnosis.
When he packed up his things to go, my face turned crimson. I knew there was no escaping. I started the conversation tentatively with a question.
I wonder if you could do me favor?
He looked at me quizzically as I tried to explain. I described Meaningful Use and the reasons the government had enacted such policies. I directed that he would get an email inviting him to join a patient portal so that he could access his medical information remotely including medicine lists, diagnoses, etc.
I told him that I was being graded on participation, and would suffer economic consequences if I failed to enroll adequate numbers of patients and have them message me through the system. I begged, nay pleaded, that he would go home and sign up today.
He shook his head. He had done this once before with the hospital and spent hours trying to sort through password problems before he gave up. He swore he would never participate in such silliness again.
Besides, I never really look at that stuff anyway. If I have a question, I just call you and you answer right away!
I have had a patient portal available for 2 years now. To date, almost none of my patients have signed up for it even though they get email reminders regularly.
The outcry of late has been "No MU without Me"
Apparently what is meaningful to the government and even healthcare advocates, may not be to the average patient.
Posted by Jordan Grumet at 3:44 PM
Tuesday, May 5, 2015
Open the windows and doors. Welcome the wayward breeze, biting cold, tendrils of sun, or beating rain. Worry not of the elements as they caress my motionless body. Discomfort, after all, is for the living of which I am still yet a part.
Talk as if I am myself. Even if I don't answer. Argue and disagree as we are wont to do. If you offend, I may curse you silently. Wordlessly. Or if you bore, I will likely ignore you altogether.
Weep and I will weep too. Laugh and I will laugh with you. Pray and I will remain solemn. Joke and my lifeless countenance will become that of the jester.
Place your hands on me. Caress my fingers. Cradle my chin and pinch my cheeks if the moment so moves you.
Fear not the skin of the dying. It remains sensitive even after the rest of the body has long forgotten.
Invite my enemies to peer down upon me. To dispel the last remnants of venom or perchance to regret. My family and friends too. Even those who I have long forgotten or have forgotten me.
Open my doors for all to see.
Except for the indifferent.
They are no longer welcome in my home.
Posted by Jordan Grumet at 4:05 PM
Monday, May 4, 2015
Bookends and Beginnings.
I Am Your Doctor And this Is My Humble Opinion.
I Am Your Doctor And this Is My Humble Opinion.
Posted by Jordan Grumet at 6:05 PM
Sunday, April 26, 2015
The nurse on the other end of the phone sighs as she tolerates my tirade regarding pronunciation. They all know that I am particular about such things. For metoprolol is neither metoclopramide or metalazone, and the difference could be life altering.
I live in a world of words. Trained in a language created to parse pertinent details. Dysarthria or dysphagia? Paroxysmal nocturnal dyspnea, dyspnea on exertion, or orthopnea?
Each variant a spectrum of flavor. A morsel chewed, swallowed, and digested into its basic parts to be rattled off in staccato sentences between physicians. A meaning conveyed to bring like minds to similar conclusions. A common language among colleagues to convey a story, to solve a mystery, to make a plan of attack.
And my patients words carry similar weight. The accent on a particular syllable drawing significance unconsciously to a hidden meaning. An atypical descriptor pushing the diagnostic engine toward a nefarious path. The absence of content, words carelessly unspoken.
My patient's future becomes precariously perched on such ambiguities. My ability to interpret separates durable medical care from chaos.
So you will have to excuse me if I occasionally get caught on words. If I become stuck on pronunciation or am a stickler about meaning.
I gently correct the cardiologist as we pass in the hall.
It's Rothberg not Rothschild. R-o-t-h-b-e-r-g.
And she died two nights ago.
Posted by Jordan Grumet at 6:48 PM
Tuesday, April 21, 2015
Sunday, April 19, 2015
We were engrossed. How could you not fall instantly in love with "Anne spelled with an E". Her hyperbolic and histrionic nature all the more endearing as the plot grows. Of course, you can't help but like Gilbert also. At first painted as a bully in his opening scene with Anne, it becomes clear that his jeering words are a school yard ruse to hide his growing affections.
It was around the half way mark that I sadly saw the breaking news on Facebook, Jonathan Crombie (the actor who plays Gilbert) died of a brain hemorrhage.
All the sudden, for me, the story took on greater significance. Unlike his family and friends, I will never know what kind of man Jonathan Crombie truly was. Yet his art, his acting, will leave an indelible mark on those of us who grew up with this timeless story.
Of course, it all makes me contemplate legacy. My father, who died from the same malady at a similar age, left behind a wife and three young boys. There are also countless patients, physicians, and students who remember his influence thirty five years later.
We all hope that the best parts of ourselves live on long after we have passed.
Legacy is an especially prickly issue for those of us who yearn to create. The builders, actors, artists, poets, and writers. For most of us, the act of creation is a lonely and solitary process. The birth of our "art" is often a complicated and painful labor of love. We continue day after day, year after year, not for glory or recognition, but because we have to.
That which we produce, the performance we act or the words we write, are the distilled parts of ourselves that we leave for the world. Long after we are gone and our families have mourned, maybe there will be a little something left.
A word, a phrase, a small bit of wisdom that will find the wayward stranger and bring knowledge, understanding,
or a comforting salve for unhealed wounds.
Posted by Jordan Grumet at 8:15 AM
Tuesday, April 14, 2015
That all changes with the publication of Dr. Stephen Schimpff's treatise:
Fixing the Primary Care Crisis: Reclaiming the Patient-Doctor Relationship and Returning Healthcare Decisions to You and Your Doctor.
And I'll take this moment to lob my one and only criticism at the book. Dr. Schimpff cogently argues that primary care is the linchpin of high-quality, low-cost care. Thus, in reality, I believe that the title is more aptly "Fixing the Healthcare Crisis". Anyway....
Never have I read such a concise and soup-to-nuts explanation of what has gone so awry in our current system. Our lopsided PCP to specialist ratio, coupled with increasing overhead, and poor reimbursements has turned our doctors into referral machines. The primary care physicians, forced to see in excess of 20 patients a day by an insurance system that under values cognitive medicine, have chosen the path of lease resistance: referrals, diagnostic exams, and procedures. It's not that they don't want to give stellar care, it's just impossible.
Good, high quality medicine, requires time. A luxury that is no longer afforded to those MDs who want to keep their doors open and also collect a paycheck.
The solution is less patients, better reimbursement. Dr Schimpff outlines several ways to achieve this goal including direct practice models, concierge, insurance incentives, and employer based wellness programs. He tackles current trends including ACO's, Patient Centered Medical Homes, and retail pharmacy clinics.
But most importantly, he defines a path forward to correct our mangled version of healthcare.
It all starts with our primary care physicians. Give them less patients and more time to think.
I highly suggest you get the longer, more articulate version of these sentiments and buy Dr. Schimpff's book!
Posted by Jordan Grumet at 3:29 PM
Saturday, April 11, 2015
I looked down at the bottle of natural spring water in astonishment. It had an expiration date. Scanning the empty hospital cafeteria on an early Sunday morning, I wondered what on earth about spring water could go bad? It had no living parts, Nothing that serves as nourishment for wayward bacteria or fungus. The container was sealed. Pristine.
I figured it was another fiscal hoax, perpetrated on unsuspecting consumers. You better drink that water fast or you'll have to throw it away and buy a brand new bottle. I could hear the ka-ching of the cash register as some billionaire somewhere just increased his fortune by a dollar and a quarter.
It was a short two flights of stairs up to the ICU. Enough for me to contemplate how we so readily believe the little date imprinted on so many of our products. We throw away perfectly good food. We dispense of old medications. There are other things that outlive their usefulness: cleaning products, beauty supplies.
We accept, that for most possessions, there is a natural beginning and end. Sure we may take that old clunker to the mechanic over and over again. But eventually it ends up in the junkyard just like every other automobile. There is only so much that can be fixed.
People, on the other hand, are not allowed such luxury. We replace the warn out parts when we are able. We prop up ill and disfigured joints with canes and walkers. We extirpate nasty cancers and use pills to counter misanthropic metabolisms.
Unlike water, however, we are very alive.
We are faulty.
And no matter how much we refuse to believe,
our time on this earth is finite.
Posted by Jordan Grumet at 5:51 PM
Monday, April 6, 2015
It was under these auspices that I came across Becoming Nursey by Katie Kleber while I was working to promote my own book. I checked her out on twitter (@NurseEyeRoll) and was intrigued enough to jump on Amazon and buy the book. I was very glad I did.
This is a must read for new nursing graduates, students, and anyone who dreams of entering this sacred profession. The practical information contained in this book is priceless. Everything from surviving nursing school, to passing board exams, to organizing your time as a floor nurse is covered. The text is a clear, organized, and easy to follow set of instructions for tackling day to day challenges. How I wish I had this type of manual for medical school and residency!
What I think is almost more valuable, however, to not only nurses but also doctors and the community as a whole, is the emotional candor of the book. Often humorous, sometimes heart-breaking, Kati paints in broad brush strokes the humanity of the profession in general.
We laugh at the descriptions of the physical pitfalls when she describes tackling the not so delicate parts of her job, and we cry when she tells of the emotional hazards we all face while caring for our fellow human beings.
It's a great read!
Posted by Jordan Grumet at 12:06 PM
Monday, March 30, 2015
After passing the original test, I forgot mostly about it. I filed my large diploma sized certificate in a drawer in the back of my office. You see, I didn't display it prominently because I really didn't care if anyone saw it or not. It meant nothing. Not a single patient over ten years asked about my certification status. It was irrelevant.
A decade into practice I recertified. This time I was forced to do a number of maintenance of certification activities. They were time consuming and expensive, but I figured it was the cost of doing business. I didn't learn anything by participating in these activities. They didn't help me take better care of my patients, and I didn't exit the process a more informed doctor. It was a waste of time and money. Irrelevant.
Unfortunately, now the ABIM is trying to be relevant. Not by creating a superior product or innovating in the continuing education space. Instead it is foisting a new, sub par, labor-some, and most importantly costly product on its it's physician marketplace. And it is doing it with the force of governmental mandate (ACA will require board certification as a quality indicator) and tacit support of hospital administrators everywhere (hospitals require board certification for hospital privileges).
This mostly annoying, but previously manageable requirement, has become a thorn in the side of American physicians.
The new MOC is just as irrelevant as the old, it's just a heck of a lot more difficult and expensive to complete.
I feel that it would be overly optimistic to expect the government or the hospital executives to release us from this arduous burden. In fact, many of us suspect the government cheers on as physicians are forced to close doors and join the big academic or corporate sweat shops. There is no political will to uncouple the ABIM from healthcare reform.
Hence, we physicians are left with two options. We can either expose The ABIM as not only irrelevant but also crooked as Dr Wes Fisher has so excellently done. Maybe this grand foolhardy organization will fall on it's own sword.
Or we can gather together and refuse to certify en mass, and see what happens to hospitals as they try to take away privileges from all their Internal Medicine doctors and specialists.
I think the time has come to make a decision. Which will we choose? We better choose wisely.
By the way, happy doctor's day!
Posted by Jordan Grumet at 3:40 PM
Thursday, March 26, 2015
She walked into the room with her head slightly bowed forward. She was physically and emotionally exhausted. Because of a scheduling snafu, there was only one nurse for the entire hospice floor. This was her second patient to die that day.
She bayed me to come forward and help prepare the body. I stared down at the lifeless figure. I don't remember all the details, but I will never forget the stillness. It was the first of many occasions where I would marvel at the appalling lack of motion that separates the living from the dead.
We were silent. When she wanted me to perform some task or another she would point with her fingers. I think we put an ID tag on the toes. Maybe we cleaned the body and removed any remaining catheters. The family had come and gone so there were no cosmetic issues of concern.
And then she took out the bag. We gently rolled the body over and placed it cleanly underneath. We pulled out the openings around the torso. Then we tucked in the limbs and head. Finally she started at the toes and zipped up the bag from the bottom until she came to the face.
For me this was the shell of a man who I had never known. But for her, for her, he was a breathing, feeling human being. One whose hand she had held, whose family she had comforted, and whose excrement she had helped clean from his weakened and frail body. She went to close the zipper but she couldn't. I put one hand on her shoulder and reached over with the other removing her fingers.
She knelt down in the corner of the room and sobbed as I closed the bag.
Through years of medical education and practice there are many images burned into the depths of my soul. But when I think of my first experience with a dead body, I don't see a body at all.
I see a nurse.
A humble, grieving, beautiful symbol of all that our profession can be.
Posted by Jordan Grumet at 12:55 PM