Friday, June 2, 2017


You've been swindled.  At least that's the conclusion I've come to.  It wasn't the hucksters or the snake oil salesman.  It wasn't big business, big medicine, or some greedy hospital administrator.  It was most likely pharma with a large dose of helping from your doctor.  Plain and simple.

I've learned quite a bit being a hospice medical director.  Covering dozens of new admissions a week has given me much insight into doctor prescribing habits.  Often it is my job to decide with meds are necessary and covered by hospice, which are necessary but not covered by hospice, and which are useless.

Do you have any idea how many useless and often harmful meds our patients are on? I'm not just talking about end of life, but healthy patients to.

Can we talk multivitamins?  Almost every patient I encounter is prescribed a multivitamin.  Healthy, unhealthy, living, dying.  When your in the grasps of stage five thousand and one lung cancer and your brain is riddled with mets, you have no business being on a multi.  It's not going to help you.  It's not going to provide that last bit of energy to overcome the calamitous collapse that is approaching rapidly.  In fact, there is plenty of data to suggest multivitamins are harmful if not neutral at best.  Even in healthy people.

How about Vitamin D?  I swear to g-d, every patient I encounter is on some sort of D supplement.  Never mind that the vast majority of medical evidence implies that supplementation is unhelpful in most disease processes.  Yes, there is osteoporosis, but otherwise, it is a non starter.

Aricept in patients who don't walk, don't talk, and barely interact with the world around them?  Again, started often because there is no other treatment, profound dementia patients are submitted to a host of side effects including diarrhea and syncope without the faintest glimpse of medical benefit.

Vitamin C, Vitamin E, Calcium?

How about statins in patients without a history of coronary disease with end stage-opathies  and malignant cancers.  Do we really think we are going to cut down on cardiac events in the fleeting few months that these patients have to live?  Is there any data to support this?  You better believe that these patients get myalgia and other side effects.

Antibiotics for foul smelling urine, screening urine cultures without symptoms, or agitation in an already agitated patient.  It seems that treating non-utis has become the national past time of our healthcare system.

I could go on and on.  Don't even get me started on antibacterials for non bacterial infections.

The point is, we are not being careful with our prescribing habits.  We are not taking into consideration the wealth of evidence and data regarding some of these treatments.

And we are not being good advocates.

We are not shielding our patients from harm.

Saturday, April 1, 2017

Letting Go

You can let go now!

As Hannah's granddaughter clutched at her skeletal fingers, the blanket fell to the side revealing the faded serial numbers on her forearm.  The family gathered, yet again, to say goodbye.  This time her acrid breath had lost humidity, her respirations dry and raspy, the extremities mottled with a bluish tinge.

Death had visited the neighborhood before.  Lounged in the parlor.  Nibbled on crackers and tea.  But letting go was not so easy. Sure the signs were there.  There were the bouts of unconsciousness lasting days.  The hours of irregular breathing with long gaps.  The clutching of chest and recitation of prayer.  All followed by merciless, unrelenting recovery.

Hannah wanted to die.  At least that is what she told the doctors.  She sang it in her sleep and whispered to the hallucinations that pranced on her pillow.  She refused medications.  She spurned nourishment.  She pulled at the tube thoughtlessly plunged into her abdomen a few hospitalizations prior.  She hissed at the Rabbi as he entered her room.

Why won't you take me?

They said she was a survivor.  A code they used in order to avoid talking about dark things. Guilty things.  She was forever marked by the fact that she didn't succumb.  She didn't die.  She was scarred somewhere deeper, more profound, than the ugly thing on her forearm.  She was marred by persistence.

Most of her family died decades ago during the war.  A whole lineage erased. And yet she persisted.  Her colon removed, her brain stroked, her heart fibrosed.  And yet she persisted.  The years passed, friends and lovers gone, a child or two perished.  And yet she persisted.

Persistence had entwined her DNA, calcified her bones, and cascaded past blood cells forever traveling in circles.

Her body was failing, but her spirit couldn't let go.

No matter how much she begged and pleaded.

It didn't know how.

Five Moments, now available on Amazon.

Also available, I Am Your Doctor: and This is My Humble Opinion.

Friday, March 17, 2017

Drip Drip

Get out.

It was not so much the words as the overall tone of the interaction.  The doctor-patient relationship had been generally affable.  There was the usual exchange of pleasantries over the years.  Questions about family, children and grandchildren.  It was a good relationship.  Until Harvey got sick, that is.

Originally there was weight loss and fatigue.  The initial physical exam and slew of testing showed nothing but a frail, cachectic, middle aged man.  A few cat scans later and he was in the oncologist's office discussing chemotherapy.  A regimen was decided on, and therapy began the next day. 

Therapy was hard.  Nausea. Retching.  More weight loss.  Far from feeling better or cured, Harvey could feel the clothes slipping from his emaciated body.  It was as if life itself was drip dripping away as the chemo bulldozed into his broken veins.  And this pissed Harvey off. 

He lashed his family.  He cursed his friends. He spun into a whirlwind of the most resistant depression. A depression, his therapist would later tell me, whose only salve was anger.  While the anger allowed him to carry on, often he left those around him scorched.

His doctors were no exception.  We often spent half of each visit withstanding abuse before getting down to the business of the appointment.  He blamed us for the cancer.  He blamed us for the lousy response.  He blamed us for the side effects of his abysmal treatment.

So when I walked into the hospital room to tell him the scans showed his latest chemotherapy had failed to stem the red tide of death, I have to admit that I had already somewhat detached.  How could I not?  Although he was fairly lathered by the results, it was the mentioning of hospice that finally led to my expulsion.  His wife ran after me with tears in her eyes.  I'm quite certain that she paid dearly for her kind act of decorum.

Harvey died shortly thereafter.

I am prone to remember the pleasantries Harvey and I enjoyed before his health deteriorated.  I am neither disturbed nor saddened by the anger.  I cannot even say that I would not have been the same way if I  had been lying in his hospital bed.

What surprises me, in retrospect, is how little he affected me.  How his anger didn't penetrate the hardened shell. 

Over my career I have been yelled at, cursed, blamed, hugged, and even loved by my patients.

And like the poor life force oozing out of Harvey's beleaguered body, it drip drips down my back.

 And into a forgotten puddle on the ground.

My new book:  Five Moments, now available on Amazon.   

Sunday, March 12, 2017

Five Moments Book Excerpt

“Dad . . . you can let go now.”
Thomas heard his daughter’s voice from a distance. It awakened him from his reverie. He relived those five moments of life and took their lessons seriously.
Rejoice in the ordinary as if you were a child seeing everything for the first time.
Unconditional love can lift you up. 

Forgive yourself over and over again. 

No matter how much we deny it, we are who we are.
Some of the most difficult battles are those in which we choose not to fight.

Thomas opened his eyes and smiled. He looked at the faces of his family before him. After all these years he finally got it. He understood the meaning of existence that eluded him till now.
Eternity . . . Immortality . . .
His family was now joined by numerous others. Thomas’s friends and colleagues, his patients and students, even the man he once gave a five-dollar bill to on the street. They were all there. He gave a part of himself to each of these people. And each of them had given a part of themselves to others. There were thousands, if not millions, of people in the room with Thomas.
His life had meaning. Like a rock falling into a pond, his goodness made a small splash with the people around him. But the waves from the rock rippled throughout the pond. Thomas would live forever. Parts of him were dispersed into the world. And those parts would live and thrive. Thomas’s body was dying but his soul was strong. He felt oneness with his fellow man.
For a moment Thomas thought if he just had enough strength he could share this beauty with his family. But then he realized this was not the sort of thing someone could teach. Each person had to experience it himself.
Isabella’s word’s came back to him as he drifted off.He remembered sitting on the kitchen floor with his daughter and granddaughter the day she almost choked to death.
“See, Dad? It wasn’t all in vain.”
Thomas experienced one last thing before he died.A cool sensation started at the back of his head and washed over his cheeks, shoulders, body, and into his toes. With pure joy, he recognized this as the first sensation he felt upon exiting the birth canal.
Beginning and End. Birth and Death. They were all intermingled in this beautiful dance called Life.
Thomas’s heart stopped.

Taken from Five Moments, now available on Amazon.

Monday, March 6, 2017

When A Loved One Dies

At first you'll query reality.  You will hear your own words, but they will be foreign; apart from you.  The ground will still reassuringly push back against your toes when you walk out the room, but you will wonder if they are your feet-your ground.  Like in a movie, you will negotiate the world convincingly.  Yet, you are an actor playing a part.  A role.  It is not the real you.  

Be assured that this will pass.  Life has changed incomprehensibly in a fraction of a moment.  It will take a few more moments for your psyche to advance accordingly.  This is not disconnection.  This is not denial.  It's shock.

Grief will not be far behind.  Overwhelming, discoloring, disjointed grief.  Some will try to ignore it.  Others will wallow.  How you manage this grief says more about who you are and less about the gravity of the loss.  There is no correct way to map this journey.  We each travel this road separately.  

My gentle advice to you dear traveler, is remember that separate does not mean alone.  Others will not feel what you are feeling, but that does not prohibit sharing parts of your journey.  The most arduous, at least.  Surround yourself with people and things.  Even if they have lost your interest.  Even if they have lost meaning.

Interest and meaning return.  The sun rises and falls.  You will not break.

By far, the greatest danger lies ahead.  In the days and weeks and years.  You may be plagued by a demon so fastidious it will devour your hours, conscious and otherwise.  It will haunt long nights and merciless days.  It will cause the ground to shake relentlessly under your feet, knocking you off balance.

I'm talking of guilt.

You will feel guilty for not spending enough time, or spending too much.  For not calling the nurse right away,  or calling too quickly.  For pushing the morphine that last time, or withholding it.  Even the quiet and peaceful deaths end here.  It is loves last grappling with earth-shattering loss. We are not programmed to let go of that which we cannot control.

And we can't control death.  So we feel guilt.

This guilt will plague you.  It will turn grieving from a process to a permanent state.

Don't let it.  Your loved one died because it was time.  Nothing you did would have changed that.

Forgive yourself.

Let this forgiveness be one last act to honor the dying.  

If you like this post, please order my new book of short fiction, Five Moments.

Wednesday, March 1, 2017

Five Moments Now Available

If Thomas were to write his own eulogy, these surely wouldn’t be the five moments that he picked.  In fact, it’s safe to say that these were memories tucked away in his subconscious.  Yet as he lay on his bed anticipating death, he relived these precious minutes as if they just happened...

And so begins my new book of short fiction, Five Moments

This collection of short stories approaches the foibles of the human condition, often as seen through a physicians view point.  Crafted over years, each draws from my experiences as a caregiver, a parent, and human being.  

During the marketing of my last book, I Am Your Doctor And This Is My Humble Opinion, I found that above all the interviews, reviews, and assorted media-It was you, the reader, who carried the greatest impact.   

So if you like what you read here week to week, please...

Buy the book!
Share on Facebook!
Tweet on twitter!
Rate on Amazon!
Post to Linkedin!

You are the most effective marketing force.  Your help is much appreciated.  

Five Moments can be purchased here.
I Am Your Doctor And This Is My humble Opinion here.  

Sunday, February 26, 2017

Neither Was Mine

There are parts of medicine that are horrendous.  Moments too painful to recount.  Events that will break even the most innocent participants.

And then there is unspeakable magic.

I live for the days when a patient comes to the office with a particularly vexing set of symptoms.  Specialist after specialist bows their head in disagreement.  Laboratory values whisper falsehoods  with jeering tongues.  Symptoms are transient, physical exam signs inconsistent, and in the midst of head scratching an answer mysteriously appears.  Maybe a common presentation of a rare disease.  Or a rare presentation of a common disease.

Explaining with words so fast that sentences jumble.  Ideas merge.  The patient shakes their head enthusiastically less because of deep understanding, and more because they know that my excitement means that finally the answer will unfold like a blossoming flower selflessly bearing its pollen.  I will eventually slow down enough to present a cogent explanation.  And things will get better.

It lifts me up when a patient sits down beside me after yet another round of chemo.  When, at the end of the day, I have a sparing moment to settle in for intense conversation.   I bite my tongue, become quiet, and listen.  I hear of hopes and dreams.  I hear of pain and suffering, joy and fear. We talk like doctor and patient.  Like friends.  Family members.

We get past the intangibles of life and death, and move on to the more palpable like dignity.  Upon finishing, we leave the room in strength.  We leave the room with resolve.  We leave the room with tears in our eyes.  All of us.

And I love when an unwitting pattern is recalled from the deepest depths of memory.  The clock is ticking.  Heart beats rise and fall rapidly.  Knowledge accrued from past struggles presents itself at the most opportune time, and a life is saved.

On the triumphant drive home from the hospital, with the radio blaring, I remember the patient whose back such life saving knowledge was attained.

And I rejoice that all their suffering was not in vain, and neither was mine.

Wednesday, February 22, 2017

A Difficult Patient

I have come to believe that humility is an essential component of wisdom.  Never have I found this more true than in the practice of medicine.  In fact, for almost every atrocious professional error in judgment I have made, I can pinpoint the exact moment where I stopped being humble.

Yet time and time again, humility quickly disappears when dealing with the difficult patient.  In fact the label, difficult, assumes the problem lies within the patient and not the technique being utilized by the care provider. Already blame is turned outward and personal responsibility abandoned.

A few years ago, when I was in a group practice, one of the senior partners had a particularly needy patient that somehow showed up on all our schedules from time to time.  Her aged joints carried her into the exam room to their own particular hobbled rhythm.  She paused before each sentence, her voice barely above a whisper.

Her litany of issues was long and nonsensical.  And this was always the precise moment when humility left the room.  We all became convinced that her complaints were largely psychosomatic.  And we were right.  It still amazes me at how cavalier I can be when I think a solution is either simple or non physiologic.

It was only after several visits that the need for a thorough exam became apparent.  I tapped my feet and waited outside the door for what seemed like an eternity as she undressed and climbed into the unflattering gown.  My stethoscope stumbled over the heart as if its mighty muscle had not thumped hundreds of thousands of beats.  Auscultated the lungs absentmindedly untouched by the unmeasurable volumes that glanced the porous surface.

My hands fumbled over the fibrosed joints that absorbed the shock of a child's prance, a young athlete's stride, and an ancient shuffle.

My conceit, however, unshakable as it was, was shattered by the faded serial number tattooed on her forearm.

And my humility, once again, was restored to a respectable level.


Sunday, February 19, 2017

No Longer There

The phone is ringing.

The phone is ringing.


I sometimes feel my heart race.  In the middle of the night.  When I get a phone call. Or during the day.  While taking a leisurely walk with my family by the lake. The sun streaming through clouds on a brisk morning, interrupted by a fall in room 36.  An abrasion.  A cardiac arrest.   One phone call on top of another,  Occasionally so many that the calls on hold are dropped.  Or not so occasionally.

During dinner.  While in the shower.  Sitting on the toilet.  Day and night. A faint pain in the ear where the blue tooth rests.  Even when it is charging on the bedside table.  A hallucination.  The feeling of something that is no longer there.  Of something that is undeniably no longer there.

The vexing confusion on the other side of the line when I answer professionally, and the call is personal.  An even greater confusion when I answer personally, and the call is professional.  Straining to hear life altering results in a crowded restaurant.  Above the raucous sounds of my frolicking children.  In the car when the light is changing.  

A bad connection.  The basement where there is never reception. At the car wash when the blue tooth flips from my ear to the car, giving the employees an unexpected treat.  Or the waiter who stammers through my conversation concerning constipation, or blood in the stool, or foul smelling urine.  To return to ordering a hamburger, after telling a family member that their loved one has just died.

Upon realizing a few minutes after being woken unexpectedly in the middle of the night, that a pertinent detail was missed.  Waiting several minutes to get the nurse back onto the phone.  And languishing the next few hours restless. despite great fatigue, because now the mind has started spinning uncontrollably.

Distracted conversations with my wife.  Consistently interrupted.  By a patient's emergency.

The ire I feel receiving yet another text.  To only discover.  That it is just my precious daughter.

Telling me she loves me.

In the middle of a blog post...

Thursday, February 16, 2017

Five Moments-Coming Soon

Tuesday, February 14, 2017

I Don't Understand Burnout

I have a confession to make.  I don't understand the concept of burnout.  I mean, I get the idea.  Medicine is, at least when you are the kind of doctor who deals with life and death, inherently stressful.  And I feel the stress.  It's as if someone applied a vice grip to my insides in the middle of medical school, and it has never let up since.  The pressure is unrelenting, progressive, and downright painful.  It has gotten worse with every successive career milestone.

Brutal.  It's brutal.  I new it would be after a few weeks of rotations on the medical wards.  The more responsibility I gained, the worse it got.  And I guess I entered the profession knowing this.  There was no expectation of reprieve.  No belief that I would be let off the hook.  I assumed that it was my cross to bear, my burden to shoulder.  As the burden became heavier, I learned how to amble through hospital halls with a stooped posture.

I just don't know if it could be any other way.  I can think of no relief from the burden of making life and death decisions.  What we do.  What we do matters.  A wrong turn, a flip on the ideological scale, can have devastating consequences for those we care for.  There is no escaping this responsibility.  No blunting the effect.  You can't go half way. You can't stand in the middle of the road.  You either make definitive decisions with definitive consequences or you get out of the business.  There is no such thing as sleeping peacefully for a physician.

So why are doctors committing suicide? Why are doctors leaving medicine in droves?  It's not burnout.  A small part of the reason is wrong career choice.  A young doctor realizes quickly that they didn't know what they were signing up for.

For the rest, it's external.  It's not the stress of caring for people or even making life and death decisions.  This is part of our genetic makeup.  Part of our training.

It's everything else.  It's the paperwork.  It's the meaningless paperwork.  It's the droves of administrators and clerical staff thwarting us at every turn.  It's the government and endless regulations, and rules, and threats.  It's the loss of respect, loss of standing, and loss of confidence that we feel everyday from our community.  It's economic distress.

We won't fix this by training our young people about burnout or haranguing them with some odd belief in resilience.  They made it through medical school, they already are resilient.

You want doctors to be doctors again?  You want us to love our jobs again?

Simple.  Get out of the way.

And let us do what we were trained to do.

Friday, February 10, 2017


My son,

You will face this.  You will stand at the crossroads of skill and preparedness.  Although your heart may tremble, your hands will be still.  Although your thoughts may race, your mind will be firm.  Each one of us must enter the coliseum unadorned from time to time.  Over and over again, we do battle.  Skill and knowledge spring forth from failure, not success.

I can help prepare you for this moment.  I can congeal my accrued wisdom into consumable morsels for you to chew.  I can arm you with knowledge and skill.  But I cannot do battle for you.  Not this time.  I will bring you to the trough, but now you must drink.

Drink from the well of fear and incertaintude.   Imbibe from the ocean of insecurity.  Place your head forward and savor both the bitter and sweet,

For you will be tested.  Again and again.  There are times when you will be ready, and times when you will not.  But there is strength deep down inside of you.  A voice that will lead the way.  Listen to that voice.  Follow its dictates.  Let your mind and heart propel you together.

You must become the clearest when you are down.  It is when you are most beleaguered, that wisdom dribbles in.  Be open to it.  Watch for it in the deepest pits of despair.  It will be you ladder.  It will be you life raft.

And you will succeed.  Maybe not this time.  Maybe not the next.  But eventually.

So, my son, I want you to go to school today and rip that math test apart.  I'll be thinking of you.

Thanks dad, I will.  No biggie.  

I hope your day at work is okay too.  

Hope none of the sick people die!

Saturday, February 4, 2017

Turned Away

Too many times I feel 
We are losing time once shared 
And only when you're in ecstasy 
You seem to really care

I recognize the song immediately.  Chuckii Booker.  Turned Away.  Not the regular version, but the extended.  As the words rush over me, caressing my nostalgia, a memory, a moment comes back.  

I was standing behind the counter at Homer's Ice Cream on a brilliant summer morning before the doors opened.  We were setting up.  One of the managers turned the volume up, and the radio blared through the speakers. The shades had been pulled back from the storefront windows, and light streamed through the door and onto the wooden tables in the adjacent dining area.  A veteran, the summer year before college, I had mastered almost every job in the restaurant.  Served ice cream.  Fry maker.  Head grill master during rush hour. I inspected almost every inch of the building.  Polished every spot.  Cleaned the bathrooms and emptied the dreaded metal containers found only in the girl's room.

My collared work shirt held the italics Homer's logo in red over the breast.  I rolled the sleeves up and squared them off above the biceps.  I like to envision my arms bulging with arteries popping at just the right places.  There was a pull-up bar in the storage room, and we often ran back if we saw a pretty girl approaching.  Quickly, we would squeeze out a few reps before returning to the front with sweat falling from our brow.   

There were all sorts of other hijinks.  I was seventeen and unsure of myself.  My heart had been broken already once or twice.  So I acted out.  Had shake eating contests when the manager was otherwise occupied.  Gave away free food to my friends, only to find that it was deducted from my paycheck weeks later.  I caroused with my fellow employees, many of them older than I, in search of alcohol and adventure.  We broke the law occasionally; got caught from time to time.  

It was all an act.  Artificial bombast to divert from insecurity.  At the time, the lyrics stung, but were an anthem played over a killer track.

Turned away.  Turned away.  Why did you have to turn away?  Turned away from love.

Like so many young people, I was convinced that I was unloveable.  I ached for a idealized connection.  A connection that both I and the objects of my affection were too immature to grasp.  Surrounded by a family that adored me, I moped at home day after day both dreading and hopeful for my upcoming departure to college.  

Those words, that tune, stuck with me.  Long after I had successful relationships and realized that I was worthy of love.  Even after I got married and had children.  

Those words still move me.  My body still sways back and forth and I feel both the pain and joy.  

And my children mope around the house much as I had.  Younger than I was at the time, but no less struggling to find their way through a confusing and cold world.  

I turn the radio up and let the words spray from the speakers and drip onto their growing bodies.  

We dance around the room with complete abandon,

and I momentarily believe that everything will be okay.  

Monday, January 30, 2017

A Stitch in Time

At first I thought the beeping was coming from the television.  I had just settled back into the couch after tucking my daughter into bed for the second time.  Her tummy was hurting.  It had been doing that a lot lately.  Especially on Sunday nights with the specter of Monday morning looming large.  She was getting headaches, stomachaches, nausea.  It had been going on for some time.

My son is similar.  His headaches and bellyaches come and go.  He is famous for vomiting at any given moment and then feeling fine the next.  And to think of it, we have all been under the weather lately.  Our house, as so many, has been caught up in the hacking, runny nose, sore throat plague making its way though our neighborhood.  Katie was lethargic and had a headache almost everyday last week.

We were all coping though.  Getting better slowly as the body is wont to do.  There were no emergency room visits or trips to the pediatrician.  But we were all tired after a busy week and a hectic weekend.

So when the incessant beeping started, the first thing Katie did was turn down the volume on the TV.  When it stubbornly persisted, I grumpily made my way down to the basement to investigate the culprit.  Once in the basement, I tried to triangulate from which hidden corner the beeping was coming from.  The boiler?  The water heater?  The fire alarm? The beeping no longer felt benign as I held my fingers to my ears to keep from permanent hearing damage.  It was about when I focused on the CO sensor, that Katie called down to me.

It was the alarm company.  Our Carbon Monoxide levels were too high, and they called the fire department.  I rushed up the stairs, opened the house doors, and we gathered the children and coats.  Katie and the kids waited in the car, and I went to the front of the house and flagged down the fire truck.

It was not a false alarm.  The Carbon Monoxide level in our basement was 108 PPM.  According to the paramedic, one can survive in this range for about 10 to 15 minutes.  Katie's office was the next highest at 40 PPM (it usually takes about 8 hours for a person to be overcome at these levels).  The kids bedrooms were in the 30's.

The Firemen shut down the boiler and the water heater and opened all the windows.  Within minutes the levels had fallen to zero. We slept last night in a chilly home using our backup heating system that is meant for only half the house.  Slept is a loose term, I mostly tossed and turned.  We will see if the headaches and nausea disappear.

It's disturbing to think of all the possible scenarios that could have played out without the benefit of that CO detector.

Did I mention that we just installed it a few months ago?

Saturday, January 28, 2017

An American Story

Sitting in the waiting room of the Oval Office surrounded by his family, Sam found it both fortuitous and ironic that he had changed his name years ago.  Amongst a flurry of millions of pressing yet inconsequential decisions, Americanizing his Iranian name, Saeed, would later save him some grief during 9/11.  He looked up at the line of government workers and their families wending it's way through the hallways and ending abruptly at the President's office.  One of the security guards had taken pity on Sam.  His eighty year old body hobbled by a bad knee, broken years ago in a tunnel explosion during his years as a foreman in Tehran, bought him a front row seat to the festivities.

Sam loved Iran. His mind could draw a straight line from a childhood spent sleeping on Hamedanian rooftops to his ascension as CFO of a multinational company.  His success and wealth, however, all crumbled that day he was jailed by the henchman of a new Ayatollah who was deeply suspicious of his bosses political leanings.  He won't tell us the details now, but his release, ushered by Shah loyalists at the prison, likely spared his life.

Months later, with visas obtained in Italy,  Sam, his wife, and three children boarded a flight into the unknown.  His wealth, property, and status remained in the country he loved.  There was a pact that if they were detained at the airport, his wife and children would flee to America alone.  A pact that would thankfully be allowed a single day reprieve.  One of Sam's colleagues was detained the next afternoon and never heard from again.

America was not easy.  Brutal in fact.  Sam's position as CFO carried little weight in the US.  He traveled hours on public transportation to jobs he was overqualified for to receive paltry wages.  His wife, a teacher in Iran, became a manicurist.  They survived day to day in a tiny two bedroom apartment.  The Iran hostage crisis insured that there was no shortage of discrimination and racial slurs thrown their way.

But Sam had no time to complain.  He was caught up in the most American of pastimes-providing a life for his three young children.   So he found a way.  When his shoe stores failed he scraped enough money together to buy an apartment building. And they had enough.  Never a lavish life like he had in Iran, but there was always food on the table.

Sam's eldest daughter became a lawyer and eventually worked for the government.  She had given much to her country including years of service in a very dangerous Afghanistan.  It was at her invitation that three generations of his family were gathered to meet our great leader.

As he walked into the oval office, Sam adjusted his eyes to the splash of light and color, flash bulbs and smiles.  A man who was forced to flee a country he loved for dubious political reasons, was now face to face with the leader of his adopted country.  Ironic that he hadn't voted for this president, or agreed on so many issues.  This was allowed here.  Celebrated.

It had never been easy.  Sam's family was nearly deported a few years after emigrating.  He had been held up at gunpoint in his shoe store twice.  He was a victim of far more crimes than any petty moving violation he may have committed while driving absentmindedly.  His family faced discrimination of almost every stripe.

America, however, was also a country of unthinkable kindness and good intention.  Her actions were often flawed, but her principles were unflappable.

At least until recently.

Sam's youngest daughter, my wife and mother of my two children, accompanied her father that day in the oval office.

He waited in line with the rest of his family.  He smiled when the President stood in front of him, and offered his hand.  His English still broken after all these years, his voice was almost a whisper as he spoke his given name in greeting.

I am Saeed.

Wednesday, January 25, 2017

I Hear the Water, I Hear the Birds

Hello. hello...Pause.  You know my heart jumps every time I see your name come up on the phone!

Every child secretly creates a story about the adult they will eventually become.   A fantasy adorned with all the trappings of honor, success, and beauty.  We imagine a world in which we will make a difference; touch those we come in contact with.  Especially if you aspire toward the medical profession.  Our particular daydream involves rushing into a room with stethoscope bouncing back and forth around neck.  With expertise we bark a series of orders, maybe grab defibrillator paddles.  The patient sits up and blinks.  He immediately knows his life has been saved.  Family members bow.  The nurses swoon at our physical prowess and the medical students at our intellectual.

And then reality hits.  Medical school and residency teach that heroic moments are few and far between.  We learn that medicine is never a sprint, but more accurately a laborious iron man.  Tenacity of spirit, a never ending curiosity, and a deep well of humanity become the characteristics we most strive towards.  Our story has changed.  Our identities have pivoted to a more realistic and passionate ideal.  The rewards become long lasting.  Durable.

The practicing physician's story is idealized into that of Kwai Chang Caine from the TV series Kung Fu.  Humble and quiet, we wander the earth alone.  We come upon misery and despair.  We bend with the wind but don't break.  Our powers are administered gently and patiently to affect injustice when possible, and to cushion the blow when not.

This is a quiet, romanticized story.  We cling to it dearly during the daily blizzard of current medical existence.  It creates warmth and shields against the daily fear, anxiety, and disquietude that haunts this profession.

It's easy to forget that those we administer to also have deeply ingrained narratives.  And when those narratives involve illness, disaster, and death, the physicians role as protagonist is in doubt.  While I have forgotten thousands of patients who have died, their family members remember me quite clearly.  I am the one who told them their loved one was dying.  Or gave a horrible prognosis.  Or it was my phone number that came up that day on their mobile phones.  The day that disrupted their lives.

It was me. In so many stories, I was the last vision before life spiraled.  My words.  The way I stammered or the fidgeting that they will remember as the harbinger of catastrophe.

I can't help but think that this story is wholly suffocating.

I dreamt of being a hero.

Then I dreamt of being the gentle breeze, warm and calm.

Never, never did I dream of being someone's worst nightmare.

Master Po: [after easily defeating the boy in combat] Ha, ha, never assume because a man has no eyes he cannot see. Close your eyes. What do you hear? 
Young Caine: I hear the water, I hear the birds. 
Master Po: Do you hear your own heartbeat? 
Young Caine: No. 
Master Po: Do you hear the grasshopper that is at your feet? 
Young Caine: [looking down and seeing the insect] Old man, how is it that you hear these things? 
Master Po: Young man, how is it that you do not?

Monday, January 23, 2017

Palliative Care Is...

Palliative care is...

I wait intently as the board members rearrange themselves in their seats and look up expectantly.  Silence.  I wasn't going to let it be that easy.  I repeat myself and pause again.  This time a few tentative answers flutter up to the podium.

hospice...comfort care...end of up?

Now this is something I can work with.  I clear my throat and smile broadly.

Palliative care is a philosophy.

I can't help but launch into a series of idioms.  I talk of the difference between the forest and the trees. I invoke Osler's famous quote about how the great (palliative) physician treats the patient and not the disease. We talk of the sanctity of quality versus the expediency of quantity. I can see heads shaking in agreement now.  The ideas are starting to sink in.  I mention patient-centeredness and I can feel the the room stir.  I talk of dignity.  The goal is to face illness with the same dignity that we attempt to face health.  The participants inhale and exhale with each word.

Palliative care is a skill set.

Palliative care is a consultative service just as a cardiology or nephrology.  Board certified physicians in hospice and palliative care treat pain, nausea, anxiety, as well as a host of other symptoms.  We also are skilled in advance disease planning.  Counseling on end of life, and not so end of life care.  Helping guide the decisions about code status and hospitalization, and timing and duration of care.

Palliative care is a team sport.

Nurses, social workers, chaplains, therapists, volunteers, and nursing assistants.  Relieving pain and suffering is complex and multifaceted.  It is not only a physician's domain.  Each skills set brings it's own version of comfort to the suffering.  But mistake me not, we all speak the same language.  It is neither medicine nor religion.  It's compassion.

Palliative care is not hospice.

In fact hospice is a small part of palliative care.  If palliative care were a bus, hospice would be a few rows of seats in the front (or back).  It is concomitant care  of chronically ill patients coordinated with other specialties.  One can continue any treatment they wish.  Chemotherapy, surgery, hospitalization. And it is not a substitute for hospice.  Hospice is a medicare benefit appropriate for up to the last six months of life for those who wish to discontinue curative treatments.  It brings with it a host of services not otherwise covered by general palliative care.  

Palliative care is important.

It is something you, your family, and your institution need to know about.

Friday, January 20, 2017

Us and Them

I think about her from time to time.  More often than I should.  Being mere acquaintances, there is a certain frequency that goes above and beyond coincidence.  I contemplate what it must have been like working as a second year resident in the ICU (I was an intern at the time). Getting a severe headache and wandering down to the emergency room in a daze.  Strangely similar to what happened to my father.  But she didn't die.

Maybe worse.  She was diagnosed with Glioblastoma Multiforme, a uniformly fatal brain cancer.   She suffered through a stay in the same ICU she was scheduled to cover for the month.  She tolerated surgery and chemotherapy.

She married her boyfriend during a prolonged stay in rehab.  Her head was partially shaved in the wedding pictures.  And one day, she showed up to round with our team on my second year rheumatology elective.  She stayed with us the whole month.  Some days she worked the entire shift, others she became fatigued and left at noon.

We laughed, we learned.  Mostly we pretended she was no different than any other resident.

I assume she died long ago.  Sadly I can remember her face, but no longer her name.  The  years have erased much.  As I said, we were never particularly close.

In retrospect, we were fooling ourselves pretending she was like any other resident.  That day in the emergency room she ceased being one of us, and became one of them.  The sick people.  The people we have dedicated our lives to treat and care for.   The people we keep at arms length.

Pain and suffering are tolerable as long as there is separation.  Us and them.

It works for the most part.  But I can't help daydreaming that maybe she was one of those few percent who survived.  That she has a family and a busy rheumatology practice in some spectacularly boring suburb somewhere.

That she came back to us.

Or that we learned how to be better at being with them.

I really wish I could remember her name.

I think.

Wednesday, January 18, 2017

Bear Claws and Veterans Who Never Die

Every morning we awaited ravenously for the bear claws.  The director of The VA would saunter by the residents room and refresh the cardboard box with various pastries, Danishes, and bear claws.  Like zombies, our sleep deprived bodies would communally aggregate in the corner and devour our prey.  Stacks and stacks of sugary pastries.

The VA was located conveniently in the middle of a food desert.  The neighborhood was so crime ridden that no delivery person would agree to drive up.  There was no cafeteria.  So we ate bear claws.  Sometimes, during a thirty six hour shift, for breakfast, lunch, and dinner.  Or a late night snack.  The only abundance greater than sugar, of course, was fear

As second year residents, we ran the show.  Supervising a few interns and medical students, we covered the entire hospital.  Hundreds of sick veterans with every imaginable disease.  More often five or six of them at once.  We had no backup.  No support.  The patients got sick and coded.  They suffered almost every complication.  But they never died.  Veterans never died.  They just got more sick.

It was one month out of a three year residency.  The month that made me into a doctor. Upon it's completion, I had learned to stick a needle into most any human crevice.  I pounded on chest after chest during endless nights of CPR.  I brought blood pressures up and took them down.  I admitted twenty new patients over night, covered the ICU, and still somehow had time to show up the next morning and get in line for the only breakfast that was going to present itself to me.

I still wake up in a cold sweat reliving those days.  It's my most dreaded stress dream next to being late for college finals.  A months experiences compressed and splayed out over a lifetime.

I will never be the same.

Since that rotation, there is nothing medicine has been able to hurl in my direction that I can't handle.

And the sight of bear claws makes me ill.