In My Humble Opinion

Valetine's Day Snapshots

2012-02-15T05:15:00.000-08:00

The bipap machine pulled and pushed against her lips as her husband walked into the room bleary eyed from a night of stolen sleep in the ICU waiting room. He arched his back and his geriatric limbs cracked with the first movements of morning. He stood next to me and put his arm on his wife's shoulder.

The raspy air moved in and out of her lungs in fits and starts. She had been in the hospital for a few weeks. Her pneumonia was the final push that caused the boulder of chronic lung and heart disease to spiral towards the bottom of the hill.

This was her third stay in the ICU. Her husband and I discussed that she may not survive this hospitalization. He stoically excepted my pronouncements and yet remained gentle and upbeat.

When I turned to leave the room, I could hear him crouch over the embattled body of his wife. His whisper was barely audible.

Happy Valentine's day, love.

*

The demented woman in the wheel chair made herself at home at the nursing station. She watched the comings and goings of the extended care facility and was sure to add commentary to anyone who happened to pass by. She was particularly smitten with a young male CNA. Her inappropriate behavior was a byproduct of her loss of executive functioning. She eyed him as he turned the corner.

Hey good looking, you want to be my Valentine.

She licked her lips and the CNA quickly jumped away from her grabbing hands. I sunk down in my chair hoping she wouldn't see me. I watched as her head jerked in my direction. Her white strands of hair frazzled and her face hidden behind thick black glasses that were missing the lenses.

Doctor, doctor, my boobs hurt! You want to examine them?

My face became warm and my cheeks flushed. At first I tried to ignore her but the pleas became more fervent. Her breast exam the week before (prompted by the same complaint) had been normal.

OK, I'll get Nurse Radcliffe to accompany you back to your room and get things ready.

When she realized we would have company for the exam, she sighed deeply and spoke as she turned her wheel chair.

All the sudden I'm feeling better.

*

My son and daughter laugh as they run towards the car. Their faces are smeared with the remnants of a feast devoured in their classrooms earlier in the day. Bits of cookie dot my sons upper lip like a mustache. My daughter has chocolate colored smudge on both cheeks.

They carry folded pieces of paper with primitive lines of crayon dotting the front cover. They offer them up to me as I struggle out of the car carrying my computer and other byproducts of a day spent in the office.

Their faces beam with the innocence and joy of experiencing all of lifes wonders for the first time. They yell out in unison.

Happy Valentine's Day Daddy!

For My Son

2012-02-14T17:43:00.000-08:00

We tell ourselves the stories about our lives that make it bearable, or better yet, magical, mystical. When my father died unexpectedly I was seven and there were no stories that made sense. How could I explain how this loving father of three and devoted husband could be taken from this earth so quickly and with so little warning? It was a question that puzzled me throughout childhood.

As I grew older, I eventually formulated an answer. When my father died, I was seven years old and he was my idol. I copied his movements, his words, and then I copied his profession. My father was a highly respected oncologist and often treated the sickest patients. He received many accolades as well as the love and respect of his colleagues.

I always wondered, if he had lived longer, would I have grown less enamored? What would have happened when I reached the age where boys question their fathers and become disillusioned? Would I have changed my mind and wanted to be a sports star or a policeman? I’ll never know.

The idea of becoming a doctor stuck with me. It carried me through successes and failures. It created a confidence that never questioned if, it only questioned when. It built a story of my life that made sense. My father’s tragic death strengthened my calling to become a physician. I would carry on the tradition and touch countless lives. From death would come rebirth. By helping others, I would turn my sorrow into beauty.

2

When I started residency in July of 1999, I felt confident that I was doing my life’s work. I came to the hospital early the first morning. The chief physician brought me to the third-year resident who was covering the patients who would become mine. This was the resident’s last day of training. I will never forget the phrase my chief used when introducing him.

He said, “This is John. You’re taking his patients. Today is his last day of residency. He can’t be hurt anymore!”

My thoughts raced. What did he mean “can’t be hurt”? Who was hurting him? And why couldn’t he be hurt anymore? Unfortunately, I would eventually learn.

3

In my second year of training, I was given more independence then before. I worked in the intensive care unit without direct supervision. During the day the ICU attending and fellows were available, but at night I was on my own.

One evening, early in my first month, I faced a situation that changed my life. One of the patients had severe respiratory problems and needed to be placed on a ventilator. He was elderly and I wasn’t sure what was wrong.

Before I began the procedure, I paged the anesthesia attending on call as a precaution. Within moments of getting started, things went terribly wrong. I couldn’t get the endotracheal tube in correctly! I kept trying, but it was useless. And, although we called over and over again, the anesthesiologist never showed up

My anxiety rose as I placed a mask on the patient’s face and delivered life saving breaths. I could feel the confidence leaving. I struggled for what seemed like hours before another resident, walking by the ICU, came in and helped. After flailing for another fifteen minutes, we finally got the patient intubated.

Within seconds the patient’s blood pressure dropped. We started CPR and injected epinephrine without benefit. The heart monitor went flat and he died.

Later that evening, I held back tears as I rehashed each moment of the hopeless code. Had I moved too fast? Had I deprived my patient of too much oxygen while fumbling to ventilate? Did I over sedate him? I will never know the answer to any of these questions.

4

The remainder of the night was a blur. I couldn’t sleep because I was busy with other patients. The man’s wife and family came and went. It wasn’t till the next morning that the phone calls started to roll in.

Apparently my patient had three daughters from a previous marriage who were unaware of what happened. I took three calls that morning. I told three young women that they had lost their father. I waited patiently as they broke down. As I listened to their sobbing, I remembered what it felt like to lose my father. Each call lasted less then five minutes and left an indelible mark on my soul. I had never experienced a grief so pure and innocent as those young women’s. I will always feel responsible.

And this is what the chief meant by being “hurt.” If you practice medicine long enough, you will make mistakes. You will accidentally harm people. You will work long hours and deal with the most primitive human emotions. At some point you either learn to sublimate, learn to move on, or get crushed.

When we say that someone “can’t be hurt,” we’re saying that they can work 36 hours in a row without sleep. They can deal not only with the annoyances of hospital life, but also with the fear and sadness. And still, at the drop of a dime, they can make critical decisions involving people’s lives. It also means that we learn how to be hard, learn how not to cry. We drop our emotions and sentimentality to survive. We change who we are.

When I became a physician, I unwittingly made this sacrifice for the sheer good that I could accomplish. I could deal with the stress, sadness, and culpability, as long as there was a pot of gold at the end of the rainbow – being the kind of physician my father was. I could give up the tenderest side of myself to avoid getting squashed by my experiences.

So that day, in the ICU, amidst the phone calls and grief I stood at the abyss. I could either let momentum and sadness carry me down or I could step away. At the time, I thought I was choosing life. I didn’t realize that I was lost.
I found myself again October 25th, 2004. The day my son was born.

5

After the ICU incident, the rest of my career had been rather mundane. I left residency and joined an internal medicine practice. My days were straightforward. I crammed as many patients into as few hours as possible to stay afloat. The malpractice crisis was a constant worry. Malpractice rates went up. Physicians were forced to see more patients in less time to cover overhead. The quality of care went down. There were more lawsuits. The downward spiral went on.

People were less happy with their doctors. I often found my patients to be angry and distrustful before they even met me. There was a constant barrage of paperwork for unknown reasons. I was repeatedly questioned by insurance companies. I rarely felt like I was helping anyone.

Physicians were also changing. Because of the lower income, decreased respect in the community, and family obligations, they were becoming less responsible for their patients’ well being. The days of your doctor meeting you at the emergency room late at night were long gone. Most young physicians believed that after the workday was over, their patients were someone else’s concern.

And I thought that I was okay with all of this -- until my world radically changed with the birth of my son. When I looked into his eyes looking back at me with complete trust, the barriers that I had erected since that horrible day in the ICU came down. I could cry again. I didn’t have to protect myself anymore.

And that left me with some hard questions. Why was I staying in medicine? Why did I give up an important part of myself for a profession that promised so much and delivered so little? Where had I gone wrong?

And what did this say about the state of healthcare today? I had come into the profession with the hopes of helping humanity. I trained at some of the top institutions in the world. I received various awards both for academic rigor and for clinical acumen. I was considered bright, caring, and hardworking. These are qualities that society expects from great physicians. But they are not enough.

The day of my son’s birth, the story that I had told myself about my life once again shifted. My father’s death had brought me to a profession that I would no longer pursue. As my son was born, I would leave medicine. I would make the change in time to teach him what is really important. I had changed once before, for the worse. This time I would be restored to my former self.

But in my heart of hearts, I eventually told myself something completely different. Maybe I truly was meant to be a physician and help humanity. Maybe it wasn’t me but medicine that had changed.

As the years pass and my son grows older, I continue to practice today. I realize that who I am is a result neither of my father’s dying nor of that horrible night in the ICU. They are sad tragedies that will neither define nor hold me back.

It’s time for me to take responsibility and embrace who I have become. For my son’s sake.

The Bearer Of News

2012-02-13T09:14:00.000-08:00

I could feel the sharp edge of fury slice through my chest as Joe's eyes darted to and fro. His grief had transformed into the bitter cud of despair. His jaw muscles grinded as he chewed desperately.

As the bearer of news, I had become the target. Joe's words were innocent enough, but his tone purveyed a sense of accusation.

How could this happen so fast?

Joe rocked back and forth with his head in his hands. He looked around the office as if he had never sat on the exam table clothed in a skimpy gown; as if he had never been my patient.

His mother in law was in the hospital medical ward with a belly full of fluid carrying clumps of tumor cells enmeshed in vital organs.

She was dying.

*

There were very few people as saintly as Joe. When he married his sickly wife, he also took on the care of her sickly parents. Over the years of watching them in my office, it became obvious that he had a special relationship with his mother in law.

Since Joe's own mother died when he was a teenager, his new family fulfilled his deep emotional needs. He doted over his mother in law, and stood by her during the tumultuous spiral of chronic medical problems. Years of rheumatoid arthritis had left her joints crippled and her lungs could barley expand against the iron cast of scarring and fibrosis.

So when her belly began to swell, Joe brought her to the emergency room. A Cat Scan revealed and abdomen full of fluid and tumor deposits. She was too frail for surgery, to weak for chemotherapy.

Joe didn't need to be told what to do next. He vowed to give his mother in law the dignity he was to young to give his own mother. He would let her die in peace. He would protect her from the long arm of medical intervention and cushion the mighty fall of the living.

Although his anger toward me had cooled, he would never look me in the eye again. I helped arrange hospice care, and moved her to a nursing home down the street. A week later, I stood above her as I told Joe the time was near.

He thanked me for all I had done.

At that moment, I didn't realize that I would never see him again.

*

Joe and his wife disappeared from my outpatient practice. It took a few months to realize something was wrong. I left a message on his cell phone but he never responded. I was hoping to at get a fax number to forward his medical records.

I guess I can't blame Joe for his reaction. Sometimes, even when everything is done right, the sadness and anger are still insurmountable. Joe associated me with the loss of his loved one. A loss that resonated deeply for someone who had lived without a mother for so long.

I hope to run into Joe one day on the street and tell him how sorry I am for his pain. I find it difficult to think about him still harboring such feelings toward me.

It's hard enough to lose a patient you care for,

to lose a whole family is devastating.

Backup

2012-02-11T18:01:00.001-08:00

When he looked down at the floor I couldn't help but feel my heart drop. The words stung to the core.

What happened to the docs who used to take care of everything.

Although I knew that the abscess was best handled by a surgeon, I too felt a a strange sense of longing. How many times did I have to hand off care to another more specialized doctor?

My patient sat quietly in his chair and stared past me at the eye chart on the wall. He labored to breath through the oxygen prongs affixed to his face. His legs were swollen and oozing edematous fluid into the kerlex wrapped around his monstrous ankles.

I was managing so many of his medical problems.

But there was a time when I handled everything.

*

The residents work room had a large window that looked onto a poorly lit street with various anonymous figures lurking in an out of the shadows. The VA hospital sat on the border of two equally poor neighborhoods. The residents and medical students dared not leave the safety of the parking lot or the medical complex.

It was midnight, and as a second year resident I was the most senior physician in the hospital excluding the ER attending. I sat with my feet on the desk and a stale pastry in my hand. My interns were dispersed amongst the medical floors, catching up on work from the previous day.

The buzz of the pager almost knocked me off my chair. A moment later, I was talking on the phone with the emergency room attending a few flights below the residents work room. He was almost hyperventilating.

Come quick, I need your help.

I alerted my interns, and we bounded down the steps. I burst into the the three room exam area that VA administrators called an emergency room. The patient was a middle aged man in extremis holding his sternum. His chest and stomach were pumping back and forth at a respiratory rate that was too high to count. The attending was fidgeting beside him adjusting the nonrebreather mask.

As the ER physician hurriedly presented the patient to me, I looked at the vitals monitor. The systolic blood pressure read 250 and the heart rate was peaking at well over 100. I barked a series of orders at the nurse.

Start a nitro drip, give a 80 of lasix and 5 of morphine stat.

I knew immediately what was wrong. The patient was in flash pulmonary edema from a hypertensive crisis. I had seen it before. Over the next ten minutes, I threw just about everything I had at him. Eventually his respiratory rate slowed. He unclenched his hands and sat comfortably in bed.

I handled it because I had no choice.

There was no else to.

*

Over the years my medical knowledge and experience have expanded exponentially. Yet, the most difficult lesson has been to know when you need help.

I am no longer a resident stuck in a VA hospital. There's ample backup available.

And I have no problem asking for help when I need it.

A Parting Gift

2012-02-09T17:42:00.000-08:00

I have come to believe that when you die, the world changes.

I believe that we each inhabit a space that forms a delicate balance in the universe. Birth and death disrupt this balance. Sometimes the shift is imperceptible to those who aren’t there. Occasionally, however, the aftershocks are felt at a distance by others.

My mother described it as a severe pain that developed suddenly in her hand. It was strong and swift. Minutes later the hospital called to say my father had collapsed. One of my patients told of severe chest pain that occurred just as his wife was dying from a heart attack. He didn’t know that she was dead yet. He had never felt this type of pain before and never would again.

I hear of these occurrences frequently and have come to believe they are real. It gives me hope that, alongside the medical knowledge and science we practice daily, there is an energy or force that connects us as human beings. This force is especially strong between those that love each other. And when a person dies, he sometimes sends a parting message to those who care.

But what is the nature of these “messages”? Are they unspoken utterances between parting lovers or a last goodbye to family and friends? And what if there are no family and friends? Is the message still sent? Does it fall on deaf ears?

Mr. Walters had been coming to my office for years. He was in his eighties and in poor health. The decline was a slow progression. It started when he was diagnosed with a lymphoma that grew rapidly in his pelvis. Surgery, radiation, and chemotherapy had eradicated the tumor but left him with severely obstructive kidney disease. By the time I met him, the stents placed to open his urinary system had begun to malfunction. No matter how many procedures the urologists performed, his kidneys were failing.

His physical condition was also deteriorating. He maneuvered gingerly around his apartment. There were no family or friends to take care of him. He lived a solitary life. His only connection was a distant niece he saw infrequently.

I tried to have many conversations about the end of life. As his primary care physician and only advocate, I needed to make sure that I knew his wishes. Unfortunately, he didn’t like to talk about such things. His usual response was similar to other men in his age group: “Doc, do whatever you think is best!”

Eventually I convinced him to move to a nursing home. He sustained a number of falls and was no longer able to cook or clean for himself. He was placed on dialysis when his kidneys failed.

Every few months he would get admitted to the hospital for a kidney infection. Each time I walked into the room, his face would light up and he would thank me for coming. We both knew that his time on this earth was limited.

I saw him one last time before he died. He was admitted to the hospital with low blood pressure and another urinary infection. He was on a ventilator.
I knew through our brief conversations that short term life support was okay, but he did not want to be kept alive for a prolonged period. As the days passed it became clear he was dying. I called his niece. She would come to visit him and then life support would be withdrawn.

As I drove home that day, Mr. Walters was the farthest thing from my mind. His niece was arriving soon and then he would be extubated. The ICU staff could manage everything. I had just picked up dinner for my wife and son and music was playing loudly in the car. It was a beautiful day and the windows were open. I felt invigorated.

Then all the sudden it happened.

It came over me like a thunderstorm. One minute I was happily bouncing to the music, and the next I wanted to cry. I pulled the car over, closed the windows, and wept.

I couldn’t stop thinking about Mr. Walters and how much he must have seen in his eighty years. He lived through world wars and depressions. He experienced the sadness of the holocaust and the fear of nuclear annihilation. He likely loved and lost many times. He had eighty years of constant motion and now he lay quietly in a hospital bed, gone.

As quickly as the burst of emotion came, it left. I wiped my eyes and turned on the car. Moments later, it was no surprise that my cell phone rang. It was the ICU; Mr. Walters had just passed away.

As the years go by, I often think of Mr. Walters. In his dying moments he sent a message to the world and I was lucky enough to receive it.

Patient Empowerment

2012-02-08T06:06:00.000-08:00

There was nothing the Professor despised more then the syrup that oozed out of his partner's lips when dealing with patients. He often cringed as he walked by the examining room and imagined the hand holding that was taking place behind closed doors.

Privately, they argued about the different approaches. One saw the world in terms of black and white, while the other was steeped in a foggy haze of gray. The professor felt that patients needed to be scolded and prodded into the preferred direction. He heard the rumblings of patient empowerment and had quite a cackle in the physicians lounge with his like minded colleagues.

If they are so empowered, why do they come whining to us?

The professor had no problem laying down the proverbial law to his patients. In fact, it was during one of these impromptu brow beatings of a young lady with morbid obesity that he felt the first twinge in his chest. It was fleeting like a wisp of air that came and went by the time one was able to think about it.

The professor dismissed such symptoms. He was healthy to the bone and wouldn't let such musculoskeletal aches and pains bother him. As the days passed he randomly rotated his shoulders and expanded his chest in order to recreate the discomfort he felt in the exam room. If he could reproduce the symptoms then surely it must not be his heart. But nothing happened.

A few days later a sharp stabbing thorn pierced his sternum while talking on the phone with a colleague. The professor almost dropped the receiver but recovered when the sensation dissipated. As the day progressed, the pains began to increase. They came more frequently and lasted longer.

The professor muddled to rationalize his symptoms as something benign (a process which he would have highly criticized in one of his patients). He tossed and turned in bed till midnight before finally falling asleep. He awoke an hour later in a panic. He felt a crushing pressure over his chest and he gasped for air. He reached over to pick up his cell phone.

Hello 911...I'm having a heart attack!

*

The professor was convinced that his ride to the emergency room would be his last tenuous grasp on a life cut short in its prime. But with a little oxygen and nitroglycerin, his pain abated.

When his partner waltzed into the exam room at three in the morning, the Professor felt a moment of embarrassment before relenting to the overwhelming sense of relief. There was not a trace of mocking in his partner's voice.

You had me scared there for a moment, I hope you don't mind that they gave me a call.

He placed his hand on on the Professor's gowned shoulder and then began to examine him. Later he sat in a chair next to the gurney and reviewed the options. To his great surprise, the professor didn't mind being treated like and ordinary patient. He felt strangely taken care of and glad to have his doctor illicit his opinion.

They eventually decided on a short stay in the hospital and a nuclear stress test the next morning. The Professor fell asleep peacefully as he waited for his bed on the telemetry unit.

*

The stress test showed no signs of heart disease. It appeared that the Professor was more likely having a panic attack. After dressing to leave the hospital, he sat a few moments with his partner who was preparing the discharge paperwork.

He looked appetisingly at the man standing in front of him. What once evoked anger and sarcasm now seemed almost angelic. He had come to understand what patient centered care meant. The idea was to place the physician and patient on the same level. There was no need for power inequality.

To his great surprise, he had become an empowered patient. Not by his own knowledge or abilities, but rather by the respect and dignity afforded by his colleague. He had been both assured by his physician, but also allowed to participate in his own care.

On that day he vowed that he would no longer be the Professor.

He would be a student,

a student of human nature.

The Dark Side Of Love

2012-02-07T07:56:00.000-08:00

It was an innocent question. I was running through the social history when the young woman sitting in front of me started to cry. I asked about her husband not knowing that he had died a few months earlier.

They were bitter tears. She smiled awkwardly though the tissue as she apologized. She never expected to find herself a single mother at such a young age. I paused and allowed my patient time to collect herself.

As we sat in silence, I searched for solace. How many times had I comforted mourning spouses? Days, months, years after their partner died, the sadness remained. I would like to assure her that it would get better, but in some ways it wont. The wound will not heal. It changes, scars, and is often momentarily forgotten. But it never goes away.

*

Where is Harry? Did he wander off?

I looked with pity at the elderly woman sitting in the corner of the activity room at the nursing home. Her husband died a year ago. At first the staff would gently remind her that he was gone. Her face would twist into a frown and she would begin to cry, but moments later the cobwebs of dementia would cloud her insight.

When is Harry coming back?

Time wasn't measured in days or hours, her attention span could barely hold on to seconds and moments. Her internal clock was set to a time when life was better. Her husband would be back from the store in minutes, and the grandchildren were playing in the yard.

It was an isolated existence fraught with confusion.

She lived in a protected shell of memories.

All pain was temporary.

*

Dementia steals away memories and the ability to function. It decimates that which makes each person so unique: the experiences, the past, and the ability to hurt and mourn.

I do not envy my young patient who lost her spouse. The boundless pain she feels will corrode and rot inside of her.

But the ability to hurt is a gift.

It's the dark side of loving too much.

Superhero

2012-02-05T17:19:00.000-08:00

Suzie remembers what it felt like to be fifteen. She can still hear the creek of the steps leading to the third floor and the quaint finished bedroom that housed her grandmother that fateful summer.

Originally, grandma was set to move into the small room next to Suzie's parents. But after his first night in the attic, Billy refused to set foot up there again. So dad lovingly wrapped grandma in his muscular arms and carried her to her final resting place. It's not like it really mattered. Grandma was bed bound and didn't know the difference.

It was a lonely summer. Unable to afford camp, Suzie's parents asked that she stick around the house and take care of her grandmother. Although she originally protested, Suzie learned to enjoy the quiet moments in the sun drenched room that became her second home.

One evening late in August, Suzie awoke to find the whispering fingers of sleep wrapped around her neck tightly. She gently tiptoed up the steps to find her grandmother staring out the window. She sat quietly in the chair next to the bed, and reached out to hold her hand. As her grandma spoke, her ancient eyes remained fixed on the moon.

Deep inside each one of us is a superhero, have courage!

Suzie laid her head on the bed and quickly fell asleep. She awoke to find her grandmother's body had grown cold. She passed during the night.

*

Suzie could find no better way to honor her grandmother's memory than to become a physician. And she held tightly to those last words as she struggled with the academic hurdles that only seem to multiply over time.

After two years of continuous studying, she was content to begin her clinical rotations in the hospital. But her joy was short lived. She found the pace on the wards exhausting, and her time was more compartmentalized the ever.

Her Internal Medicine rotation was particularly vexing. She labored alongside a group of residents and attendings that seemed more interested in patient disposition and discharge than health and well being.

Suzie was criticized repeatedly for spending too much time with her patients. After interviewing Mr. Smith for over an hour, she walked out of the room to find her attending rolling his eyes in the direction of the other medical students. His voice dripped with sarcasm.

Oh yeah, spend all day with a homeless alcoholic dying of cirrhosis, you'll learn alot there!

But Suzie saw the world though a different lens then the rest of her colleagues. She knew Mr. Smith as a lonely man who medicated himself with the only means available. So in her mind, the hour was time well spent.

*

Days later, Suzie followed her attending and residents into Mr. Smith's room for morning rounds. He was unconscious and each breath struggled past his lips as if it might be his last. The attending shook his head.

The DNR is already signed.

He turned abruptly and walked into the hallway with the residents chasing behind. Suzie's voice cracked as she spoke from the back of the crowd.

He has no family or friends, can I sit with him.

Suzie's resident became white as a sheet. The attending stopped mid step and turned back. He looked at his watch and then his eyes narrowed. He spoke in Suzie's direction without looking directly at her.

We don't have time.

As the group continued down the hallway, Suzie pealed off from the edge and hurried back to Mr. Smith's room. She walked through the door and leaned over his body and placed her lips close to his ear.

Your not alone anymore!

Suzie held his hand and waited. His chest became less labored and his body visibly relaxed. For a moment, she felt her grandmother's presence in the room as Mr. Smith drew his last breath.

Suzie had reached the pinnacle of her medical education.

The knowledge and experience would come with time.

Father And Son

2012-02-04T15:29:00.000-08:00

My son is busy. He holds a binder in his hands that was given to him at school. On the back he has affixed a photograph of himself.

The author page.

He explains this as if I should already know. Next he works on the title before beginning the body of the story. He has plans to scan the result into his mother's computer and then print several copies. Tomorrow, he imagines he will go to the Barnes and Noble and put them on display.

Later, he collects all the books in his room. He arranges his furniture to create an entrance to his new "library". He cuts out ten long strands of paper and writes "librari Kard 50 sents" carefully on each one of them.

When he's finished, he runs down the stairs to the mud room and puts on his boots and jacket. He calcualtes that if he sells all ten, he will have plenty of money to buy a toy at Target.

An hour later, he returns with the same handful of papers and frown on his face. I try not to laugh at his energetic entrepreneurial spirit.

Sometimes my son plays with old cell phones. He holds them up to his ear and paces back and forth disrupting the quite of the living room. His eyes become tense and he speaks in commanding tones. Occasionally he clicks on the icons on the screen, and tries to access the Internet.

The other evening my wife asked me if I wanted to watch a movie. I replied that I was too busy working on my manuscript of poetry, calculating next years financials for the office, and I had a few pages to return.

As I reached for my cell phone, I thought of my son tucked away soundly in his bed. On the good days, I think of his imitation as a form of flattery. On the bad, I wonder if it is me who is copying him. Maybe we both are childlike with an inflated sense of our own abilities.

Although we sometimes dip our toes and test the water, more often we jump in head first with no idea of what awaits below the surface.

And we occasionally leave the house with high experctations only to return shortly with a frown on our faces,

and little to show for our efforts.

A Gentle Landing Place

2012-02-03T06:38:00.000-08:00

65 years. We've been married 65 years.

I take a seat in the chair next to the bed and wait quietly. The nursing home is strangely inactive so early in the morning. The sun has begun to rise and light washes over the grassy prairie outside the window.

An elderly man is sitting in the recliner beside me. He leans over to hold his wife's frail hand. She lays unconsciously next to us. As I imbibe the scene, it becomes rapidly apparent that I have little to offer as a physician. My stethoscope is impotent, my medical knowledge is transparently thin.

I stand and begin my physical examination. Not out of medical necessity, but more for the husband's comfort. There is something about the familiarity of the laying of hands that brings calm and control to an ungraspable situation.

The woman in the bed is almost lifeless. Her pulse is thready and her respirations labored. She does not respond to my voice or touch. When I finish, I stand motionlessly. My presence may be the only poultice I have to offer.

She hasn't really been herself the last few years.

Such a benign statement to describe the utter destruction of dementia. First, her short term memory flew away like a bird migrating for winter that never comes back. But she was smart enough to compensate for that. Eventually the forgetfulness metastasized to names and faces. Old acquaintances became mocking strangers.

With the passage of time, such life defining tasks as eating and bathing became unmanageable. A woman of stature and bearing was now childlike and innocent. The transition was made from husband to caretaker to babysitter.

The only respite lounged in a past littered with old photographs. They held tightly to memories of vacations and hobbies. Life as it was before the unrelenting cruelty of senescence dealt its mortal blow.

We were waiting for death.

Not the cruel arrogant taker of souls, but more the soft gentle landing place for the addled mind.

Vacation?

2012-02-02T06:41:00.000-08:00

I knew Leslie my whole life. A friend of my parents, she remembered the day I was born. So I felt a slight sense of trepidation when she asked me to be her doctor. But how could I refuse?

I have always been cognizant of the pitfalls of taking care of family and friends. I constantly worry that personal feelings will blur the lens of objectivity. On the other hand, I could see where my loved ones would enjoy knowing that their doctor has extra "skin in the game".

Little did I know that a few years later Leslie would be gone,

and I would find out in the worst way.

*

I couldn't help but sigh as I sat down to the large stack of papers that had collected on the desk in my absence. I stared up at the clock. One hour before my first patient would arrive.

I hugged my shoulders tightly and shuttered. After a week of tropical sun, I wasn't yet ready for the torrent of cold that came with returning to Chicago. My seven day vacation felt like an eternity. Now I was a foreigner in a foreign land.

I grabbed a pen and started to sign. Papers flew right and left as I scanned each document and affixed my eligible scrawl. Ten, twenty, thirty signatures into the pile I stopped abruptly and held up the death certificate.

As I read Leslie's name my heart dropped. Nausea bubbled up from my abdomen. Guilt and remorse wracked my chest.

My partner must have forgotten to tell me that she died when I was gone.

I should have been there!

*

As the years pass, I no longer differentiate between taking care of loved ones and complete strangers. My fears of losing objectivity have been replaced with reality.

The closeness and personal bonds I form with long term patients are often more durable then ones with mere acquaintances. We suffer, we socialize, and we mourn together. I no longer draw such strict lines.

I believe the covenant between patient and physician is sacred. When I accept a person under my care, I pledge that I will stand by them through good times and bad. It is my duty.

But the problem is, when you oversee thousands of patients, it's like you always have a loved one in crisis.

No matter how hard I try to prepare for each vacation, I generally return to some type of tragedy or another. And I wish I could have been there to fulfill my covenant as promised. But what is one to do? I am only human!

I really look forward to the 1-2 weeks each year I leave the practice and go on vacation.

I kind of dread them to.

The D Word

2012-01-31T05:15:00.001-08:00

My daughter has begun to use the D word.

When I die, people will walk on me?

Even at the age of four, she knows that the dead are buried in the ground. More questions follow rapidly. She thinks that if a grandparent doesn't show up to pick up her classmate from school one day, he must have died. The same if someone goes on vacation for a week.

Her statements are crude but yet shockingly honest. Unfettered by the complexities of the adult mind, she is free to explore unencumbered. There is no guilt or embarrassment in her voice. Our conversations lack the fear and angst that so often cloud this kind of discussion amongst grown ups.

She is curious.

Was I dead before you had me?

*

In some ways, my daughters fascination with death will not likely evolve as she grows older. She will lose the innocence as she forgets the mechanics and begins to contemplate deeper meaning.

What happens to our soul?

The pang of love that shatters our hearts, does it just disappear?

And I will tell her that I don't know. I have helplessly watched life slip away countless times, but I am no closer to the answer.

I have both battled death as the enemy and humbly welcomed her mercy. I have travelled her paths and attempted to veer away at every turn. I no longer see friend nor foe, more a quiet mistress who waits patiently in the wings.

Like my daughter, we are all just children. Bobbing and floating in the vast ocean, our minds turn yet we have no control over the direction of the tide.

My daughters voice pulls me back to the little bed in her quiet room.

Daddy, what does it feel like to die?

I draw her close and hold tightly.

My sweet child,

I'm still trying to figure out what it feels like to live.

The Sway

2012-01-29T16:50:00.000-08:00

My son's hands are moving back and forth quickly over the finger board of the violin. The bow bounces back and forth rhythmically. Like most every day, he is painstakingly practicing. He moves from one piece to the next, pausing to make adjustments. When he's done, he turns the pages back and starts again.

Eight months ago he stared at the gleaming instrument. For the first few weeks he practiced his plucking. Then, in no time, he was bowing. Now he plays a plethora of songs and learns something new each lesson.

The sounds coming from his violin are becoming less squeaky. The melodies are more constant and the clarity of each note is beginning to shine.

But more remarkable than his technical acumen, is the joy that is growing in his heart. He has started to smile as he plays. His lips curl upwards despite the furrowed brow of concentration.

Yesterday, toward the end of practice, he came to one of his favorite pieces. As he played his legs bent slightly, and his eyes began to close. Instead of the rigid stance so often practiced, his shoulders began to sway. For just a moment, his body and the notes dancing off the violin had become one.

It was pure ecstasy.

*

Unlike many other endeavors, music allowed my son to reach this moment without mastery. Only a novice, the feeling and emotion transcended his abilities. It will be years before his technical skills will match the expression of his body.

But we all have witnessed someone who's abilities and training match the emotion of the instant and reach "the sway". I am reminded of watching Michael Jordan dominate during a championship series, or Barack Obama deliver a speech. There is a point when years of education meld with thousands of hours of practice to produce a sum that is greater then the parts. This can't be taught. It is cultivated over back breaking effort and indomitable will.

Mastery is often difficult to quantitate.

*

There is a time when physicians also reach "the sway". It is usually after ten or fifteen years of practice when the doctor-patient relationship loses the rigidity and transforms into an elegant dance. Diagnosis and treatment are not only cogitated but also felt.

As a conductor, the doctor learns to anticipate the vibration of the instrument as well as sense the emotions of the musician.

Anyone who has been lucky enough to interact with a clinician during this period, will recognize how powerful the relationship can be.

It is a time of grace.

*

I worry about what is happening in medicine. We are losing our physicians at the prime of their careers. They are leaving clinical medicine for greener pastures. They are pulling back, abandoning the hospital, and cloistering their abilities behind the veil of increasingly specialized offerings.

Those clinicians who are choosing to continue are finding that they have to trade in their dancing shoes for boxing gloves. We fight with insurance. We fight with pharmaceutical companies. We fight with the government for the right to trust our instincts.

"The sway" is becoming fractured and labored.

That which has been lost,

may never be retrieved.

A Pittance

2012-01-28T18:43:00.000-08:00

I glanced quickly at the papers on my desk. I had a few minutes between patients, and the biller had placed the statement neatly on top of a pile of labs. The word denial stood out amongst the jumble of letters on the page. I read further.

Claim denied due to duplication of care. Services payed already to emergency physician.

I shook my head in disbelief.

*

The notification that John was in the emergency room came blinking across my screen. Of course, he hadn't called me to say anything was wrong. I looked down at my watch. I could be out of the office and in the emergency room in five minutes.

I ran down the steps and pushed my way between pedestrians as I crossed the hall entering the emergency room. The morning rush had yet to materialize. John was one of the only patients.

I scanned through the nursing notes and the emergency physician's impressions. A cat scan of the chest was already ordered. When I entered the room, John was sleepy from a dose of morphine. We discussed his chest pain. Although he felt a little worse then usual, it was the same pain that had been present for years. I palpated his right rib cage and he yelped in pain.

His labs, EKG, and chest X-ray were normal. When I perused the medical record further, I found that the same emergency physician had scanned his chest the month before when he showed up with a similar complaint. In fact, He received five CTs in the last year. Surprisingly, none of them showed a pulmonary embolism.

It took a few moments to find the ER Attending. When I questioned her about the need for another cat scan, she looked at me appraising.

He said he never had chest pain before.

I gently reminded her that she saw John recently for the same complaint, and she started to blush.

*

I discharged John with a diagnosis of costochondritis and a prescription for a non steroidal anti-inflammatory. By the time he followed up a few days later, his pain was gone.

As I see it, I saved John an unnecessary dose of radiation and IV dye. I relieved the emergency room physician by doing her job for her. And I reduced the cost to the insurance company by hundreds of dollars.

Apparently the pittance I bill for my services,

is asking too much.

In Memory Of A Wonderful Friend

2012-01-27T06:44:00.000-08:00

He was my guy. You know, my financial guy. The kind of guy that everybody loves when the market is up. When the market is down....well you know what I'm talking about.

He took me out of pity. The meager sums I saved were nothing near his average client. I was well below his minimum. But we had a common friend. And he liked me and my wife. We were his kind of people. Bargain shoppers. We bought low and sold high.

Over the years we talked every few months. He would take my wife and I out to dinner in the early days. Later, he would come to the house and entertain my children before we could chase them off to bed and talk financials.

It was a working relationship. But certainly he was the type of guy I would be friends with anyway. He invited us to his house many times to meet his wife and kids. We always had some reason to decline. There was usually something going on. We never had enough time.

We eventually learned his story and he ours. About how he met his wife in India. About how he didn't think he would marry and Indian girl. And about his children and the various activities they were involved in.

Occasionally there was turbulence. After all, the market was doing horribly. But we still came to him for advice; sometimes about money, sometimes about life.

He was kind and considerate. He was patient and calm. He always had a smile on his face.

Awhile back he called to tell me he had excepted a job with a new firm. I was proud that instead of expressing dismay or concern about my own financial well being, the first thing I said to him was "Congrats...I'm happy for you!"

He was surprised. I was the only client who had congratulated him. Later, we talked about how we would move our funds over to his new firm. I could care less who he worked for, it was his advice I was interested in.

A week later I called for a brief question about funds transfer. He was in the middle of a meeting, but took the time to answer me anyway. Little did I know that those were the last words I would ever speak to him. Thirty minutes later he collapsed in his office. In a few days he was gone. He never woke up.

My wife and I went to his funeral. As I watched his children, I flashed back to my own father's death. He died the same way. I approached the casket and mumbled condolences to his family. And there he was. His face edematous and puffy. Unrecognizable compared to the handsome smiling facade imprinted on my memory.

During the ceremony family and friends spoke about his affect on their lives. His clients were especially vocal. A widow talked of how he had promised to take care of her finances after her husband's death. And he had. An older man spoke of how he had traveled with him to India to guide him in search of his parents ancestry and to spread their ashes. He called him his son. There was no blood relation.

Then there was me. The fool that I was, I had thought that this gentle human being was brought into my life to teach me about money. Money! Useless money!

In reality his lessons were much more valuable. He demonstrated compassion,joy, and love. All these things he gently taught, quietly, and in his own humble way.

And I think of his distorted face and body lying in the casket. They were not a true window into his soul, but more an unkind reflection of what I had become.

One last lesson taught by a masterful teacher.

I wonder If I deserved as much.

Will Anybody Care?

2012-01-25T18:01:00.000-08:00

There are certain habits I'm not proud of. Certain things that are better left unsaid. But there's no embarrassment in the radio station that I have chosen to grace my ears each morning as I drive to work. That's right, I have ditched the top forty dance music, escaped the salacious morning DJ's, and landed on something more sublime.

My dial is set to 91.5, national public radio. There's something about the reporting style, the ebb and flow, that draws me in. The content is superb; the stories informative. My car becomes a haven of calm and warmth in the midst of the frigid Chicago winter.

So when I heard the name of my hospital role gently off the lips of the voice on the other side of the speaker, my ears perked up. It appears a celebrity was admitted overnight. Someone who garners a lot more attention than any of the poor souls who mistakenly end up in my office.

As the story continued, I was gratified to hear the reporter specifically mention that the patients "primary care" doctor attended to him in the hospital and even accompanied the ambulance to the tertiary medical center for further care.

She didn't say surgeon. She didn't say neurologist. She said primary care. For once someone, a newscaster nonetheless, was giving credit to my beleaguered and haggard choice of specialty.

But who was this brave soul? Who was this role model for the next generation of internists and pediatricians? My heart sank as I got the answer, it was a local cardiologist. He was not an internist, not a family practitioner. He was a cardiologist.

Now don't get me wrong. He's an excellent physician who over the years has done his share of general medicine. But I couldn't help but feel a little let down. How are we going to get young physicians interested in primary care if the only time it's cool to be one is when your are a specialist taking care of a celebrity patient?

God forbid, don't leave such an important case to an ordinary primary care doctor with so little training.

One day you'll look and we'll all be gone.

Will anybody care?

The Evolution Of A Love Affair

2012-01-24T12:05:00.000-08:00

My husband was a wonderful man!

Geraldine fidgeted on the exam table with her purse in her lap. Her porcelain skin and quaffed hair were betrayed by hands that carried the wear and tear of eight decades. Her eyes bounced back and forth between my face and the handbag. Eventually she produced a series of aged photographs and handed them over one by one.

The man staring back at me in the first photo was wearing a soldier's uniform. He was handsome and tall with broad shoulders. The edges of the paper were worn and had frayed over years of handling. The second picture showed a young couple and was marked "tenth anniversary".

As I fingered through the pile, the faces became wrinkled and the postures stooped forward. In just a few moments, I witnessed the evolution of a love affair. Young feverish lust became life long companionship.

When he died in 2000, I didn't know what I was going to do.

She was now prim and proper again. Her back straightened against the pull of osteoporosis. I studied her face. The makeup was applied a bit too liberally. But looking back at her photos, that was obviously a lifelong habit. Her feet were swaying back and forth slowly. Every time our eyes met, she would look down quickly.

Her husband died suddenly. Healthy into his mid seventies, she woke up one morning to find his body lying next to her; his soul had departed. The doctors told her that it was likely a heart attack, or a stroke.

After his death, Geraldine tried to maintain the household just how he left it. But over the years the strain became too great. Her daughter swooped into town one weekend and helped her pack. The majority of her belongings would land in storage, but her husband's pictures, framed with a loving hand, would accompany her to the assisted living.

I still wake up every morning and stare into his eyes.

Fifteen minutes into the appointment, I was starting to get a little antsy. I waited for a lull in her soliloquy and then jumped in.

So what exactly brings you in today?

Her face turned a deep shade of pink and again she batted her eyes down toward the ground. Her words were almost inaudible.

I was wondering if you could prescribe some Viagra for my new boyfriend.

Empathy's Limits

2012-01-23T05:24:00.000-08:00

Has your mother died?

When I heard the words, a strange memory popped into my head. My wife and I had just been married and were sitting on an airplane. As we prepared for the flight, a family of five bungled by and occupied the seats directly behind us. I gave my wife a knowing look. There were three children and the eldest appeared to be about seven.

I sunk down in my seat, and placed the headphones over my ears to no avail. The next few hours were filled with screaming, crying, and pushing on the back of my chair. I was livid.

I couldn't understand how adults could have so little control over their children. That is, until I became a parent myself and had to negotiate the perils of travel.

There are just some things you have to experience to understand.

*

Mrs Jones was dying. After years of dementia, she suffered a catastrophic stroke. Instead of rushing her to the hospital by ambulance, I asked the family to meet me at the nursing home to discuss her situation.

I entered the room and marveled at the number of family members stacked like sardines into such a small space. I introduced myself, and shook their hands individually. Mrs Jones daughter stood at the front of the crowd, and faced me as I began to talk.

I explained the prognosis was particularly poor for someone who was in the end stages of dementia. Heads shook in agreement as I continued. I discussed the different options and finished with my personal opinion.

If this was my mother, I would opt for comfort care only.

Upon hearing the last sentence, I sensed a change in the daughter's stance. Her lips pursed and her shoulders hunched forward in anger. She turned and talked to her family for a moment, and then calmly asked if I would speak to her outside the room.

*

Has your mother ever died? Because if not, you may not want to recommend withdrawing care so strongly.

I took a moment to think about what she just said. Although I had watched many patients pass over the years, I have never once walked in their loved ones shoes. Of course, my father and grandparents died. But each relationship is special and unique.

And in this way, empathy has its limits. I can't truly know what it feels like as they preside over such difficult situations. All I can do is remind the family that I have accompanied many patients and families through similar situations.

Often the acknowledgement of my own inabilities,

provides comfort in itself.

Notification

2012-01-21T04:50:00.000-08:00

No it's alright, I'll notify the family.

I hung up and took a moment to clear my head before making the phone call. It was the middle of the night and my eyes felt as if they were sown shut. I hobbled into the bathroom and stared at my cell.

I was about to make a call that would forever change someones life. Right now, they were tucked away in their beds sleeping quietly. In a few moments there would be chaos. I felt uncomfortable conveying such information over the phone, but I had no choice. I couldn't just wait till morning.

I listened to the ringing and thought about the nature of being a physician. It always made me sad to know that I become aware of such profoundly intimate news before the family. A few moments later a sleepy voice picked up.

Hello?

I try not to mince words when giving notification. It's not something I practice, but I make sure to use the word "death" or "died" in order to be absolutely clear.

I apologize for waking you up. But early this morning your dad's heart stopped. The nurses and physicians performed CPR but were unsuccessful. Your father died. I'm so sorry.

I never know what the reaction will be on the other side of the line. Often there is grief, sometimes anger, occasionally relief. On this particular night there was silence. The static of my phone connection was interrupted by rapid staccato breaths. She was hyperventilating.

Unable to hang up and certain that my words would be unhelpful, I held the receiver to my ear and waited. In those fleeting moments my mind began to drift back to childhood.

I thought of my father.

*

I knew that my dad was sick, but at the age of seven it hadn't quite sunk in. The week before, I was pulled out of school and brought to the hospital. I sat with my mother in the ICU waiting room, and played with crayons and blocks. I had no idea that he was already dead. A brain aneurysm had ruptured and the damage was done. His physiologic functioning was now dependent on machines that could fill his lungs and help his heart beat. But nothing could replace the brain tissue that was lost.

The next Monday I went to school as normal. But upon returning, the living room was full of relatives. In the center stood my mom. She was crying. She took me in her arms and whispered in my ear.

He's gone.

I sat on the couch next to my brother. As I looked around the room the faces were sullen and glum. I wasn't quite sure the significance of everything that was happening.

It was only later that I realized how permanently my life had changed.

*

My seven year old son is more emotionally mature then I was at his age. Occasionally while sitting in his bed, before he falls asleep, he'll ask me about my father. He questions me about death and what It feels like. I tell him I don't know.

He wonders what will happen to him if I die.

I start to say that he will be okay and that his mother will take care of him, but stop mid sentence. I look into his melancholy brown eyes.

If ever someone comes to tell you that I have died, I want you to remember how my face looks right now. I want you to think about how happy I am and how much I love you. No matter what happens,

both you and I will be just fine.

Another Trip To The Moon

2012-01-20T07:33:00.000-08:00

The young man walking in the door looked vaguely familiar. I glanced down at the computer screen sitting on my lap, and clicked through the visit history. I had never seen him in the office before. I studied the landscape of his face searching each wrinkle and furrow for the hint that would unhinge the avalanche of memory. He looked up at me quizzically and our eyes met.

You don't remember, do you?

By now my embarrassment was replaced by curiosity. He proceeded to explain that he had seen me as a patient ten years ago in my previous office. I marveled at the idea of time passed. A decade younger, I had just married and my kids weren't even born yet.

I was a recent graduate then. Wet under the ears and fresh out of training, medicine was more like a space odyssey; a trip to the moon. I marveled at each new patient, each diagnosis. The unflappable professional cynicism had not yet mushroomed into the all consuming giant that it eventually would.

As my reverie cleared, I began to populate the electronic medical record at a rapid pace. I discussed the intricacies of his medical history and paused occasionally to tease out details. His previous diagnosis of ehrlichia intrigued me. A tick born illness, known to cause fever and rash, that is notoriously difficult to diagnose. I probed further.

Tell me about how your ehrlichia was diagnosed?

His face broke into a grin and he started to laugh. He thought I was kidding, but then realized I was serious and cleared his throat.

It was you. After two emergency rooms and one primary care doctor missed it, you put me on medication, and everything got better.

I was stunned. Not only had I forgotten the patient, I had lost all memory of making the appropriate diagnosis. I had only seen a few cases of this disease in my life, you would think that I would remember each one.

The next day, I scoured the medical records department for the old paper chart. As I read through the hand written pages, I couldn't believe my eyes. My admitting note mentioned ehrlichia as a probable diagnosis, and I started the appropriate antibiotics immediately.

Years later, I am often stunned by how much medicine I have learned and forgotten over time. If the same case presented to me today, would I divine the right diagnosis?

The practice of medicine blinds us with the haze of familiarity. New attendings remember their recent residency training and often are up to date on even the most obscure diseases. But as time goes by, what we gain in experience we lose in knowledge of the long tail.

It has been said that physicians spend the majority of their career learning.

For me, it's remembering that proves to be so difficult.

Selling Primary Care Down The River

2012-01-19T04:57:00.001-08:00

Dr. Lake used to be a businessman. His books were clean and orderly. His staff was efficient and kind. He steered his ship agilely through troubled waters and still managed to provide the highest quality care. His was not only physician but small business owner. He was proud.

As the political climate changed, Dr. Lake became more distressed concerning his situation. His overhead was increasing and the regulatory culture was expanding. Laboring under the strain of advanced technology, the time for patient care diminished.

Looking in the mirror one morning, Dr.Lake decided that this wasn't the job that he trained for. He shuttered his doors, and signed a contract with the hospital owned medical group. At least now he would be able to ply his trade and leave the regulations to someone else.

Dr. Lake used to be a hospitalist. Trained in the care of the complex ailing individual, he enjoyed rounding at the hospital between appointments in the office. The bonds formed with each patient were strengthened by being available in times of greatest need. He took pleasure in seeing the nurses and consulting physicians on a daily basis. It was a community.

So when the administrators started to enforce the rule about using the medical groups hospitalist program, Dr. Lake felt a certain sense of loss. It was true, however, that unencumbered by those troublesome phone calls and travel time, he could see many more patients in the office.

Dr. Lake used to be a kind of emergency room. Often the sickest patients would walk through the door needing immediate treatment or triage. The phone lines were always open, and there was always enough space to fit someone into the schedule.

But as the onslaught of physicals, well patient visits, and followups increased, Dr. Lake found it easier to refer to the Emergency Room. After all, he couldn't just sit on the patient with abdominal pain for 24 hours while he tried to find a space in his schedule. And what if they needed a cat scan?

Similarly, the patients who wanted to be seen for colds and flu had to be scheduled a week in advance. Dr. Lake occasionally resorted to suggesting pharmacy clinics to lighten his load.

Dr. Lake used to be a master diagnostician. His skill was honed over years of experience and reading. Unlike his specialist friends, he was able to see the patient as a whole. While his knowledge was not as deep, his range was far greater. There was nothing more satisfying than making a difficult diagnosis.

If only there was enough time to use his clinical acumen. Dr. Lake was to busy with an overbooked schedule, and checklists and boxes to fill on his brand new electronic medical record. If he worked up each patient appropriately, he would have to keep his office open till midnight. A good thing his specialist friends were salivating to take his referrals.

Dr Lake used to be a physician. But one day an administrator from the medical group called to say his position was being filled by a nurse practitioner, PA, or a medical assistant. A person of his pay grade and education was no longer appropriate for the job.

As he packed up his office, he wondered what the future would hold. His best employment opportunity was to work as a consultant for a pharmaceutical company.

In a moment of clarity, Dr. Lake divined that he had been sold down the river.

He also realized, that he had done quite a bit of paddling on his own.

A Two Way Street

2012-01-17T17:19:00.000-08:00

As I approached the room, the nurse stormed out with an exasperated look on her face. Half way to the computer bank, she turned back to warn me:

I wouldn't get too close if I were you. She kicked the CNA in the chest

I entered the room to find Myrna pinned to the bed by her middle aged son. Russian curses spewed from her mouth intermixed with deeply accented English. Her legs kicked and her arms tried to flail against human flesh. The fatigue on her son's face showed as he let her go and sprung back to stand beside me.

Myrna was delirious. Her brain encumbered by plaques and tangles was unable to stave off the ill effects of fever and dehydration. Her usually calm demeanor was replaced by demonic screaming and unwieldy thrashing. Her ninety year old body was suddenly strong and agile.

Myrna looked up at us from the bed like a tiger ready to pounce. Her eyes rested on her son's face and then moved in my direction. My muscles tensed reflexively awaiting the possible onslaught. Her face softened.

The baby girl. How's the baby girl?

And then she smiled and looked at me knowingly as if we shared an intimate secret that no one else was aware of.

Even through the thick foliage of delirium,

she remembered.

*

I reclined in the chair and placed my legs on the desk in front of me. Just one more patient before lunch, and then I was done. My wife was thirty eight weeks pregnant and I looked forward to another weekend of peace before the new baby complicated our quiet lives.

My cell phone began to buzz and ring loudly. I almost fell out of my seat as I yanked my legs off the desk and dove into my pocket. Moments later, I listened as my wife spoke quickly on the other end of the line.

The ultrasound showed a problem. The doctor wanted her in the obstetrics ward immediately to be induced. My wife's voice was calm but firm.

Come home now!

I threw my lab coat on the chair and grabbed my jacket. I ran down the hall with one arm pulled through the sleeve and the other dangling out. As I passed my office manager, I spit out directions to cancel my last appointment and clear the next week.

The secretary and medical assistants huddled in the doorway and wished me good luck as I flew out of the office onto the landing, and jumped down the stairs in groupings of two. When I arrived at the bottom, I bumped into Myrna and her son who were making their way up to the office for an appointment.

They looked at me questioningly. I turned briefly and exhaled an explanation as I gasped for breath. Myrna shook her head and smiled. Even with her deep accent, I caught her words while racing out the door and into the parking lot.

It will be OK!

And it was.

Four years later, this memory came back to me as I sat with Myrna in her hospital room. Although her sensorium had not completely cleared, she was calm now. In time her fever would break and her mind would return.

*

I often marvel at how as a physician I am present during critical moments in my patients lives. I witness birth and death. I fight alongside them when it is time to fight, and console them when it's time to stop.

But every once in awhile a patient bears witness to one of my moments. And it is only then that true intimacy occurs.

Because between Myrna and I,

it was a two way street.

Hippocrates Or Hypocrite; Let's Make A Deal

2012-01-16T16:57:00.000-08:00

I never said I was perfect. Nor do I feel that even on my best days I approach such a pristine state. Of course there are appearances. My pressed gray lab coat and buttoned down shirt contrast your suit, jeans, or sweat pants.

The roles and expectations are set in a frigid stone of familiarity. I will point, prognosticate, and occasionally shame you. You will listen, cower, and shake your head in agreement.

Often my voice will be strong and confident. For one who has never smoked, it is easy to rail about the evils of tobacco. No longer having the time or taste for alcohol, convictions will drip convincingly from my lips.

But other times, I will squirm and struggle to keep my voice steady. I will tell you that three hundred pounds is too much, yet secretly I lust for the jelly donut waiting in the break room. Have I never medicated with food?

I counsel on exercise, but my brand new running shoes have not yet left the closet.

If you only knew my addiction. The secret I carry in my belly.

I'm strung out. Strung out on stress like the rest of my physician colleagues. I imbibe it first thing in the morning with bleary eyes and queasy belly. I inhale it on quick breaks in back allies between patients and hospital rounds. I chew it, and hock the disgusting byproducts into a used coke can during late night phone calls.

Would my own foibles and humility strengthen the conversation? Would it help you to know that I struggle also? Could we become comrades instead of teacher and student?

More importantly, could I convince you that between horrendous and perfect there is a place called "good enough"? Because I feel fairly certain that if you exercise a little more and eat a little less, things will be better. For my part, I'll work on the stress.

Do we have a deal?

In Praise Of Mothers

2012-01-15T17:09:00.000-08:00

I cradled my son's miniature body in my hands. Only moments old, he looked up with large glassy eyes. He was so alert, so perfect. I carried him over to the bedside. The obstetrician worked on the afterbirth as my wife waited patiently to hold her child.

At the time, it hadn't sunken in yet how much our solitary lives were changing. The nurses swept the baby away for routine testing and measuring. I settled into the chair and reclined for a few minutes before the the first signs of morning.

I didn't wake up for hours. Overwhelmed and exhausted, my body stumbled into deep sleep. My dreams were vivid and startling. And they brought back memories locked away and guarded with a key.

*

Any student rotating through the obstetrics department can tell you the stories. Every academic center has them. At my hospital, it was the cardiothoracic surgeon whose wife was delivering her third child and had an amniotic embolism. My attending shook as he told me how he heard the screams for help coming from the delivery room.

When you hear a guy like that, an experienced surgeon who has seen just about everything, yell with panic in his voice...

The attending stopped and looked up as if trying to question the Divine himself. After a long pause, he turned his attention back to me and changed the subject. I later found out that the poor woman was rushed to the operating room and her chest was cracked. It was futile.

I couldn't shake the image of an unfazable surgeon walking into his home alone with a new baby to face his other two children.

*

During my pediatrics rotation, as a student, I held a little girl in my arms in much the same way as I would eventually hold my own child. She was a few months old when her father brought her into the pediatrics clinic. He stared at the ground lifelessly as I examined his daughter. Occasionally he would grunt in response to my questions.

The first thing I noticed was that unlike most of the Hispanic baby girls brought into the clinic, her ears were unpierced. I unsuccessfully tried to question, but my pigeon Spanish failed me. I wondered why her father came to the clinic alone.

As I flipped through the chart the answers became clear.

The mother died during childbirth.

*

Last week, my wife was out of town and left me alone with the children. Every morning, I would wake up early before the kids started to stir in their beds.

Later, I sat with my four year old daughter and stared blankly at a closet full of clothes. We both looked at each other and started to giggle. I agonized over finding a suitable outfit. When we were done, I stood in front of the mirror with her small brush and hair clips.

After multiple failed attempts, I reached into the drawer and pulled out a head band. My daughter guided my hands as we affixed it properly. She looked appraisingly at my reflection in the mirror and spoke softly.

A good thing we have mommy!

If only she knew how simple hair and clothes are compared to everything else.

Yes. Good thing we have mommy.

Jordan Grumet Interviews Himself

2012-01-13T13:16:00.000-08:00

Q: Thank you for agreeing to this interview. Before we start, I just wanted to say that your much more handsome in person than I expected.

A: Ya, I get that alot!

Q: Um...OK. Moving on. I notice that you write a new blog post on most days. How are you so prolific?

A: I have been writing my whole life. As a child I was greatly impacted by the death of my father, and growing up with a learning disability. Living through these experiences made me think deeply about my surroundings. I learned to search for the profound in every day life.

I categorized my thoughts, one by one, in the recesses of my brain. The actually placing pen to paper (hand to keyboard if you will) only occurred later as I developed the requisite vocabulary to do justice to my observations.

I try not to think too much about my blog posts, otherwise I may stifle the creativity that bubbles up.

Q: Taken as a whole, what is your blog about? What are the major themes?

A: If you asked me this question a few years ago, I would have said that my blog is a love letter to my patients. As I grow wiser, I realize that it is more accurately a love letter to my father.

When my father (a prominent oncologist) died, I was seven years old. As silly as it sounds, I spent a great deal of my childhood and young adult years trying to forgive myself for his death. Even though I knew I wasn't responsible for his aneurysm, I struggled with issues of being worthy of love.

As I read my own writing, I'm struck by the parallels. I fight to be protect my patients and lead them through the dying process, much in the way I wish I could have done for my father.

Q: I have noticed that you can be a harsh critic of yourself as well as other health care providers.

A: As with any love letter, My words are filled with angst, self deprecation, and remorse. I pine for the unrecoverable loss. My father is never coming back.

When I'm critical of other physicians, I am also criticizing myself and the foibles of our profession.

Q: So if this blog centers around personal issues and your father, why make it public? Why Facebook and Twitter?

I think there's value in the conversation. Although my inner creative process may stem from personal issues, the themes of my writing have broader applicability. Through my blog I attempt to record the epic battle fought by physicians between maintaining their humanity and protecting themselves from the atrocities of everyday practice.

We are both flawed and scared, as well as brilliant and steadfast. Physicians bleed when they are cut, just like everybody else.

If we don't let the public know who we are, how will we ever move toward equality and intimacy?

Q: So your saying that the doctor-patient relationship needs to be a two way street.

A: Exactly, I couldn't have said it better myself. As health care reform progresses, there will be a power struggle as resources become scarce. The sooner we open the door to our patients, the better we will survive the tumultuous future.

We need to build a partnership based on trust and common understanding.

Q: Any last thoughts before we end this interview?

A: No, other then to say that I enjoyed this conversation immensely. You really are superb!

Q: Thank You.

For Just About Everything Else

2012-01-12T07:40:00.000-08:00

The sound of squeaking shoes and huffing ventilators filled my ears as I sat to type at the desk in the ICU. I was lucky to steal the only remaining station from a nurse who had left her chair to give report.

The nurses were dispersed in groups of two huddling around computers and signing out to each other. The ancient ritual of the changing of shift had modernized by technological necessity. Quiet voices recounted patient histories and recent lab tests. Occasionally my ears would perk up when a nurse placed special emphasis and her voice catapulted above the hum of the crowd.

A middle aged woman stood with her back to me with tattered blue scrubs and a stance of authority. She spoke melodically with occasional stops and starts. The young woman receiving her soliloquy was petite and outfitted in pink. Her scrubs were freshly pressed and free of biologic spatter or remnants of a hastily eaten meal.

I couldn't help but listen to the conversation as blue scrubs spoke.

Mr. Slip presented to his local pharmacy clinic with chest pain and shortness of breath.

I almost fell out of my chair. Who in their right mind would go to a "quickie" clinic with such complaints? I imagined the chaos as an ambulance pulled up to the local pharmacy. I craned my head to listen closely as blue scrubs continued.

An EKG was done at the clinic and was noted to be abnormal. So the patient was directed to the ER.

Again I was incredulous. They do EKG's at these places? Are they capable of interpreting them? I imagined a sign in bright colors with a beautiful, young, athletic woman smiling back at me.

We now do EKG's. Get one today at your yearly physical in the pharmacy department. By the way, did we mention we sell aspirin?

Pink scrubs looked as confused as I. Although she didn't interrupt her senior partner, her lips pursed and she flipped curls of hair out of her face in mock frustration. Blue scrubs was not finished:

After returning home to walk the dog, the patient arrived in the ER and was found to have S-T elevations in leads II, III, AVF. His blood pressure on admission was 80/50.

She went on to describe the rest of the sordid hospital stay. By the time I finished my own charting, my head was swimming. How did we get to this place?

It's like I always tell my patients:

If you have a medical problem that will go away on it's own without intervention, go to a pharmacy clinic.

For just about everything else,

see me.

The League Of Custodial Healers

2012-01-10T05:08:00.000-08:00

For the first six months at the hospital, Leandro try to avoid The LOCH business. It was a new job and he desperately needed the money to support his wife and baby. But when the League of Custodial Healers approached a second time, he found himself sitting in a small room in the bowels of the facility with a group of serious looking environmental service consultants (or that's what they called themselves).

The leader was an elderly gentleman with a thick creole accent. He learned the Voodoo art during his first assignment at Charity hospital in New Orleans. Since then, he had taught thousands of custodial assistants the refined art of patient healing. His eyes became large and hands moved in an animated sweeping motion as he described to the group the ancient technique.

For centuries, doctors and nurses felt that the surgeries and medicines they provided were curing their patients, but the truth was an underground group of custodial healers was actually saving the day. They would sneak into the room and perform their sweeping rituals before it was too late.

At this point the old man grabbed his broom tightly and looked out at the crowd.

Why do you think so many people die in the ICU? It's because we have limited access.

He then placed his broom on the floor and demonstrated the ten cardinal techniques and their appropriate application. Leandro scribbled on a scrap of progress note paper as the demonstration continued. The presentation ended with the circular method. This method, only for the most dyer situations, began with a twisting motion in the middle of the room, and worked its way out to the far corners.

*

Although Leandro was skeptical, he honed his skills late at night in dark hallways of the hospital where patients slept soundly or were to ill to notice the lowly janitor cleaning their room. With time and practice, his skills improved.

And low and behold, the majority of the patients got better. They awoke from comas. They withstood chemotherapy. They conquered pneumonia.

Six months later, Leandro had perfected his technique. Each morning he would round on his recently treated patients before signing out of the night shift and going home to his family. He felt invigorated and connected. The patients and doctors may not know about the important service he was delivering, but he could live with that.

At the end of his shift, he tucked his trusty broom under his coat and left the hospital. He couldn't leave such a valuable and powerful tool sitting around for just anyone to use!

*

Upon arriving home one morning, Leandro found his wife cowering in bed. She had been vomiting and having diarrhea all night, and the baby was at his mother in laws. When Leandro looked down at his ailing wife, his clinical skills took over. Her face was pale and her skin was dry. He put his hand on her head and felt her temperature. She was hot! His intuition told him something was very wrong.

Leandro panicked. Even after all he had seen in the last six months, he packed her into the car and brought her to the doctor. When they arrived, they sat in the waiting room for what seemed like hours.

Eventually they were ushered back to the examining room. The doctor walked in and without introducing himself, began asking questions. He sat with his head buried in a lap top computer and his eyes never left the screen.

After a hasty examination, the doctor declared that his wife had a viral gastroenteritis that would resolve over the next few days. Leandro couldn't believe his ears. He started to explain that his wife had never gotten sick like this before.

The doctor looked at Leandro, and then up at the clock above his head. He was already an hour behind and had to return to the hospital to do rounds. He could either take the time to explain to the agitated man and his wife, or he could give them a prescription to placate them.

*

Leandro took the prescription to the pharmacy and ushered his wife back home to bed. He gave her the first dose, and then waited till she fell asleep. When the room was absolutely quiet, he snuck into the closet and pulled out his trusty broom.

He knew that this was a situation which called for the circular technique. As his wife snored in the background, Leandro performed the centuries old ritual. He stopped when he had successfully cleared each corner of the room.

Five hours later his wife awoke refreshed and feeling healthy again. Although she praised the doctor and antibiotic, Leandro knew what was really responsible for his wife's miraculous recovery.

After all, both Leandro and the doctor had their own form of medical Voodoo.

But at the end of the day, Leandro's method had one major advantage over the physicians.

At least the floor got cleaned.

Dignity Transcends

2012-01-09T05:32:00.000-08:00

Leslie was the kind of person who made both men and women's heads turn as she walked down the hallway. Her back arched forward with perfect posture as she waited for me to enter the exam room. She stood, using one hand she parted the blond curls that fell in front of her face, and extended the other towards me in greeting.

I sat comfortably at the desk and opened my computer in preparation to start the physical. Leslie swayed back and forth in her chair slowly, and I sensed that something was bothering her.

Because she was a new patient, we chatted about her current health and past medical problems. I asked gentle probing questions to tease out the source of her discomfort. Although I had finished all the requisite social and family history, I still found myself searching

I opened the cabinet above the desk and pulled out a gown in preparation for the physical exam. At the sight of the white flimsy covering, Leslie's face became a bright shade of pink, and she turned in embarrassment. I was surprised by this kind of reaction from such a strong, confident appearing woman.

Is something wrong?

Leslie turn to face me again, and paused as she mentally rehearsed the next sentence.

You see Dr Grumet...I thought you were a woman....and I didn't shave my...

Her words trailed off as we both started to laugh. I offered her an appointment with my female partner, but instead she decided to return and finish the exam the next week when she was better prepared for the visit.

I sat in my office and giggled as I looked out the window and watched Leslie gracefully lower herself into the driver seat of her car.

And then I remembered something.

*

The morning rhythm of the ICU greeted my ears as I walked through the doors. The sound of shuffling feet, blowing ventilators, and beeping machines formed a raucous chorus. I stopped at the computer bank and looked at my patients labs and vitals.

She was much to young to be in this setting. Her twenty five year old body was stronger and more resilient then the average ICU patient. But the effects of chemo had taken their tole. Her immune system damaged and short handed, couldn't fight off the bacteria that plunged into her respiratory system.

Things were looking up. The chemo had finished. The ventilator was removed and life was beginning again. A bed was ready in the step down unit and hopefully she would go home soon. We chatted for a few moments before I started my examination. The lungs were clear; the heart was normal.

As I went to examine the legs for edema, my patient threw back her covers to reveal newly manicured toes with a bold shade of red polish. I looked up to the head of the bed to see her smiling.

She had been waiting all morning to spring this on me.

*

It becomes very easy in medicine to shun vanity. We looked past the dirty, unkempt, disease ridden bodies of our patients as a matter of course. We somehow picture ourselves too much above the fray to stoop to such banality.

But one thing I've learned from my patients is that dignity transcends sickness and health. That caught in the middle of a health care system that focuses on depersonalization, it takes courage to maintain ownership.

These women were trying to remind me that they are not just patients.

They are people: flawed, vain, courageous, and awe inspiring.

Reports Of Our Demise

2012-01-07T21:03:00.000-08:00

I shuffled some papers on the desk to avoid looking into the hospital administrator's eyes. His lips curled into a half baked smirk as he talked. I marveled at the tailored suite and the crisp tie.

He was a business guy. And it didn't take long to ascertain that he saw me as an asset. I was a widget; an interchangeable part. If one physician wasn't on board, find another. I imagined that somewhere in his slick briefcase there was a list with each physician's name and two columns. Check marks were neatly penciled in to demarcate the doctor's status. Pens were never used because they were not erasable.

The majority of the conversation was like a Peanuts cartoon where most of the words sounded like distorted rubbish. Occasionally my ears would perk up as a phrase caught my attention.

Blah blah blah, blah blah ACO blah blah blah ICD-10. Blah blah blah blah healthcare reform blah blah ACA.

*

When are we going to stop talking of Armageddon? We treat private practice as the red headed step child, and not the predominant mode of physician organization. We huddle in the corner of dark alleys and wait for the boogey man that never comes.

And we jump ship the minute the going gets tough, and become employed physicians. It's what happened in the era of HMO's and it's whats happening now. The scramble to escape the unknown becomes more important then thinking about self interest.

We try to forget that we are staunchly independent professionals who don't like being told what to do. Certainly we can submerge our needs for a time, but eventually our true nature bursts forward. And when it does, we break through the chains of employed existence and venture out on our own.

It has happened in the past, and it will happen again

*

I have worked for hospital owned medical practices. They stand on the backs of their laboring assets. Physician sweat leads to profits that exsanguinate through administrative fluff and overblown salaries. Economies of scale give way to inconsistency and bloat.

The government is sadly mistaken if it thinks that ACA will lead to a tenable solution by placing the power and money in the hands of greedy hospital systems loaded with administrators and oozing with self interest.

You want to see who's running the tightest ship in the business? Find the little guy; the few physician practice that lives or dies by its own ingenuity. There are no unnecessary administrators, no burdensome policies, no political flotsam.

The consultants say that the ACA will end private practice. They say that ICD-10 and the new regulations will make small practice untenable.

I say let's look at history.

The reports of our demise are frequent and uncompromising.

They're also greatly exaggerated.

Metamorphosis

2012-01-06T13:01:00.000-08:00

When I heard the phrase, I couldn't quite believe what I was saying. Not only were the words cruel and unforgiving, they were intentional and calculated.

I hope you sleep well tonight knowing that you tortured this poor lady in her last moments before death.

I could hear the sounds of CPR in the background as the nurse paused to digest what I said. I imagined strong arms pushing against the cracked ribs of a frail, demented, elderly woman whose quality of life had been minimal for the last few years. Even though I spent months trying to convince the family, they had only agreed to the Do Not Resuscitate order a few days prior. I dutifully placed the paperwork in the hospital chart, but apparently it meant nothing till the power of attorney signed the form.

Days later, as my patient was coding, it was noticed that the order had never been signed by the family. The nurse was unapologetic.

We've got liability issues doc. No order....No DNR!

I slammed the phone down in anger. I hoped the sting of my words would at least convince the code team to move in slow motion.

*

I grew up the youngest of three boys. I was shy and withdrawn. I spent a good deal of my youth afraid of my own shadow. I was soft and supple, pliant. By the time I reached medical school, it was safe to say that I had never raised my voice to anyone.

It is impossible to explain the deluge of medical education to someone that is unexposed. Students and residents learn to fight for scarce resources. In an attempt to advocate for patients, voices are often raised, threats are made.

I learned quickly that in order to protect those under my care, I either had to become a master of confrontation or get trampled. For the first time, I used cruelty and anger to force the unwilling hand.

And it worked: the X-ray tech would schedule the MRI early, the specialist would leave a full clinic to meet me at the bedside. The more voracious my attitude, the more I could accomplish.

*

A few minutes later my thoughts were interrupted by the jolly ringtone of my cell phone. It was the nurse again. The code was over. I took a deep breath and began to apologize for my inexcusable behavior. She interrupted me.

It's okay Doc! If it was me on that table, I would've wanted someone like you as my doctor!

I thanked her for being gracious.

I hung up the phone.

And then I wept.

*

It's only now that I realize that the anger of training wasn't about advocacy or about getting the job done.

It was about grief.

We fought so many unwinable battles that we grasped at any form of control that was available to us. We may not be able to cure the disease, but we certainly could get our patient to the front of the line.

We yelled, we threw things, we were cunning and underhanded because that was better then crying.

Ten years out of training, I realize that I've seen enough suffering for a lifetime.

And it has changed me.

Often in ways that I'm not proud of.

Dirty Little Pills

2012-01-05T07:47:00.001-08:00

His hands shook as he unfurled the sack of bottles. He placed them on the examining table one by one. He looked at each label, and then shook his head quietly as if he was reaffirming his own good judgement. Much to his chagrin, I noticed the empty can of Jolt laying in the wastebasket. It hadn't been there a few minutes ago.

We talked a few moments before I tackled the supplement issue. I could picture a cigarette dangling from his brown stained fingers. His belly protruded over his waist and struggled to conform to his undersized pants.

He was working too hard, eating poorly, and spending little time with his family. He felt too nervous to quite smoking, but too lethargic to stop imbibing energy drinks. His business teetered from complete destruction to overwhelming success on any given day

*

Doc...why do I feel so bad?

Again he glanced over at the pill containers sitting on the table. While I knew the answer, I could tell that I wouldn't make much headway till I addressed the passion of his wandering eye. I reached over to the counter.

So what do we have here?

I mentally read through the list while I tapped away at my computer: Ginseng, vitamin E, Vitamin D, Vitamin C, Multivitamin, folic acid, St Johns's wart, fish oil, aspirin, and chondroitin. It was a myriad off supplements costing hundreds of dollars a month.

I picked up each bottle as I explained why it was inappropriate. Vitamin E had never shown to be beneficial for almost anything. Vitamin D was unnecessary in a person who had healthy bones and was not deficient. Folic acid could be harmful. Aspirin was ridiculous in a thirty year old with no heart history regardless of some risk factors. He stared at me impatiently as I droned on about one pill after another. Eventually he interrupted before I could spit out the last words of my prolonged run on sentence.

But if I stop those, what are you going to give me to take their place?

I paused. I could either go with the hard sell or the soft sell. I wondered which would work.

You want to feel better?
Stop all pills.
Quit smoking and energy drinks.
Exercise, lose weight, and sleep better.
Spend more time with your family.

His head slumped down towards the ground and for the first time during the visit, his legs stop shaking. He looked up and our eyes met. For a brief moment, I thought that I connected. But then he opened his mouth.

Isn't there some pill I can take instead?

A Gift To The Dying

2012-01-04T05:59:00.000-08:00

The photo was more for my benefit then hers. The ninety five year old woman staring at me through the frame was completely blind. She wouldn't be able to enjoy it. Yet she had her young companion bring a camera to the visit. We snapped the shot, and two weeks later she walked in with a beautifully framed picture. It would be our last visit before she died.

I studied my own face. Had it been a full decade? My features were softer, my hair thicker. I glowed with an innocence that has long since faded. As I contemplated my growth as a physician, I struggled to remember her name. My face burned with embarrassment and then settled with a heavy sense of guilt.

So much had been gained over the last couple of years, and so much lost.

*

I have watched hundreds of patients die. I start each journey with a full emotional tank of gas. But as time passes, complications arise, and fuel is consumed at an ever rapid pace. As we reach the finish line, I often feel like I'm existing on fumes.

And when the death certificate is signed, and condolences are given to the family, I run on empty. Of course the tank refills with each and every new patient that walks through the door. But the truth is, my endurance is limited to one fill per customer.

So as time goes by, I often forget details. Names and diagnosis slip through my clenched hands like sands in the hour glass. But themes remain. Love, fear, rapture, joy, and connectedness permeate my soul and affect the person that I have become.

*

When I look at the decade old picture, I realize that my patient was giving me one last gift before she died. As the memories flood back the details become more concrete.

I may not remember her name, but I can tell her story.

I can tell their stories.

An Officer, A Gentleman

2012-01-02T18:06:00.000-08:00

I wasn't surprised by the sirens. As I pulled over to the side of the road, my speedometer floated down from the fifty mile per hour mark. The first sign of sunlight was inching over the horizon. I was one of the only cars on the road.

The officer moved at a glacial pace. I imagined him tapping away at his computer similar to how a physician does as he enters a patients room. The flashing lights reflected in my rear view, blinding me. My feet shook nervously as I waited.

It was a hell of a welcome back from vacation. The night before my partner called to tell me that Mrs. Silver was in the ICU. As I listened to his report, I couldn't help but feel guilty.

Mrs. Silver was a charming eighty five year old with her share of chronic medical conditions. For some reason, I doted over her like she was my long lost grandmother. There was something about her essence that brightened my spirit every time she entered the exam room. She was like a whirlwind. Before she left each appointment, she had my nurses and medical assistants pealing with laughter.

*

The day I left for vacation, Mrs. Silver was admitted to the hospital for pneumonia. My partner examined her and started antibiotics. Although she originally began to improve, she suddenly developed chest pain and severe shortness of breath. She was placed on a ventilator and her cat scan revealed a large pulmonary embolus.

Days later she was dying. Her blood pressure was dropping and her kidneys were failing. The family had gathered at the bedside and were waiting for me to arrive to turn off the the ventilator.

After the dismal report from my partner the night before, I barley slept. I sprinted out of bed five minutes before the alarm went off and hurried through my morning routine. Although I couldn't verbalize why I was in such a hurry, I knew I needed to see Mrs. Silver one last time before she died.

*

The officer eventually strode out of his car and walked up to my door. I rolled down the window and started to speak, but he interrupted me.

Are you OK?

It is only years later that I realize that my face must have been a pale shade of gray. My eyes were bulging and the sweat was starting to form on my forehead. Afraid, confused, and worried, I said the first thing that came to mind.

My favorite patient is dying!

His stared at me intently and then his gaze turned to the passenger seat where my lab coat rested comfortably. His voice was steady and commanding.

Go!

As he walked back to his cruiser, I put the car in gear and pressed down cautiously on the gas petal.

It wasn't the first time a police officer would show me a simple act of kindness,and it wouldn't be the last.

I arrived in the Intensive Care Unit minutes later.

Mrs. Silver passed quietly.

Y

2012-01-01T12:51:00.000-08:00

I would have sold my soul for those secrets. I gorged on the remnants during gross anatomy, ward rounds, and the sleepless nights of residency. I drank from the cauldron, and inhaled the magic till my jowls were complacent and full. I sat at the table of humanity. My chair neither higher nor lower.

Afterwards, looking into mirror the reflection was anything but transformed; older, but not measurably more wise.

*

I have seen the question in your eyes as you stare blankly at the pathology report held inches from your face. You read the word "leukemia", but shock rearranges the letters as if you are at home playing a game of Scrabble with your youngest son. Your wife holds your other hand, and you both sit silently. You haven't yet begun to process the difficult and possibly fruitless battle that lies ahead.

Until now, denial had been your shameful bedfellow. It whispered in your ear countless times like a forgotten lover.

Just wait. The shortness of breath is only allergies. It will pass.

Your friends noted how the pallor of your face changed. Your wife fretted over gasping breaths when you walked up a few stairs to the bedroom.

*

I have listened to your voice beckon and coax during the silence. Your husband smiles as he sits next to you, oblivious. He laughs one minute and cries the next. His memory is like an annoying fly that buzzes back and forth, but always is barely out of reach.

Your partner has become an innocent. You lead him back and forth about the house as if he is one of the children of your children. Moments and details are lost and replaced with sinister plots.

Someone has been in the bedroom and stolen my glasses!

He sits in a haze of plaques and tangles. He inhabits a world in which you no longer belong. You fill the same space, but he is not your companion.

*

I have interpreted the rise and fall of your syllables as your look longingly toward your son. The beast of mania, swollen and bloated, becomes as sad as the depression. His twenty five year old body is strong and agile, but guided by a brain that is no longer nimble.

You heave on the bile of his physical vitality as it mocks you. You survived the fear and uncertainty of childhood to land here. You talk of your friends, the empty nesters, and how they complain about free time and unused bedrooms.

You long to have space that is yours alone.

*

And as I look back at my four year old daughter who has fallen asleep on the way home from the airport with her hand intertwined with my seven year old son's, I can't help but choke on the irony. How can the world hold such sweet and passionate hope alongside the desperate, crushing pain.

As a physician, I thought I would have developed answers to such riddles. But as I grow older, I realize that my training has been more about answering "how". Such banal descriptions of cells and physiology rarely satiate the hungry. The answers to the fundamentally pressing questions are left to philosophers and clergy.

So you'll have to forgive me. When I thought I was learning secrets, I couldn't have been more wrong.

And besides my empathy, I have little else to ease your suffereing.

I don't know why.

I Know This Much Is True

2011-12-30T05:20:00.000-08:00

I walked out the door and down the steps on a clear St. Louis morning. The air had a slight chill as the sun began to rise in preparation for the new morning. Spring had not yet transitioned into summer and the humidity was minimal.

As I had done on so many other days, I walked with my lab coat slung across my arm. My stethoscope would occasionally pop out of the pocket and dangle from a thread before I scooped it back up and placed it awkwardly into its temporary resting place. If the temperature dropped, I may slip the coat over my shoulders and wear the stethoscope around my neck.

When I arrived at the hospital, I walked through a side entrance and took the elevator to the medical wards. The resident's office was busier then usual. The interns awoke and left their adjacent call rooms to find that they were no longer on the bottom rung. The new interns, donning neatly pressed and clean white jackets, had arrived for their first day of work.

My fellow residents and I basked in the glow of our final day of training. We would stay for a few hours and hand off patients, help with rounds, and generally enjoy the absence of true responsibility.

We walked the floors as if we were kings. We strutted back and forth and chatted with the nurses.

A few hours later it was time to go.

We left the sheltered and protected existence of training and launched ourselves into the vast unknown.

And we never looked back.

*

There is a sense upon leaving residency that you know just about everything. That you've seen and done all that is important. You've cared for the sickest of the sick, and dealt with the poorest of the poor.

A list of dieases and procedures has been appropriately checked and checked off. An air of confidence lingers.

But I have to admit that the majority of doctoring, I learned after training. The ivory towers provided a good working knowledge of the arcane, but the day to day, bone on bone grinding of patient care was learned on the fly. Each encounter provided a new skill, a new fount of knowledge from which to draw from.

And I was often surprised at my own prior misconceptions. I would have never imagined that as an attending, I would sleep less and work harder then in residency. I couldn't comprehend the crushing responsibility of being the bottom line. No one prepared me for the three am call from the nurse when there was no one higher up on the food chain to call for advice.

Yet the hardest skill to achieve was not the science but the art. How to become a "healer" and not just a doctor. How to know when to place your hand gently on the shoulder of a mourning patient or to raise your voice to an unyielding family member.

I still struggle with how to remain humane and kind, as well as stay effective. Medical knowledge comes and go. Diseases are discovered and cured. But in the purest sense, the job of the physician is to be a beacon, a lighthouse, to guide each ship safely to land in the harshest of conditions.

This is what it is to be a doctor. After all these years of training and practice,

I know this much is true.

On Carrots And Sticks

2011-12-28T18:37:00.000-08:00

Larry knew he had to make a doctor's appointment immediately. The searing chest pain almost stopped him in mid stride. For a moment he considered going to the emergency room and then thought better of it. He remembered the heart attack 10 years ago, this felt nothing like it.

The doctor's office answered on the first ring. He began to explain his predicament but the receptionist interrupted him.

Sir, you haven't been in the office for over a year. You better come in right away!

As Larry hung up the phone, he realized that he didn't mention the burning over his left rib cage. No matter, he thought, he would bring it up with the physician.

*

Later that day, Larry strode into the waiting room. He caught his breath in pain as he leaned up against the front desk. The receptionist took his insurance card and began to click on the computer screen.

Are you married?
What race are you?
Do you subscribe to any religion?

Larry answered each question cautiously, but wondered why he was being interrogated. The gum in the receptionists mouth cracked and popped as her eyes concentrated on the screen in front of her. As she looked up at Larry, she realized that he was losing patience. She focused on the screen as she mumbled in his direction.

New government requirements! If we don't ask, the doctor doesn't get paid.

When she finished with her questions, Larry was directed to sit in one of the flimsy chairs and wait. He placed his left hand over his heart and probed for the source of pain. He winced as if daggers were skewering him. The front desk person hadn't inquired about the reason for his visit either.

*

A few minutes later a nurse walked through the sliding glass doors and called his name. He shuffled gingerly into the exam room and waited as the nurse signed into the computer.

Boy Larry, you haven't been here for greater then a year. We have alot of work to do!

The nurse measured his weight, height, and waist circumference. She asked about domestic violence and gun use. As the minutes passed, Larry marveled at the detailed and often nonsensical material being covered.

To her credit, the nurse did ask Larry about pain. She even had him rate it on a scale from one to ten. But she didn't bother to ask any other details.

*

When the doctor finally walked into the room, Larry heaved a sigh of relief. He waited quietly for direction. The doctor shook his hand and sat down at the computer.

Wow! We haven't seen each other in a year.

He then preceded to stare silently at the computer for a few minutes. Larry watched as he clicked and typed from time to time. Moments later he was being motioned onto the table. The doctor examined him head to toe and then directed him back to the seat.

Everything looks good. We'll see you next year.

Larry was stunned. He stood to get the doctor's attention.

But what about my chest pain?

The doctor turned and removed his hand from the door knob, and glanced back at the computer.

That reminds me. With your history of heart disease, it says here that you're due for a stress test.

Without another word, he left the room.

Larry sat back in the chair and tried to put the pieces together. If the doctor had given him the chance, he would have explained that he tripped and slammed his chest against the book case. Did he really need a stress test?

When Larry made the appointment that morning, he was thinking more along the lines of an xray.

He figured he cracked a rib.

Evolution/Devolution

2011-12-27T11:52:00.000-08:00

Sitting in my office, I tap the last words of the progress note on the keyboard as the student shifts in his seat. He looks up at me with all the innocence and naivete of one who is at the beginning of an arduous journey. I strain to hear his words.

So, how does it feel to be a doctor?

I'm taken aback by the sincerity of the question and the rawness in his quivering voice. I ponder carefully how to respond. A million cliches pop into my head, and I fight them off one by one.

This time will be different.

This time, I'll tell the truth.

*

I can't remember a time when I didn't want to be a doctor. In fact, my identity and profession have intermixed to such an extent that I often can't tell them apart. My internal image includes a lab coat and a stethoscope. It always did. Even as a child.

My voyage through medical education was powerful. Like a flower, the seeds of identity blossomed and became external reality. But I couldn't help feel a certain sense of unease. It was as if the more I learned, the less the burning embers of humanity would glow.

When you encounter death and destruction at every turn, such things lose their profundity. And patience and tolerance become the exception and nary the rule. Such a treacherous path for a wandering soul.

Once, while sitting in the exam room, I found myself staring at the clock while I talked to a patient about her recent cancer diagnosis. I listened to the barrage of questions, but secretly I was calculating how to end the appointment early to run errands.

As the patient left the office, I realized how far I had fallen. I promised myself that that would never happen again. But now my eyes were wide open.

After all these years in medicine, it wasn't the difficulty of diagnosis nor the desperation of disease. What I find myself continously struggling with is maintaining the beauty and humility that were present when I started this process. Because somewhere amongst the paperwork, fears of malpractice, sleepless nights, and unexpected outcomes, something broke.

How does one build armour strong enough to repel the demons of sickness and despair yet allow the skin to bask in the piercing barbs of humanity? How do I evolve as a physician without devolving as a person.

*

How does it feel to be a doctor?

Well, how does it feel to be a human being?

Mired in the morass of moral frailty, I struggle with my own imperfection.

The difference is, as a physician,

the affect is greatly magnified.

From Birth To Death

2011-12-25T19:52:00.000-08:00

As luck would have it, she happened to die while I was in the room. I sat with her family as the last breath precariously left her lips. We waited for the next as if it was a forgone conclusion. It never came.

Walking toward the nursing station, my mind wandered back to medical school.

*

I tentatively followed behind the resident as we entered the birthing room. The patient writhed in bed and opened her mouth, but nothing came out. Her face tensed and then relaxed. The contraction had passed.

We stood quietly for a moment, and then the resident cleared her throat.

This is Doctor Grumet, he will be delivering your baby.

My back muscles tensed and I gritted my teeth. My mind bobbed back and forth between embarrassment at being referred to as a physician, and fear of performing the delivery myself. I looked over at my patient. After months of going to the residents free clinic, she learned to accept what she was being told without questioning.

Although she refused the epidural from the beginning, her sighs of pain made me wonder if she regretted it. The nurse and resident stood by her side bracing her legs. As she started to push, I looked down in anticipation.

A tuft of hair bounced in an out of the birth canal with every contraction. After a few minutes, the head broke free and I tentatively pushed down and delivered the anterior shoulder. I slipped my hand over the baby's neck hoping to gain traction as the posterior shoulder broke free. I caught the body clumsily with my other hand, and held the baby up for the mother to see.

After forceps were applied, the umbilical cord was cut. Minutes later I delivered the afterbirth and sutured a small lacertaion.

I left the room, and sat at a desk with the chart in front of me. I paused and looked down at my hands. Only moments before they had taken part in the ritualistic dance of childbirth.

It was a familiar dance.

One that had been performed over and over again since the beginning of time.

*

I often marvel at how similar birth and death feel. The ephemeral movements of the soul are difficult to diagram, but it is impossible to escape the feeling that as the last grain of sand slips free, the hour glass is just waiting to be flipped back over.

And we struggle to control that which occurs between bookends. Doctors and patients fight to write more pages to prolong introduction and ending. Yet sometimes I wonder If we miss the point.

I haven't delivered any babies since medical school, but I see my share of deaths. And each time, I can't help but hear the same words echo in my head.

This is how it's always been. This is how it always shall be.

There is nothing to fear

Dying Of The Old Guard

2011-12-23T12:00:00.000-08:00

Millicent couldn't help but feel out of place. The sterile white sheets were anything but soft and downy. They rubbed against her feet like sand paper. She twisted herself into a ball and waited. The edges of her gown creased in the back exposing her derriere.

Millicent's histrionic nature plagued her from childhood to her mid seventies. Although she pictured herself waiting for death, more likely she would spend a few days in the hospital till the antibiotics eradicated the mucous in her lungs.

The nurse said that her personal physician would see her once she got settled on the floor. But it had been hours since she left the chaotic emergency department, and still no hide nor hair of Dr. Howard.

Milicent couldn't help but smile through her febrile haze. Dr. Howard was an "old fart" like herself. They had been together for decades. The graying of his hair reflected in the bowing of her spine. Of course he was probably in his fifties and she in her seventies, but that didn't stop Millicent from overestimating their equivalence.

*

Millicent dozed on and off. The much needed sleep was interrupted by occasional fits of barking cough. Each time she opened her eyes she glanced at the clock. Her IV dripped beside her bed, and beeped from time to time as if jealous of the silence.

The nurse came and went. Around midnight, she walked in and woke Millicent from a deep sleep.

Your doctor is at the nursing station. He will be in shortly.

Millicent sat and rearranged her hair. although she felt miserable, there was no reason to appear so to the handsome Doctor Howard. She glanced at the clock in the corner of the room and almost fell out of her bed. Midnight-why the heck was he rounding so late? Millicent briefly worried about poor Dr. Howard's wife before her reverie was interrupted by a knock at the door.

A young boy walked into the room wearing an over sized lab jacket and a stethoscope that twisted around his neck and likely got lost somewhere underneath his scrubs.

I'm Dr. Thomas. I will be taking care of you here at the hospital.

For a moment Millicent thought that she was still dreaming. She rubbed the sleep from her eyes and looked up at the young man questioningly.

There must be a mistake. Doctor Howard is my doctor!

*

Dr. Thomas sat at the bedside and quietly explained how Dr. Howard no longer came to the hospital. That instead, he use a group of physicians called hospitalists. Hospitalists were available twenty four hours a day to take care of people like herself. Times had changed and many physicians, like Dr. Howard, no longer felt able to see patients in the office and hospital.

Millicent couldn't believe her ears. After all those years.

So you will call Dr. Howard first thing in the morning?

By now Dr. Thomas was half way out the door. His beeper had gone off, and he looked like he was rushing out of the room to another emergency.

No, I will be gone in the morning. But one of my partners will come by tomorrow and he will call Dr. Howard.

As the door closed, Millicent found herself feeling very alone. The cough that had been a mere nuisance hours ago now exploded in her chest.

Being laid up in the hospital with pneumonia was bad enough.

But what really burned Millicent to the core,

was the feeling of abandonment.

Transfer Of Addictions

2011-12-22T11:11:00.000-08:00

We danced around the subject. James wasn't going to ask me directly to increase his meds, but I knew that's what he wanted. My brain did a silent eye roll as I watched him hop around the room.

It was true that his foot looked swollen and bruised. But the xray was negative and there was no reason to expect a more sinister process. He stubbed his toe; no more, no less.

But James had a problem when it came to pain.

Or had he just become a victim of our medical system?

*

There was a time when James was not strung out on pharmaceuticals. Alcohol was his poison then. But he got into a car accident and suffered a knee injury. The DUI was the least of his problems.

The MRI of his knee was normal but his pain was excruciating. Visit after visit to his internist and orthopaedist left him with a medicine cabinet full of narcotics, which he felt good about because at least he was no longer drinking.

The custody agreement for his son required regular breathalyzer testing. But they couldn't fault him for taking the medications his doctor prescribed, could they?

By the time he came to see me, he was taking several norco and oxycontin a day without relief. I reviewed his MRI and lab tests skeptically. When I explained that in the absence of pathology I wouldn't accelerate his dosing, he almost fell out of his seat.

It never occurred to him that maybe the medicine wasn't helping. Our conversation went something like this:

What is your level of pain when on medication?
10/10
What is your level of pain without medication?
10/10

We argued back and forth, month after month. Each time I prescribed less pills.

*

Finally when the courts threatened to take his son away, James got serious about kicking his medication habit. He got admitted to the hospital and was treated for withdrawal.

The next few months were difficult. James struggled with daily activities. He found a job and spent more time with his son. I would be lying if I said that he didn't have pain. But he learned to use more mature coping mechanisms. He attended physical therapy, acupuncture, and biofeedback.

He was making significant progress, or so I thought.

And then he disappeared.

*

Six months later he waltzed through my door with a large medication list. As I silently read through the consult note, I felt my eyes popping out of my head. He had seen a pain specialist at the local university and was again using large doses of narcotics.

We were back to square one.

I buddy-taped his bruised toe and sent him on his way. I assumed shortly after leaving the office, he would be on the phone with his pain specialist.

*

We've created a nation of junkies. The tide began to turn when the government made pain the sixth vital sign. The miserable and wretched learned that they could stop cowering under illicit and costly activities. Now all they had to do was show up at the doctor's office where kindly nurses would check their blood pressure and pulse before serving up the perfect lob:

Are you in any pain today?
Why yes I am!

Instead of protecting the cancer ridden and orthopedicly adventurous, we have turned our offices into dispensaries.

Unfortunately we still haven't come to terms with the fact that narcotics do not treat psychic pain. Furthermore, they are particularly poor at relieving chronic orthopedic conditions.

So the treadmill continues. We use pain medication inappropriately. The human body becomes use to it and then needs more. Minor traumatic injuries become emergencies.

And as a nation, we transfer our addictions.

Educational Distress

2011-12-21T05:38:00.000-08:00

I woke in a panic. My heart felt like it was thumping out of my chest. I sat up and waited for the blare of the alarm radio to wash out of my ears. The room was pitch black. I pushed the covers aside and crawled out of bed and inched my way to the bathroom. The cold morning air did nothing to soothe my nerves.

I showered, dressed, and locked the door behind me as I made my way to the garage. Although my stomach was growling, mild nausea overpowered my sense of hunger. I turned the key in the ignition and was met by the throaty voice of a public radio announcer.

By the time I hit the on ramp, I settled into my morning drive. I felt an overwhelming sense of unease as I remembered the dream that yanked me out of sleep.

*

It's the first day of high school, or maybe college, and I am sitting contentedly in class. As I look around the room a panic overtakes me.

I forgot to bring my class schedule!

I forage through my backpack without luck. It's a new semester and I have no idea where I need to be next. Without room numbers or building names, I am lost. I start to breath rapidly as the fear overtakes me. My head pounds and my eyes begin to water.

I feel a strange sense of doom about starting the year off this way. It's as if somehow by missing the first day of classes, I will suffer great harm. I will lose some essential piece of information that will be devastating. I will fail miserably.

I jump out of my seat and sprint to the door. I have to quickly get to the administration building to print up a new schedule. But when I exit the class, I can't seem to remember which way to go.

I walk back and forth aimlessly trying to reconstruct the correct path. With each failed attempt my mind races even further out of control. I feel like I just got punched in the gut. I glance repeatedly at my watch as if I could freeze time.

When I finally get to the front of the administration building, I heave a sigh of relief. I walk up the steps and approach the entrance.

The door is locked.

*

The fetid odor of cleaning products mixed with the refuse of human illness is the first thing that hits me as I enter the medical floor. I try not to breath out of my nose. A demented patient is lost somewhere in the jungles of Viet Nam and swings at his nurse. He just barely misses her.

It is six in the morning and the maintenance man walks past me pushing the floor cleaning machine. It sounds like a garbage truck and the noise disrupts the otherwise quiet hallway where sick patients try to get their rest.

I take a deep breath, and for the first time this morning, I feel the calm wash over me. My heart is no longer racing and the nausea is gone. I have finally shaken the stress of my nightmare.

Thank God I'm no longer a student!

Loyalty

2011-12-20T05:01:00.000-08:00

I broke my stethoscope the other day. Or actually, the stethoscope broke, it really wasn’t my fault. A couple of weeks ago I noticed that the tubing was beginning to tear. As I am wont to do, I ignored the situation and tried to tape it up. Of course my temporary solution only worked for a short while. After multiple tapings, it finally broke. Imagine my embarrassment as I went to put the ear piece in my ears and it split in half, right in front of a patient. There I was wide eyed with half the stethoscope in one ear and the other ear piece dangling disconnected in my hand. As you can imagine it was quite a site.

So I threw my stethoscope in the garbage and borrowed a loner from a colleague. I ordered a new one and waited for it to come in the mail. A few weeks later I tried out my new model and it didn’t feel the same; maybe it was the way it fit in my ears, maybe the length of the tubing. Who knows? It just didn’t feel right. And then I started to think.

I threw out my stethoscope! The same stethoscope I bought with such pride on my first day of medical school. The stethoscope that had literally touched every single patient I had seen throughout my medical career (it had never broken before). And like an idiot I just tossed it aside. I didn't perform any ceremonies, no thank yous for a job well done, no tender thoughts of all we had been through together.

Sure my new stethoscope will likely be just as good. Hell, it probably will function better. But I guess that’s not the point. The point is that somehow down the line I lost my loyalty. I lost my respect for a relationship forged by closeness, shared experience, and yes years of time spent together.

I know what you’re saying:

it’s a stethoscope-an inanimate object!

But maybe there is some importance here we’re missing. Maybe our health care system is taking a turn for the worse. Maybe we are losing our loyalty in other places. Hospitals and doctors are becoming less friendly. Staff turnover is rampant and you no longer recognize the faces when you enter your doctor’s office. Physicians are moving, changing locations, or even swapping careers.

I got a letter from a patient the other day. We had been through so much together. She battled depression and a divorce. She survived a horrendous cancer and was still dealing with her diabetes. We knew each other for years.

I guess I didn’t take it personally that she was leaving. Her health insurance changed and I was no longer on her plan.

But as the tears well up in my eyes I can’t seem to stop thinking about that damn stethoscope.

How could I have just thrown it away?

Disclosure

2011-12-18T17:41:00.000-08:00

Jack's youthful appearance and boyish eyes were betrayed by a body more fitting his grandfather. He hobbled into the office in his usual manner. His ambling gate was hampered by painful knee joints which creaked and crackled with every movement. His forty year old posture was marked by the cruelty of early onset rheumatoid arthritis.

His visit to the rheumatologist had been modestly fruitful. After injections to both knees, he was able to stop using the wheel chair. But joint replacement surgery was coming on the horizon. No matter how long he tried to prolong the inevitable, his day of reckoning was near.

He leaned back in his chair and tried to get comfortable. As he closed his eyes the sweat began to poor down his face. He reached over to the desk and helped himself to a tissue. He dabbed his forehead and looked in my direction.

If I knew how painful my forties would be, I would have had a lot more fun in my thirties!

We both laughed, but I knew that he was only partially joking. We spent alot of time in the exam room talking about what this disease was doing to his self image. The physical toll was matched, if not overcome, by the metal anguish of disability. Once a track star in college, he now considered himself a cripple.

As so often happens, I struggled to express comfort and understanding without being demeaning. How could I know what it felt like for Jack to not be able to ruff house with his kids;to not be able to pick up his crying daughter? I had no inkling of the painful stiffness he woke up with every mourning or the feeling of nausea brought on by his medications.

I found myself repeating familiar words.

I won't even pretend to know what it feels like to walk in your shoes because I haven't. But I've seen people in your situation and I know it is very difficult. Let's see if there are some things I can do to lessen your burden.

Jack sat quietly for a few moments absorbing my words. When he looked up, our eyes met and he started to speak. What he said next caught me completely by surprise.

I read your blog.

I felt a sense of doom arise from the pit of my stomach. I mentally scanned through my last few posts. Had I said anything inappropriate? Jack recognized the look of panic on my face and quickly reassured me.

I was really impressed! It would have never occurred to me that doctors think about such things.

As I listened to the squeaking of Jack's walker as he rolled toward the checkout counter, the weight of his words began to sink in.

Maybe our patients don't know that we suffer through difficult decisions. Maybe they don't realize that our insomniac brains toss and turn during sleepless nights where worry and fear become our dark companions.

And they likely don't realize that the pain and suffering we witness leaves disfiguring scars.

How could they?

Unless, of course, we tell them.

Post Traumatic

2011-12-16T05:44:00.000-08:00

You'll have to excuse my pessimism.

I've bathed in death. The senescent skin cells fall into the basin and expose new facial wrinkles. My hair is thinning and strands of gray streak through the jet black landscape. The gulp of water streaming down the drain is the only interruption of a perfect mornings silence.

I've choked on grief. The tasteless globs of oatmeal stick in my throat. I barely awake from my reverie to notice the glass of juice sitting beside me. The windows reflect the last memories of undisturbed night.

I've exhaled desperation. The breaths escape and take form and then disappear into the air. The path from the parking lot to the hospital expands and contracts with the whim of my mood.

And I've stumbled on sadness. The land mines in the office are frequent and offer little space to negotiate in between.

So you'll have to forgive that I jump at the sound of an unexpected phone call or the pleading voice of my daughter.

She has woken up in the middle of the night.

It's probably just a headache.

Will It Hurt?

2011-12-14T05:20:00.000-08:00

Will it hurt?

I am lying on the bed in my parent's room. My six year old legs fidget like a frog who has been pinned on his back. My father stands over me and opens a small box of tools by splaying the paper wrapping and spreading it across the night stand.

He gingerly unfolds two thin sheets of wax paper to reveal a set of sterile gloves. He grasps the first on the outer bent lip and pulls his arm through. Using his covered hand he scoops his fingers under the bend of the other glove.

As my father lifts the forceps out of the box a stream of sunlight catches the metal and bounces onto my face, blinding me.

Should I close my eyes yet?

He doesn't answer my question but commands me not to move. He takes a moment to survey the clean line of sutures above my right brow. As he pauses, I feel his breath caress my skin. The faint smell of mustard reminds me of the deli sandwiches we ate an hour before. It intermingles with the acrid perfume of alcohol being applied to my skin.

He squints through his glasses as he approaches my forehead with scissors in one hand and forceps in the other. I shut my lids tightly, waiting for the pain that is sure to come.

His shadow blocks the light from the window and I sense his body leaning over me even though my eyes are closed. He pulls at the edge of the suture with one hand and snips with the other. I feel a sharp sting as my skin leaps to meet the scissors.

Each suture is methodically cut and removed in similar fashion. Minutes later we are finished. I sit up on the bed and smile at my father. He is arranging his tools. He stops what he is doing and reaches up to my face. He cups my chin and gently pushes upward. He surveys his work.

Not bad!

Six months later I will fall and need stitches again. But by then, my father will be dead and I will have to go back to the doctor's office to have them removed.

This memory came flooding back to me the other day as I stood over my own patient with scissors and forceps in hand.

It had been so many years-I had forgotten.

Forgotten

2011-12-13T05:02:00.000-08:00

I want a Diet Coke!

It was the first thing I thought as I woke up this morning. Although I had mostly kicked the addiction, occasionally the urge was strong. I recently relegated my caffeine drinking to availability. I refused to buy soda at the grocery store. I strutted past the vending machines as if they didn't exist.

Once in awhile, I allowed myself to partake: a drug lunch here, a sporting event there. If a Diet Coke was placed in front of my face, I would drink it. So it wasn't a complete surprise that I woke up with such cravings. After years of drinking six pack after six pack, I was convinced that my brain chemistry had been altered.

When I stopped by the office before rounding at the hospital, I rummaged through the refrigerator hoping to find buried treasure. No such luck! I knew that I would pass a bank of vending machines in the long hallway that led to the hospital, but I had sworn off such a willful solution to my lusting.

This morning, I would have to forgo my needs.

*

The hospital census was large and active. I worked my way through the telemetry and ICU floors. I stopped at each patent's bedside and then the nursing station to chart at a computer. There was a hodge-podge of bread and butter medical and surgical care.

I quietly entered the room of my last patient for the morning. Mrs. Brooks was nearly one hundred years old. Her dementia had progressed severely over the last few years, and she was admitted for a urinary tract infection. Her verbal ability was limited to the single word "yes".

Mrs Brooks, it's good to see you....yes.

Are you feeling better then yesterday...yes

Do you want to go back to the nursing home....yes

Mrs. Brooks had no children and the rest of her family had died or moved away. Her medical decisions were made by a distant nephew, who I had talked to on the phone, but never met in person.

After examining Mrs. Brooks, I turned to leave the room. Out of the corner of my eye I saw a glimmer of aluminum on the desk. I turned my head and my mouth started to water like one of Pavlov's dogs. Sitting on the table was a six pack of Diet Coke.

I couldn't resist the lure of the silver can enshrouded in a white label. Perverse thoughts ran through my head. I was Gollum from Lord of the rings stretching for my "precious".

She's demented! She'll never know!
Mrs. Brooks can I have a Diet Coke....yes.

*

As I reached for the can I had a shocking moment of clarity. It was if, all the sudden, someone turned on a spot light and pointed it in my direction. I was standing in a demented woman's hospital room stealing her Diet Coke.

I felt a great sense of shame. After all of these years learning and caring for the elderly I had stooped to this.

Mrs. Brooks had been forgotten. She was abandoned and relegated to the dark corners of a nursing home where society didn't have to acknowledge her.

It somehow escaped me this morning.

It was my job to protect her.

Sign Of The Times

2011-12-12T05:12:00.000-08:00

No matter how hard I tried, I couldn't control Lisa's blood pressure. We experimented with countless combinations of medication with no luck. She was working on diet and exercise. I started to feel desperate. I imagined her confidence in my abilities was faltering although she hadn't said a word. Our weekly visits had been fruitless.

As she climbed up onto the exam table, I retrieved the blood pressure cuff from where it rested on the wall. I repeatedly squeezed the bulb until the meter read above 200. The cuff crackled on Lisa's arm. I released the air valve and became quiet. I held my breath in anticipation.

Please be lower. Be lower...

When the liquid past the 180 mark, the dreaded thumping pounded through my stethoscope. Lisa's blood pressure was no better.

I took the cuff off and settled back into my chair.

So tell me what's going on in your life?

Lisa stared blankly at the wall for a moment, and then a tear formed at the corner of her eye. I could barley hear her speak.

If debt was a cancer, my husband and I would have been ten feet under long ago.

As the words stumbled out of her mouth the image of her twelve year old twins flashed through my mind. I leaned over the desk and handed her a box of Kleenex. I had little in my bag of tricks to fix her situation.

We sat silently in the room for a few minutes. How much had changed with my patients over the last few years. The faltering of our countries financial health was being mirrored in the day to day ailments that crossed the threshold of my office doors. The illness was contagious.

I took out my prescription pad and started to write. Lisa glanced at me quizzically. She waited in anticipation for me to explain which new medication was being added.

Often the great difficulty of being a doctor is discovering what it is that each individual truly needs. Sometimes the answer is something that we as physicians are not trained to give.

Lisa read silently the scrawled glyphs on the paper that I handed to her. She looked up at me with confusion etched into her tear soaked face.

Whats this? She asked as she wiped her face with a tissue.

I waited until our eyes met.

It's the number of my accountant, he can do more for your blood pressure then I.

Saving Death

2011-12-10T05:15:00.000-08:00

The orders came indirectly from the government.

Reduce hospital re admissions. Cut costs.

So the hospital contacted the local hospice/palliative care center and asked for help. Of course, overwhelmed with work and understaffed, the project was handed off to me.

My task sounded simple. Create a palliative care program at the nursing home. But as I gathered for the first meeting with the administrator, social worker, and clinical staff, I knew there would be resistance.

And, in fact, I had my own feelings of reticence. Although I had learned much over the years, I was not trained in palliative medicine. As I gazed around the room, I realized that neither were any of my colleagues.

*

I looked Nancy squarely in the eye as I explained my vision. Our beginnings would be simple and humble. Admissions would flag appropriate patients based on predefined criteria. Then social work would approach each patient and family within seventy hours and have "the talk".

When Nancy heard her profession mentioned her ears perked up and her face twisted in confusion.

What do you mean, "the talk"?

Ready for her question, I pulled out a POLST (physician orders for life sustaining treatment)form and passed it around the room. The two page document was a series of basic questions.

Do you want to be resuscitated if your heart stops?
Do you want to be hospitalized if your condition worsens?
If you are unable to eat on your own, would you want a feeding tube?
Can IV fluids or antibiotics be given?

Attached, on the back, was a series of questions I had created myself.

Do you have a religious affiliation?
Would you like to be visited by clergy or a therapist?
If you knew you were dying, would you rather pass at home, in a hospital, or in the nursing home?
What are your health care wishes for the next six months?
What is more important to you: quality or quantity of life?
*

I looked around the room as the participants read the form. Nancy was becoming more anxious.

Isn't this the doctor's responsibility?

I answered her with a tinge of melancholy.

Yes, it is the doctor's job. But it's also the nurse's, social worker's, and therapist's job also. It's all of our jobs.

*

We met each week. Nancy presented new patients, and then the nurses and I would discuss clinical issues and pain control. The difficult cases were referred to the associated palliative care doctor from the local center.

During the first few sessions, I continuously hammered Nancy on the POLST form. For each patient, I wanted to know the answer to all of the questions. At first she rolled her eyes, but as time went on she got the hang of it.

A transformation occured during our fourth meeting. We had ten people in the program. As Nancy presented each patient, I could sense a diference in the tone of her voice. She was now approaching the project with a new sense of zest and zeal.

At the end of the meeting, I asked her what was going on.

Well, you know Mr. Smith? He passed yesterday.

Mr Smith had end stage dementia. He was in the process of dying for months, but his physician had not bothered to talk to the family about end of life care.

His daughters and I completed the POLST form a few weeks ago. So when he started to die, we were all on the same page. He passed quietly in bed without ambulances, IVs, or CPR.

I could see the change in her posture. She got it. She now saw how powerful these conversations could be. I smiled and congratulated her on how well she was doing such an important job. She looked down embarrassed.

It's not like I saved his life.

Our eyes met.

No, you did something most doctors have forgotten how to do.

You saved his death!

Turning Tables

2011-12-08T13:32:00.000-08:00

Dr. Borak's voice was uncharacteristically timid. The authoritative lull and crisp enunciation had receded into a awkward bucket of uncertain phrases. For a moment, I felt as if I was back in grade school discussing the object of his affection.

Did you talk to her? What did she say?

I could feel the intensity through the phone as if the mouth piece had arched upward and was staring me dead in the eye. I felt bad for poor Borak. He suffered greatly the last few months. Although he was dropped from the malpractice suit, the scars brought on by years of finger pointing remained.

Then, there was the dispute with hospital administration. When they formed their own oncology group, Borak's referrals dropped significantly. His years of experience and relationship building couldn't stem the tide of inevitable change.

It was not an opportune time to be part of the old guard.

*

It wasn't particularly notable when Borak's patient asked for a new oncologist. She had visited him once and felt like there was no connection. Hell, people left me all the time! So I offered up a few names and thought nothing of it.

When Borak called to discuss the situation, I was caught completely off guard. I stammered as I tried to explain why I had given her other names. It wasn't the accusatory nature of his questioning that rocked me off balance, it was the hurt and uncertainty in his voice.

Borak was fighting for his professional life, and apparently he was losing ground quickly.

My discussion with the wayward patient was unfruitful.

We just didn't click.

When I reported back to Borak, his anger had receded. With sad recognition he accepted the fact that he lost another patient. He always considered the grim reaper to be his greatest opponent, not his fellow colleagues.

*

Most people become physicians because they feel a calling to help their fellow human beings. For better or worse, doctors are also driven by their own primal wish to be needed.

Our perfectionism, our selflessness, and our ability to waltz in the room and save the day are all self created concepts. They justify our actions.

Rejection, to someone who has spent their whole life learning how to be needed, is a bitter pill to swallow.

In all fairness, I am very aware of how the actions and words of a physician can evoke pain and hurt in his client.

But I wonder if patients realize that they haven't cornered the market on suffering. Do they know that behind the emotionless facade, doctors are soft and pliant on the inside?

Sadness, fear, and rejection are another part of our daily existence.

And it hurts us just the same.

Of Apes And Men

2011-12-07T06:01:00.001-08:00

There is a time for sitting in classrooms. When such heady topics as congestive heart failure are abstract and intangible. Discussion veers from myocytes to cardiac output and stroke volume.

The world, through the student's eyes, is inflamed with passion and opportunity. The reality of doctoring is a distant dream. Hope peals back layers of fear and loss of confidence. Reward is imagined as a handshake, a return to health, and gentle guidance and counseling.

And there is no better place to be.

*

There is a time for rounding in the hospital. Groups of students and pharmacists trail the blue coat tails of residency. Voices tinged with false authority scoff at the regurgitated nursery rhymes of biochemistry and pathophysiology.

Clinical reasoning becomes her majesty's bejeweled throne. The vagaries of the heart are enumerated in clean categories: systolic and diastolic, valvular and ischemic.

The world, through the resident's eyes, is a masterfully structured algorithm guided by skill and knowledge. An apprenticeship forged in sleepless nights and the cold, hard steel of the analytic process.

*

There is a time for taking phone calls at home. Your table is set for thanksgiving dinner.

Congestive heart failure, through the attending's eyes, is neither about biochemistry nor algorithms. It's about missing a night of sleep. It's about another admission for Mr. Miller who forgot to fill his lasix prescription and then ate three servings of salt coated mashed potatoes.

And as you lay down on the stiff couch in the living room, you think about your family. They will sleep quietly in their own beds and not be bothered by the pager and cell phone tethered loosely to your pajamas.

You smile as you remember those student days with a mix of fondness and melancholy.

As your mind drifts lightly off to sleep you wonder:

where has the magic gone?

Spoils of War

2011-12-05T17:30:00.000-08:00

When asked about his breathing, George would puff out his chest and release his booming tenor. On good days it would seem to last for minutes; on bad, it would peter out in seconds.

If I noted the soars on his feet, he would reminisce about his infantry days. His eyes would sparkle as he described how the heal of his brand new army boots would develop holes after hours of marching through rough terrain.

And if I questioned him about his blood sugars, he sat quietly with a blank look on his face and held his arms up at his side. George was nearly blind. He couldn't read a glucometer or decipher the tiny markings on an insulin syringe.

*

George was alone. He had no living family or friends nor money to hire a caretaker. He spent his days in a small apartment that he rented after the death of his wife. His physical existence was limited by illness and geographic disability but his world was anything but small. His mind was alive with music and poetry. His heart was overflowing with memories of his beloved wife.

Every two weeks he ventured out of his apartment an hobbled over to my office. Each visit was filled with questions which he often answered obliquely with stories. I learned that his wife once worked in an exclusive club for Hugh Hefner. That to pass the time, in his younger days, he would take a twenty mile walk from city to suburbs and then back again.

As he left my office, I was keenly aware that the doctoring skills that I learned in medical school had no place here. I had metamorphasized from an advisor to a student. I had become a companion, George's last connection to the outside world.

*

When I told him that I was moving my practice, The smile vanished from George's face. He knew that he wouldn't be able to travel the thirty minutes to my new location.

With artificial enthusiasm, I promised that I would find a local doctor to take care of him. He looked more feeble than usual as he described how his next door neighbor had recently died of a heart attack. She was a year younger then George.

As I watched him amble out of the front door that day, I felt a deep pang in the pit of my stomach. I knew I was choosing my own well being over his.

It was at that moment that I decided I would take care of George at home. I could stop by his apartment a few times a month on my way to work.

*

When I called the next morning to break the good news, no one answered. A few hours later, I received a note from the local coroner.

George died the night before. The paramedics found him lying on his kitchen floor. The coroner believed that it was a natural death. When he examined the body, he found and old frayed photo clasped tightly in George's hand. It was a picture of a woman dressed in a playboy bunny uniform.

If there's a heaven, I'm sure that George has found it.

It probably looks like an upscale club with a large picture of Hugh Hefner in the corner.

And George is being served

by the prettiest woman in the room.

Pedagogy

2011-12-04T19:39:00.000-08:00

People often ask how I write so consistently. They wonder how I have so many stories to tell. But for me, that's like asking why I breath. My answer is always the same.

How could I not?

I wouldn't describe writing as fluid. To capture the moment to moment drama played out in the confines of the exam room is anything but straightforward. I grasp at the straws of fluency and try to clarify through garbled grammar and awkward phrasing.

But what choice to do I have? How else can I integrate the hum drum reality of family dinners interrupted by phone calls regarding code status and withdrawing life support? How do I explain why I tear up at the end of a sad movie yet negotiate pain and suffering as if I was a weatherman announcing another sunny day in San Diego.

When I stop writing my soul shrivels behind a protectionist shell. I become a shadow of the husband and father that I used to be. I transform from a healer to a nameless, faceless physician. The kind you look up in the index of some health insurance guide book.

But maybe, just maybe, when you read my words you'll feel a little bit closer to understanding.

Physicians will nod their heads in a shared brotherhood of traumatic experiences.

And patients will know that someone is finally listening.

The Cost Of Closure

2011-12-03T20:28:00.001-08:00

You know Mr Miller?

I adjusted the phone on my ear as I slipped out of bed and snuck into the bathroom. I tiptoed across the floor and winced as the old hardwood started to creek beneath my feet. I craned my head and listened for signs of stirring children.

Remembering the resident holding on the line, I whispered into the cell.

Yeah. What about him? He had a choleycystectomy this morning.

I waited impatiently. I suspected that Mr. Miller had spiked a fever or needed some changes in his pain medication. It was a naive moment. The moment before I was about to hear something awful.

He coded. We were unable to revive him!

The phone slipped from my shaking hand and crashed onto the floor.

Seconds later, my two year old daughter started to cry.

*

I immediately felt out of place as I entered the church. The suit clung uncomfortably and the tie was strangling. I meandered past the pews in the front, and found a seat in the rear of the room.

As the ceremony began, I marveled at how many people had shown up for Mr. Miller's funeral. I watched as men sat stoned face and women wept silently. I searched through the crowd, but couldn't find a single familiar face.

The preacher was standing at the lectern. I tried to concentrate on his words, but It was impossible. The sweat poured down my forehead and I started to tremble.

I couldn't shake the feeling that I let Mr. Miller down. That the medical community offered cure but delivered heartbreak instead.

How did we allow this healthy fifty year old to die?

I quietly extracted myself from the chair and left mid ceremony. A few heads turned as I walked down the center isle and exited through the ornate swinging doors.

*

Sadly, I've never attended another patients funeral. Mr Miller taught me that I don't have the emotional fortitude.

The covenant between doctor and patient is sacred. My commitment to my patients well being is absolute. I vow to stand by them in sickness and in health. I will support them when they are hurting and I will tend to them when they are broken.

And when they are dying, I will devotedly attempt to ease their pain and suffering. But then the commitment ends.

Sure, it would probably be more healthy to go to the funerals. It would be personally gratifying to mourn appropriately each and every time. But when you have a hundred people die a year, it can be emotionally exhausting.

Sometimes the cost of closure

is too great.

The Revolution Will Be Tweeted

2011-12-01T17:08:00.000-08:00

The doctor/patient relationship is like a conversation. Physicians have been quiet for so long that patients feel like they are talking to themselves. But there is great import in what the doctor didn't say.

It's time you heard the view from the other side of the stethoscope.

*

I am not the government. I am not a politician. I did not choose your insurance for you.

When I accept an invitation to lunch or covet a plastic writing utensil, I am not suckling on the teet of big pharma. Chances are, I'm either hungry or need something to write with.

If you left my office with a referral for an xray, cat scan, or mri it was not given to pad my wallet. You will not see me standing in the parking lot of the imaging center high fiveing a radiologist. It is more likely that I had a clinical question that I couldn't answer with history and exam alone.

I am not sadistic. I withhold antibiotics because it is the right thing to do. Not because I want your Thanksgiving, or flight, or 20Th high school reunion to be miserable. My life would be much easier if I was less of a stickler.

When my treatment plan is unorthodox and doesn't follow protocol, it's because I saw something that doesn't fit. I am trying to balance the art and science. I do not make such decisions lightly.

And when you enter the office and I seem hurried or distracted, it's not because I don't care. Sometimes I am preoccupied with worry and fear over another one of my patients.

*

You will not hear these words on the TV. You will not see groups of physicians clad in lab coats march on Washington or leave the hospital on strike.

We vote on our feet. Doctors retire early or move to non clinical careers. Primary care becomes extinct and goes the way of the dinosaur. Hours are reduced and lifestyle is chosen over commitment.

But, If you're attuned to social media you'll catch the whispers. The discontent oozes from our keyboards and smart phones.

Because we want things to change. We want to remain physicians. Secretly we hope our words will waft into your ears and be the flint that sparks revolution.

Fundamental change is coming. The question is whether it will be for better or worse.

This revolution will not be televised.

It will be blogged.

It will be tweeted.

A Cutter's Diary

2011-11-30T18:06:00.000-08:00

The neon lights of the hospital corridor boldly contrast the bland gray of the morning mist creeping through over sized windows. My feet shuffle and then stumble as I absentmindedly propel myself toward the ICU. My eyes shudder, deflecting remnants of last nights sleep.

At this early hour, the hallway feels like a forgotten graveyard. My reverie is interrupted by a flurry of activity. Transport personnel wheel their patients in front of the door well that leads to the operating room. Family members scurry to give one last hug, say one last goodbye, before their loved ones are pushed through the swinging doors and into the unknown.

I can't help but stare at each face as they pass by. I recognize the strange mix of terror, hope, and desperation brought on by powerlessness.

*

If Dagny Taggart existed in real life she would have been a surgeon.

Josie is standing in a circle of men who don't usually take direction from a woman. They belong to an era of medicine that has long past. Like in the days of the giants, they stalk through the hospital indifferent to their surroundings. They are cardiothoracic surgeons.

Josie presents patients like a machine gun. Each diagnosis and vital sign sprays forth in rhythmic staccato. The appearance of her torso is lengthened by her unorthodox posture; one leg is a stilt while the other folds into a triangle. Her hair is slightly disheveled from missing a night of sleep.

I watch from the corner of the room with the other medical students. Josie is pretty but not in the classical sense. Her jaw juts forward and her body is sleek and thin. As she finishes her conversation with the attendings, she strides effortlessly in my direction.

Come with me. We're opening Mr. Simpson's chest.

*

Mr. Simpson is dying. His blood pressure is dropping and his anemia is worsening. His emergent coronary artery bypass, the night before, has kept Josie busy till daybreak.

She leans over her patient in the cardiothoracic ICU. He is too sick to take to the OR, so Josie scrubs and steriley drapes him in his room. She is on the front lines of a battlefield and has created MASH unit.

She expertly removes the sternal wires and opens the chest cavity. Her eyes survey the operative site. I watch from the corner mesmerized. Her hands move with ease and fluidity. She performs a complicated dance with the attending who is functioning as her first assist. They communicate through movement without the exchange of words.

The blood pressure stabilizes. The anesthesiologist transfuses another few units. Josie closes up and takes off her gown. Their are other patients to tend to.

*

I can't help but feel a touch of anxiety as I pass by the operating room doors every morning. Sometimes there is a rush of fear as if I am the one kissing my wife and saying goodbye.

But no patient enters this solemn and sterile world alone. They are accompanied by a surgeon like Josie. Someone who has sworn to protect and cure with the precision of a scalpel.

Surgeons have been called butchers and carpenters. They have been mythologized as goons and thugs.

But, if you ask me, It takes guts to willingly put another person's life in your hands. It takes skill and mastery.

I think we owe them a debt of grattitude.

Anatomy Of Dying

2011-11-29T05:34:00.000-08:00

Two weeks ago I told a man that he was dying. We sat together in the mid afternoon haze. Puffs of snow meandered by the hospital window and wended their way down to the ground. The sun was lost behind winter's never ending clouds.

The tempo of my voice was steady, lacking variation in tenor and pitch. I clung to my lab coat as if I was floating outside the window and being blasted by the inclement conditions.

I waited coldly for a response. At first, he stared at me quizzically. His eyes asked so many questions but his lips remained still. He shook his head and sighed. I glanced above him at the ticking clock.

You're wrong. It's not my time yet!

*

Two days ago I entered the same room. I watched as my patients chest heaved up and down slowly. His laborious breathing like spikes piercing the insides of his family members. They sat somberly around his bed in a circle.

It won't be long now.

As the words slithered out, I realized that I failed to convey the proper warmth. My voice box robotic and stale. The phrase lost in a haze of familiarity.

*

Two minutes ago I pronounced him dead. The room still heavy with doubt and false expectations. The social workers and case managers huddle around the family as funeral plans are made.

And in two days, I will call his wife. I will express my condolences and ask if there is anything I can do.

Then, most likely, I will never speak to her again.

*

Two weeks from now I will tell a man he is going to die. He will sit calmly in my exam room as he shifts his weight from side to side. Although his hair has grayed and his body has weakened, his face will sparkle with youth and vibrance.

He'll stare deeply into my eyes and I'll detect a hint of mirth.

We're all dying my friend.

He will draw in a deep breath and put his hand on my shoulder.

The trick is learning how to live!

Is It Just Me?

2011-11-28T06:08:00.001-08:00

I use the words "death" and "dying" so often that I sometimes forget that the majority of my life's work is focused on avoiding such things. In a geriatric population like mine, end of life issues are a part of everyday practice. Lately, however, there seems to be a rent in the fabric of my reality.

Where previously these conversations were nurturing and beneficial, recently they've turned quite negative. As hospice and palliative care are moving forward at a breakneck pace nationally, on the ground, there's more resistance than ever.

I'm finding that my relationships with patients and colleagues are souring around such issues. No one wants to acknowledge the elephant in the room.

Or is it just me?

*

I really hated you that day!

I see the anger migrate through her face as Agnes looks at her elderly parent. Her eyes soften when she walks over to the bed and gently combs her fingers through her mother's hair.

She is referring to when I told her that the dementia had progressed and that death was near. The evidence was incontrovertible. Her mother hadn't spoken in weeks. She wasn't eating and her weight had dropped significantly. Now her breaths were prolonged and erratic.

But the neurologist said she could live for years!

Tears drop slowly from Agnes's eyes and cling to her cheeks to avoid the perilous pull of gravity. I can see the question in her posture before her lips part to vocalize. I interrupt her softly.

A feeding tube would provide more harm then good.

Agnes stops mid sentence and her head bobs down toward the floor. Could I tell her that I don't agree with her neurologist? Should I explain that his reputation is to flog his patients well past the point of no return?

Maybe we should call the neurologist again. He says we should put in a feeding tube.

The same neurologist crucified me on the phone the week before for signing the DNR order.

*

Eventually Agnes sent her mother to the hospital for a feeding tube against my objections.

A few days later it fell out.

When her mother's heart eventually stopped, an ambulance was called.

CPR was performed to no avail.

Someone's Gettin Scoped! A Farce

2011-11-25T04:56:00.000-08:00

Icicles shot down Lisa's back and into her left calf. Standing out in the cold, waiting in line, wasn't the best place for someone with severe sciatica. But this is how Black Friday had become. At least she could stand.

The police had just carted away a belligerent man and his wheel chair bound daughter. There had been a kerfuffle with a young couple standing in front of them. It had been whispered among the crowd that the girl had some sort of brain tumor.

The gold slips for the brain MRI's were going fast. Lisa was lucky. Her spine films were not in such great demand. Although she was easily the hundredth person in line, she would likely limp away with the coveted referral form.

*

Everything had changed since the great healthcare reform. No one had dreamed that hospitals would profit so handsomely. But the provision that allowed billing for uncovered services had unintended consequences.

Fettered by poor reimbursements from medicare and private insurance, the market took over. Every other commercial on the TV was hocking some uncovered medical procedure.

Mercy Hospital is going out of business. Everything must go! MRI's half off, CT-thirty percent discount, elective choleys starting at $5000.

Black Friday was the biggest day of all. The people would crawl out of their beds early Thanksgiving morning and push, wheel, or be carried to the nearest medical outlet to stand in line and hope for a bargain. Sure insurance covered many essential procedures, but like Lisa, the panel often denied basic requests. She knew her back surgery would never be payed for unless she obtained the MRI on her own. Once the results came back, it would be a gamble to see if the panel would OK her procedure. If not, the neurosurgeons down the street were having a buy one get one free sale for Christmas. Of course, Lisa would have to hire a lawyer to make the legal arrangements to find and share costs with a complete stranger (anyone no someone trustworthy looking for back surgery?).

Lisa sighed as she crept toward the front entrance. Her chances were good. She wondered if poor John was having as much luck.

*

John couldn't help but salivate as he watched Lisa and the kids slurp down turkey and stuffing for breakfast. Unlike his wife who would receive a referral to have her MRI at a later date, if John was successful he would be whisked off immediately for the procedure. And, of course, you couldn't eat the morning of an endoscopy.

After breakfast, Lisa's parents arrived to watch the kids and it was off to the races. Lisa dropped John at the GI suites, and then rushed to the radiology center. Luckily the parking lot was not yet full when she arrived.

Twelve hours later Lisa left the facility with her hand greedily clutching the thick gold referral form. She sent a quick text to John, but no answer. She hadn't heard from him in hours.

She clicked the Facebook Application on her smart phone. Amidst the pictures of Thanksgiving feasts and newly purchased flat screen TVs was a mobile upload from John.

He was siting on a gurney dressed in a skimpy gown with his black socks covering his dangling feet. He had a large smile on his face and was holding his thumbs up in mock triumph.

Lisa couldn't help but laugh out loud and exclaim to no one in particular.

Someone's gettin scoped!

Thankful

2011-11-23T13:59:00.000-08:00

As I pull out of the hospital parking lot, I feel nothing but gratitude. The cold Chicago morning has transformed from blustery to pleasantly sunny. I become acutely aware of the gifts bestowed upon me.

I have a mind to think, a body to work, and a heart to love.

*

I walk into the house to find my four year old daughter singing along to an old Squeeze CD.

Tempted by the fruit of another..

She hops back and forth as her button dress flies through the air. My wife stands over the stove, and the smell of Ghiradelli's brownies wafts through the kitchen. My son's face is stained red from the seeds of a pomegranate that he greedily grasps between his fingers.

I will answer phone calls tonight but how can I complain? I will round at the hospital tomorrow, but it is a small price to bear witness to humanity. To experience such profundity on a regular basis that I am often unable to choke out the words to describe my experiences. Instead I write to clumsily record that which I fail to express by other means.

*

And it is you my dear reader.

You have allowed my words to seep out of your computer or cell phone. You have followed me on facebook, twitter, or read my blog. You, who has given me the greatest honor and pleasure to awkwardly juxtapose my thoughts and phrases into something that pleases.

It is for you reading these words at this moment that I am thankful.

Happy Thanksgiving!

Missing The Boat

2011-11-22T12:53:00.001-08:00

Arthur's voice rattled as if small bits of gravel were stuck in his throat. His words resonated over the phone and felt more like commandments then questions.

Lillie's coming back home?

By home, he was referring to the assisted living that they both had inhabited for the last few years. But Lillie developed a severe case of shingles and was transferred first to the emergency room and then to the nursing home.

She was like many of the other patients in the dementia unit. Her complaints of pain were both persistent and monotonous. When it was explained that her belly discomfort came form shingles, she would calm down and become quiet. Moments later, however, she would forget the explanation and start to moan all over again.

As the weeks passed, Arthur would call from time to time. The nurses rumored that he was abusive and controlling. Lillie's son mentioned that having them apart was not necessarily a bad idea.

*

So when Arthur made plans to move into the nursing home and sleep in a bed alongside his wife, there was a general uproar. The nurses scurried in and out nervously expecting his arrival. The administrator paced back and forth in her office. Lillie's son sat quietly in the room with his mom.

When Arthur arrived I was surprised that the small thin frame belonged to such a powerful voice. He barraged the staff with a series of demands. They shook their heads but dared not disobey.

The months passed and a routine was established. Every now and then Arthur would spew forth another unreasonable request. The nurses felt less trepidation and grew bold over time. They began to understand that his bark was much worse then his bite.

*

I walked into their room this morning for my monthly visit. Lillie was perched low in her wheel chair and Artur was stooped over her, sitting on his bed. The TV was on and they were holding hands.

I flipped through the chart as I talked to them. Lillie's use of pain medication had dropped seventy five percent since her husbands arrival. I asked Arthur about her tremor.

When her hands start to shake, I reach out and hold them. She then stops within a few seconds.

There was no signs of being overbearing here. There were no accusations of alleged abuse.

*

There is no doubt that as health care practitioners we need to make decisions based on slivers of information. We become like cameras. We store a series of snapshots and use them to tell a story.

Yet clearly we occupy such a small portion of our patients life. We miss 99.99% of their existence. But sometimes it is in those miniscule moments, when doors are shut, that we see a true window into their souls.

If we are lucky, we may get a chance to be a part one of those moments.

If we are not-we might just miss the boat.

Concussion

2011-11-21T18:26:00.000-08:00

The thud vibrated through my body as the pipe refused to budge against the sudden upward force. Damn crawl space! My eyes closed and bright shards of light shot through my visual field. I struggled out into the open and put my hand on my scalp. I could feel the lump beginning to form.

The vague pain in my head and neck lingered. I payed little attention as I continued to inspect the house. My thoughts limped forward as if caught in a deep haze. When I was finished, I slid into the passenger seat of the car and my wife began the long drive home.

My eyes felt heavy and my head woozy. A spasm of nausea started in my abdomen and worked its way up my throat. The saliva spilled into my mouth as I gulped to keep from vomiting.

*

It's just a concussion. It's just a concussion.

I kept repeating as I crawled into bed. The nausea abating only in complete stillness. My head was pulsating. My eyes felt heavy as they rotated to survey my surroundings.

I fell asleep hoping that I would feel well enough to make the long drive to work the next morning. Every few hours I awoke and choked back the uncomfortable feeling in my belly.

As morning came, I arose and walked down the stairs to get a Tylenol. I stumbled over the ledge. I felt like each step was another turn on a roller coaster. I walked past the bathroom but thought better and turned back quickly.

As I lay on the ground in front of the toilet my body heaved and convulsed rhythmically. Each wretch sent spasms of pain up my spine and down my forehead. After a few minutes I was able to get up and flush the toilet. I wandered up the stairs and woke up my wife. It was time to go to the emergency room.

*

The ER is such a different place seen through the eyes of a patient. I slumped in the chair at the front desk as the intake person took my insurance information. As she asked me questions, I tried my best to control the war that was raging in my abdomen.

I was walked quickly back to a bed. The gown was cold and the bed had neither sheets nor pillow. I laid flat and moved as little as possible. A nurse came in and placed an IV. The blood trickled down my arm as she applied pressure.

Sorry we hit a bleeder!

Zofran and ativan were pushed through my IV. The nurse dutifully scanned my wrist band after each new medication as If I was a box of cereal being checked out of the grocery.

The attending came in and checked me over. I fidgeted at the thought of the radiation of the suggested cat scan, but I felt too sick to argue. This is what I would have suggested for my patient.

*

The cat scan was negative and I was sent home with an anti emetic. After sleeping most of the day I finally feel well enough to sit up and write this blog.

Tomorrow I will return to work and forget this day as if nothing happened.

But maybe I'll be just a little bit more understanding of what it's like to be sent to the emergency room.

Maybe, from now on I'll avoid crawl spaces.

False Intimacy

2011-11-19T06:31:00.000-08:00

When I saw the name pop up on my schedule, I sighed deeply enough that the nurse and secretary both turned to stare. I ducked into my office. Mrs. Lange had just been double booked into my last opening of the day. I quickly perused my calender. The likelihood that I would make it on time to parent teacher conferences just plunged to zero.

Mrs. Lange was an old, crotchety, lady that belonged to my partner who was currently out of town. The cracks and crevices in her face formed chasms that only seem to deepen with each visit. Each clinical note began with same mirthful statement.

The patient is a ninety year old Caucasian female appearing older then her stated age.

*

As the day progressed, I felt a sense of dread in the pit of my stomach. Each visit with Mrs. Lange ended exactly the same. After a mind numbingly difficult history and physical, I would shoo her out of my office with a set of referrals and no likely explanations for her miriad symptoms.

Her testing always came back negative. By then her complaints were replaced by a new set of maladies.

And we danced this peculiar dance. Like fencers we sparred relentlessly. Each jab defended and countered in short order. Each match ending without the delivery of a fatal blow.

Mrs. Lange evoked in me the most difficult emotions as a doctor: anger, pity, frustration, and helplessness. She made me feel like a prisoner trapped behind the cold metal bars imposed by the exam room.

I left every appointment feeling beaten down and hopeless.

*

And this appointment was no different. I struggled through a dizzying list of nonsensical symptoms and signs. She spouted forth a complaint and I shot back an answer. Finally I convinced her to climb onto the examining table.

Her vital signs were normal. Her lungs and heart were regular. I lifted her sleeve to examine her elbow. My hands shook as I peered down at a patch of skin I hand never seen before.

Below her elbow, on her forearm, was a faded series of numbers. My heart fell into my abdomen as I realized that this was the branding of life's atrocities.

I must have been too hurried in the past to elicit a detailed social history.

She was a Holocaust survivor.

*

As physicans we suffer from false intimacy. We are given a pass to delve into the most delicate parts of people's lives. We see the best and worst of human nature.

But in reality, how well do we really know the innocents that sit before us? How often do we make snap decisions and judgements based on faulty and incomplete information?

Mrs. Lange taught me alot about making assumptions.

Every time I feel my temper rising and my patience ebbing I picture her ancient face.

And then I remember her arm.

Complexity

2011-11-18T09:10:00.000-08:00

As I opened the chart on the computer screen, my eyes glazed over. It was the third case of shortness of breath in a row. I combed through the records of yet another octogenarian: stress test (check), xray (check), echo (check), pulmonary function tests(check).

It wasn't even lunch time yet. I sat down quietly at my desk. The screen blinked reminding me that a patient was ready for assessment. The overhead pager system was calling my name. My cell phone started to ring.

I laid my head down on a stack of papers.

When did life become so complex?

*

I push the mop and bucket out behind the counter and move slowly as not to spill. Inching toward the smaller of the two dining areas, I stop at the entrance and remove the garbage can. As I dip the mop into the bucket of soapy water, I listen to a group of girls giggling at a table a few feet away. They look my age, maybe fifteen.

I glide from one end of the room to the next. Pausing to place the mop back in the bucket, I push a row of tables onto the newly mopped floor, before starting the process over again. My arms relax and contract and my hands grip tightly around the handle.

I enjoy this work. My thoughts are free to wander. I calculate how to complete my task more efficiently as I bounce to the music overhead. I think about my life, school, and work. My mind hums like a machine. It jumps from thought to thought without pause or interruption. The sweat roles down my back and the white ice cream parlor uniform clings to my sides.

My muscles ache from physical labor intermixed with occasional jaunts to the equipment room where the teenage employees do pull ups on an old rusted pipe. I am youthful and proud.

I finish the small dining room, and move a garbage can to block the entrance to the large one. I will sweep and mop. Then the bathroom, break room, and equipment room await me.

*

I leave the exam room with more questions then answers. Maybe it's just a bad case of sleep apnea, anxiety, or deconditioning.

I think back fondly to those days in the ice cream parlor. When, at the end of day, I could look out and see all that I had accomplished. I could peruse, contemplate, and record my inconsistencies.

But as time went on, life changed. With education comes complexity.

And as a physician, I spend most of my day flopping in a sea of the abstruse. There is so rarely a finite beginning and end. My work product is subjective and ephemeral.

But sometimes I dream of dropping it all, leaving my profession, and donning the apron once again.

I'm sure I would enjoy myself immensely,

for about a few hours!

Empathy

2011-11-16T19:01:00.000-08:00

As Sylvia swept through the door into the waiting room, the receptionist called out from behind the counter.

Dr. Kris, Dr. Kris, Mrs. Beckwith is on the phone. She's having back pain again!

Sylvia paused, the bag carrying her laptop propelled forward and then snapped back on the shoulder straps. Her laboratory jacket was folded neatly across one arm and the adjacent hand held a cell phone. She was about to call the Nanny. She pushed the power button on the phone and glanced at the display.

Technically, it's after four. Give it to Dr. Short, he's on call!

The secretary opened her mouth to explain that the covering physician wasn't familiar with Mrs. Beckwith, but then thought better of it.

It wouldn't have mattered anyway, the front door of the office had already slammed shut.

Sylvia was gone.

*

The choice of practices was perfect. Sylvia could work a full schedule and still have time to cart the kids back and forth to their various activities. Hospitalists had taken over the inpatient responsibilities. Call duties were light and spread among a large group of physicians. The clinic closed at four.

Sylvia congratulated herself on finding the perfect post residency job. The work-life balance was exactly what she and her classmates were looking for. At first, she had been worried about being able to handle the more difficult patients. But she quickley realized that there were always specialists to refer to, and she could send the sick ones to the ER. And when the clock struck four, they were someone elses problem.

As Sylvia bent down to place her bag into the passenger seat, she felt a faint twinge of pain radiate down her stomach and into her pelvis.

I wonder what that was?

She quickly walked around the side of the car and got into the driver seat. Her son would be finishing soccer practice soon, and she didn't want to be late.

*

Upon awakening, it took a moment for Sylvia to realize that she was about to vomit. As she jumped out of bed, she felt a sharp stabbing pain emanate from her epigastrium and spread into her chest. At first her mouth watered, and then she heaved violently. Her body spasmed over and over again until she had completely emptied the contents of her intestines.

She crawled back to bed and fumbled with the phone.

Hello...hello...I need to talk to Dr. Phillips immediately.

She silently prayed that her personal physician could give her some guidance. She felt alone in the large bed left absent by her traveling husband.

Dr. Stone is on call for Dr. Phillips. Please call back If you don't hear from him within the next half an hour.

Each minute seemed like an eternity. As Sylvia watched the clock desperately, she wondered if the phone would ever ring. When she walked into the bathroom to rinse her mouth, she was taken aback by her own reflection. The whites of her eyes had turned yellow.

*

Sylvia watched the nurses bustle back and forth in the emergency room. The dose of dilaudid had calmed her abdominal pain, but not her anxiety. She was all alone. Her husband was thousands of miles away. Her parents were sleeping in her guest room next to the children.

She reached over to the table to check her cell phone. Maybe Dr. Phillips had returned her call. Maybe he would walk through the exam room doors like Marcus Welby, and grasp her hand and tell her that everything would be okay.

Unfortunately, the only one who came was the Surgical PA. He explained in an emotionless tone that the ultrasound showed choleycystitis. In a matter of moments the antibiotic would finish running and then it was time for surgery.

Dr. Carson is on the way. The anesthesiologist will explain everything and then we'll put you under.

Sylvia grasped for words as she felt a sense of terror rise from her belly.

But don't I at least get to meet my surgeon.

The PA's back was turned and he was moving quickly toward the door.

Sure. After the procedure.

*

As the anesthesiologist placed the mask on Sylvia's face, her mind raced. First she thought of her husband and children. She wished that they were by her side.

Then she thought of her parents and how they used to comfort her as a child.

But as the intense feeling of fatigue washed over her body and she started to lose consciousness, she conjured up the face of poor Mrs. Beckwith. She imagined her sitting alone in a cold room with her arm retro flexed and her hand grasping her painful flank.

She recognized the fleeting sensation of empathy.

It was something she hadn't felt recently.

Not since the early days of medical school.

Having Your Story Told

2011-11-15T17:34:00.000-08:00

Mrs. Fitz clasped her husbands dangling hand as her son and daughter sat in the empty chairs next to the examining table. The children had brilliant black hair with the beginning of gray streaks at the edges. The family waited quietly while I maneuvered the stool into the corner so I could interact with each member without craning my head. The daughter cleared her throat to speak and looked affectionately towards her father's wheel chair.

Since you are going to help my father die, we thought you should know his story.

*

The mustang glided easily under Captain Fitz's steady hand. The World War II era fighter was reserved for only the most advanced fliers. He was finishing a successful mission in enemy territory, when he noticed a flash out of the corner of his right eye. The staccato sound of gunfire was brief but ended in a large thudding sensation that he felt in his fingertips as he struggled to control the flubbing aircraft.

Seconds later he felt a heave of pressure on his chest as the cabin rolled. He fell into a tailspin. His body hurdled violently toward the ground as the unbearable g-forces lead to a loss of consciousness. As his eyes closed for what he believed to be the last time, he pictured the pale face of his fiancee waiting innocently for his return.

Like a bird suffering from a heart attack in midair, he tumbled lifelessly out of the sky. He later calculated that he fell at least forty thousand feet. He awoke expecting to meet his maker at the pearly gates.

Instead, his first recollection was searing pain coming from his right leg. He looked down to see the bottom half of his lower extremity shattered and bent disfiguringly under his thigh.

Three men stood above him speaking in a foreign tongue. One pointed a rifle in his direction and gesticulated wildly. The other two walked calmly over to the captain and lifted him onto a stretcher.

On the thirtieth anniversary of the crash, Captain Fitz would return to the exact site and be reunited with the three men who had had every intention of killing him. But in a strange twist of fate the men decided it would be a bad omen to kill a man who had survived such an incredible fall.

*

Captain Fitz was taken to a POW camp where a fellow prisoner happened to be an orthopaedic surgeon. His leg was meticulously cleaned and splinted. His extremity was spared but his luck was brief.

The Captain refused to speak of what happened in the camp. But he survived years of torture and forced labor. When the war was over he limped back across enemy lines.

He came home to find a fiancee who had already attended his funeral. Within months they were married and soon were expecting their first child. Captain Fitz became a proud father.

He returned to school and earned a PhD. His research would eventually have profound effects on modern medicine and biology. He would educate the next generation of researchers and physicians.

As he entered his eighties, the miracles would run out. Captain Fitz developed a progressive neurological disease that first stole his words and then his thoughts. Relegated to a wheel chair, his body failed in the same manner as his mind.

As Captain Fitz sat silently in front of me on that day, his daughter's eyes brimmed with tears. His son put his arm gently around his mother's shoulder.

I took a moment to enjoy the silence. We were all lost in thought.

Captain Fitz died a few months later. None of my subsequent visits were nearly as profound.

*

Sometimes part of dying is having your story told.

Sometimes being a healer is less about talking and more about listening.

Medicare has no way of measuring such things. There are no ICD-10 or CPT codes for this kind of interaction.

But ask anyone who spends their life taking care of others.

This is where the healing takes place.

If I Die Young

2011-11-14T05:12:00.000-08:00

It's funny how a few words, a phrase, or music can bring back buried memories.

If I die young, bury me in satin
Lay me down on a, bed of roses
Sink me in the river, at dawn
Send me away with the words of a love song

The sharp knife of a short life, oh well
I've had just enough time

I heard this song on the radio this morning. A rush of memories flooded my brain in the form of the smiling face of a beautiful little girl.

*

Hola Flaco!

Hola Flaca!

A peel of giggles erupted from the small figure enveloped by the hospital bed. Her frame was lithe and frail but her eyes were large and luminous. Sparkles of light and fire shot forth when she honored me with her melodic laugh.

I was a third year medical student and unaccustomed to the wall building that accompanies most medical education. I had been assigned to the case because I was the only medical student on the team who spoke passable Spanish.

Although we sometimes had trouble communicating, the relationship had attained a certain level of fluidity. The family called me "flaco", the Spanish word for skinny, because I had started to work out during the rotation and lost ten pounds. My clothes were hanging uncomfortably off my body and my pants were barely held up by my overextended belt.

Although the miniature girl in the hospital bed was alive with passion and spirit, her body was dying. In better times, I referred to her as "flaca", the female version of my nickname. But, as the days passed, I became leery as she lost more weight and her illness progressed. Her rampant giggling reprimanded me for my political correctness and reminded me that it was just a small intimacy between inconvenient friends.

*

Flaca was struggling. Her energy was waining and her laboratory values told the story of a fairy tale that was coming to an end. Her body could no longer sustain the repeated insults of medication and dialysis.

One night toward the end of my pediatrics rotation, she spiked a fever. The nurses hurried to administer Tylenol and draw blood cultures but they were unsuccessful. As I walked into the room with a tourniquet and butterfly needle, Flaca's eyes turned cold.

I fumbled with words in both Spanish and English to explain why I needed to draw her blood. My resident stood above me tapping her foot in disapproval because she felt there was no time for explanations.

Flaca pulled her arm away from me and spit in anger. The fear in her parents eyes was overcome by determination. They nodded at the nurse who walked over and pinned Flaca's arm down against her struggling torso. I quickly grabbed the needle and jabbed her arm. As the blood flowed, we all gasped a sigh of relief.

*

Flaca would never speak to me again. When I entered the room she would turn her head in disapproval. The frailty of her body was betrayed by the unending strength of her anger. It was as if my face had become the form of all the hurt and sadness brought on by her terrible illness.

She died a few days later. And along with her a small part of myself.

I will always hold the greatest respect for those who take care of our ill and dying children.

But I could no longer be one of them.

Practice

2011-11-13T17:17:00.001-08:00

My son plays his violin. He practices every day. He attends group and private lessons multiple times a week. Occasionally he learns new pieces. Mostly he plays the same music over and over again. There are days when the music seems to glide sweetly from his hands with little effort. There are also days when screeching mangled notes seem more the norm.

It's a tiring process. Day after day and week after week, he struggles. He concentrates on his posture and fingering. He battles to hold the instrument in just the right manner. His fingers bend and contort. His hands cramp. His progress is measured in small increments.

And if he is lucky and persistent, he will improve. His practice will pay off. His notes will be more melodic and pleasing to the ear. He will graduate from one set of pieces and move to the next. The complexity and pace will increase.

Each time he studies a new composition, he will need extra hours of training. His arms will learn the exact twists and turns. He will repeat over and over until his mind no longer thinks of each separate movement, but learns to play as a whole.

But the violin is knowable. While there are some minor differences to each instrument, he will expect roughly the same sound from any violin he picks up. There are a finite number of sounds and notes to learn.

After countless years and thousands of hours of practice, he will approach mastery. Likely this will take decades of both persistence and luck. It is definitely possible. There are no short cuts. Some will reach mastery faster than others. Some will not reach it at all. But every one will have to put in the appropriate time.

*

I don't understand how we think we can short circuit medical education. Under the rubric of reform we are undermining our training programs.

Residents are being told that they must work shorter shifts and take call less often. As they finish their programs, they are entering their profession with less accrued experience. Their knowledge base is lacking and they learn to consult often, order more tests, and refer to the emergency room.

Primary care physicians are being replaced with nurse practitioners and physicians assistants without requiring the same requisite hours of training. While basic care is surviving, the art of the differential diagnosis and the treatment of the complex patient is being punted to specialists.

Yet my son continues to practice. In order to obtain mastery, he will be expected to study more them most residents and medical students, more then nurse practitioners and physician assistants. And he will learn this tiny instrument. With its four strings and single bow. With its countable number of pieces that move in finite and measurable ways.

No one would expect him to reach his goal without putting in the appropriate time.

Why don't we expect the same out of our medical professionals?

Hubris

2011-11-10T13:19:00.000-08:00

The clanking of the wheel chair destroyed my memory of Tim's last visit.

He was healthy then. His long torso sat on top of spindly legs. He strode into the exam room confidently. Although he described burning in his chest, his gait and demeanor were unhindered. He seemed reassured that the work up in the hospital was unrevealing.

The cardiologist's report from the outside facility said that he had clean coronaries. He showed me the bandage on his groin to prove it. Eventually he was given the label of gastroesophageal reflux or anxiety.

His chest pain was worse then ever, but he could manage as long as it wasn't life threatening. He grinned at me as I took out my stethoscope. His exam was normal. I thumbed through the hospital records. His cardiac catheterization, chest xray, ekg, and lab reports were normal.

We discussed different treatment options and finally decided on watchful waiting. As I ushered him out of the office, I had no inkling of the torment that would soon befall him.

Hours later, he collapsed in his living room.

*

Ya, I know he has chest pain!

The caller annoyed me. I just saw Tim in the office. Why was he in the ER now?

The last thing I expected to hear was that he suffered a devastating heart attack, and was being resuscitated. I rushed to the hospital to find him in the Intensive Care Unit on a ventilator.

His status wavered from day to day. His wife and I talked about the poor prognosis and the likelihood of death. But as the days passed, Tim got stronger. When sedation was weaned, we removed the ventilator.

Tim's mind was as sharp as ever. But he couldn't talk, and he was having trouble moving his right leg. The lack of oxygen during the initial days in the ICU took its toll. Tim had suffered a stroke.

I wrote his discharge orders with a heavy heart. He was transferring to a rehab facility and then a nursing home. I didn't have privileges at either location, and I would have to surrender his care to another set of physicians.

*

Months later, Tim was leaving the nursing home and returned to my office to reestablish care. His eyes rested on the ground as his wife pushed him into the room. This was one of his bad days. I could sense the depression before I even talked to him.

I felt a great compulsion to apologize. I wanted to say that I deeply regretted not sending him to the emergency room. I wanted to explain that even when all the protocols are followed correctly, the body is a fickle master. Even the bravest of lion tamers occasionally gets bitten.

I couldn't feel the ache of the tooth marks nor the restraint cast upon his soul. It is only with great hubris that the physician pretends to understand the reality of illness.

So I sat silently next to the wheel chair and put my hand in his. A promise to unlock the bodies secrets would neither be offered nor accepted. Instead I looked him in the eyes, and gave the only thing I had left.

I'll be right here.

You're not alone!

Biofeedback

2011-11-09T05:39:00.000-08:00

The spasms of pain were gentle at first. The large muscles of the right side of my neck and shoulder would tense and then ease up. The pain radiated up my spine and ended in my right temple. I sat at the nursing station hunched over a desk with twenty charts sitting by my side. The chair was stuck on a low setting and I had to arch my back and shoulder to reach the desk. Apparently the environmental controls for the building had just two settings: hot and cold. Today it was hot.

I rushed to finish charting so I could drive home, feed the kids dinner, and get my son to his violin class. The pain in my head ebbed and flowed. Some moments severe, like when I turned my shoulders the wrong way, others bearable.

As I cleared the dinner plates, I could feel the nausea building. We hurried to the car and arrived just in time for the violin lesson. The squeaking of bow on string compounded the stress as my cell phone was abuzz with new admissions. As I walked outside to take a call, I perched the phone between my right shoulder and head. The jolt of pain lanced through my scalp and landed above my eye. I stepped into the cold air and took a few deep breaths.

By the time I arrived home, I was fidgeting with discomfort. My stomach was raw and bilious. I fumbled with the ibuprofen container and crawled into bed. I could hear my son and daughter screeching a floor below. My wife was vacuuming the floor.

As I laid in bed prostrate, I knew there was only one way to make the pain abate.

*

Without thinking, my mind began the process autonomously. I started with slow deep breaths as I tried to disassociate myself from the searing enemy. I mentally took stock of each muscle group and localized the pain. I concentrated first on neck and shoulders, then the intricate muscles of the face. I imagined the flexed, agitated, spindles as flaming red orbs.

As I had done so many times in the past, I completed the inventory and then started the process of relaxation. I isolated each inflamed muscle group. I systemically tightened and relaxed. All the while, I visualized the muscle fibers. I commanded them to let go of the tension.

My body swayed up and down rhythmically. My torso sunk into the bed below me. I finished the muscle work and moved on to my breathing. I felt as if a tight band had been released from my cranium. The nausea was gone.

As I tried to fight sleep, my mind drifted off to childhood.

*

I could hear my mom yelling frustratedly at my father behind the closed door.

But your the doctor, what is wrong with him.

We had been to some of the best clinics in the city. I had taken test after test. Xrays, cat scans, and blood work all came up negative. The pediatric neurologist was at a loss on how to cure my headaches.

My mom and dad were struggling. I complained daily of head pain. Some days were mild, others were severe. I was missing school on a regular basis. After months of failed attempts, my mother made an appointment for me to see a new type of doctor.

As the years pass, I can no longer remember his face, but his words stick with me. He wouldn't take any more tests or draw more blood. He simply wanted me to relax in his chair and listen.

We met weekly. He called his technique "self hypnosis". He explained that we have great power over our bodies if we know how to access it. This access is granted when we bring ourselves to a state of relaxation and visualize the changes we want to take place.

He gave me homework. Each day I sat in my room alone and practiced. At first I would lie flat in bed. But as I got better, I was able to do my relaxation exercises sitting up and with my eyes open.

Over the next few months my headaches disappeared. But more importantly, I learned a life skill. Although I no longer practice anymore, I return to biofeedback often. It has helped me with both physical and emotional pain. It has improved my performance academically as well as physically.

Biofeedback has centered me as a human being.

*

My voyage into medicine has been littered with positive role models and teachers. I have many people to thank for becoming the physician that I am today.

But the truth is, this amorphous man whose face I can no longer remember, taught me more about the human body then any gross anatomy professor.

On Cell Phones And Primary Care

2011-11-07T17:33:00.001-08:00

For a brief interlude, the world moved in slow motion. I saw the cell phone leaving my hand and twist and turn wantonly in the air. It fell onto the pavement with a loud thud. I stared at the lifeless object. It's face hugged the ground. I cautiously bent down and turned it over in my palm.

With great horror, I looked at the distorted face. A large fissure splayed from the corner like children's fingers striving to frantically grasp the unreachable.

I felt a vague sense of discomfort vibrate through my body. What could I do now? The phone calls from the nursing homes would not stop for a broken phone. I pressed the power button. The display lit up, but half of the view was shrouded in black. The dial pad worked but the smart functions were unusable.

For the next few hours there would be no email, no twitter, no blue tooth, and no Internet access. I was in the middle of nowhere. In, of all places, Wisconsin.

And so the odyssey began.

*

I cut my trip short and drove to the Sprint store close to my house. I browsed for nearly an hour while I waited for the customer service agent. I impatiently explained that, as a doctor, I needed cell phone access restored as soon as possible. The calls were already piling up.

The room suddenly started to spin. I lifted my arm to wipe the sweat off my forehead and tapped my feet. Apparently, I had few options. I could buy a new phone for $500 or I could take it to their service center.

I stomped out of the store and drove twenty minutes to the Mecca of phone repair. By the time I walked into the building, my levels of agitation were rising. It had been hours already, and still no resolution.

The clerk at the front desk was courteous but unhelpful. He explained that although they had the capability, the service center wasn't authorized to fix trauma induced phone damage. As I turned to leave, he slipped me a piece of paper with the name of an independent repair company.

Shh. You didn't get that from me!

I slammed the door on my car and frantically dialed the number. After multiple rings the line went dead. I called back again. The same response.

It was Sunday afternoon. Come Monday morning, I would be faced with an onslaught of phone calls without blue tooth or hands free dialer. I only had use of half of the dialing pad. And I couldn't use twitter!

Needless to say, it was a sleepless night

*

As I explained to my office manager my predicament the next morning, my medical assistant chimed in on our conversation.

I know exactly what you need!

She made me an appointment to a repair shop close to my home. I struggled all day to use my nonfunctional phone. I pulled over three times on the highway to return pages.

By the time I walked into the shop, I was at the end of my rope. I was hungry and tired. I was grumpy. And I wanted my cell phone fixed.

The gentlemen who owned the store greeted me at the front door.

You've come to the right place. We'll have it fixed in no time.

They were kind and courteous. When they didn't have the right parts, they came up with a creative solution. At one point, they called Sprint themselves to fix my settings.

They were not only professional but empathetic. How many stressed out customers had walked through their doors with similar needs? One of the owners pulled out a bucket of broken cell phone parts.

This is just from today!

An hour later, I was on my way home. My phone was fixed for a third of the price I expected. My blue tooth was perched on my ear and my hands free dialer was reinstalled.

I felt the knots in my chest relaxing.

And then it dawned on me. I wonder how often patients walk out of my office feeling this cared for?

How did we PCP's lose our way?

Medicare For All. Be Careful What You Wish For.

2011-11-06T17:16:00.000-08:00

John's facial tick reminds me of a shark. His upper lip curls behind his teeth and he makes a hissing sound. He does this every time we talk about health care reform. He smiles and teases, but he's only half joking.

You doctors have it coming! Boy do you have it coming!

We banter back and forth as I examine him. John's muscular limbs are surprising for a ninety year old. His opinions offend, but only slightly. He belongs to the far left. He is most comfortable discussing universal health care and the public option. To him, medicare is the final answer.

Medicare for all!

He looks at me with both sincerity and pity. He realizes that my colleagues and I think this will be the death knell of modern medicine. But he doesn't care. He's fairly certain that we are wrong.

*

Although John's emphysema is much improved, his ankle is now swollen and painful. It's bruised and barely able to support his weight. He hobbles through the door with a cane. He is finished with the prednisone and levaquin, but now is suffering the consequences. His tendon has ruptured.

A week later his orthopaedist performs a short surgical procedure. He is discharged home hours later with detailed instructions. His only support is his eighty five year old spouse.

The next morning John's wife calls. Her voice trembles with panic.

John's too weak. He can't even get out of bed. We're bringing him to the nursing home.

I pause a moment. While I definitely think a skilled facility is a good idea, I'm doubtful that medicare will pay or it. I begin to verbalize my concerns, but John, who has now joined the line, interrupts.

Oh don't you worry. Medicare will take care of me.

*

Weeks later John is recovering at home. His physical therapy is going well. As he stoops to lower himself down on the chair in my office, he slams a stack of papers on the desk. I look up quizzically.

Five thousand dollars! Can you believe five thousand dollars of nursing home bills? And medicare won't pay a cent.

It is now I who looks at him with pity.

Medicare for all.

Be careful what you wish for!

I Could

2011-11-05T15:01:00.000-07:00

Adapted from the poem "I Could"
Cook County hospital 1998
Breast center

Who's next?

He calls to the residents, as if he is a bank teller waiting to accept his next deposit. He walks from room to room with the medical students trailing behind. He enters the cubicle without taking the time to introduce himself. He touches breast tissue with precision and tenderness. Yet to put his arm around the shoulder of a suffering patient would be considered to intimate.

How could you?

He stops momentarily to scan a mammogram. He is decisive and arrogant.

You will need a biopsy!

The crying woman looks up and her trembling finger points to the adjacent light box where last years mammogram sits uninspected.

Oh. Those calcifications were present before. I guess we can wait on the biopsy.

Her head is now in her hands. She doesn't look up.

How could you?

I wince as he shoves the needle into her breast. Her face contorts and a tear roles down her cheek. As he smirks, I find myself more worried about the amount of local anesthetic than the accuracy of his technique. He high fives the resident.

We got it

How could you?

A young woman sits on a chair with her two children playing on the floor with a set of checkers. He buries his head in her chart as he delivers bad news.

Your lymph nodes are positive.You will need chemotherapy.

He hands her a referral and leaves the room without waiting for questions.

How could you want to be a doctor?

He asks me in my dreams.

Because you will hurt for each and every patient who walks through your doors.

And in my dreams, I scream the answer, ablating his image from the depths of my being.

How could I not?

A Calling

2011-11-03T12:54:00.000-07:00

Would it surprise you to know that I often contemplate leaving medicine? That I awake some mornings with eyes drooping and jaw clenching. And I begin the day with the promise that it will be my last.

I have sworn off this profession more times than a bad habit. I have stormed out of the office with belly churning and head swimming in a migrainous ocean.

Each time, I feel more resolute then the last. Yet somehow I remain. I sit in my little office typing away on my lap top. The phone is ringing, my pager is buzzing, and the paperwork is piling up.

Yet, I'm still here.

*

Howie was like a tank. His thick muscular arms were covered in tattoos. His belly usually protruded proudly over his Harley as he drove into our parking lot. Needless to say, he wasn't the kind of guy who complained.

So it was with great surprise, that I watched him hobble into my office. His cherubic face was flaming red. Sweat soaked the front of his t-shirt. His left arm wrapped around his son, and they walked in unison as if they were participants in a three legged race.

I paused for a moment as Howie got settled on the examining table.

Doc. I think I'm dying

I was amazed at how this giant of a man had been transformed into a cowering mouse. I waited patiently as he explained the agony of the last few weeks. His knees were aching. His feet were swollen. He couldn't bare to walk or move. His pain was only tolerable if he remained perfectly still.

His trip to the ER had been fruitless. He was told that he didn't have blood clots in his legs, but was otherwise given no explanations. I surveyed the situation. His knees were warm and swollen with small circles of color radiating downward. He jumped with any attempt at manipulation. His ankles were also sensitive and edematous.

I diagnosed him with gout. I faxed a prescription for prednisone to his pharmacy and requested he come back the next day. He limped out of the office unconvinced.

Twenty four hours later, he strode through the hallway towards me a changed man. He walked confidently into the room. He smiled broadly showing his stained front teeth.

Doc. You saved my life!

I was about to disagree when he unexpectedly grabbed me around the shoulders and gave me a bear hug.

I didn't say a word. I was speechless.

*

Sometimes I feel that being a doctor is like fighting a pit bull. You scratch and claw against the vicious opponent in an attempt to survive. And when you finally pick yourself up off the ground in victory, the dogs owner walks over and kicks you in the groin.

Yet there are few professions that give back so much. Physicians are allowed a unique window into the lives of their fellow men. We help people live; we help them die. We bear witness to all that is laid at our doorstep.

We are treated as both kings and peasants. Our rewards are fleeting but much appreciated: a handshake, a pat on the back, a hug.

Years ago my parents asked me what I want to be when I grow up. I didn't know then what I know now. This profession is a calling. A loud, disruptive, unswerving calling.

And with every breath, of every moment, of every day,

I humbly answer it.

The Hand Holder

2011-11-02T05:14:00.000-07:00

When the residents referred to Dr. Foster as a "hand holder" it wasn't meant as a term of endearment. In fact, we universally dreaded taking care of his patients. It wasn't just his wishy washy decision making, but also his syrupy bedside manner. Although the patients loved him, we often wanted to run out of the room and vomit.

I remember my last interaction with Dr. Foster. I was a third year resident and we were rounding together on a patient in the ICU. We examined the unfortunate gentleman. He was on a ventilator and his kidneys and heart were failing.

After methodically writing his note, Dr. Foster and I walked over to the waiting room to talk to the wife. Her eyes were stained with tears as she broke the news. The family had decided to withdraw life support.

Dr. Foster held her hand tightly as he looked deeply into her eyes. He begged her.

Don't give up yet. I feel like I could have done so much more!

The wife placed her hand on Dr. Foster's cheek and then embraced him.

Doctor. Don't blame yourself. You did all you could. It's time for him to go now.

I was disgusted. How had Dr. Foster become the center of attention. He should have been comforting the wife and not vice versa.

I would never see Dr. Foster again. But years later his memory would come clearly into focus at a most unexpected time.

*

Walter and Sarah were my favorite patients. Although their bodies had withered seventy years of abuse, their spirits were far younger. They bounced into my office with energy and kindness. They greeted the staff and physicians with equal measures of respect.

A year ago, Walter developed a persistent cough. After various remedies failed, a chest xray revealed a nodule in the lung. A cat scan was highly suspicious for cancer, and Walter's diagnosis was confirmed by lung resection.

He tolerated surgery well and was plugging along when a surveillance cat scan showed multiple new nodules. Months of chemotherapy and radiation followed. We met in the office frequently to discuss each new development. Sarah worried that her husband was dying. She agreed to the various treatments, but wondered if they were doing more harm then good.

Walter, for his part, put on a brave face and took his "medicine" as directed. He also knew that he was dying, but didn't want to leave Sarah behind.

As time passed, Walter's disease progressed. He was so weak that the oncologist cancelled all remaining appointments for chemotherapy. When he woke up one morning and couldn't get out of bed, Sarah took him to the hospital.

It was with great heaviness that I walked into Walter's room. Sarah was seated at his side. She held his hand as they talked. Sarah stood when she noticed me. I leaned over the bed. A faint smile came over Walter's face.

Doc. I think it's time to call it quits.

I felt the air leaving my lungs. I doubled over. As I opened my mouth to speak, I couldn't believe what I found myself saying.

I'm not ready for you to go!

Sarah was now standing next to me, her arm around my shoulder. The iconic image of Dr. Foster in the ICU waiting room came rushing back to me. Maybe I had been to harsh.

Sometimes when the cards are on the table, it's okay to let your guard down and allow this gentle act of submission. There is a time to transcend the doctor-patient relationship and to no longer be physician, patient, and family member.

We were just three human beings with deep emotional attachments.

And we were grieving.

Together.

Why I Blog Part 2

2011-11-01T05:26:00.001-07:00

There's an ongoing struggle for the hearts and minds of the American people. The battle rages on quietly, but occasionally bubbles over into the public consciousness. One side is loud, veracious, and spits its tyrannical philosophy far and wide. The other is sheepish, and docile.

We all know that I'm talking about health care. There are those who feel that our system is undeniably broken. They think that we have journeyed so far off course that our moral fiber has eroded. They say our values languish under a system driven more by personal profit than public good. The detractors are a motley crew of journalists, politicians, policy wonks, and health care consultants.

They point their criticism at health care providers and coin new terms to describe the so called depravity. They talk about "accountability" as if they are the ones in the ICU having the family meetings. They pray at the alter of "quality" yet fail to define the specifics of such a term. They resent "over treatment" but never have suffered the consequences of not doing enough.

The veracity of one group of combatants is only equaled by the meekness of the other. Practicioners, actually providing the care in America, find themselves too busy to respond. They watch as the public's confidence erodes but feel overwhelmed by the complexity of patient care. Wasteful exercises in futility steel away their time: billing, coding, preauthorizations, meaningful use, electronic medical records.

It is a learned helplessness. The quiet rebellion continues. Doctors become businessman. Nurses become managers. We cling to new models like concierge and cash practices.

The public, inundated by the power and volume of our detractors message, has noticed our silence. Without a dissenting voice they are left to believe that what they are hearing is true. They are losing faith.

We as physicians and nurses, therapists and social workers, have but one choice left. We must recast the characters and rewrite the plot. We must repaint the fresco to be more airy and accurate.

We must tell our stories.

Agents of Torture

2011-10-31T05:11:00.000-07:00

I don't know when I became the angel of death. It was never my plan to be the patron saint of hospice. In fact, I started my career dealing with much less terminal illness. But as I spend more and more time in nursing homes, end of life discussions are a large portion of what I do.

*

I had multiple admissions to the facility this weekend. Of course, there were the occasional rehab patients recovering from hip and knee replacements. I was shocked, however, to see how many people rolled through our doors with end stage illnesses. The expectation was that they were coming for rehab.

There were metastatic cancers, devastating cerebrovascular accidents, and centenarians newly started on dialysis. As I sorted through the admissions paperwork, I started to see familiar patterns.

Peg tube placed for malnutrition. Dialysis initiated for failing kidneys. Chemotherapy scheduled for lung cancer with diffuse metastases.

Since there was no documentation of detailed end of life discussions, I made a point of asking each patient and family member a few questions:

How do you think treatment is going?
Has anyone told you about prognosis?
What are your goals?

Surprisingly, many of these questions had never been asked or answered. I found my patients and families to be largely oblivious. Many of their responses were shockingly uninformed.

*

I don't know how we got to this place. I understand that we as a profession need to make money. That gastroenterologists need to place peg tubes, that oncologists need to give chemo, that internists need to rack up visits.

I accept these facts. But when did it become okay to practice futile medicine and batter our patients?

How did we become agents of torture?

Breaking Up

2011-10-29T09:01:00.000-07:00

As I walk out of the building, I wonder if I will ever step through these doors again. I feel a faint ache in my chest and my eyes tear up. We had a few good years-the building and I.

How many mornings had I rushed in at 6AM to evaluate and ailing patient? How many afternoons had I sat at the nursing station writing in charts and chatting with residents and staff?

My letter of resignation was an abrupt and unexpected end to an emotional connection.

I could no longer come to the facility.

*

There was a time, in my career, where I pictured myself a superhero. I swooped into patients rooms in the nick of time. It was a one sided arrangement.

As I matured as a physician, I realized that the doctor-patient relationship is much more complicated. It's more like a dance. Sometimes our steps are in unison. Other times it is as if we are listening to completely different music. But it's two sided. Like most relationships it is messy and complex. Each party has both needs and gifts that require nurturing.

How could I not be changed by my years at the nursing home? I think of the resident who would accost me while I was charting at the desk. How often we talked about baseball and the Cubs. I never had the courage to tell him that I knew nothing of such things. But with time, I came to expect this camaraderie. I learn to look forward to these encounters.

*

It's hard for a physician, nay a person, to admit that we can no longer meet other people's needs. Or better yet, that meeting these needs will encroach on our own.

As we grow and change, we take on these transitions with little thought. We leave practices and hospitals. We move to different cities or change careers. And for the most part, we are oblivious to all that we have left behind.

But today I will be cognizant. I will say goodbye to years of hard work and countless relationships built on blood, sweat, and even tears. I will not be ashamed of my sadness, nor deny that I am leaving behind some who truly need me.

I will also admit that my absence will not be a contradiction to the fact that I need them too. I will not pretend that this is just another day. I will not pretend.

That breaking up isn't hard to do.

The Outliers

2011-10-28T08:30:00.000-07:00

Believe it or not, most of the time medicine works the way we expect it to. Those who are supposed to live continue breathing and those who are supposed to die don't. Human beings generally follow the simple laws of nature.

But occasionally someone surprises me. I'm often left wondering whether we don't spend enough time deciphering the magic of the unexpected. Maybe the outliers are the key to expanding medical knowledge!

*

William sauntered into my exam room in his usual manner. His eyebrows furrowed as he purposely fell backward onto the table and rested both hands on his immense belly. He took a deep breath and sighed before staring at me expectantly.

Taking my cue, I launched into my regular litany of questions. William was generally feeling well. His list of medical problems was short and under control. I placed my computer on the desk and prepared to start the physical exam.

So how is your wife doing?

I met William's wife once, four years earlier. She came into my office after a long and difficult hospitalization. She was discharged with a terminal cancer diagnosis and a poor prognosis. We reviewed the results of the cat scans as well as pathology.

There was little I or the oncologist could do. There was a treatment plan for both radiation and chemotherapy in hopes of prolonging her life. After much discussion, we decided that she would be better served by hospice.

*

She never walked through the doors of my office a second time. Yet every month, for the last four years, I get an update from the hospice team. I watch as her weight plummets. I hear of each complication as it happens.

But the death certificate never comes. Each visit, William and I marvel at her resilience. We often spend only a fraction of our time talking about him. His wife couldn't be more present if she was sitting in the room beside us.

As the years pass, our little miracle almost feels commonplace. I expect any day now, she will waltz through the door at her husbands side. I, of course, probably won't recognize her.

I remember the day I asked William why he thought his wife had lived so long with such a poor prognosis.

He met my question with a deep hearty laugh.

It was the chemo!

His surprising answer caught me off guard. I mentally checked myself before replying.

But she didn't get chemo!

His lips parted slightly and raised into a smile. His eyes were now shining.

Yep. But her mom and sister did. They both had the same diagnosis and died within weeks.

I defensively rose preparing to defend my profession.

But then I sat back down and thought better of it.

Humanity

2011-10-26T10:17:00.000-07:00

I'm not sure when I lost my humanity-at least for the most part. Maybe it was the hazing in medical school or the unending nights of residency. I prefer to speculate it was the dull thud of yet another pile of papers dropped on my desk.

Whatever the excuse, it happened. The soft, compassionate, eager student who started this journey is morphing. My skin withers and thickens into sheets of heavy chain mail. My eyes turn a colder shade of grey. My hands become dry and leathery in the midst of the frosty Chicago weather.

My body and soul adapt to form a protective shell. My heart battered and bruised beats in it's restless cage.

But sometimes, for just a moment, I remember the former strength of my innards. How my heart stood front and center. Occasionally knocked by the harshest of realities but never backing down.

Those days seem so far away now.

*

I gently rock back and forth as I stand at the nursing station. Three racks of charts rest beside me. Every few minutes I close one chart, place it back in it's holder, and pull another. I am acutely aware of the ticking clock on the adjacent wall.

My billing sheets collect dust in a pile next to me. I'm tired. For two hours I roamed the hall of the nursing home, interviewing its inhabitants. I put out fires. I calmed angry family members. And I am about to finish documenting, when a young woman walks up to the desk and waits quietly for my attention.

Are you Doctor G? I was wondering if you could come talk to my father.

I glance at the chart the nurse placed on the counter next me and feel an odd sense of relief.

Your father is not my patient. You should call his doctor.

She taps her feet impatiently and looks slightly annoyed.

Well the nurses told me you're covering for Dr. K who is out of town.

I vaguely remember that I offered to manage Dr. K's patients while he is gone. My heart falls. I'm already late and the last thing I want to do is walk into the care of a train wreck.

The woman watches my response closely. She senses hesitation. She's angry

Look! If you don't want to help...

She turns away and stalks down the hallway.

*

I walk into the room with my tail tucked between my legs. A kind elderly man lies in the bed in the center of the room. He is surrounded by his wife and daughters who fawn over him to adjust his bedding. None of the fangs that I witnessed earlier are now apparent.

Their needs are minimal. A simple explanation. Some interpretation of tests. Mostly they are looking for attention. They search for a sign that someone is commanding the ship through the relentless tempest of illness that they bravely face.

And I remember back to a time before my mind was clouded by all this "education". When I would give myself freely to sit with an ailing patient and provide the sort of "doctoring" that now has been squeezed out of me.

I started on this path to provide service to my fellow man.

How have I wandered so far off course?

Actively Dying

2011-10-25T17:44:00.000-07:00

The group of students walking behind me move uneasily through the bustling hospital halls. Their crisp clean coats stand in stark contrast to the faded linoleum and stained wallpaper. Doctors and nurses dart quickly to avoid slowing down behind the ambling herd.

I pause for a moment at the end of the hall, think better of it, and walk on. I turn quickly toward the group as my legs propel me forward mechanically. Our next stop is just three doors away. I check to make sure the hallway is empty before addressing the group.

I think we'll skip room 214. She's "actively dying."

A few steps later, it dawns on me that such a term is likely confusing to a third year student. I stop abruptly in front of our next patients room.

So who can tell me the definition of "actively dying"?

The row of faces look up quizzically, but I am already lost in thought.

*

My mom's voice sounded shaky over the phone. I could hear my grandmother breathing heavily in the background. Her silence spoke volumes. I adjusted the receiver and took a deep breath.

How's she doing?

My mom's answer was almost imperceptible. I felt, for a moment, like I was talking to a child.

Okay.

I strained to interpret her uneasiness as I calculated the distance between St. Louis and Chicago. If I left immediately, I could reach the assisted living in six hours.

Is she still talking to you?

Instead of answering, my mother lifted the phone to my grandma's ear and coaxed her to speak. I listened to each struggling gasp. The prolonged breaths were punctuated by pauses.

My mind clicked. As a second year resident, I'd dealt with this before. I slammed down the phone and rushed to my bedroom to pack a few things before leaving the house.

The roads were dark as I sped down the highway.

Time was running out.

*

Six hours later, I walked into my grandmother's room. I was oblivious to the grime and sweat caked on my body. I had driven all night. I knelt next to the bed and placed her hand in mine. My mother and father sat quietly in the corner.

Her breathing had slowed since the night before. The pauses were more apparent. I leaned over and kissed her forehead. I whispered into her ear.

It's OK. You can go now!

I placed the radio on the nightstand and put on the My Fair Lady CD.

Grandma's chest moved up and down slowly with the rhythm. Each rise and fall more gentle till the energy in the room palpably changed.

Her body was still.

Her soul had left us.

*

After a reflective moment, I answer my own question.

"Actively dying" is the final phase of life. The short interlude in which the dying process takes place. It often lasts between twelve and twenty four hours. Patients are usually unconscious and exhibit cheyne stokes breathing.

I can see the puzzlement wash over the student's faces. A few raise their hands as if we are in a classroom. One speaks up.

So what do we do when this happens?

The first thing that comes to mind is my mom's face. She still can't talk about that day without breaking into tears.

We comfort the family.

They are the ones who will carry the scars.

Memories Of My Father

2011-10-24T06:12:00.000-07:00

So it happened again the other day. I was admitting a patient with kidney failure and his potassium came back at 6.9. I quickly got on the phone and dialed the patient’s nephrologist. He was an older gentleman who I rarely worked with. His secretary kindly took my information and replied,

“OK Dr. Grumet, I'll let him know you’re holding”.

After a minute he picked up the phone:

"Hello....Jerry?”

It took me aback for a moment although it shouldn’t have. It’s already happened a few times since I moved to Highland Park.

“High Dr. H, this is Jordan Grumet. Jerry (Gerald) was my father”

"Of course, Of course, Jerry died years ago. I knew your father well. Hell of a physician. We worked together at Northwestern”

Although my father died in the early eighties, i’t sometimes seems that he is still alive and well, roaming the halls of the hospital. No matter where I practice, someone goes out of their way to tell me what a wonderful physician he was. One day it will be a colleague and the next a nurse. A few of my patients even knew him.

And yes, I still get called “Jerry” all the time. I have mixed feelings about this. On one hand, I am extremely proud that twenty plus years after his death his memory is still strong. That he was a great physician and people carry his kindness and wisdom with them. On the other, I'm getting to the point in my career where I am no longer content to be known as the son of a great physician. Sometimes I want to be acknowledged for my own achievements and merit.

But the truth is, when I reread the last paragraph, I guess I'm lying to myself. Because what really burns is that all these people have a piece of my father that I will never own. They knew him as a physician.

And there have been times when I really needed to know that aspect of him. When I was struggling in residency after countless sleepless nights, I could have used his encouragement. When I did my best and watched my patients die anyway, I so yearned for his support. When I became disillusioned with medicine and felt like leaving, it would have been helpful to know that he went through the same thing. And when a colleague accidentally picks up the phone and calls me “Jerry” it would be nice to hear his laughter as he slaps me on the back and exclaims,

“if only I was half as good a physician as you are at your age!”

Because at the core, stripped of the years of education and medical degrees, I am still just a little boy trying his best to gain the respect and love of his father.

And sadly, I am all to aware, that thirty years after his death...

that is no longer possible.

Ode To The Computer Guy

2011-10-22T18:43:00.000-07:00

The computer guy (our trainer) is starting to look stressed. The sweat roles down his forehead as he hunches over the lab top. A cell phone is perched between his shoulder and ear. A line of people are standing behind him. He tries to inconspicuously look at his watch while he waits for a response on the telephone line. Only a few more minutes till quitting time.

Our "go live" has ended horribly. It's the close of day two, and there are still major glitches in the system. The eprescribe functionality is missing in action. Scanning of external documents is restricted and the auto fax is nonoperational.

My partner, who hadn't bothered to peruse the online learning modules, runs after the trainer between each patient. He struggles to input precious information that swirls randomly in and out of his consciousness.

My office manager is perturbed. Half the staff aren't up to speed. The other half are threatening to quit.

It's a miracle that any medical care has actually taken place in the last few days.

*

I feel strangely above the fray as I observe the seen unfolding in front of me. I can't help but harboring a touch of scorn for the computer technician.

He thinks he's stressed!

At the moment I have a patient in the nursing home dying of lung cancer. He's in severe respiratory distress. His family crowds around as he struggles to suck short wisps of air through fibrotic lungs. He is like a fish out of water. I order intravenous morphine and ativan around the clock.

A nurse just called to report that my psychotic patient who ripped open his scrotum spiked a fever. A moment ago, the lab informed me that my demented patient with "non cardiac" chest pain has positive markers.

I'm thirty minutes behind in the schedule and my last patient managed to vomit on the medical assistant

Yet, I haven't broken a sweat. I manage these, as well as all other crises, with an air of confidence. This is a typical Friday afternoon. I feel completely at home in the midst of chaos.

*

But maybe I'm not giving the technician enough credit. Maybe he is wiser then I. His job is methodical and orderly. He finishes with one problem, and then moves to the next. At the end of the day he's done.

Physicians, on the other hand, have let their profession get out of hand. We have lost control of our most important commodity-time.

It probably happened decades ago when the pressure of paying for overhead spurred us to become more efficient. Take on more cases. See more patients.

Now we manage thousands of lives. We takes histories, answer overhead pages, and tend to our cell phones simultaneously.

As our heads spin, our hearts palpitate, and our blood pressures rise, we find our internal rhythms changing. We become over-caffeinated. We concentrate intensely in small spurts.

We live in a facebook/twitter society. One blink and everything changes.

But wouldn't it be nice, for once, to be like the computer guy. To greet each patient as if there aren't four other crises or five other people trying to get our attention.

As if the patient sitting in front of us is the only one.

The only one who exists in the world.

Hospice and The Way Of The Master Diagnostician

2011-10-21T20:09:00.001-07:00

I had the privilege of giving the keynote address for the Amedysis Hospice Strategy Summit last week in Louisville, Kentucky. Below find an abridged version of my comments.

Hospice and The Way Of The Master Diagnostician

We are facing a crisis in our healthcare system. If you listen to the politicians, two forces are growing that are diametrically opposed. On one side, the right composed mostly of Republicans. On the other, the liberal left and Democrats.

Although they never seem to agree, if you listen closely, we are all searching for the same thing. Our arguments, when distilled to their basic tenets, are similar.

We have to define the most salient indicators of quality and learn how to motivate our practitioners to adhere to them.

Quality and motivation. It sounds simple. But in reality it is anything but.

*

Defining quality, in our current healthcare system, is often a struggle. If you ask my colleagues what makes a "good doctor", we will likely mumble something about excellent care. But if you push us further, you'll mostly get blank stares.

Our progress, to date, in aspiring towards quality has been limited to measurement of indicators. We ask ourselves over and over again. What are the indicators of optimal care.

Anyone who understands Goodhart's law, however, knows that we are probably off base. Goodhart's law is an economic principal that simply states:

When an indicator becomes a target, it loses its quality as a measure.

A fun example is Soviet Russia. The government tried to incentivize nail factories to create more product by paying personel according to the number of nails produced. The employees ingeniously increased production by thousands a day by making small ineffective nails.

A more sobering example is the four hour pneumonia rule. Researchers found that patients hospitalized with pneumonia who received antibiotics within four hours of admission to the emergency room fared better. But when they incentivized EDs to give antibiotic faster, their were disastrous results. Over use of medications in inappropriate patients caused worse outcomes and higher costs.

This is Goodhart's law.

*

So even if we could identify the indicators of quality health care, how would we motivate our practitioners to follow them?

The government espouses pay for performance and the carrot and stick method. But one wonders if this flies in the face of motivational theory.

Self determination theory says that we shouldn't try to externally motivate behaviors that should be internally motivated. It never works.

Picture growing up in a crowded neighborhood. The kids on the block run roughshod on all the beautiful lawns. One day the smart guy on the corner lot says to the children:

Please....I'll pay you ten dollars a day. Come play on my lawn.

A week later he returns and scolds the children for doing a poor job and decreases their "wages" to five dollars a day. Another week later he returns and tells them he no longer will pay. When he asks them to play on his lawn they smirk. And they never step foot on his grass again!

This story may sound far fetched until you realize that the UK has been using pay for performance since 2000. A study in the British Medical Journal recently found that the carrot and stick method had no effect whatsoever on blood pressure control or hypertension related morbidity and mortality.

It appears that for people to become internally motivated to perform a complicated task, they need to feel autonomous, competent, and connected. Although it sounds hard to believe, having a central authority dictate your actions can have negative effects on such feelings.

*

I have come here today to tell you that we don't know how to measure quality, and even if we did, we are poor at motivating such behavior.

So we might as well give up, right?

Well, I have an idea that there is a better way. It's the way of the master diagnostician.

Our current healthcare model is a biological one. We focus on genes and diseases, symptoms and treatments. The problem is although we are 99.9% similar genetically, each one of us is very different. We react to stress differently. We get sick differently. And we respond to treatment differently.

The master diagnostician not only recognizes the biologic aspects of health, but also understands biologic variability, the psychological, social, and spiritual components of well being. In other words, the master diagnostician excels at giving each individual patient exactly what they need.

Take, for instance, two patients with coronary chest pain. One is fifty five years and otherwise healthy. The other is ninety five and has end stage cancer.

My fifty five year old will get maximal aggressive hospital care. My ninety five year old will get nitro, morphine, and be told to take it easy at home. Both patients will get appropriate care.

There are no quality indicators or carrots and sticks that can easily accomadate both of the above scenarios.

*

The master diagnostician learns to focus on what each patient needs and not necessarily what they want. The thirty year old with constipation does not need a cat scan of the abdomen. He might want it. He might believe that it will be the only way to calm the fear in his heart. But the risks and likelihood of incidentalomas is too great.

The master diagnostician also realizes that medical care has to respect each individuals right to make decisions. Although everyone should get a screening colonoscopy at age fifty, some patients just don't want one. And that's OK as long as full disclosure of risks and benefits has occurred.

The theory is simple. Give people all that medicine has to offer, but also search each patient for what they really need. Patient centered care that is tailored to each individual's circumstances.

*

I believe if we go the way of the master diagnostician we will achieve the penultimate heathcare reform trifecta. We will increase survival, decrease costs, and improve quality.

I not only believe this, I know it.

How do I know it? Because their are master diagnosticians among us who practice truly patient centered care. They are one of a kind, and their numbers are growing.

They are hospice and palliative medicine practitioners.

Hospice medicine is the only field that has resisted getting stuck on biologic necessity, and has learned to evaluate the psychological, social, and spiritual components of health.

To the hospice and palliative medicine team your cancer is only one concern. They also want to control your pain, prepare your family, and even make sure your dog is taken care of after you die. And why do they focus on such inane things....because that's what the patient tells them to. They look to help each and every soul receive exactly what they need.

*

Earlier I boasted that the master diagnostician theory would bring about the healthcare reform trifecta. That longer survival, lower costs, and increased quality of life are achievable.

I you look at recent data, hospice and palliative medicine have conquered all three goals.

Data from a New England Journal of Medicine article from 2010 showed that patients with metastatic lung cancer lived three months longer if given a palliative care consultation at the time of diagnosis. Data out of Duke in 2007 showed that being on hospice saved medicare roughly $2903 per patient. And finally, too many studies to count have shown that people who die in hospice suffer less pain, are more likely to have their needs met, and their families reported calmer deaths.

*

For all these reasons, I believe we are entering the golden age of hospice. These master diagnosticians are standing as shining examples of what we need to achieve to usher in the age of true healthcare reform.

In order for the movement to continue, two obstacles need to be overcome. First we need to rebrand the movement. The term "hospice" is too old and misunderstood. It no longer serves.

Second, hospice and palliative medicine need to become an earlier part of the health care continuum. Too often, they are relegated to "end of life care". The true power lies in early intervention.

Thank you for listening

We All Need To Slow Down

2011-10-20T17:28:00.000-07:00

Oh shoot!

I looked up from the computer and glanced in my wife's direction. She was standing over a pot with the last drops of milk pouring out of the carton.

We're out of milk.

As straightforward as the statement sounded, I knew the alternate meaning. I would be running to the store shortly. I pouted pathetically.

Come on. You know they need to have chocolate milk before they go to bed.

If I left immediately, I could be home in time for dinner. I walked over to the mud room and struggled to get my shoes on quickly. When I looked up, two sets of small feet blocked my way to the door.

Can I come too?

They both spoke in unison as if they belonged to some sort of synchronized cult. In the blink of an eye, both kids were somehow decked out in boots and rain coats. I paused. My eyes moved from the clock to their quizzical faces.

Daddy is just running out for a moment. I will be right back.

Their smiles turned into frowns. My three year old daughter started to cry. I pushed my way out the door while they followed in tow. They stopped on the porch and waved as I opened the garage door. A sheet of rain separated me from their pitiful little figures.

*

While driving to the grocery store, I couldn't help thinking about the office. Today was the "go live" for our new electronic medical record. As expected, the stress in the air was palpable.

My patients stared glassy eyed as I fiddled with the computer. I repeated myself. I interrupted them. I was distracted. My agenda clearly wasn't their well being.

And strangely, it felt similar to what just happened with my kids.

I was going to the store for their benefit. But my children didn't really care about milk. They just wanted a ride with their father. If I listened to their opinion, I probably wouldn't be alone in the car at the moment. And that's how our patients must feel.

We're moving so fast with meaningful use, ACO's, and patient centered medical homes. We're punishing hospitals for re admissions and collecting "quality" data on our doctors.

We say that we are doing this for the "good" of our community. We talk about "patient centeredness" as if we own the term. But is anyone asking their opinion? Or are our patients left standing in the cold in raincoats and boots like little children?

*

When I arrived at the grocery store, I sprinted through the isles. I quickly grabbed two gallons of milk, and tapped my feet impatiently at the check out counter. I reached for the wallet in my back pocket, and was shocked at what I found. Or better yet, what I didn't find.

I left in such a hurry I forgot my wallet. It was the law of unintended consequences.

Has anyone explained to the government that you can't buy milk If you hastily forget your money?

I think we all need to slow down!

*

I left the store and drove back home. I picked up my wallet and kids, and we all went together on an adventure.

Our destination was the grocery store.

A Physician's Prayer

2011-10-19T05:18:00.000-07:00

As I sit down to drink coffee tomarrow morning and type away at the computer, I will do something quite uncomfortable for a non religious person.

I will pray.

I will pray that my children make it safely to school

That the weather is good and the sidewalks are not slick.

That their feet will be steady and their minds alert to the dangers that lurk in any suburban neighborhood.

That my wife will have an excellent day.

That she will face the uncertainties of being a mother and a professional with her usual grace and certitude.

I will pray that I am a humble physician.

That I will be a beacon of strength and hope to those who choose to walk through my door.

That I will garner the right mix of compassion and authority to guide those who seek answers. Mourn with those who receive them, and rejoice in the human condition.

I will pray that the EMR upgrade in my office will be flawless.

That the new platform is indeed a major improvement and not just another money maker for some corporation.

That the emotional distance placed by increasingly complex computer systems will melt away as does the physical distance when I reach for my stehoscope.

That the creators of HIPAA will turn their heads as I sneak out of the exam room in order to ask a trainer the correct way to enter "hemorrhoidectomy" .

That the patients hue of crimson, as they walk past the trainers desk and towards the checkout counter, will be short lived.

I will pray that this government has been wise.

That penalizing me for not checking off the "race" box on the EMR will indeed be the one missing ingredient that will help mollify the pain of the patient with chronic pancreatitis.

Or stem the the sadness of the family watching their loved one fade away from Alzheimers.

I will pray because it seems that this space we call healthcare has denigrated from rational debate and scientific method to an orgy of magical thinking.

And I want to make sure the central authority knows not to penalize me.

That I'm on board.

My Career As A Hospitalist

2011-10-17T17:32:00.000-07:00

George's mind was spinning. The surgeon described how he would make a hole in his wife's skull. The procedure was called a "hemicraniotomy" but to George the words made little sense. All he knew was that his wife had been dancing in his arms two hours before.

At first, when she collapsed, he thought she was pretending. But then she didn't get up. He saw her chest moving up and down. But she wouldn't respond.

The ambulance came quickly. The paramedics gathered up his wife and placed a breathing tube down her throat. They whisked her off to the hospital.

Two hours later, George sat in a conference room with the neurosurgeon. His wife suffered a devastating stroke. The swelling had already caused sgnificant damage to her thirty five year old brain.

*

I shifted uncomfortably in my seat as I listened to the neurosurgeon. He would offer George's wife a procedure. It would release the pressure on her brain. But there was no mincing words. She was unlikely to recover fully.

After the surgeon left the room, George and I talked for a few moments. I gently pushed him to consider what his wife would say if she could speak for herself.

He rocked back and forth in his chair. In the main ER the PA system called a doctor overhead. The monotone voice of the page operator broke the silence.

She would want to be there to see her kids grow up.

There was little certainty in his statement. It was more a question than a declaration.

I reached out to put my hand on George's shoulder but was surprised to see him pull away. I was neither a trusted advisor nor a long time friend. I was a stranger newly assigned to the case.

It was precisely at that moment that my thoughts began to crystallize.

My career as a hospitalist would be short lived.

A Physician's Credo

2011-10-16T11:09:00.000-07:00

There was only one point to the Morbidity and Mortality conference. We ordered the xray. We could have looked at the result sooner. But how was I supposed to know? I was in my first week of internship and had no idea why my resident wanted an xray of a cellulitic leg.

The next day it became clear. The film showed pockets of gas. She had necrotizing fascitis. Within minutes the antibiotics were infusing. Within hours she was on her way to the OR. My fellow interns and I lined up at the back of the operating room. It was a particularly slow call day and there weren't any medicine patients to admit.

We watched as the surgeon expertly filleted opened her thigh. First pus and then black necrotic tissue. He took wide margins and then packed the wound. He didn't close up. He knew he would return to the OR multiple times in the next few days.

Miraculously she survived. Even with the delay, we evaluated and treated her infection far faster then the national average. A number of residents gathered at the door the day they wheeled her out of the hospital. Over her three month incarceration, many of us had taken care of her.

*

She bounced in and out of the hospital over the next year. After her original surgery, she developed bouts of intractable nausea and vomiting and would need to be admitted for intravenous fluids. She accepted each visit with serenity and calm. Her children and grandchildren surrounded her in the Emergency Room. It was as if she knew she was operating on borrowed time. Maybe the grim reaper had missed his chance once. But now he was circling in on his pray.

Between hospitalizations she came to see my partner in the residents clinic. She was physically fragile but mentally strong. She beamed as she talked about her family. Her blood sugars were atrocious. She spent most of her time in a wheel chair. But she was happy.

She returned to our clinic one last time. She had just been discharged from an outside hospital. Dangling from her neck was a central IV catheter that someone forgot to remove. The resident cut the sutures free with a scissor. He advised her to bear down as he pulled the length of the catheter out of her neck. She looked up and her eyes went blank. She took a deep breath and then fell over in her chair.

She was dead. Nothing about the next thirty minutes of resuscitation would change that. Father death had found a weakness in the fabric of her life and moved in swiftly. She may have escaped her fate once, but not twice.

*

As the years pass, I often think of her staring up at the resident as she was getting ready to have the catheter removed. An autopsy would later reveal no obvious cause of death.

As physicians, we have much less control of our patients destinies than we would like to admit. Sometimes, we are like a strong wind that blows the hand of fate inches in either direction.

Other times, we are like a gentle breeze bringing momentary relief to the fevered battle front, but rarely making an impact on the outcome.

So we try to be gentle and humble in our dealings with fate.

Often our true power comes not from altering that which we can't control but controlling that which we can.

We offer a kind heart, open arms,

and a devotion to those we serve.

Sentimentality

2011-10-14T18:16:00.000-07:00

I don't know when I lost my sentimentality.

Whaaap

With a thud the fish stops flopping up and down. It lays still on the floor of the boat. My camp counselor, a tanned college student, carefully places the paddle on the seat and cuts the fishing line. The hook remains dangling from the lifeless mouth.

He grabs the fish with his bare hand and throws it back into the water. He talks slightly above a whisper. I don't know if his words are directed at me or into the air.

Couldn't get the hook out of that one. He would have never survived!

*

My son and daughter sit on the curb in front of our house, stunned. The car pulls over as the dog's owner sprints around the corner. She stops a few paces away and screams.

The animal's chest heaves up and down slowly, but he is otherwise incapacitated. My daughter looks up at me quizzically?

Can we call an ambulance? Can we take him to the hospital?

I don't respond at first. The owner is now leaning over her beloved pet. She strokes his head and whispers softly into his ear. She is crying.

No honey. The dog is dying. There's nothing we can do

My son instinctively grabs my daughter's hand. They sit silently and watch as the dog's respirations slow.

I feel a strong urge to cover their eyes and walk them into the house. But I don't. I put my arms around my children and wait.

We all just wait.

*

So you're putting 421 on hospice?

The nurse leans over my shoulder as I write orders. It's been a long day and I don't feel like talking. I'm starting to drift.

Whaaaap

Sometimes I dream that all those fish are swimming after me. The hooks wag back and forth in their mouths as they pull IV poles behind them.

Her primary sent her here to get therapy. She's due for another round of chemo next week.

The nurse persists even though my mind is clearly elsewhere. She's starting to get on my nerves.

You know, most docs let the oncologist take care of this stuff.

Now I'm angry. I growl as I look up at her, but then think better of it. I turn my head back to the chart.

I mutter under my breath...

just loud enough to make sure she understands.

I wouldn't treat a dog that way!

Departures and Arrivals

2011-10-13T17:39:00.000-07:00

The woman sitting across from me is sniffling. Her chin is tucked into her neck, and a small tear barely leaves her eye before she wipes it away with a tissue. She balances her cell phone under her ear. She talks quietly. Her face contorts as she struggles to control her expression. As I watch, I listen to another flight begin to board.

We are in an airport. I can't help but wonder who this poor woman is talking to. I am a voyeur. I turn my head with embarrassment in the opposite direction, but against my will I glance back.

How often does human drama unravel in places like this? Is she breaking up with a boyfriend? Has she just been to a funeral? Did she say her last goodbye to a favorite aunt or uncle who is dying?

*

Sometimes my office also feels like an airport. There are many arrivals and departures. Each person comes on a different schedule. Occasionally many at once. Other times just a few stragglers.

And they bring their baggage. Usually I am more a helper and less a voyeur. I may procure a larger bag or help them rearrange their contents. Often a few things get discarded.

Before long they are running back to the gate to catch their plane. Waving goodbye until our next visit.

Where we will do the same thing all over again.

*

The woman is boarding her flight. By the time she leaves, the tears are gone. Maybe it was simply a bad day. She smiles as she hands her pass to the man at the counter.

And I remain in my chair, waiting. An elderly gentleman is talking on the phone a few seats away. I catch the last few sentences of his conversation.

Shingles....shingles you say.

My Keynote Address

2011-10-11T17:44:00.001-07:00

My son's hand shoots skyward. The teacher appraises the group of students and then motions him to the front of the room. He smiles as he skips forward. All sense of trepidation is lacking. He is aware of the other students, the parents, and the teacher. But he seems unconcerned.

He gently lifts his bow to the strings. The piano starts with an introduction. And he plays. The bow screeches awkwardly at first. A few notes in, he catches his stride. His eyes close slightly.

Seconds later he is finished. He puts his violin in rest position and bows deeply. The crowd claps. He skips back to his seat with a smile on his face. He knows his performance is imperfect.

He doesn't care.

*

Tomorrow I will wake up early and leave my family. I will take a taxi to the airport where I will board a plane to Louisville, Kentucky.

I will attend the Amedysis Strategy Summit. On the second day I will step on stage in front of hundreds of people. My voice will be my bow. My knowledge, my instrument.

And I will play. With a little more trepidation than my son and likely a greater measure of imperfection.

But my joy,

my joy will be the same.

A Brave New World?

2011-10-10T13:51:00.001-07:00

As I walked up the stairs I thought about the history of the building I was about to enter. Although the foundation was the same, almost everything else had changed. The hallways were updated. The patient rooms decked out with comfortable furniture and fancy televisions. I even marveled at the bathroom as I answered nature's calling. I could have been in a fancy hotel.

Yes. Things were different than when I started as medical director. Back then, no one doubted upon walking into the entrance that they were in a nursing home. The five senses exploded with unwanted stimuli. The moans and groans, the smell, and the faded, run down facade.

They were "the good old days". Hindered by appearances, we felt we had to provide excellence beyond compare. The patients were old, demented, and psychotic. But they were ours. The names rolled off our tongues with an ethnic flavor. We took care of our neighbors. Before the boundaries blurred. We were part of the community

There was something about being the red headed step child, the underdog. It created a strange sense of identity. We knew who we were.

*

With an infusion of money, the construction trucks trampled in. The act of breaking ground was an affirmation of survival. But it was also the beginning of a new era.

Staff changed. Our patients changed. No longer constrained by second hand clothes the facility attracted a new clientele. We didn't need the support of our community, we expanded against it.

I looked at my patient roster. So many names were holdouts from a time long passed. But there were also new names. New responsibilities.

It was time for me to say goodbye. I was no longer captain of this boat. My ship had sailed and I didn't belong. It was as if it was I, and not the building that was antiquated.

*

We are entering a new era of healthcare. Old ways are being replaced at a staggering pace. The cracked and crumbling facade of our institutions has given way to the technological marvels of modern day society.

But sometimes I feel like a lonely ship floating in the ocean. As I struggle against the seismic change of tides, I wonder whether I will drift along with the waves or be swallowed whole.

We have changed our outsides. We have slapped lipstick on the pig. But on the inside are we really any different?

Can we, as physicians, survive the new world that is being foist upon us?

Poor Role Models

2011-10-09T18:04:00.000-07:00

He was cocky and arrogant. The kind of attending every medical student feared. I heard the rumors before his arrival. But I was hoping that reality was less harsh then word of mouth. I had only one week left in my Internal Medicine rotation. So far, I received glowing reviews from my residents and attendings. Seven more days and I would clinch the sacred "honors" grade that I needed to be eligible for the top residency programs. A "pass" would just about eliminate all the highly competitive options.

It was the beginning of my third year of medical school and I had chosen general medicine as my first rotation. I was already signed up for the early subinterniship like many of the other students who were entering the field.

As he walked into the resident's room for the first time, I waited cautiously. He scanned our faces briefly before flopping in a chair beside us. There was no formal introduction. No exchanging of names or titles. He nodded at the third year resident and spoke to no one particular.

So what do you got for me?

*

The rest of the week went similarly. He spoke only to the residents and barely looked in the direction of the students. His condescending demeanor dripped with sarcasm and contempt.

Occasionally he accompanied the team to the bedside. He rarely asked the patient questions or spoke to them directly. His statements were curse and robotic.

Unfortunately, he was brilliant. He was able to pick apart a patient presentation and pull out the relevant facts with ease. His skills were adroit. There was no doubt his presence was highly valued by the university. He spent ninety percent of his time in the lab. Likely some administrator relegated his minute clinical duties to the VA to minimize his ability to do harm.

*

On the last day of the rotation he walked into the lounge with a smirk on his face. He would return in the afternoon to watch each student perform a blind history and physical.

My resident scrambled to find an appropriate patient. He looked for someone who could tell a good story, and had a problem befitting a third year medical students fund of knowledge and abilities.

The attending returned later that day and we walked quietly to the patients room. To our surprise, when we entered, the room was empty. She had gone for a stress test.

Looking mildly annoyed, he asked the head nurse for another suitable patient to examine. She, of course, not realizing the purpose of the interview chose a complex medical patient with a rare disease. She thought it would be a good learning experience.

*

The interview was a disaster. The patient was demented and confused. His self described pneumonia was, in reality, a pulmonary embolism. He also had empty sella syndrome.

I absolutely flopped. And to add injury to insult, after I finished the attending performed a superb history and physical and elicited everything I missed.

He later sat me down and berated me for half an hour. He was disappointed in my abilities. That morning he had been ready to give me honors, but now...
*

My final grade for internal medicine was "pass".

Although I aced many other rotations as well as my subinternship, I would not be offered interviews at many of the top residency programs that I applied for.

Years later, as I look back on the experience, I realize that that hour changed my life.

I would never have been motivated to become the teacher that I am today

if I hadn't started with such a poor role model.

Mortally Wounded

2011-10-07T20:11:00.001-07:00

I remember it.

As the call room door closed behind me, all semblance of light disappeared. I felt no guilt about missing rounds. I stumbled to the bed and sat down. Cradling my head in my hands, I waited for the gush of tears. They never came. Neither did the gut wrenching nausea or the searing pain in the chest. Nothing.

I felt absolutely nothing.

And that's when I knew I was lost.

*

I was overwhelmed within the first few minutes of internship. I clutched my stethoscope with sweaty hands as I followed the chief resident from ward to ward. He chattered incessantly listing a series of do's and dont's. I was barely listening.

The nurses bustled to and fro as I loitered by the chart rack. Eventually the chief returned with another resident in tow.

This is Jim. It's his last day of residency. He can't be hurt anymore!

My mind reeled. What did that mean..."can't be hurt anymore". Hurt by whom?

My question never made it to my lips. Jim quickly sputtered off a list of patients for me to follow. He handed me his pager and placed his arm around my shoulder.

Good Luck!

Sometimes, in the lonely moments over the next few years, I would wonder how Jim became invincible.

*

It's not like patients never died before. As a second year resident, I manned the ICU on my own. But this one was different.

Maybe I was a little to cavalier when I decided to intubate. Maybe not. But the damn tube wouldn't go down. And then Anaesthesia never showed up. We kept on paging and paging.

I finally got the tube in and within moments, he coded. We worked on him for thirty minutes.

When I called his wife, she seemed strangely distant. She came at 2am to sign the papers and make funeral arrangements. She didn't ask any questions.

With a heavy heart I worked through the rest of the night. There were too many sick patients to stop and mourn. To process. It was only later that it hit my like a ton of bricks.

*

The first daughter phoned from out of state. She explained that she didn't talk to her stepmother and was wondering how her father was doing. Moments later she was screaming at me. No...no...no.

The second daughter called from the road and would be arriving in a few hours. Her crying horrified me. It never stopped. After a few minutes the line went dead.

I told the last daughter in person.

She collapsed into my arms.

*

I would never hear from any of these women again. But they changed me.

Their grief left an indelible mark on my soul that would last long after residency.

By the time I handed my pager to a brand new intern I was mortally wounded. I was dead.

I guess I couldn't be hurt anymore either.

I Was Still The Apprentice

2011-10-06T05:16:00.000-07:00

Dr. G was like the Jedi master of our residency program. He was board certified in multiple specialities. But it wasn't the training that set him apart. He was just brilliant. An educator at heart. No nonsense. He told you how it was and he was right most of the time.

The residents actively searched for cases to stump Dr. G. We connived to present to him at case conference, something he had never seen before. But mostly we sat back and enjoyed watching the mind of a master clinician at work.

He taught us lessons about being a physician. He hammered us on deductive reasoning. I can still here his raspy voice scolding me in the exam room when I'm struggling to put the pieces together:

Be the detective.

*

While Dr. G could expound on almost any topic, he was known as an expert in one disease in particular: Hereditary Hemorrhagic Telangectasia (HHT). An autosomal dominant disease, HHT was widely recognized among our residents. Patients came from far and wide to see Dr. G in his clinic. By the time I finished training, I treated at least ten patients with this rare problem.

Although years later my mind is fuzzy on the details, every time I see a person with chronic nose bleeds I think of HHT. Often when I hear hoof beats I think of this zebra.

*

I watched in the ER as my patient rolled back from xray. She was thirty five years old and plagued by anemia. She had been admitted to the hospital five times over the last decade for transfusions. She showed up at our door when fatigue and shortness of breath had become unbearable.

The laboratory values confirmed it. She lost quite a bit of blood. Given her good pressure and pulse rate it was likely that this occurred over several months. I introduced myself and started to question her.

As the details unfolded I became excited. Apparently she had nose bleeds since childhood. There was no other cause of blood loss. I examined her. When she opened her mouth I saw a few small red dots on her tongue. Telangectasias! The hallmark of HHT.

As I explained the diagnosis, I informed her that I knew one of the world's experts on this disease. We would transfuse her blood. Have her see an ENT to help with the nose bleeds. If she was willing to travel the few hours to St. Louis, she could even see Dr. G. himself.

*

As the phone rang I felt like I was in residency again. I was calling Dr. G to tell him about another patient. Could I stump him?

After exchanging pleasantries, I informed him that this was not a social call. I had a patient to discuss. I was about to begin with the details when he interrupted me.

What's the patients name?

I stammered. Epi...Mrs Epi Staxis

He laughed a deep belly laugh. I felt small. Like I was a student again.

Another HHT case!

I was taken by surprise.

How...how did you know?

He paused. Well I take care of at least ten different people from the Staxis family! Didn't she tell you she comes from St. Louis?

I felt a growing sense of embarrassment. Dr. G. made the diagnosis without even hearing a single detail of the patient presentation. He was still the Jedi Master. I was still the apprentice.

Didn't we teach you anything hear in St. Louis?

You gotta take a thorough Family History!

What The Undertaker Said

2011-10-05T05:32:00.000-07:00

I bolted upright with the sound of the alarm. The first thing I noticed was intense jaw and head pain. My wife sleepily looked up at me.

You were grinding your teeth again last night.

Thirty minutes later I was in the car half way to the hospital. I rubbed my jaw with one hand as I steered with the other. Damn TMJ. It had come back recently as my stress levels increased. One of the physicians left our practice, and my partner and I had to pick up the slack.

I was on call every other day. Every other weekend. The nursing homes were packed and the phone kept ringing. Not to mention that I had taken on other administrative responsibilities and a few speaking engagements.

And of course my son and daughter were getting older. Each day filled with a new activity for me to supervise. Violin practice, homework, dance class. For the first time I felt truly overloaded.

*

I'm not afraid of death.

The gentleman sat on my exam table with a jovial smile. He was strangely at ease in the doctor's office. I suspect this was due to his fifty years as a funeral director. When you spend so much time among the recently deceased, the specter of illness is less a demon and more an old friend.

He liked to take the last appointment before lunch. Countless times he watched as I raced out of the office to go to the nursing home. He would show up early to give me a little extra time. He was all to aware of my tight schedule.

As I finished my exam, I typed the last few sentences into the emr. I would have just enough time to avoid construction and breeze into my noon lecture. After that, I would visit nursing home patients and then rush home to make dinner, feed the kids, and take my son to violin.

I vaguely listened as he started to tell a story. At the funeral home he had an employee who was always bugging him for a promotion. The employee did a good job but was exceedingly slow. So slow, in fact, that he usually had to stay late into the night to finish his daily responsibilities.

That guy just needs to speed up!

I listened to his exclamation as I tried to nonchalantly look at the clock on the wall behind him. If I left immediately, I could make it in time.

He noticed my glance. Unexpectedly he placed his hand on my shoulder and looked me dead in the eyes.

And you, you kid have to slow down!

I paused. It's not everyday that the undertaker offers unsolicited advice.

But even now, as I quickly put the final flourishes on this blog post before facing the onslaught of patients in my waiting room, I wonder.

Will I listen?

Why I Moved To Private Practice

2011-10-04T05:15:00.000-07:00

Chief of Medicine
Evanston Hospital
October 23, 2005

To whom it may concern,

I would like to take a moment to express my deep displeasure with one of the interactions I had with a physician in the Church Street location. I use the term "interaction" loosely since the doctor in question, Dr. Jordan, never actually saw me. Apparently he was too busy.

Last Thursday I was shopping in downtown Evanston when I felt the sudden onset of severe abdominal cramps. I ran into the nearest restaurant and spent the next thirty minutes on the toilet. After finishing I felt much better and packed up to leave. As I exited the restaurant, I noticed your clinic across the street.

Thinking that this was my lucky day, I entered the waiting room and asked for an appointment. Since this was my first time in the office, I was asked to fill out numerous forms. A few minutes later a nurse brought me back to an exam room.

She asked a lot of questions about my diarrhea and abdominal pain and then examined me. She then left the room for a few minutes. When she returned she explained that Dr. Jordan was the only doctor in the office and currently seeing other patients. The nurse made up some excuse about another doctor calling in sick. He could see me but it would have to be at the end of the day.

My jaw dropped. That would be like four hours later. Why couldn't I see him immediately? The nurse explained that she had evaluated me and my vitals signs were stable. She said my abdominal exam was normal. She then tried to shoo me away by saying that most diarrhea is self limited.

By now I was quite angry. I demanded that the nurse at least give me an antibiotic before I left. I could be dead by the the end of the day. The nurse left the room yet again and returned a few minutes later. Apparently Dr. Jordan felt that antibiotics are not usually indicated for most forms of diarrhea and he would prefer to examine me himself before he made that decision.

I stormed out of the clinic with my mind made up never to return to one of your facilities again. When I got home I took some amoxicillin which was left over from my root canal. I felt better within minutes.

I am lucky I had the antibiotic in the cabinet or I could have become very sick. I believe Dr. Jordan is a horrible physician and he brings down the quality of care that you are trying to provide. I hope you work to correct his attitude!

Sincerely,

Disappointed Customer

Written in neat cursive on the side of the letter was a note from an administrator:

Dr. Grumet. Can you please call this patient and apologize. We definitely handled this one wrong.

My First Patient

2011-10-03T05:57:00.000-07:00

It didn't really happen in the beginning. The atmosphere of awe and mystery was too great. In fact we barely spoke a word those first few sessions. Half the class was buried behind their books while a few students clutched at their scalpels wildly. I made a point of being the first to place blade against cold leathery skin.

As time passed, however, familiarity cut through the tension much like our scalpels. The air of humility was replaced by the buzz of students busily working through their lessons. The quietness was interrupted by voices: some laughing, some arguing, and others carrying on everyday conversations.

*

The inappropriateness was subtle. One day it would be a classmate holding a dismembered limb up to his own body. Or occasionally a group of students would gather around a tank to stare or snicker at a particular body part.

although, on the outside, we each had come to terms with the gruesome act of dissecting the human body, a process of internal hardening had begun.

I disdained my classmates for their lack of taste. I cowered in the corner with the dissector pretending not to notice. Ever dour, I was building my own walls of protectionism but I chose a slightly less infantile route. I abandoned the scalpel and retreated behind the anatomy primer. I would direct the dissection from afar. My hands would not get dirty.

*

There were days in the anatomy lab that seemed to last forever. The students developed back and shoulder pain as they huddled over their tanks. Their were a number of finger sticks. We all carried our scars.

The physical discomfort paled in comparison to the emotional. We didn't like to talk about it. But sometimes, in the middle of a session, the whole mood of the room would change. We sat helplessly as the whirr of the bone saw cut into our cadavers pelvis. The fetid smell of singed bone filled our nostrils and we wanted to vomit.

We carefully dissected the genitals in pure silence. For some, it was the idea of physical discomfort that made them wince. For others, it was the total obliteration of all semblance of privacy. There is a certain amount of human dignity that we expect, even for the dead.

*

My hardest day in the lab came towards the end. As we entered the room, we were confronted with the most human of body parts...the face. I found myself handing the dissector to my tank mate and grabbing a scalpel. It was my first foray into cutting since early in the semester.

As I started to peal layers of skin, I thought about the lady whose body laid below my fingers. I knew so few details. Just some demographics.

As I came to the cheek muscles I wondered how they contracted to form a smile when her grandchild walk into the room. Or how here eyes, now dead and distant, would shine when she was happy. How her tear ducts would create moisture when she was sad.

As the hours passed my neck grew stiff. My joints grew tired. A tank mate had offered to take over but I resisted. I couldn't bare the idea of someone else doing such a horrific and personal task. Certainly not one of those who had previously made fun of the cadavers.

As I finished the dissection my nose began to run underneath my mask. My eyes were tearing. I excused my self and ran to the bathroom

By the time I returned the tanks were closed and the room was empty.

*

She was my first patient.

I tried to give her in death that which I couldn't provide in life. I attended to her with the sanctity and dignity necessary for such an intimate task. To me she was a person, not just a bundle of bones and tissue.

I left the gross anatomy lab that day with a promise.

I protected my patient in death.

For each person who walked through my exam room doors in the future, I would work equally hard...

to protect them in life.

Are You Listening?

2011-10-01T20:19:00.000-07:00

I did what all good interns would do in the same situation. I rolled my eyes in the direction of the ER resident and waited for his response.

You have to be the sieve....the sieve.

We all did it. Stonewalled the ER in hopes that they would send our new admission packing. It rarely happened though. Somehow each admission always made it up to the floor. There was no turning back once the papers were filed and the bed was assigned.

Scottie was no different. His twenty year old body was fit and lean. His chest moved up and down in a rapid rhythm. I took my time examining him. As we talked his respiratory rate slowed. I placed my stethoscope on his chest. Maybe a few wheezing sounds but I had my suspicions that they came from his neck and not his lungs.

The paperwork classified him as an admission for asthma and bronchitis. My resident and I were doubtful. Scottie wanted, not needed, to be in the hospital. We just couldn't figure out why.

*

I spent the next three days trying to convince Scottie to go home. By day I would find him sleeping in bed with the covers pulled over his head. At night he awoke. His cell phone dangling from his tattooed arms. He teased the doctors and nurses. He convinced the dietary staff to bring him extra portions. He was king of the ward.

His charm was his greatest weapon. He smiled. He cajoled. He begged. But as another call day was approaching, my resident and I became more stern. We had to clear our census for the next onslaught of patients.

As I wrote the discharge prescriptions, Scottie tried again.

If I leave today I'll die out there. I just need more time!

By now I was immune to his pleas. His lungs sounded great and he was ready to be discharged. He pulled his hat over his eyes and his pants fell low on his waste. A few of the nurses gathered to wish him well. They whistled and catcalled as he disappeared through the hospital doors.

*

A few days later I was paged to the ER at three in the morning. As I yawned and rubbed the sleep from my eyes, A man dressed in sports coat approached from the door. He wore a cowboy hat and boots and I could see the outline of a gun tucked behind his coat.

He introduced himself as a detective from the St. Louis police department. He reached deep into one of his pockets and produced a tattered piece of paper. He held it up in front of my face. I squinted to read the writing. It was a set of discharge instructions with my signature at the bottom.

We found this in Scottie Pearson's back pocket. He was shot in the head and dumped in a field.

*

Scottie's story quickly spread among the physicians in our program. Everyone had a different idea of why he was hiding out in the hospital. Was it drugs? Gangs? Organized crime? A love triangle?

For many, Scottie became another memorable book mark in a series of odd and difficult experiences that marked our years in training. But as I get older, I think more about what he really had to teach me.

As so often happens in our lives, Scottie was trying to tell me exactly what he needed. Although I heard his words, I kept trying to interpret them based on my own point of view. Clearing my patient census for my next call rotation was more important to me then keeping him in the hospital. Sure I justified my actions by saying that he was healthy. But I never took the time to step outside of my own space to understand his.

Whether professionally or personally we all express our deepest needs to the people around us. Years ago, Scottie was trying to tell me his.

I just wasn't listening.

The Ties That Bind

2011-09-30T05:15:00.000-07:00

I saw a familiar face amongst the crowd of children dusting the snow off their boots and replacing them with soccer shoes. My wife and I stood in the corner and watched our daughter run into the middle of the gym and socialize with a group of little girls.

As the woman approached I realized she was a former patient. After a brief exchange of greetings her eyes opened wide and she developed a lump in her throat. She turned to my wife.

Your husband saved my life!

She then excused herself to fetch her parents who were helping her daughter get changed for practice. She wanted them to meet me.

*

I will never forget the early morning during residency when I struggled into the hospital with the stomach flu. Between each patient I had to run to the bathroom to vomit. It was one of the hardest days of my career.

Or the time when one of my fellow residents showed up for a weekend on call yellow. Literally yellow from jaundice. It took several hours to convince him to go to the emergency room. Fortunately it was just a bad case of Mononucleosis.

So when Sheri arrived for her ICU shift with a severe headache, she sucked it up like everybody else. As the night progressed, however, she knew something was wrong. Her vision became blurry. Her speech started to slur.

The nurses put her in a wheel chair and sped her through the maze of passages to the emergency room. Upon arriving she had her first of several seizures. Two weeks later she would leave the hospital for a rehab facility with a diagnosis of terminal brain cancer and a fresh scar on her head to prove it.

Sheri struggled over the next few months. She measured life's ups and downs with little triumphs. By the time she walked down the isle with her long time boyfriend, she used only a cane.

A year later she was rounding with the rheumatology consult service. She was no longer a resident but she didn't want to abandon her life's work. She missed every other day for chemotherapy, or radiation, or doctors appointments.

Her life had been extended but her clock was still ticking.

Each resident regarded Sheri in a different manner. Some ignored her. Others acted like nothing had happened. And some of us struggled to treat her as if she was anyone else going through something horrible. We walked the tightrope between caring and melodrama.

After leaving residency I would never hear of Sheri again. A decade later I assume she is dead.

*

As the soccer game began my wife stood by my side smirking. She knew how uncomfortable I was with public recognition.

After all, I didn't really do that much for the woman. She came to me with a mild case of post partum depression. We talked about medications and therapy. But mostly we just talked. I was also a new parent. Like her, I was exhausted and overwhelmed. I was tired all the time.

For brief moments, during our visits, we felt like fellow soldiers in a an arduous battle. Apparently, for her, the personal connection did more then medications or therapy could.

And I thought of my residency program. I thought of my years as an attending. As physicians we spurn our own personal illness as if it does not exist. We stand above it as if we are superhuman. Our patients may get sick but not us. We try to lift ourselves out of the fray.

But what if our own mortality serves a purpose?

What if our frailty is neither embarrassing nor an Achilles heal?

Maybe. Just maybe.

It is the tie that binds.