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?

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.

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?

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 life...giving 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.

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.

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.        

Thrive

It was only later that I discovered the underlying reasons for the move.  My parents purchased a home in neighboring Wilmette.  The contract was signed and a date was set.  Being in second grade, I doubt I worried about the details.  Maybe I was concerned about enrolling in a new school, I don't remember.  It was nothing in comparison to the tumult I would feel when we relocated after the wedding, before high school.

When my dad died, I assume the contract was nullified.  The overwhelming upheaval to our lives was so great, that a seven year old boy couldn't possibly comprehend the complexity of adult decision making.  We were going to move and then we weren't.  My dad was with us one day, and then he wasn't.

And my life was afloat in uncertainty.  Stalwart in the idea of becoming a physician like my father, I struggled with a learning disability profound enough to keep me well below the level of my peers.  I sat in homeroom coloring while my classmates read from textbooks. I had an army of school provided tutors as well as a private learning specialist.  The picture would have been fairly bleak if I had been old enough to recognize.

But children can be unfalteringly ignorant toward melancholy.  Their unfettered engines continue to run.  They continue to run free.

My two memories left from that year color almost all that I am. In the living room surrounded by family, as my mother whispered in my ear that dad was gone.  And months later, the day my teacher placed a textbook in front of my face and I read.  Surprised, she place another.  A slightly more complex.  And I read.  Then another.  And another.  The children looked up in awe as a pile of textbooks formed on the side of my desk.

My reading and writing improved so much, it was decided that I indeed could matriculate to third grade. Which was incidentally the reason my parents had planned to move in the first place.  They were going to hold me back, and felt it would be less devastating if I transferred to a school where none of the kids knew me.

Years later, my mom would remarry and move us into the same district that I narrowly missed in grade school.

And I would thrive.

Identification and Intimacy

To say that there is no fear in the examining room is an inaccuracy.  I'm not only talking patients here.  Physicians may harbor just as much worry and discontent .  There are the old standbys of course.  The swat team of malpractice attorneys lounging in the waiting room ready to pounce.  Or the old demon of misdiagnosis and the consequences that may follow.

Few of us talk of that sinking feeling that comes with the realization that in the course of doing our jobs, we invite physical danger.  During medical school, I remember a psychiatric patient barricaded one of my peers in an interview room.  The standoff lasted forty five minutes until she was able to escape unscathed.  Physically at least.

I can no longer count the various times I have treated criminals, psychotics, or just plain agitated dementia patients who were willing to take a swing at whomever was in reach.  For the most part, these interactions have melted away quietly leaving me with little lasting effects.

My escape from the traditional examining room has also brought a new set of challenges.  Knowing a patient had a loaded gun a few feet away was somewhat jarring.  Or traveling to a not so safe neighborhood during erratic hours.  One becomes aware of ones surroundings more quickly. There are countless dangers that won't bow to our flowing doctorly lab coats.    

But by far, our biggest unspoken and often unrealized fear, is that of identification.  How does one break the horrifying news to a dying young person and not look in the mirror and see a similar countenance?  How do we not envision our spouses, our parents, and our children in every hapless medical misadventure that we are a party to?

The answer is that we don't,  We use our walls to create a sense of otherness.  We shield ourselves to such an extent that it my twenty year career, I have rarely had these conversations with colleagues.

And as I get older, I wonder if we should.  There is a certain intimacy in identification which has been lost on those that hide behind the stethoscope.

We give ourselves a pass.

My Advice to You

It will start as a minor curiosity.  Maybe a student will seem slightly too close to the resident on your team.  When the grades are posted you'll wonder why you didn't get honors but he did.  You might wallow for a few days.  Make an off-handed comment to your fellow students.  Then you'll let it go, and move on.  Or so you think.  Until during surgery when the scrub nurse rips into you to make a point to the rest of your peers.  And then the surgeon does the same to her in the operating room.  

There will be other times.  During residency you will roll your eyes when you realize your co-intern is sick again, and you're up for all the admissions.  You will curse the medical student who created the cockeyed explanation and scared the heck out of the frightened social admit in room 5.  You might not yell.  You might not lose your cool.  But rage will boil over from time to time.  You may let it loose on the radiology tech who is refusing to get up in the middle of the night and do your stat study.  

Your path will continue even after you are done with training.  There will always be plenty of culprits.  The secretary who double booked your over packed schedule.  The prior authorization phone tree that will waste the precious moments you could be spending with your children.  The paranoid anxious patient who will put it off all day, and show up to the emergency room at midnight and awake you from a deep sleep.  You will argue incessantly with the emergency room attending who will refuse to send him home and insists on observing for cardiac ischemia.

And you will find yourself yelling uncontrollably at the cowering patient who pulled you out of the examining room with the young guy with melanoma who was finally willing to talk about hospice, because she forgot to ask a question thirty minutes ago during her appointment.

When you look into her tear soaked eyes, a hard reality will come upon you.  You are angry.  You have been for years.  Rage is constantly simmering below the surface scalding you and those you interact with.

You have truly become a doctor.

My advice is simple.  Forgive yourself.  Remember that that medical student who undercut you was wallowing in much the same way as you.  The surgical scrub nurse had felt a hundred times the abuse from the surgeon who was still scarred from his own training.  Your fellow resident was actually sick and spent all night puking in the bathroom.  The radiology tech hadn't slept well for weeks.  The secretary had been cursed out by the patient for not making room in your schedule.  The anxious patient was suffering, and the ER attending was trying to be compassionate.

And yes, the young melanoma guy is dying and no one is dealing with it.

Then shrug your shoulders, exhale, and decide to turn the anger into love and understanding.

Life is much better that way.

The Guidelineification of American Medicine

His voice was gruff and his expression surly.

I don't want any more medications.

His face was indented by deep clefts, remnants of eight decades of  life hard lived.  His tone was commanding and certain.  I knew that he was fond of me, but I could feel his patience slipping.  He neither asked about nor accepted his diagnosis of heart failure.   I could tell him till I was blue (or he was for that matter) in the face that his low ejection fraction portended a poor prognosis, and national guidelines suggested both a beta blocker and defibrillator placement.

He wouldn't budge.  And before the age of electronic medical records, evidence based medicine, and quality scores, no one really cared.  Before we would have taken the patient's wishes into account.  Noted that he couldn't afford the new med, nor was particularly compliant with his other medications.  Considered that his wife had died a few years back, and he had no interest in extending his life.  Weighed the positives and negatives from the patients perspective, and come to a tailored decision for this particular human being.

But now the guidelineification of American medicine has turned this proud and aged skill into a humdrum maze of algorithms.

Algorithms that are more expert opinion and less evidence based. Algorithms that rely on evidence collected from typical white male patients with isolated disease processes and may not be generalizable.  Algorithms that will change often and probably contradict themselves in the decades to come.

The true art of medicine, expertly meshing the known with the unknown.  Factoring in human variability and preference to develop a unique plan.  Has been lost.  Ridiculed. Chewed and spit into the trash.

We pray to the ever eroding alter of longevity.  Even as our patients have abandoned such false deities.

They want quality of life.  They want control over their own decisions.  They want to go with their gut sometimes.

And I think we should support them.

A Doctors Story

Many years ago, three doctors formed an internal medicine practice and were proud of the thousands of patients they accumulated.  They were fine physicians and very dedicated to the masses who walked through their clinic doors.  They saw patients in the office, rounded at two hospitals, and visited a number of nursing homes.  This was truly a full service practice.

Around 2005, Dr. A was starting to fatigue.  He was well into his sixties and did not like the direction medicine was going.  The hours were too strenuous, the documentation requirements were getting increasingly complicated, and he saw the writing on the wall.  Regulation was coming and the results would be devastating.  So he decided to retire.

Luckily, Dr. A's patients (around 5000 at the time) could be seen by the two younger physicians in the practice (Dr. B and Dr. C) after he left.  They both, by now, had thousands of patients of their own, but were happy for the extra work.  A final retirement date was set, and Dr. A officially left the practice in 2006.

Unfortunately, without Dr. A's influence, Dr. B and Dr. C had a series of disagreements and decided to break off the relationship.  Half the practices ten thousand patients stayed with Dr. B, while the other half moved locations to join with Dr. C.

Dr. B needed extra help handling all those patients and hired Dr. D.  Dr. C needed extra help handling all those patients and in 2007 hired Dr. E.  Both practices thrived.  Their client rosters swelled even as they faced the continuing assault of governmental regulation.  Thousands of dollars were spent acquiring and utilizing electronic medical records.  Countless hours were wasted filling out forms and on administrative phone calls.

Around 2013 Dr. E realized that he was spending more and more time on paperwork, and less and less time on patient care.  His patients were upset, his personal life was suffering, and most importantly, he was no longer proud of the quality of medicine he was practicing.

So in 2013 Dr. E made a momentous decision.  He left his 2500 patient practice and started a home based concierge model consisting of only 100 of his former patients.  The rest stayed with Dr. C.  Dr. E also continued to do nursing home work taking care of other physicians patients, as well as started an administrative role with a local hospice.  And he thrived.

Dr. C continued to manage his own patients as well as all those extra that were no longer under Dr. E. But by 2015 he was having trouble maintaining a reasonable lifestyle, and his economic fortunes had worsened.  Feeling forced, Dr. C  also converted his practice to a concierge model and his patient panel shrunk from over 5000 to less than 500.   And he thrived.

Now we must not forget Dr. B and D. They made a successful run at private practice and hired various other physicians and nurse practitioners over the years.  The ranks of their patient population swelled.  By 2015, however, they began to feel the futility of the current medical system.  Thus Dr. B and Dr. D also eventually went concierge, and limited their practices to 500 patients each. And they thrived.

So if we do the math:

Dr. A had 5000 patients and retired.  He no longer is involved with patient care.

Dr. B moved to a concierge practice and narrowed his patient population from 5000 to 500.

Dr. C moved to a concierge practice and narrowed his patient population from 5000 to 500.

Dr. D moved to a concierge practice and narrowed his patient population from 2500 to 500.

Dr. E moved to a home based concierge practice and narrowed his patient population from 2500 to 100.

Now before you get in a huff, of course there is some overlap here.

Most of the abandoned patients joined the prominent medical group in the area and still have doctors, though often have to wait months for simple appointments.  Many of them barely know their physicians and are seen by nurse practitioners.  None of them have the benefit of having their own doctors in the hospital or nursing home.

You might think I am being hyperbolic.

You might think this story is an exaggeration or fairy tale.

But I'm here to tell you it's not.  I know.

Because I am Dr. E.

Just Like She Said

If Bob had realized that these were his mother's last words, he might have stopped what he was doing and stood by her side.  But her foley catheter was leaking again and the sheets were a mess.  Besides, he didn't want to wake Rhonda in the adjacent bedroom.  She had just gotten off third shift and needed to rest before taking over in a few hours.

Bob felt guilty about losing his job, but given his mother's current state, he couldn't justify taking another gig out of town.  Because the Medicare days at the nursing facility had finally run out, his aging mom was forced back home.  At first she was able to smile and even talk occasionally, but that was mostly gone.  She mumbled from time to time.  Nonsensical mumbo-jumbo. Or stared blankly.

Bob listened to his mother's distorted vocalizations as he undid her flimsy coverings  He had debated whether to change the diaper or remove the bed sheets first, and settled on the diaper.  The morning news blared on a TV which had been optimistically moved into the room before her arrival.  She no longer could focus on the screen, but at least there was background noise.

Bob's hands moved quick and efficiently.  He sometimes wondered during these long days if he should have become a nursing assistant.  He was strong and able.  He had the right constitution and didn't get queasy when dealing with the indelicacies of the human body.

His mom exhaled and then did something she hadn't done in months. She spoke.

Bob, Bob quit messing with those sheets.  I'm dying.

Of course Bob didn't think.  She has been talking out of her mind ever since leaving the hospital.  He secured the diaper and pulled up the sheets.  It was then he noticed that she wasn't breathing.  Her chest was completely still.  He called out for Rhonda and she rushed into the room blurry-eyed.  They stared at each other for a moment, not knowing what to do.  Then he called 911.

Bob new the chest compressions were futile, but allowed them for a short time before asking the paramedics to stop.

His mother was gone.

Just like she said.  

Evolution

You won't at first.  But then you will.

It will start innocently.  Probably even before medical school.  You will have a morbid curiosity about passing ambulances and motor vehicle accidents.  Your original empathy for the victim will disappear when you begin to think of them as patients. Test cases.

The commodification accelerates during the early years of medical school.  Anatomy, pathology, and physiology provide you a vocabulary to replace human pain and suffering.  In gross anatomy you violate the viscera even as you hear your fellow students snigger in the background.  You may not take part in their school-boy antics, but it loosens in you a certain callousness that you were previously cautious to recognize.

During the clinical years you will learn to build walls with the most rudimentary artifacts.  Your first death.  A mistake.  Your resident standing over blaming you for the post op infection and eventual demise of a beloved patient. Your hands will scramble as you crouch amongst the linoleum of some hidden dark corner of the hospital ward, collecting dust and discarded gum.  Your eyes no longer seeing, your heart trying desperately not to feel.

Residency is when you will become the master builder. Unslept nights.  Missed meals.  Standing on the front line wading through the intolerable excrement and blood of actual healthcare.  You will learn not to cry, not to contemplate.  To traipse from life to death wearing the same distracted grimace.  And you will yell at that poor medical school student about the post op infection for which you secretly wonder if you caused.  You now work with brick and mortar, clay and stone.  Your tower rises above and beyond, up to the sky, encircling you.  You are alone.

Your expertise will be so great by the time you are an attending physician, nothing will penetrate your ironclad barriers.  Unlike those walls, however, your heart will be porous and ooze sadness, anger, and despair.  Trapped inside that small space.  Devouring you.  And love, and family, and friends, and light, and oxygen will all be awaiting on the other side.    

A breath away, a mile apart.

If you're lucky, you'll fall to your knees to the grit and grime and start clawing with bloodied knuckles.

Brick by brick you must undo that which you have built.

That which has been built for you.    

And You Will Answer

There is a basic communication gap between you and I.  How could there not be?  It's not what you expect.  I say you have cancer, or heart failure, or emphysema.  Full stop.  A conversation ensues.  This is not what I'm talking about.

It's more like when I report to you a series of normal lab results, and at the end flippantly mention a slight elevation of the white blood cell count.  In my mind, it is a minor issue and likely do to that viral infection that you are recovering from.  As the days pass, my words simmer and eventually come to a boil, consuming you.  The elevation could be leukemia after all.  You could be dying.  You could be like your uncle Stew who went to the office for routine blood tests and was gone a week later.  You search the Internet and are confused by what you see.  You wait anxiously to repeat the blood tests four weeks later.

The white blood cell count comes back normal.  You are relieved and tired.  It has been a long and scary four weeks.

And I had no idea that you even suffered through this.  I apologize.  The problem with familiarity is that it is easy to forget perspective.  I have spent the last few decades becoming intimately familiar with the ebb and flow of wayward lab results.  And you have not.  Frankly, I sometimes forget to look at my words, my utterances, through your eyes.  The big stuff, sure.  But it's the minor less tangible that escapes careful scrutiny.

God knows, there are also many other barriers.  I am rushing off the phone to get back to the call from the emergency room.  We are separated by an electronic elephant in the room that stubbornly inserts itself between us, and blocks my view.  There are boxes and checks to be marked, and I am stuck trying to figure out whether you are a Pacific Islander while you just want to talk about your chest pain.

Per usual, I don't have adequate answers to this conundrum.  Sometimes the gulf is overwhelmingly vast.  Although I take full responsibility, I doubt that I will always be attuned to which of my words affect you so.  Unfortunately, my experience will still color me blind from time to time.

But going forward there is one minor adjustment I will pledge to make.  One way we can work together as a team.

At the end of every visit, every phone conversation, I will train myself to ask:

Tell me what questions you have?  What haven't I made clear?

Then I will pause.

And you will answer.