Saturday, December 20, 2008

The Day I Lost My Confidence

I brace as the sheets of white assault my car. My foot on the clutch sways with each loss of traction. The clock reads 5:30 or some ungodly hour. The roads are empty except f0r the occasional companion that passes in the early morning darkness. My mind is distracted. The forecast is bleak. Snow all day. The department of streets and sanitation has released a travel warning and suggests staying off the roads.

Why not work from home? Call into the office? Not exactly an option for a physician. The patients in the hospital can't be cancelled. I can't just wait to see them the next day. And then there's the expectation. That I will be available. Even on the worst of days. I'll be there...Just call. I'm not sure if the unreasonableness is theirs or mine.

And my brain races back. To a year ago. On a morning like this. Before the snow plows. Hurrying to make it to the hospital for who knows what. Just a few blocks from the office. On the expressway. When I lost control I thought I was going to crash into the barrier. But then to my complete horror the car skidded in the opposite direction. I had just moments to contemplate before I hit the semi. Luckily in the back. And then I swayed to safety to the side of the road.

Unscathed...physically at least. But a year later I 'm still a little skittish. Moment by moment trying to recover.....from the day I lost my confidence.

Wednesday, December 17, 2008

The Caregiver Phenomena

A thought gelled in my mind today which has been subconsciously stirring for years. I was seeing a 90 year old women who came to the office accompanied by her daughter and caregiver. She had not been feeling well for the last few weeks. She was coughing, having chest pain, and generally feeling under the weather.

The patient didn't look sick. In fact she looked pretty good. She even voiced that she felt OK. The daughter agreed that her mother was looking fine. The only one in the room who seemed in disagreement was the caregiver. The caregiver described how her charge was getting worse and failing to turn the corner. In fact I could almost predict the care giver's responses to my questions before I gave them. Basically for any open ended question there was almost always a negative response suggesting that the patient wasn't doing well.

I have known this caregiver for years. And she does a great job. Very attentive, loving, and hard working. She is present for every cough, and sneeze, and complaint. She works tirelessly long hours. So what gives? Am I and the daughter missing something significant or is the story from the caregiver not exactly accurate? And if it's not accurate then why?

While pondering this question I quickly realized that I encounter this type of behavior regularly. In fact I often find myself going to great lengths to corroborate information given from caregivers. My experience has shown that they often overstate or occasionally exaggerate their charges complaints. In the beginning of my career I took these reports literally and found myself over treating: ordering too many tests and giving too many antibiotics.

I have coined the term the caregiver phenomena to describe this type of behavior. I suspect it stems from two different causes. First, the caregiver who is not medically trained, is often present for every complaint and is afraid that something bad will happen during their watch. They are terrified of missing something significant. Second, I believe the caregiver is often the one who blows the whistle by alerting the family and thus initiates the actions that eventually lead to the doctors visit. Many caregivers feel pressure to justify the visit by making sure the doctor knows the levity of the situation.

Whatever the cause of this effect I feel that most caregivers are genuinely interested and preoccupied with performing their job well. But I now consider the caregiver phenomena when ever I interview an elderly patient.

By the way thanks to Tracy for this. Even if all my ten readers vote for me it still wouldn't be enough!

Sunday, December 14, 2008

Inside The Examining Room

The elderly gentleman limps into the examining room. His 89 years etched into his gait as if each day delivered a small but crippling blow. His callused hand grips mine briefly but with the confidence of experience.

He didn't trust me. At least not in the beginning. I could have spoken his first words before they left his lips....I generally don't like doctors. But pain is a strongly coercive force. He spent the first few visits feeling things out. But over time he learned to confide in me. And as the protective layer of fear and angst were discarded...the humanity came through.

He was having surgery. The orthopaedist had convinced him he needed a new hip. My litany of questions were usual. I left short pauses for him to answer. No chest pain. No shortness of breath. Good exercise tolerance. No tobacco. And alcohol.....I quit years ago!

His answer was unexpected. I pictured him the kind of guy who lived hard...and drank hard. A generalization.....but generalizations got your far in the doctor business. I knew I shouldn't have asked but I couldn't help why did you quite?

He took a moment to collect his thoughts.

It was the forties. I and a bunch of buddies worked for a company that put up television antennas across southern Illinois. It was the early days. A new technology. I left my wife for months at a time.

We worked all day in the sun during the summer and in the cold in the winter. They were long days. After work there wasn't much to do. We usually left early and went directly to the bar. Often not taking time to eat dinner. And we would drink. Well into the morning. Then get up a few hours later and go back to work.

It was the same thing six days a week. The same fellas. The same bar. The same drinks. I was wasting my life away but I can't say I minded. We didn't know any better. It was just what we did.

So one day I walk into the tavern in a bad mood. It was something insignificant; I can't remember why now. The owner, Charlie, was standing behind the bar in a full hunting suite. He had a brand new expensive rifle. And he was holding up a picture of a ranch. He bought it for his wife and kids.

And there I was eking out this existence. Sharing bunk bends in a dirty motel. My wife and I barley able to afford our apartment. And I was pissing away my money getting drunk. That son of a bitch... I was paying for his four star ranch and his shiny rifle.

So that was it.

That was it?.... I repeated

That was it....never took another god damn drink again!

Friday, December 12, 2008

In Memorium

My whole life I have been immersed in a world of words. Not just meaning but sounds. The cadence of a sentence. The emotion behind the basic structure. I have surrounded myself with diversity. Often associated with people who don't look like me. I grew up sitting at tables where the language spoken often wasn't my own.

It never bothered me. I would get lost in the rhythm of a foreign tongue. Picking up on the nuances and facial expressions. Missing the exact definitions but understanding the meanings. The better I knew a person the more I could piece together. There was always more in common then not. One had to look for it.

Recently I accompanied my wife and children to a relative's house to mourn the loss one who had recently departed. As we entered the women and children were directed to one location and I was shuffled off with the men to another. The room was solemn. Twenty men gathered dressed in black. Many bearded. I immediately felt a stranger in a strange land. My hand absentmindedly pawed the top of my head were the ritualistic covering was glaringly absent.

I socialized with many of these men a dozen times over the years. Separated by foreign birth and a religious orthodoxy I had never felt much kinship. American born and uninterested in religion I was more like the foreigner.

The conversation started with a deep philosophical discussion of Jewish law and culture. The Rabbi in the center of the room paused between points. Intermixing Hebrew and English. The gentleman sitting next to me noticing my discomfort whispered softly in my ear, "It is only after years of studying Jewish law that you can have such conversations!"

The words took form and shape in front of my eyes. They were no longer English and Hebrew but musical notes dancing through the air. The rise and fall with each pause as the Rabbi spoke. The room moved in unity. Chests filled with air and then exhaled. Release and expand. Release and expand.

Yit'gadal v'yit'kadash sh'mei raba....

The men of the room had now stood and were reciting the Mourner's Kaddish or Jewish Prayer For the Dead. And suddenly I was transported back to childhood. My mother, brothers, and I are in temple. It is my father's yahrtzeit (anniversary of his death). I must be about ten years old. Every year we made the trip to temple on this particular week.

Most days we lived our lives as if nothing happened. But on this day. We came to temple. We remembered. The service always felt unending. Standing up and sitting down. Standing up and sitting down. My brother's and I distracted ourselves the best we could. Making funny faces....playing silly games. Anything to pass the time.

But then the Rabbi would clear his throat and boom from the lectern, "And now let us remember those loved ones who have passed this week...". He then recited the mourners kaddish followed by a list of congregation members who had died. Our ears perk up and we wait to hear my father's name. And then we leave the synagogue shortly thereafter.

I awake from my reverie. the group of men have now finished praying and are chatting comfortably amongst themselves. I long to join my wife and children in the other room. I scan the faces around me. We are so different. For them, religion is their life. For me, my life is my religion. Yet it dawns on me that we share common bonds. Our words may be different but we all experience happiness and pain. We all mourn...

And when wounded we all bleed the same.

Tuesday, December 9, 2008

Some Thoughts on Quality

Recently in response to a post (somewhat tongue in cheek) about renaming primary care physicians "prehospitalists" Mathew Mintz commented:

Don't like it. Pre-hospitalist implies that everyone will eventually go to the hospital. Though we certainly do our best to prevent patients from needing hospitalization, this doesn't capture the bulk of what we do: screening, prevention, counselling, chronic disease management,etc.

Mathew's comment really made me think. While he is right....keeping people out of the hospital does not describe the bulk of what we do. He misses the point. Our ability as primary care physicians to cut down on admissions may be the single best indicator of physician quality.

The physician who keeps his patients out of the hospital probably:

Is an excellent diagnostician
Manages chronic disease states well
Is timely
Calls his patients back promptly
Likely is highly active in screening and prevention
Sees urgent appointments on the same day

The list goes on and on. Sure there has to be an adjustment for patient age, socioeconomic status, and overall health of the patient population (a clinician who treats esrd, end stage copd, end stage cad...will have a higher hospitalization rate then others).

But I like hospitalization rate as an overall indicator. It certainly is hard to game this one...unlike the other quality indicators that have been used (a1c, colonoscopies, etc.).

So what do you think?

Sunday, December 7, 2008

When Passion Meets Talent

There is a moment in some peoples lives were god given talent and passion mesh to create something beautiful and unique. Those who are lucky enough to experience this rare gift have a special power. The power to change the world.

I was born thinking medicine was my passion. From the earliest ages I can remember wanting to be a Doctor. I have no idea where it came from. I have no idea how it grew. But it was my goal. It was my dream. Most of my waking moments were consumed by it. It didn't matter that I had a learning disability. It didn't matter that I almost had to stay back a grade. All hurdles were temporary. All surpassable.

And so I spent my youth on this goal. I expended countless sums of money. Studied for hours without reprieve. Worked excessively long shifts without sleep. I did whatever it took.

And I succeeded. I finished medical school and residency and began living my dream. But something was missing. Maybe it was the paperwork. Maybe the sadness of watching people die and being helpless. Maybe the anger so commonly directed towards physicians which often felt unjustified.

Being a physician no longer ignited longer set my heart on fire. But something did. Strangely and unexpectedly it was writing. First poetry and then stories. It would wake me up in the middle of the night and force me to turn on the light and jot down a word or phrase so that I wouldn't forget in the morning. And I was least sort of.

Friday was a perfect example. In the morning waiting for me in my in basket were rejections from four publications refusing my poetry. They all came on the same day. I can't say it was unexpected. Anyone who has submitted poetry for consideration knows that rejection is just part of the process. You have to develop a thick skin they say.

So I was down as I made my way to the hospital. One of my partner's patients had been in and out of the inpatient service for months. She was a mystery. Several hospitalizations, and specialists, and cat scans later my partner still wasn't sure what to do with her. As I reviewed the data and finished my examination everything clicked. I knew that I caught something that everyone else had missed. So I made a few changes and added a key medication and within 24 hours she was better. It might take some time but I know she will recover.

On my way home yesterday it hit me like a ton of bricks. I always say that each person has a gift and if we are lucky we find it while there is still time to act. For years I have been searching for my gift. I was hoping it would be poetry. In reality it isn't. It's medicine....medicine is the one thing I am truly gifted at. Medicine is what I was meant to spend my life doing.

I am the luckiest man on earth. I have a wonderful wife and children. I have a job and enough money to live. And now I have found my calling. My one offering to humanity. But sadly....somewhere in the process after all those years of yearning, and striving, and working...I've lost my passion for it.

Gift and passion. Passion and gift. Somehow they've missed each other so far in my life. But what if....what if for just a moment I could realign them again.

Oh the the things I could accomplish!

Wednesday, December 3, 2008

The Slow Down

Its happening again. I'm entering my second year of practive in my new location. And strangely....unexpectedly...I'm finding myself not very busy. In fact if I look back at my schedule I was busier six months ago then today. This really worries me. Surely I have more patients now then I had six months ago. In fact I usually see at least one new patient every day if not 2-3. So what gives?

At first I thought maybe its just the economic slow down. Maybe people don't want to pay their copays. I guess thats possible. But at least 50 percent of my patient population is medicare. They don't have copays. Then I thought maybe people are leaving me. That I am being ineffective. But we haven't recieved any record transfer forms. In fact a number of patients have moved considerable distances but still come back in town to see me.

Now that I think about it the same thing happened in my last practice. Coming out of residency I joined an internal medicine group that I stayed at for five years. Over time I accumulated about 2000 patients and was one of the busiest doctors in the office. But the truth is....the same thing happened there also. 2-3 years into it my numbers went down. My hospital census plummeted to one patient a week (after maybe having 2-3 patients in the hospital on a given day).

So what to make of all this? Previously I made up for low numbers by covering the other docs in the office. Although I saw more patients then any of them, I also would see most of their overflow. There were 5 more senior doctors in the same office who provided a steady stream of acute visits.

In my current practice there is only one physician more senior then I. So I really don't get much overflow. I still see my partners patients in the hospital...this keeps me a little busy. And for the first time in my life I am going to nursing homes and have taken on a medical directorship.

Maybe my patients just aren't that sick. I guess thats possible...but I have a huge medicare population. In fact....occasionally I have days where I see 4-5 patients in the office on the same day who are in their nineties. One of my biggest referal sources is the local nephrology I have more then average number of dialysis patients.

I guess in my heart of hearts my hope is that I am slowing down because I am taking good care of people. Because I am catching disease earlier, treating it more aggressively, and keeping them out of the hospital. Becuase I am getting my dying patients enrolled in hospice so they can die at home.

In other words....I think my patients are needing me less and less each day. Gratifying...but bad for the bottom line.

But who knows...I could be wrong....maybe I am just pissing people off and they are leaving me!

Monday, December 1, 2008

A Dirty Rumor

There is a rumor out there. And it says that primary care practicioners are running up the cost of medicine. That they have been squeezed so tightly by busy schedules, paperwork, and short visit times that they have become careless. More on this in a moment.....But first a story.

A young lady enetered my office 6 months ago for a physicial. Among other things she was having trouble swallowing. She felt food would get stuck. She was healthy. No weight loss, her symptoms were intermittent. So I questioned her, examined her, and carefully explained my thought process. Given that there were no alarm symptoms we decided to start with an acid reducer for possible reflux and a promise that if she was no better after two weeks she would call and I would send her for a barium swallow.

Months passed and I heard nothing. Then last week she walked into my office crying. She did not try the acid reducer. Instead she went to see an ENT (Her PPO allowed her to go without a referral). The ENT did a scope and sent her to a speech therapist for a swallow evaluation. The speech therapist did a video assisted swallow study and was convinced the patient had a mass in her pharynx. She then sent the patient to another ENT. Who scoped her again and sent her for a ct of the neck. When those were both negative he scoped her one last time for God knows what reason.

So she returned to me, crying, anxious, and having even more frequent difficulty swallowing. So I again suggested an acid reducer (which she promised she would take) and an anti anxiety medication and hopefully she will see me again in a few weeks. And if that doesn't work I'll either do a barium swallow or send her to gi for an egd. The right workup that should have been done in the first place. I bet, however, she won't need it. I bet her symptoms will be gone by the next time she sees me.

So back to that rumor. You can argue that internists consult too much. That they send patients for too many tests. But as my story illustrates....specialists do the same thing. You see...good doctors treat disease expediently and cost efficiently. Bad doctors don't. It has nothing to do with a percieved time crunch. Give primary care doctors more time....the good ones will still do a good job, the bad ones will still do poorly. Period!

It's not a time issue ias much as a quality issue. The harder question is how do we reward quality!

By the way...I think PCP's could benefit from more time with each patient. I just don't think economic ramifications will be as drastic as most think.

Saturday, November 29, 2008

I'm Rebranding

That's it. I'm taking a tip from the hospitalist movement. I'm rebranding. I'm no longer a primary care physician. "PCP" now seems to be synonymous with overworked, underpaid "loser" who at least by some people's opinions aren't carrying their weight. That's not me.

So starting today I will be known as a "PREHOSPITALIST". That my ticket. I see patient's before they get to the hospital and try to divert them before they get sick enough to be admitted. I see the sickest of the sick. End stage renal disease, transplant patients, double transplant patients, end stage copd, end stage chf, end stage anything, and frequent fliers.

Send them all to me. Send me your hardest patients. And I will bend over backward to keep them out of the hospital. I will see them weekly. Daily if I have to. I'll manage them aggressively. I'll return their phone calls promptly. I'll fit them into my schedule at a moments notice.

And I will manage them. Comanage them with their specialists. In fact I will call the specialists so often to discuss management that they will be sick of me. But I will cut their hospitalization rate down by 75 percent. And they will get better. And utilize less resources, and thrive.

Yet I will still see healthy people. And do annual screenings. And make unexpected diagnosis. And while I may not be an expert in any field I will still know enough about most fileds. And when death comes I will be there to comfort. And to advise. A jack of all trades.

And I will be what used to be known as an internist. Or a pcp. Back in the days when those titles garnered respect. But don't you dare call me that now! I am a "prehospitalist" to you bucko. And don't you forget it!

Wednesday, November 26, 2008

Happy Thanksgiving!

Blog break for the holidays...Happy Turkey Day!

Monday, November 24, 2008

My Weekend

It was another weekend on call. Filled with the usual phone calls, hospital work, and Saturday clinic. I dread weekend's on call. Mostly because they take me away from my family. There is also, ofcourse, the lack of sleep. Getting up at 5am on Saturday is no fun. But this is what I do. Every third week. It is what it is.

My call, at least, this time was brightened by the morning clinic. I was a little bit less busy then usual so had more time to talk with my patients. A rare luxury, I like to take advantage of extra time when I get it. My first two patients were a man and a wife in their eighties who live in a local nursing home. After going into the regular littany of medical questions I started my exam. While taking blood pressure, stethoscoping, pushing and pulling.... curiosity got the best of me. I started in with the personal questions.

"So how long have youy been married?....How many kids to do you have? Grandkids? Great Grandkids? where did you both grow up?". I am always amazed at how much I learn from people by asking these type of questions. And as usual this couple surprised me.

I would have never guessed it from looking at them...but they had been only married for fifteen years! Apparently they had met in their teens and at the tender age of twenty she had refused his marriage proposal. Years passsed. They both married other people and had kids, they both got divorced. And forty years later after minimal contact he picked up the phone and called her and they realized that they lived blocks away. The rest was history.

A little later in the day I saw another patient who was relatively new to me. I had seen her only a few times for minor problems. Each time she came in accompanied by her daughter. And each time I kept thinking that I somehow had met her daughter before. But I just couldn't place her. As my patient was preparing to leave her daughter mentioned that, "oh by the way mom will be on TV next week!" And that's when it dawned on me. Her daughter looked familiar becuase I had seen her before...many times in fact, she is on a TV show I occasionally watch. How funny! I didn't even recognize her.

I guess it just goes to show that even a monotonous, boring, weekend on call can turn out to have some surprises.

Friday, November 21, 2008


It all starts with a sparkle.

As if the devil himself had placed just enough mischieviousness in your eyes to be bitter sweet. The sparkle evolves into a comet of bright white light sweetening your beautiful brown skin soft and smooth. Your lips part. The lower hiding your teeth while the other curls upward. Your face and body radiate, brightening the room and releasing all unwanted thoughts that dwell in my mind. And those word return. Filling my soul. Over and over again....

I love your smile

Tuesday, November 18, 2008


Early morning

The exam room.....

When I look in the mirror

A stranger stares back at me

How so?

The face is not mine

The eyes are too far apart

The left higher then the right

and the lips are too close to the nose

Could it be that you no longer recognize yourself?

And when I walk

Everything is leaning...

roads, sidewalks, people

Has your life lost balance?

And my chest

Every time I think

or worry


Is it your heart that hurts? Has the sadness consumed you?

And sometimes


when I'm alone

I talk to myself

Like you have not a friend in the world?


And then a knock on the door


"Yes?" I respond awaking from my reverie

"Your first patient is here....

shall I send her in?"

From the chapbook Primary Care, The Lives You Touch Publications


Here's something you won't here your physician say everyday.....I hate hospitals!. I hate emergency rooms! I hate when my patients are sick enough to need emergency care. I hate when they get admitted.

Why...because hospitals are dangerous places where bad things can potentially happen and bad bugs hang out. It's a place for sick people...really sick people...deathly ill people. And I don't want to ever let my pateints get that way.

As I am fond of saying in my office...If you find yourself in a hospital you better be one of a few things....either really ill, visiting a friend, or at work. Because it's not the place for the kinda ill or sorta ill. Only bad things can happen to these people.

So if you call me in the middle of the night and expect that I'll tell you to go the the emergency room for your got another thing coming. Or if your an emergency room doctor and you want to admit my 50 year old patient with bronchitis....I'll probably give you a hard time.

It is my responsibility to protect my patients from the harms that they don't recognize. And let me repeat this to make it clear....the hospital is a great place if your on the cusp of dying.....but incredibly risky for everybody else.

Monday, November 17, 2008

My First Medical Blog Post (classic post)

This is a little bit long...but this is what started my medical blogging (around 2005?):

We tell ourselves the stories about our lives that make it bearable….our better yet magical, mystical.

When my father died unexpectedly, when I was seven, I had no words or 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 unconsciously formulated the answer to this question. You see…my father died when I was seven years old. At this age, he was my idol. I wanted to be just like him. I copied his movements, his words, and of course I wanted to be a doctor too. My father was a highly respected oncologist and often treated the sickest people. He had received many accolades as well as the love and respect of his patients.

I figure, if he had lived longer, I may have outgrown this period. Maybe I would have reached an age where we fought more or I might have become disillusioned with him. Maybe I would have changed my mind and wanted to be a sports star or a policeman. Who knows? The point is this idea of being a doctor stuck with me. And it carried me.

It carried me through a learning disability; it carried me through a move. It carried me through successes and failures. It created a confidence that never questioned if…only questioned when.
That story made sense. My father’s death, tragic as it was, made concrete in me the idea of becoming a physician. And by doing this I would carry on the tradition and touch countless lives. From his death would come rebirth and renewal. I would help people….I would save lives. I would turn my sadness into good and beauty.

It almost pains me to read this last line. If I had known then how far this was from the truth………………………………
When I started residency training in July of 1999 I felt relatively confident. After all, this is what I was meant to do! I showed up to work early the first day. As luck would have it, I was on call. What this meant is that my first day of work would last 36 hours with very little sleep. The chief physician brought me to the third year resident who was handing over his patient’s to me. This was his last day of residency. I will never forget the phrase my chief used when introducing him. He said, “This is John, your taking over his patient’s. Today is his last day of residency. He can’t be hurt anymore!” My thoughts raced…what do you mean “can’t be hurt”? Who was hurting him? It took me about year before I understood what this meant.

In the second year of residency you learn what it feels like to be independent. You do a minimum of 2 months in the ICU where you function without direct supervision. Of course, during the day there are ICU attendings and fellows to help but at night you are on your own.
One night early in my ICU month I was faced with a situation that changed my life. One of my patients had severe respiratory problems and required to be placed on a ventilator. He was an elderly man and we weren’t completely sure of what was wrong with him. I paged the anesthesia person on call to help me intubate him in case I had problems and then I got started.

But things went terribly wrong. I couldn’t get the endotracheal tube in! I kept trying but it was useless. Furthermore, the anesthesiologist never came. We paged and paged but he didn’t show up. My anxiety started to rise. As I placed the mask on the patient’s face and delivered life saving breadths, I felt out of control. I could feel the confidence leaving. I struggled for a few minutes and finally another resident was walking by the ICU and came in and helped. After flailing for about 15 minutes we finally got the patient intubated. Within in seconds his blood pressure dropped. We started CPR and injected epinephrine without benefit. The heart monitor went flat…..and within minutes he was gone. I held back the tears and rehashed every moment. Had I moved to fast to intubate him? Had I deprived him of to much oxygen while fumbling to get him on the ventilator? Did I over sedate him? I will never know the answer to any of these questions.
The rest of the night was a blur. I didn’t sleep a wink because I was so busy with my other patients. The man’s wife and family came and went. They didn’t seem to have many questions. It wasn’t till the next morning that the phone calls started to come in.

You see…the family was his new wife and step family, he also had three daughters who were unaware of what had happened. I took three calls that morning. I told three young women over the phone that they lost their father. I listened patiently as all three broke down on the phone. I listened to their moaning and wailing. I remembered what it felt like to lose my father. Each call lasted less then 5 minutes. I never met these women in person. I never spoke to any of them again. Each one of them has left an indelible mark on my soul. I have never experienced grief so pure or innocent. And I will always feel responsible for that grief.

And this is what that resident meant by being “hurt”. If you practice medicine long enough you will make mistakes. You may accidentally hurt people. You will work long hours and deal with the bassist human emotions. At some point you either learn to sublimate, learn to move on, or get crushed. When you say that someone can’t be hurt what you are saying is that they can work 36 hours in a row without sleep, deal with not only the annoyances of hospital life, but also the shear fear and sadness, and still at the drop of a dime make critical decisions involving peoples lives. It also means that you learn how to be hard, learn how not to cry. Your drop your emotions and sentimentality to survive. You change who you are.

When I became a physician I unwittingly made this sacrifice for the possibility of the shear good that I could accomplish. I could deal with the stress, the sadness, even the culpability for people’s lives, as long as there was a pot of gold at the end of the rainbow. I could give up the tenderest side of myself, in order to carry on as a physician and not get squashed by my experiences. During residency there really was no place for tenderness!

So that day, in the ICU, amidst the phone calls and the 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. At that point I didn’t realize that I was lost and that I wouldn’t feel like myself for many years. In fact, I found myself again October 25th, 2004. The day my son was born……..
The rest of my career has been rather mundane. I left residency and joined an internal medicine practice. My days are straight forward. I cram as many patients into as few hours as possible to stay afloat. The malpractice crises is a constant worry. Malpractice prices go up. Physicians are forced to see more patients in less time to cover overhead. The quality of care goes down. There are more law suits…..and the circular trend continues.

People are less happy with their doctors. I often find my patients to be angry and distrustful before they even meet me. There is a constant barrage of paperwork for what seems to be useless reasons. I am constantly being questioned by insurance companies on why I am ordering certain tests and whether I am making the right decision. I so rarely feel like I am helping people!

Physicians are also changing. Because of the poorer income, decreased respect in the community, and family obligations…..they are becoming less responsible for their patient’s well being. The days of your physician meeting you at the emergency late at night in times of need is gone. Most young physicians believe that after the work day is over….their patients are someone else’s concern.

And I believe I would have been okay with this except my world radically changed on Oct 25th, 2004. When my son was born I became a different person. When I looked into his eyes all the barriers that I had erected since that horrible day in the ICU came down. I had found myself again. After years I could feel the warmth return. I could cry again. I could love again. I didn’t have to protect myself any more.

So why was I staying in medicine? It clearly wasn’t making me happy! 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 does this say about the state of healthcare today? I had come into this profession with the hopes of helping humanity. I had trained at some of the top institutions in the world. I had received various awards both for academic rigor as well as patient care. I was considered bright, caring, and hardworking. These are qualities you would suspect would make a great physician. But they don’t! And that is the problem.

The story that I told myself about my life had changed. My father’s death had brought me to a profession which I eventually would not like. As my son was born I would come to this conclusion and leave medicine. I could change in time to teach him what is really important. And change I surely had.

But in my heart of hearts, I really tell myself a whole different story. Maybe I truly was meant to be a physician and help humanity and that it wasn’t me at all but medicine……. medicine that had changed.

Either way I realize it is time to change my way of thinking. Who I am and who I will be was neither a result of my father dyeing nor that horrible night in the ICU. It’s time I stopped looking for a cosmic truth in my father’s death and accepted it for what it was….A sad tragedy that will neither define me nor hold me back. It’s time for me to take responsibility and embrace….

Who I have become.

Saturday, November 15, 2008


Diving into the
The bodies
A return
In the deep

Friday, November 14, 2008

Our World

So I'm watching TV in my family room when I here my 4 year old son crying in his bedroom. I bound up the stairs and walk into his room to see he is clearly upset.

"Cameron....what's the matter?"
"I can't sleep Daddy....everytime I close my eyes I dream a wolf is coming to eat me!"
"We read Peter the Wolf in class today and now I can't stop thinking about it!"

I try to convince him that it's just a dream. That it's not real. That he is safe at home in bed. But to no avail. So I try a different tact.

"Just imagine that right before the wolf gets you that your daddy is there and jumps in front and saves you at the last minute!"

"Daddy....that won't work...what if you are not fast enought?....I want Mommy"

By that time my wife walks into the room.

"Honey...what's the matter?"

Cameron Speaks up, "we read Peter the Wolf in class today and now I keep dreaming that a wolf is coming to eat me!"

"Oh that..." she replies, "I forgot to tell you that I talked to your teacher about this exact subject today."

"You did?"

"Yes...and after I picked you up from school, while at work, I wrote an email to the wolf and told him not to bother you tonight.....that there are much tastier kids down the block and to leave our house alone!"

"You did...thanks Mommy...I thin I can go to sleep now."

I, forever the smart ass, to my wife, " I hope you cc'ed evil spiderman and the boogeyman also!"

Cameron turns to his mother quizically with eyes wide, "the boogeyman?"

Thursday, November 13, 2008

Stroke of Genius (Conclusions)

As Scott mixed the vials together he knew that this could change everything. His left hand was shaking as he lifted the flask to his mouth. He was alone in the lab. Cecilia droped him off at lunch and wouldn't be back till after work. His mind raced as he felt the cool concoction wash past his lips and down his throat. It had a gentle taste. Neither sweet nor bitter. Rather pleasent. As he consumed the last ounce he dropped the flask onto the lab top where it smashed into a thousand little pieces.

Scott was feeling weak and dizzy. The blood rushed into his face. His right arm and leg started to tingle and then burn. Oh no! This is going to kill me like the rabbits. I miscalculated! His mind quickly replayed the formula in his head. But his brain was working slower now. He couldn't quite remember how he had arrived at the master formulation he just consumed. As he drifted off into unconsciousness he felt his body falling and finally thud onto the ground. Oh Cecilia....Cecilia...would I have not suffered this fate for you?

Scott felt someone gently pulling his arms. He opened his eyes to see his beautiful Cecilia towering above him. He struggled to explain but he couldn't. His mind was moving at what seemed to be a snail's pace. But then he realzied that he wasn't slow at all....he was back to himself. Back to how things were before the stroke. Before his thoughts began to race and his ideas began to quicken.

Scott grabbed onto Cecilia's hands and pulled himself upward. They stared at eachother dumbfoundedly. He had used his right arm. It was no longer disabled. Then he walked around the desk. His leg was working perfectly. He was cured! He looked down at the was empty. Now what was that formula?

For month's Scott tried to piece together his frantic notes. He would sit for hours at night thinking in his dark bedroom. But it was all gone. His mind could no longer make the mental leaps it had before he cured the stroke.

He returned to the lab convinced he would eventually recreate his success. But he never would. His life work would have meaning....he would win many many people. But he would never remember the formula. He would never cure the epidemic.

Scott eventually came to terms with the fact that his genius was short lived. That It came with the stroke and left with the cure. But he was always keenly aware of how slow his mind now worked. He felt like a turtle. He may eventually win the race but he would do it at his own tortured, humble pace.

And then there was Cecilia. The magic potion that cured his stroke did nothing to diminish his feelings for her. He still was sensitive to her needs and emotions. He could still read the expression on her face before she said a word.

The fact was that even before his illness he always had the ability to love and be loved......and maybe that...that....

was Scott's true stroke of genius.

Tuesday, November 11, 2008

Stroke of Genius (4)

Scott's pace was becoming frenetic. He abandoned physcial therapy in order to spend more time with his research. Cecilia begrudgingly dropped him off at the lab every morning and picked him up every night. Often he would bring his notebooks home to work further after Cecilia went to sleep. His lab assistants and students had been reassigned so he worked alone. As his pace quickened his organiztional skills started to fail. His once neat and clean notes were now scattered about the lab and apartment. At some point his thoughts were coming so quickly he abandoned keeping formal accounts of his activities. He used any piece of paper he could find around the house for quick calculations.

And Scott was energized. Never had he felt so capable. Never had his ideas been so vibrant. He was getting closer and closer to the answer. The unique solution that would bypass the damage to the oxygen starved, seemingly dead cells and bring them back to life. He visualized the compound entering the infarcted area of the rabbits brain. He saw the alterations occuring at a cellular level. But the compound was a loose cannon. An unguided missile. Its effects spread to other parts of the body. Sensitive parts. Parts that eventually led to the rabbits death.

It was as clear as day. He needed to modify the compound. Allow it to hone in on the incapacitated tissue in the brain but ignore the rest of the body. A coating to keep it centered and not allow it to cross back over the blood brain barrier. He again went over the chemical formula. How could it be modified. What component changed such that it would get stuck in just the right place.

The answer came to Scott in a dream. He had fallen asleep in his chair while studying the numbers. The chemical he had been using to treat the rabbits was flawed. Although it erased the damage from the stroke it eventually led to toxic metabolites that killed the rabbit prematurely. But in the subconscious depths of sleep he stumbled upon the answer. It was a simple adjustment. A basic organic reaction.

He fell back asleep with his mind made up. Tomarrow after Cecilia dropped him off he would alter the compound. And then....then....

He would try it on himself.

Monday, November 10, 2008

Stroke of Genius (3)

If Scott's brain had been an abacus before it now worked more like a supercomputer. Ideas would bounce from neuron to neuron. Becoming form and substance, changing, taking on new meaning. Inverting to show a previously incomprehensible view. His mind took off like a rocket. Craving complexity and embracing the abstract. He became keenly aware of the intricate.

And his body...his body languished under the austere framework of physical therapy. While his brain could move mountains his muscles were powerless. It took supreme concentration to wiggle the fingers on his right hand. He spent hour after agonizing hour in bed, in the wheel chair, sitting on the couch. And Cecilia patiently attended to him. She was a godsend.

After the hospitalization she came obediently after work each day to prepare him dinner. He never asked. But he dare not refuse. She kept him up to date with the comings and goings of the hospital. She checked on the lab and brought his mail. She even wheeled him over to the office a few times.

She was beautiful and sweet. Smart and caring. So many things Scott had never taken the time to notice. And he loved her for it. Loved her like he had never loved before. The stroke had rendered him so physically weak....but had opened up other forms of strength. The strength to see that which made another person so wonderful. It had been years since he let someone into his life.

It started rather innocently. She would stop by to help, run some errands. But then the visits became longer. And eventually she began to stay over. All with Scott's tacit consent. He wouldn't have had it any other way.

And late at night while Cecilia was sleaping Scott would pour over his data from the lab. He no longer could sleep. When the lights were out and the apartment was quiet his mind would start to race again. Keeping him up. Driving him back to the numbers scrawled meticulously in his notebook. Turning them over and over agian in his mind until they became characters dancing through his brain. Pausing briefly over the damaged tissue and studying that which was out of place.

Scott had become like the rabbits in his experiments. He had studied them and reversed the defects from their strokes. But they were dying to quickly. Now he turned an inner eye on his own damaged tissues.

How would he fix it?

Saturday, November 8, 2008


Classic post

Published a few years ago on my old blog

It was a sunny spring day as the bus turned the corner. It was a yellow school bus filled with young children jumping up and down in their seats. It was an average day in an average school year. Nothing about that day stood out. Let’s take a closer look.

The boy sitting in the front of the bus holding tightly to his lunch box is named William. His clothes are tattered and jeans have patches on them. The lunch box is empty but no one around him knows that. His is quiet and withdrawn. He doesn’t play with the other children. He is much too thin. He will one day grow up to be a successful businessman and buy his mother a house. His children will not have to live like he has. But, of course, he doesn’t know that yet.
The girls sitting across the aisle from William are Suzette and Lisa. They like to sit in the front so they can rush off the bus when they get to school. They must each be about nine. Suzette is widely known as the school gossip. If something is going on she knows about it. She will grow up to be an advice columnist for a major newspaper. She always did like to tell other people what to do. Lisa’s rode is a little bit different. She will fall into a drug habit and get pregnant way to young. As her child is born she will clean herself up. She will never go to college or see herself as a success in her own eyes. But she will bring up a beautiful young daughter who will take advantage of all the things she never got to do.

Behind the two girls chatting are Terence and his best friend (who he currently is wrestling to the ground) Paul. Terence will grow up the class bully. He eventually will be arrested for armed robbery and during prison will find god. After serving his time he will work at helping released inmates find jobs. He will change many lives. Paul will be known as the boy who never took any chances or risks. Almost afraid of his own shadow. Until the day, at the age of thirty five, that he rushes into a burning building and saves three children before he collapses and dies.
Sarah screams across the aisle at Terence and tells him to stop bullying Paul. She knows in her heart that one day she will find Mr. Right and settle down and have five children. Seems a bit premature for an eight year old but…that is exactly what she does.

So many faces you could see if you were riding on that bus. Each with a unique story and future. But the point here is not them, but to take a closer look at the man sitting in front driving the bus. He is a beautiful and courageous man….. and he is dead.
Well, he is not exactly dead yet but he will be in a matter of days. Neither he nor I, his physician at the time, know this is going to happen. Neither does his wife, the lady sitting in front of me, who looks for the first time in two years to have found some peace over the death of her beloved husband. I ask her what has changed. This is what she says…..

The call from the cardiologist surprised me. She was in the ICU and was visiting our mutual patient who just had a routine bypass surgery that afternoon. The surgery had gone very well without complications. I could hear the concern in her voice as she asked me what to do. She had been talking to him when all the sudden he started seizing. I told her to give him five milligrams of diazepam immediately. Start a dilantin drip and get a stat head CT. She called neurology immediately. Both of us knew this couldn’t be good. "By the way is his wife there?"
He had come to my office at the suggestion of his wife. She had been seeing me for about a year. Like so many males in their fifties, he started the visit by telling me he didn’t like going to doctors. He had always been healthy and didn’t feel the need. But this chest pain he started to feel recently while on the school bus was bothering him. It had been about a month and he thought it was time to do something.

His testing showed coronary artery disease and he was sent to a cardiologist. She recommended a cardiac catheterization that showed extensive blockages in multiple coronary arteries. He was scheduled for a bypass surgery the next week.

The call from the radiologist confirmed our fears. There was a large tumor in the anterior part of his brain that had bled from the blood thinner that is necessary during bypass surgery. This tumor had been asymptomatic to this point. It was a benign tumor and likely if it could be removed the patient had a good prognosis. None of us had known it was there. He had none of the telltale signs. No headache, no visual problems, no signs on physical exam. It was just bad luck.

The neurosurgeons were antsy about taking him to surgery right away. It was Saturday morning and the blood thinner used in the bypass surgery was still in his system. Also this would be a complex surgery and they felt it would be better to wait till Monday when full staffing would be available. So he sat in the ICU and waited.
On Sunday night he started to feel a little nauseous. He sat up to call the nurse and said quietly….."Something is wrong". He then collapsed back on the bed and died. Likely the bleeding in his brain had restarted causing the brain to swell. The increased pressure then caused the brain to herniate which is incompatible with life. CPR was performed for about thirty minutes to no avail. His wife and daughter were called at home…..they had left the hospital a few hours before.

The next two years were a blur. There had been multiple visits with his wife. We had met together with the cardiac surgeon to go over what had happened. There had been tears and more tears. I felt horrible for her. I watched with time as the depression set in. We discussed medications which she decided against. We discussed therapy which she attended. The birth of her daughter’s baby, he first grandchild, was bitter sweet.

When she walked into my office two years later I knew immediately that something had changed. I could see it in the way she walked, her facial expressions, the way she talked. She had stepped away from the sadness and started to live again. We exchanged small talk for a few minutes and then I gently asked her what had changed. Her explanation was straight forward. And this is what she said…

Since her husband’s death, she and her daughter had been focusing on loss, focusing on tragedy. They were morning life that was taken away too early. After the birth of her daughter’s child they started to look at things differently. Her husband, she explained, was a bus driver for a local school district. Everyday he drove young kids to school. He loved it and he loved the kids. She figured that he had two ticking time bombs. One in his brain and one in his heart. Each of them could have instantly caused death while he was driving the bus. Each of them could not only have taken his life but the lives of all those precious children. She told me that now instead of morning his death, they celebrate all the beautiful lives that were saved the day he died quietly in the hospital. She said that now when they feel sad, her daughter and her sit down and make up stories of what would become of those young lives…you see….

The boy sitting in the front of the bus holding tightly to his lunch box is named William. His clothes are tattered and his jeans have patches on them. The lunch box is empty but no one around him knows that……….

Friday, November 7, 2008

Diagnostic Acumen

I have spent a lot of time pondering what makes a good physician and have come to some conclusions. While medicare and other rating companies are developing lists of what constitutes good medical care.....I think they miss the point. Sure it's nice if hgb a1c's are checked every three months. Sure its important to make sure every patient with coronary disease is on a beta blocker. I won't argue with that. But in my mind what makes a good physician is not soo cookbook.

In my mind what makes a good physician is diagnostic acumen. In otherwords, how quickley will your physician diagnose and treat your problem correctly. Without a keen mind for diagnosis, a physician is average at best. They will continously miss important clues and often fail to prevent their patients from life altering consequences.

A few months ago I read Jerome Groopman's book, How Doctors Think, and continue to study medical decision making. How I think about a given problem often dictates my success or failure to diagnose. It's something I will spend my whole career doing. I especially remember the times when I miss diagnosis. This really burns me.

The other day I saw and elderly anxious lady with back pain. I examined her thoroughly. Asked many questions. And the pain seem to be muscular. But it was getting worse. So I set her up with an xray to rule out a spinal fracture. The xray was negative. When I called today she told me the pain was gettign worse.

So I did what I normally do in this situation. I asked her to come back to be reexamined. She was not happy. As I felt her temper rising I explained that sometimes when the answer is not apparent we have to start again at the beginning. Take a fresh look at the information and make sure nothing is missed.

She eventually agreed....and came for a visit. After a few minutes of questioning I lifted her shirt to find on her back a typical shingles rash. It had not been there two days ago. I treated her with valtrex and narcotics. Nothing earth shattering here but a simple answer to a simple question.

It's something I have to teach myself over and over again. If things don't make sense take another look. Start again. Don't be too intellectualy lazy or afraid to help those in need.

Thursday, November 6, 2008

Stroke of Genius (2)

There wouldn't be anymore research. There may not even be anymore life. Scott's mood was getting progressively dour as he languished in the hospital. It was already three days and still minimal movement on the right side. The thrombolytics did nothing. Physical therapy was doing nothing. Thank god he was left handed! He could still perform some tasks for himself. He would be able to go home and not some forsaken rehab facility.

But he was useless. How could he run experiments. How could he set up the stroke patients if he had no use of one side of his body. Sure he had students. Sure he had post docs. But he never felt as good as when he had his own hands were in the mix.

And what tortured Scott the most was that his mind was more clear then ever. In fact his thoughts had started to race. He was quicker then before. His mental cogitations were less labored. In the ER the nurses were trying to figure the TPA dose and Scott did the complex calculations instantaneously in his head. He had always fumbled with calculators before.

He was also learning to read people better. He was able to hear the changes in pitch in his doctors voice relaying bad news even before he got to the point. Or the look on the nurses face appraising his physique when helping him put his shirt on. Strangely these were things that Scott had never picked up on before.

And when a colleague he had known for years came to visit him in the hospital the day before discharge he sensed something that completely took him by surprise....


Wednesday, November 5, 2008

I grew up knowing a family. The father was a doctor. A funny guy he was strict with his kids but loving. Generous. All the other kids in the neighborhood adored him. The mother was a lawyer. It was clear she was the boss of the family. But she was also fun and caring. Everyone knew to go to her if you had a real problem.

They were afluent but not outwardly rich. Intelligent. They were keenly aware of what was happening in the world. I remember passing through their living room and seeing world events on the TV.

Their kids were typical. Often well meaning but making the common mistakes of youth. Usually getting into some kind of trouble but never anything serious. They were like all the other kids on the block. Occasionaly overly virtous.

They were you and me. They were American Pie. They were the best we strive to be.

And the way....they were black. And they were completely fictional (this family at least).

If you haven't figured it out I am talking about the Huckstables (The Cosby show).

As I watched Barack Obama and his family last night I found myself thinking back to all those evenings I invited the Huckstables into my living room.

Over the next few months you will hear the pundits discuss the luminaries of the civil rights movement. I would like to add Bill Cosby's name to the discussion.

Without him, I feel relatively certain that white America would never have had the courage to vote for a black president.

Tuesday, November 4, 2008

Stroke of Genius

Fucking irony. As Scott sat on the gurnee they were the only words running through his mind. Just hours ago he was happily in his lab reviewing data. He finished with the last stroke patient for the day and was enjoying the luxury of an extra few moments to crunch numbers.

His research was promising. He already secured funding from multiple sources. He had a few medical students and PhD candidates working for him. Scott was making a name for himself. Early into his career he had given up most of clinical responsibilities. And he felt his research was showing progress. In the last year his data had sharpened. He could feel in his bones that he was close to something big.

Scott had discovered a novel compound that when used on rabbits reversed the most egregious effects of strokes. Rabbits who had been induced to suffer strokes could have their symptoms completely ameliorated. Even if the event occured months before. The coumpound regenerated damaged neurological tissue. Restoring it to its prestroke condition. But safetly data was lacking. And a number of the treated rabbits died prematurely for unknown reasons.

He was so close. He knew he was missing a key concept but just couldn't put his finger on it. He stayed up late at night reviewing the data. Often he would forget to eat because he was so busy. He was losing weight. His family and friends had given up on him. His social life was at a standstill. He was fourty years old and hadn't gone on a date for a year.

And then this. First he felt a heaviness in his right arm and leg. He tried to get up and walk around the lab but he was clumsy. He kept tripping. Then he tried to steady himself on the lab bench. But he couldn't lift his arm. He fell against the bench and then slid to the ground in a seated position. He was alone. He lifted his left arm which was still working and reached towards the table. He clutched at his cell phone. With one hand he gingerly dialed 911...

"Hello....hello..." he fumbled with the phone...

"I think I'm having a stroke!"

Fucking irony

Monday, November 3, 2008

The American Way

Its the American way......I eversogently tiptoe down the linoleum lined hallway of the nursing home. As dawn breaks I listen to the squeek of my new shoes drowned out by the upheavil of the alzheimers ward. The screaming and the cries no longer catch my attention after so many early mornings. Confusion reins as I wipe the fatigue from my eyes after a long weekend on call. Trying to fit in a few quick visits before rushing to the hospital and then the office.

I enter the room quietly and stumble for the bathroom light to shatter the heavy darkness. " that you?". An elderly woman squints through the haziness of sleep. The clock on the side of the bed reads 6am. "No, it's Doctor Grumet." "Oh...I thought you were Joe....where is he?" Joe has been dead for a decade. After having this conversation on multiple visits I no longer correct her.

"So how are you feeling....any pain?" She again squints trying to avoid the light eminating from the half closed bathroom door. She talks with her head pointed slightly to my right, " can't see! I could see yesterday but now everything is blurry!" The macular degeneration robbed her years ago. But every morning she wakes up with the same tortured sentiment.

I gently rest my hand on her shoulder for comfort. My stethoscope probing her back and then chest. I recognize the same faded night shirt that she wears every day. Over her heart a sticker is gently pealing from the fabric. Someone had obviously decided a pin would be too dangerous.

The words on the sticker pound my eardrums with laughter and mock my own sense of self importance as I drive to the hospital....

"I voted today"

Thursday, October 30, 2008

Walking on Water (conclusions)

Derek was so devastated after the funeral that Sarah decided to move back into the house. Her psychiatrist was amazed at how rapidly she was getting better. It was as if the sickness of her child somehow snapped her out of a fog. Or maybe it was Derek's need. She started a new antipsychotic and was doing well. Based on her improvement her diagnosis was changed from schizophrenia to bipolar with psychotic features.

Derek didn't care what you called it. Sarah was back again. She was alive and loving and supportive. And he really needed her. Because he had to find a reason to continue breathing. Jason's death formed a wound on his heart that would never heal. He would wake up in the middle of the night calling his son's name as if he was still in the adjacent room sleeping quietly.

And Derek would find solace in the fact that the world was generous. That other caring human beings would donate a hundred thousand dollars to save his son. That by returning this generosity he could affect others who were desperately in need. His life could have meaning again.

And above all he knew that he had done his best. Because even those who walk on water occasionally find themselves stranded in the middle of the ocean. It was time to grow up. he could either let his sadness drown him or he could learn how to swim. So Derek abandoned his superhuman qualities......

and dove into the merky abyss.

Walking on Water (4)

The problem with bone marrow transplants was the expense. Derek had done his home work. Between doctor and hospital fees he would need about one hundred thousand dollars. Simple..he thought...Jason had good insurance. But ofcourse given the experimental nature of the procedure his insurance categorically denied the request stating the lack of evidence.

So Derek again braced for war. Again he consulted the experts. He had Jason's oncologist write a letter to the insurer. He wote a number of personal letters documenting Jason's struggle and emphasizing that he surely would die without drastic action.

In the meantime he went to religous organizations, the local media, and even the AMA. Anyone who could help was welcomed. He set up a fund at their local bank for donations and Sara helped put together a web site. After a month they had collected twenty five thousand dollars. Not enough....but a start!

The insurane company finally relented and invited Derek to personally present Jason's case to a board of adjucators. As he packed up his materials that morning, he felt mildly optimistic. He had not come this far to fail. He had thirty minutes to win over the hearts and minds of the insurance comany representatives.

Derek's presentation was the perfect mix of science and emotion. He blended the hard data with the soft picture of Jason, his mentally ill mother, and his struggling father. He ended with a short video of Jason himself pleading the case. The jury of ten men and women were visibley shaken. A number of them had tears in their eyes. As Derek left the room to allow them to deliberate he felt he had reasonable odds.

Fifteen minutes later he was summoned back to the small room. It was decided that the insurance company would not cover the transplant given its experimental nature. However, Jason's case would be sent for review to the charitable branch of the company which may consider donating to the cause.

Derek's sadness and dissapointemnt were brief.....the next day he recieved a check for the remaining seventy five thousand dollars.

Looking back, Derek would remember this as the highpoint of his struggle. He had walked on water. He had accomplished the impossible.. That night he picked up Sarah and Jason from the hospital. They went out for pizza. It was one of Jason's good days.

Jason eventually recieved the bone marrow transplant.

When it failed to eradicate the cancer he was enrolled in hospice.

He died a month later at home with Derek and Sarah at his bedside.

Wednesday, October 29, 2008

The Power of One

I wrote this in highschool. Its kind of simple but I like it. I almost never use rhyme in my poetry. I always was fond of the saying....My body is a temple.

The Power of One
My body is a temple
My mind is my god
My heart is a prayerbook
Its expression my facade

Tuesday, October 28, 2008

Walking on Water (3)

When a person hears the word cancer directed towards him for the first time it's like a dagger thrust through his innerds. It's sharp. It hurts. It leaves a gaping hole. When a person hears the word cancer directed towards his beautiful 10 year old son..... it eviscerates him. It turns his world upside down.

Vertigo.......thats what Derek called it. From the moment the word left the doctor's mouth his world started to spin. And he had not been able to regain stable footing since. He struggled for composure....for Jason's sake. He tried to remain calm. But he lost his ability to eat. He couldn't sleep. He constantly felt nauseous. And the spinning overtook him. It was not his head that bothered him so much....but his heart.

The upheavel remained until the day, weeks later, that he decided to take control. After many restless nights of tossing and turning in bed, he finally got up and went to the computer. What he found on the internet amazed him. Hundreds of pages documenting cases similar to Jason's. Thousands of research papers cited. The doctor said the prognosis was poor. But maybe....just maybe there was something new to be found. New research....a new doctor....a new chance.

As Derek's hope rose, Jason's health deteriorated. The chemotherapy had made him sick. He was hospitalized twice for dehydration and low blood counts. His spirits were low. But Derek couldn't tame his need for optimism. He contacted multiple experts in the field. Talked to families with children in the same situation. He couldn't shake the desperate belief that there was something that would snatch Jason from death's clutches.

And one early the sun started to rise on yet another sleepless night...Derek came to the answer. In an obscure medical journal...a small case study had found a successful treatment. It was a long shot, Derek thought to himself, but it might just work.

Before thinking about it he picked up the phone and dialed Sarah's number. They had been talking alot lately. She was improving.

As Sarah answered the phone Derek hurriedly interrupted her. He couldn't contain himself.....

he had found a way to save their boy.

Monday, October 27, 2008

Walking on Water (2)

How can a father explain how he feels for a son? How can he put together a series of words that adequately describes the mix of love, fear, and absolute desperation involved in being a parent. How the sum total of a man's dreams become bundled into those little hands and feet. And how the idea of that boy experiencing pain is anathema.

Derek remembered falling in love with his wife. He remembered the stomache churning roller coaster ride of emotion. How could his feelings be so strong?.... He never believed that he could feel love so true again. But then Jason was born. It started so small. Just a twinge of pride and disbelelief.

Yet over time the twinge became a monster. Derek had swooned for Sarah. His love for her had kept him awake at night. But his son...his love for his son ripped him apart from the insides. Tore him to peices and laid him bare on the cold concrete. Broken...yet still conscious of his helplessness. And strangely enough...still wanting more. It was the kind of love that we all hoped was the kind that ruined you.

Derek's biggest fear was that Jason would become ill like his mother. The idea of watching his son battle schizophrenia was horrifying. And it could happen at anytime. But as the years passed, Derek's fears lessened. Jason was 10 years old and thriving. A cold here....some stitches big deal. He was such a good boy.

So when Jason began to lose weight and feel tired, Derek thought that it was something routine.

It certainly wasn't schizophrenia......

Saturday, October 25, 2008

Walking On Water

He was going to be like Michael Jordan in the championship game. He was going to be like Martin Luther King as he stepped up to the podium to give his "I have a dream" speech. He was going to be every underdog who had ever been written off only to then unexpectedly succeed. If the heavens had to open and God himself had to reach down through the clouds and place this mighty hand on Derek's shoulder....he would.

Because it was now or never. Just the act of being hopeful meant that Derek had walked on water already . And he wasn't turning back now. He had entered a foriegn land. Learned the language and culture. Learned the theory and intricacies. Studied for months what others had spent lifetimes on. And he nailed it. Talked to all the experts in the field. Come to one conclusion and one conclusion only. It was his last chance.

If only Sarah was still by his side. Sure he still talked to her but it was different now. Before the break she was so lucid. She could pick apart a situation and attack it from all sides. So insightful. But it had been years. Something happened to her after the birth. She started the slippery slope downwards and was swallowed by her illness. After years of bouncing through mental institutions she found a permananet home. But she couldn't take care of herself. She couldn't take care of their son. She couldn't give any meaningful support during this difficult time in his life. The schizophrenia had erased everything.

So Derek was on his own. He had a few hours to prepare before the meeting. One last time to review his notes. The house was oddly quiet. No child. For the first time Derek felt truly alone. The idea of failing was so horrifying he only allowed it to cross his mind briefly. He had to succeed. Because if he didn't then what was the sense of living. He had to succeed...his son depended on it.

Friday, October 24, 2008

She Must Have Been

It must have been...about this time of year. The brisk cool days leading into fall. The leaves parachuting from the trees effortlessly. The breadth leaving my mouth as my body numbingly glides down the sidewalk. The ache in my knees becoming familiar. Diffferent from her aches and pains. Different from the heaviness in her heart.

She must have run...down these same streets. In this same town. She said it was to lose the weight she had recently gained. Or maybe it was to run away. For a moment. From the three young boys left at home. Or possibley the never ending list of tasks that needed to be accomplished. I run for health....she ran for sanity.

She must have hoped...that these jogs would never end. Dreading the finish line. Just one more moment of silence. The absence of thought....must have been such a relief. And yet all I do is think. To forget the physicality.

She must have been...about my age. And miserable. And scared. And lonely. That year.

The year my father died.

Wednesday, October 22, 2008

Commentary (thoughts related to the story Obsessed)

A physician I greatly admired once told me something I found quite sad and depressing. He said, "Jordan.....if you practice long enough, no matter how goood a physician you are, there will be a small graveyard with your name on it filled with people ." When I heard this I was at the begining of my career. And I did what most young physicians in my place would do....I laughed it off as an exageration.

Afterall....most of us became physicians to help our fellow man. Most of us took seriously the oath to "do no harm". And most of us would have trouble sleeping at night knowing that our actions could lead directly to someone's death.

As time goes on, however, I realize that as with most of life....things are not so simple. For instance what doe's it mean "to do no harm." Sounds pretty straight forwad doesn't it? But it's not. Almost everything I do as a physician has the possibility of doing harm. Every time I dole out an antibiotic for a respiratory tract infection I risk the possibility that the patient will have a life threatening reaction. It happens! Furthermore, often when the clinical situation is not clear I am forced to make decisions that will either benfit or harm the patient depending on whether I am right. Is the patient wet or dry? If I give fluids I could cause worsening heart failure and box the lungs. If I withhold and diurese I could box the kidneys. If I do nothing the patient could die.

And what about all those missed diagnosis. As Jerome Groupman talks about in his book How Doctor's think being a primary care physician can be a scary proposition. Like watching a train pass by with thousands of people and you have seconds to pick out through the windows the 1-2 who are desperately ill and need immediate action. How are you going to catch those? Is inaction that leads to harm the same as "doing no harm".

And lastly there is plain old human error. If you perform an operation enough times occasionally something will go wrong. Occasionally a hand slips. Occasionally a clinician misses the elephant in the room. The longer you practice.....the greater the consequences of your actions. It's a numbers game.

So how do we as physicians deal with this reality? Some leave medicine when the sadness becomes to great. Some become overly obsessive. Many try to protect themselves by becoming arrogant and considering the idea that they make mistakes blasphemy. Many cry...or write...or get started on antideppresants.

When it comes to me......I choose to hope. To hope that if somewhere there is a small graveyard with my name on it then next to that graveyard is a larger city of happy, healthy, thriving people also with my name on it. To hope that the sum total of my actions (like Lawrence's in the story) falls on the positive side.

Because no matter what we do, being a physician is just a magnified version of being human. We all effect the world around us. We all make decisions that have far reaching consequences. We just don't think about it as much.....should I drive home or stay at a friends house becuase I am too tired...should I spank my child or put them in time out.....should I eat that last piece of chocolate cake or should I stay on my diet.

We all make mistakes...

We all occasionally have blood on our hands...

It's just that being a physician makes it so much more painfully obvious.

Obsessed (conclusions)

As Lawrence pulled up to the house he reached into his glove compartment for the garage door opener. He had never returned it. She had never asked. What used to be "their" house was now "her" house. But at least he still had a part of it.

Strangely....he never questioned his actions. Entering unannounced into someone's house is generally frowned upon. But Lawrence was caught in the premise that something must be amiss. The voices were pushing him.....go must find her. And he couldn't resist the urge. From the depths of his soul he thought, better yet knew, that something was wrong and that Carole needed his help.

As he pressed the garage door opener he leaped out toward the entrance. The first thing he noticed was that Carole's car was still running and there was noone inside. He ran to the door connecting the house and the garage and wrenched it open. Then he grabbed the metal trash can in the driveway and heaved it through the bay window in the front of the house.

Lawrence then covered his nose and leaped through the window ...and took stock of his surroundings. Carole's body was spralwed on the floor five feet from the phone and her chest was still moving up and down. Her husband had collapsed on the couch in a pool of vomit. Quickley he grabbed Carole and dragged her through the door. Next he returned and picked her husband off the couch and carried him to the front lawn. Finally Lawrence took out his cell phone and called an ambulance.

Carole and her husband would survive. After being revived it was discovered that after a long day of work Carole's husband had accidently left the car running and closed the garage door. Unfortunately they did not have a carbon monoxide detector in the house.

Lawrence would leave medicine. After saving Carole's life he finally felt free. He had no more use for rituals. Based on his own existential calculus, in the game of life, he he had come out slightly ahead. He had traded one life sadly lost on the operating table for two lives pulled from the clutches of death.

Lawrence, ofcourse, knew that it wasn't that simple. Obviously throughout his career he had touched many lives. Helping some....hurting others, it was all par for the course. And in a sense this had nothing to do with being a doctor. We all affect the lives of people around us. often not as obviously as in the operating room. But in subtle ways we constantly shape the world.

Lawrence now preffered sublety to the brasch and egotistical life of a surgeon. He almost felt that the act of surgery, ie cutting open the human body and mettling, was to close to intervening with God's plan.

He would leave that to others.

Monday, October 20, 2008

Obsessed (4)

Come on...answer the phone...answer the dam phone!

Lawrence was starting to panic. It was 10 pm and he was making his nightly call. But no one was answering. In all the years since he broke up with her, Carole was always there. If he couldn't reach her on her home phone then at least her cell. But Lawrence had tried three times already.

Why today...why today he thought out loud. On the day he was going to apologize and tell her that he would never call again. Today was going to be different. Today he was taking control of his life. But suddenly he felt the red tied coming back. The cruel waves crushed against his small and insignificant boat of life. Mocking him. Turning him over and almost capsizing....but then jerking him back upwards.

Pick must pick up or something bad will happen. He heard the refrain from the bowels of his soul. Lawrence collapsed onto the floor. He cradled himself in the fetal position hoping the voices would stop. He begged them to leave him alone. He tried to counter their logic..Just hang up the phone and go to bed. He would call Carole back in the morning. She was probably fine. Nothing bad was going to happen.

But the voices spoke searingly...burning a hole in his logic. Imprinting an idea on the soft inner belly of his mind. They commanded him to go to the car. To drive to her house. Or else there would be consequences. They spoke hissingly.....

You don't want her to die like the other you?

Lawrence had to concentrate with all his might to keep his hands steady...

as he steared his car down the driveway.

Saturday, October 18, 2008

So live your life

So live your life


sadness and regret

only go away

once you stop



Dreams will die

a million deaths

but that doesn't mean

you should stop



love leads to loss

most of the time

but if you wait enough

even your heart

will stop



Your demons are faster

and stronger

and meaner then you

but you'll be okay

as long as you

see them

So put your head down

hold on tight

And live your life

Obsessed (3)

The ride home from work, for Lawrence, was aways slow. Calming. In some ways he relished the spare moments with nothing to do. His mind would wander over the events of the day. No rituals. No stopping and starting over again. For whatever reason the car was his safety zone. A place where he felt free from the clutter. A place to listen to the let go of the stress of the day.

But today was different. Lawrence's thoughts returned again to the day that ruined his life. Thoughts he usually only allowed in those fleeting moments at the window sill in the locker room. He saw her face again. He remembered his cocky swagger as he entered the operating room. He had told the family that this operation was routine. That he had done hundreds of them. That she would be just fine.

But she wasn't fine. Thirty minutes in she started to bleed.....and she never stopped. Lawrence tried to stem the red tied of death that sprung from her belly like a torrent. But instead of deterring.... his hands became clumsy. Knocked about between waves of futility he struggled to gain control. And somehow his loss followed him home from the OR that day.

The red tied of death ripped a hole in his heart. And the hole enshrouded his marriage in dependence and it too hemmorhaged, exsanguinated, and died as quickly as the poor girl on the table. So Lawrence did the only thing he thought he could to avert going completely crazy...he went kinda of crazy.

His rituals inhibited his life. They marked him to all those who cared to look. They changed his priorities. But they allowed him to creaste a barrier of safety between him and a total mental breakdown. There were now rules. And rules could either be followed or broken. As long as rules were honored....he would be safe. Patients wouldn't die....marriages wouldn't break up...and Lawrence could bear to look at himself in the mirror again without complete disgust.

Today, however, was a major departure. One of his most strict rules was that he would never think about this again except at his normal specified time. He was breaking the mold. He was going out on a limb. And damb it felt good. Maybe it was time for him to let himself off the hook. Hadn't all his colleagues had patient's die on the table? Hadn't he done some good in all his time as a doctor?

Lawrence made a promise to himself as he pulled into the garage. Tonight when he called Carole he would apologize to her and her husband. He would tell her that he had an epiphany and it was time for him to move on. He was going to thank her for being so patient. And most of all he was going to tell her that he would never bother them again.

Or so he thought. It was not even in his relm of imagination that when he called later that night Carole wouldn't answer her phone.

Something that she had never done in five years.

Friday, October 17, 2008

Obsessed (2)

Every morning was the same for Lawrence. His alarm went off at four thirty reliably. Although he didn't need to arrive at the OR for hours he had soo much to do. He had his rituals. And his rituals took time. He had to do them correctly. And if he didn't.... they needed to be repeated...or something bad would happen.

Five steps from the bed to the bathroom. Water on. Open and close the toilet seat three times. use the toilet. Flush twice. Two more steps back to the sink.

And so the morning went. A choreographed dance he performed daily often interrupted by repetition and occasionally by the need to start all over again. Lawrence hadn't always been this way. In fact this all started when his world fell apart. Five years ago. The unimaginable had happened. The unthinkable. So Lawrence tried to order the parts of his life he could control. If he just followed the right steps. If he just didn't mess up.....he would be protected.

By the time he showered, got dressed, and ate breakfast Lawrence was already late for his nine oclock OR slot. In fact he never made it on time. The schedulers at the hospital were so aware of the problem that they always scheduled the first case an hour late. And like clock work Lawrence would arrive at 10am. The staff would trade glances as usual. Mainly they felt sorry for him. They had watched him unravel over the years.

As Lawrence finished changing into his scrubs he walked briskly to the back of the locker room and sat awkwardly on the ledge of the window facing the courtyard. He had exactly five minutes. This was his last ritual before going into the operating room. A tear rolled down his eyes as he replayed the horrible day over and over again in his mind. The day his life went from light to grey.

Never...never again he told himself.

And then he left the locker room and went to scrub for the first case.

Thursday, October 16, 2008


Accepted today to the Annals of Internal Medicine Ad Libitum Section:


I’ve started
To bleed

It happens
Every winter
With cold
And dry

I wash my hands
20-30 x a day
Before and after

At first
The dryness
Was bothersome
And I used
But eventually
I stopped

And my hands
Became painful
But the pain

On my knuckle
Where the skin
Would crack

The other day
I was calling

A normal stress test
A high cholesterol
And lastly
I came
To your

I told you
Over the phone
You cried

I explained
What happens

As I hung up
I noticed
I was wringing
My hands

I looked down
With alarm
To see
I was covered
In blood

The cuffs
Of my white coat

I ran
To the sink
My tears
Joining the water
The drain

I guess
I have been hurting
For a very

I forget
To think

From the chapbook Primary Care, The Lives You Touch Publications

Wednesday, October 15, 2008


As lawrence listended to the phone ring he thought back to a time when he wasn't this sick. The clock on the nightstand read 10 pm as usual. Not a second before. Not a second after. The lights in the room were all off sparing the overhead lamp on the bedside table. He was in a pair of flannel pajamas but no shirt. The temperature in the house was set at 78 degrees exactly.

Precision had become Lawrence's life. Not a bad thing for a surgeon. Afterall.....hadn't his patients depended on his precision. Couldn't just one small misstep lead to disaster? Lawrence told himself you have to stop thinking that way. It's not healthy! Ironically the disaster that Lawrence was trying so hard to avoid had already happened. Both his personal and professional life were in ruins.

His wife had left him...over five years ago. He had lost most of his friends. His colleagues look at him as an oddity. And although he was still operating, his patient load had dwindled severely. Who wants a surgeon who is so caught up in their personal issues that they show up to the OR 2 hours late for the first case?

The phone continued to ring. Come on Carole.....come on....answer the damn phone. Just this last time. Lawrence felt ill. He remembered pleading with his ex wife similarly when she left him. And now he was doing it every night. Silently. In his own mind. Waiting for her to answer the phone. So he could turn off the light and go to sleep.

"Hello?" Carole's annoyed voice woke him from his reverie...
"Just...just checking," Lawrence sputtered as he could hear Carole's husband recite explatives in the background.
"Go to bed Lawrence!"

And then Lawrence hung up the phone and as usual drifted into a sound sleep.