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.

Tuesday, October 14, 2008

Saying Goodbye

Mrs. Jones.....

I am calling today to give my condolences. I heard this morning of your husbands passing. I am truly sorry.

I will never forget the day you both walked into my office. As often happens we ended up laughing as much as talking seriously about his health problems.

Through all the years I have known your husband, he always had a smile on his face and a bounce in his step. He faced every new medical problem with bravery and courage. Each step forward was welcomed. Each step backwards was tolerated.

Your husband lived with great diginity....I saw this in the way the people around him looked up to him. How when it became apparent that death was forthcoming your children and their families rallied around him. How you now celebrate his life as well as mourn his passing.

His body may have passed but his spirit will never die. It lights up the faces of all those little grandchildren you probably have running amongst your feet right now. He will never be forgotten.

I wanted to take a moment to say thank you. For allowing me to take care of him and bear witness to just a fraction of the beauty he has bestowed on this world. I am humbled by the honor you have afforded me. I will never take light of your decision to entrust me with his health and well being.

I will miss him....

I will never forget....

Please don't hesitate to call if I can be of any assistance.

You will always be welcome in our office.


Monday, October 13, 2008

You and Me

I woke up
From a nightmare
A decade ago
About being

I got up
And looked in the mirror
And saw You
Your beautiful soft face
Wavy hair
And those eyes

I looked inside
And saw myself
So I went
Back to sleep

I awoke again
This morning
From another nightmare
And looked in the mirror

And there you were
Just As I had left you
I peered again
Into your eyes

And this time
I saw you
And the kids
All my happiness
But yet something
Was missing

I tried
To turn over
And scream
"How could you
Have gotten rid
Of me?"

But then
I realized
That the mirror
Was more a reflection
On me
Then you

Sunday, October 12, 2008

By The Way, I'm Also Great at Removing Wax from Ears

Years ago, before I started medical school, I thought it was so simple. I would become a doctor. The answers would role off my tongue. People would come to me and I would fix them. I would rush into the hospital room and singlehandedly save the day. It was so obvious. It was so straightforward. It was so laughable.

Back in those days I didn't undersatnd the complexity of medicine. I didn't understand that often the answers are not so clear. That sometimes there are multiple possibilities and it is difficult to differentiate which is right. That sometimes no matter how hard you try.... you miss the mark. That diseases are more likely to present atypically then in textbook fashion.

My naivete was shattered throughout residency and my first few years of practice. I would continually search for the textbook answers and they would often miss lead me. A clear case of cardiac chest pain would end up being heartburn.....and a clear case of constipation and indigestion would end up being a heart attack. The gods of medicine were laughing at me and I was fodder for their cruel sense of humor.

But as time has passed I have started to understand the patterns of human beings better. I am now more likely to diagnose appendicitis by the look on a person's face and their demeanor then anything I specifically note on physical exam. I am now apt to understand that testicular pain in a young man is just as likely anxiety and depression as it is orchitis or a hernia. I have learned these things. Not by reading them somewhere in a textbook but by missing something vowing never to forget.

The medicine I practice today is much more nuanced. I watch the way patients walk into my office. I pick more up in their facial the words that aren't said. I understand a little better how people work. How they describe their own pain. What the diffetence is between psychic and physical pain. And how to try to treat each.

I also have learned that as a primary care physician I rarely race into the hospital (or office) to save the day. I will leave that for the surgeons. What I do is a lot more tame, a lot more calculated. Although I have never found myself to be a religious man I still beleive that we as humans have only so much power over our own lives. Sometimes people will either live or die and I as a physician may have very little to do with it.

I see my role as more behind the scenes. In those who are living I try to foster life with less pain and suffering. Less worry and concern. I manage their back pain, and diabetes , and heart disease. Like an insurance policy I am a crutch to help face the unimaginable...the unthinkable.

In those who are dying I try to fashion a softer landing. Ease the pain and desperation of what they are going through. I try to get them home and with their families. To die pain free surrounded by those who love them. Sometimes it works, sometimes it doesn't. But there is beauty and salvation in the attempt.

So I guess you could say as a primary care physician I am a jack of all trades. I help people live. I help people die. I try to manage ilness behind the scenes so people can live their lives. And occasionally...occasionally I rush into to save the day (if I'm lucky).

Oh...and by the way

I'm also great at removing wax from ears

Thursday, October 9, 2008

A Tale of Two Vertebral Fractures

Mrs. Jones is an eighty year old lady with a history of sudden onset acute severe back pain. She walks into Dr. A's office for evaluation. After a thorough history Mrs. Jones is examined and Dr. A notes point tenderness over the lubar vertebrate. He suspects a vertebral fracture. He sends his patient immediately down to xray for a film of the lumbar spine and asks for a wet read. Thirty minutes later Dr. A recieves a call from the radiologist that indeed there is a lumbar fracture. Dr. A then calls the interventional radiologist at the hospital and arranges for Mrs. Jones to get an MRI and a consultation later that day. The next day she undergoes a vertebroplasty as an outpatient and is sent home with her pain relieved. Here's how it breaks down....

Dr. A saw the patient for a simple office visit and billed a 99213 (mid level visit) and spent 15 minutes with the patient.

Dr. A spent 30 minutes reviewing films, talking with radiologists, and organizing Mrs. Jones' care. This time was not compensated for
Mrs. Jones' cost to our medical system: 1 office visit, 1 xray, 1 MRI, costs associated with vertebroplasty (including outpatient interventional radiology consultation).

Alternatively Mrs. Jones walks in to see Dr. B with the same problem. Dr B is not as well trained, not as well informed, or doesn't have enough time. He takes a history and examines the patient. He diagnosis osteoarthritis of the spine and sends Mrs. Jones home with vicodin. Over the next few days Mrs. Jones' pain becomes excruciating. Furthermore more she is constipated. She calls Dr B for advice. He does not have enough time to see her so he sends her to the ER. Mrs. Jones has an xray in the ER that shows vertebral fracture (hospital day 1). She is admitted to Dr B's service. Dr B orders an MRI and gets the result later the next day Hospital day 2). He calls the interventional radiologist. The radiologist sees the patient the next day (hospital day 3)and sets her up for a vertebroplasty the following day (hospital day 4). Mrs. Jones is discharged after post op observation the next day (hospital day 5) with good pain control. Here's how it breaks down...

Dr. B saw the patient in the office and billed a 99213 but then admitted the patient to the hospital billing a 99223 for admission, 99233 x 3 for follow up days, and then a 99239 for discharge.

Mrs. Jones cost to our medical system: 1 office visit, 5 inpatient visits from Dr. B, 1 ER physician charges, 1 inpatient consultation from interventional radiology, 1 xray, 1 MRI, 5 days worth of hospitalization, costs associated with vertebroplasty.

Who benefits (IE MAKES MORE MONEY) from our current medical system: Dr. B, the interventional radiologist (in either scenario), ER physicians, The hospital

Who gets the short end of the straw: Mrs. Jones, Dr. A (good primary care physicians)

I have seen this soo often. Poor doctoring leads to increased costs across the board and increased revenues for those who deserve it least.

Tuesday, October 7, 2008

Letting Yourself Off The Hook

I was all excited yesterday. I finished work early and was enjoying the drive home when it hit me. What a beautiful day. Maybe I'll go for a jog. This was a rare luxury to have time to do this in the middle of the day. The sun was shining and I was psyched at the idea of running along Lake Michigan.

I have started to excersize again. It's been awhile. The first week was just walking on a treadmill. Yah....I'm in that bad a shape. But I figure if I am going to tell my patient's to excersize...I better do the same. All I have to do, I told myself, is start out slowly. Thirty minutes a day on the treadmill translates into roughly a 2 mile walk. A little sweat. A little increased heart rate. No big deal.

But yesterday was different. I had to take advantage of the beautiful day. So I ran into the house. Put on some shorts and a log sleave T shirt and headed out. It took less then 2 minutes to realize how painful this was going to be. First my chest started to hurt. Then my lungs felt like they were going to fall out of my chest. And last my legs and knees ached.

I could have given up. I could have quite. But I told myself that I was going to jog for 30 minutes regardless. So when my body, after five minutes, warned of near death I ignored it. Instead I psyched myself up for the pain. I vividly imagined other times in my life when I was met with harsh realities. In childhood when I had a learning disability...I didn't give up then did I? In residency when I worked 40 hours in a row without sleep....I didn't give up then did I?

As pathetic as it sounds I do this all the time when confronted with difficult situations both physically and emotionally. I turn a basic challenge into a referrendum of my previous successes and failures....a referendum of my character. It's not just getting a workout, it's an epic battle between good and evil. Between success and failure. What if my whole family was kidnapped and held at gunpoint and the only way I could save them was to run a marathon without stopping? Even in my current poor physical condition? Could I do it?

And as funny as it was these thoughts carried me. My breadthing became less labored. My stride became more secure. Although I was in immense pain I made it to the lake and enjoyed the stunning view. As I looked at my watch I realized that I had been running for only fifteen minutes. So I turned course to head back home. The terrain was more up hill and I began to struggle. But as I reached the twenty five minute mark I knew I would make it. I said that nothing would stop me from running the full thirty minutes and I meant it. I would conquer this challenge and live to fight another day.

And that's when it happened. A little girl rode passed me on the sidewalk on her bike. She must have been about ten. I watched as her figure slowly peddled in front of me. About 100 feet ahead she hit an uneven area in the pavement and fell. I looked down at my watch. A few minutes to go. Then I looked over at the girl....tears streaming down her face. As I came to her figure lying on the ground I stopped. I would not accomplish my task. I helped lift her up. She was not hurt. I bent over and picked up her bike as she wiped a tear from her eye. She let out a small embarrased giggle. I laughed. She took her bike and climbed back on. "Thanks," she said as she rode off.

I looked again at my watch and saw my thirty minutes had expired. Strangely and unexpectedly I had not reached my goal. I had not jogged for thirty minutes. I still had a good workout. I still would ache in the morning. But, by no fault of my own, I had fallen short.

As I walked the rest of the way home I thought again about my actions. Maybe life isn't always as black and white as I make it out to be. Maybe sometimes no matter how hard you try to succeed you fail. Maybe failure is not something to flog oneself over but a choice that we often have to make. And that choice can be beautiful and enrich us as opposed to leaving a stain on our character.

Maybe I haven't been feeling as good lately as I want to admit

Maybe it's time I stopped being so damn hard on myself

Monday, October 6, 2008

Don't Be Afraid (conclusions)

Don't be afraid!

Darren's mind had drifted again into a peaceful sleep. He once again relived the day his father was killed. The gun shot. Huddling into his mother's arms in the corner of the room. The fear. The strange look on his father's killer"s face. And then the jolt. He again saw his father's life flash before his eyes but it was different this time.

He saw his father at his own birth....but then he rushed out of the maternity ward to go check on one of his own patient's in the emergency room. He saw his father sitting at the bedside holding a patient's hand as he suffered....but he also saw how at the same time his mother was struggling at home because his father wasn't there. And finally Darren saw himself. At his own kindergarten graduation.....looking anxiously for his father to enter the auditorium...but he never came.

Suddenly Darren's own memories and his father's melded as if they were one story. His father had given up soo much to be a physician...but also had reaped certain rewards. He never had to worry about money because he always made enough. He wasn't concerned about being with his child becuase it was expected that as a physician he would have other responsibilities. His wife accepted it. Society accepted it. And finally he was deeply respected. He carried a certain stature just by the nature of his profession.

But Darren realized that all those things had now changed. He didn't make enough money like his father. Between medicare, insurance companies, malpractice insurance, and medical school debt he was always struggling. And his wife and child didn't accept the time and commitment it took to do his job. In fact society frowned on being soo involved with work that you missed out on your children's lives. And the respect of his fellow man....well that had gone long ago. Most people's views of physicians had changed.

Don't be afraid to choose happiness!

Finally Darren felt his dad's profound sorrow at dying too young. The moments lost to his profession would never be reclaimed. He could never hold his son again. He could never kiss his wife. And all the sudden the words Darren lived by changed. Had he always misinterpreted his father's dying advice. Or had he just been to young to understand? Did it matter anymore?

Darren's head jerked upward and became aware of his settings. The sounds of the ICU came back to him. A nurse had been standing patiently waiting for him to wake up..."Doctor...Doctor.....your patient will be up from the ER in a few minutes.....any preliminary orders?".

Darren stood up briskly and pulled his jacket off the chair. As he reached the exit of the ICU he remembered the nurse awaiting his response....."when she arrives please let the hospitalist on call know that they will be following her...I have to get home!".

As the words left his lips the whole ICU became quiet....other doctors, nurses, even secretaries looked up quizically at Darren....

In his ten years working at the hospital...

He had never given up the chance

to care for one of his own patients.

The Doctor has left the building

Thursday, October 2, 2008

Don't Be Afraid (Cont)

Darren could barely keep his eye's fixed on the computer screen in front of him. The ICU buzzed with early evening activity. He tried to stay awake but he kept on drifting. I should be home now! His anger came and went quickly. Afterall he signed up for this job. He didn't, however, have any idea how hard it would be at the time he entered his training. It was supposed to be medical school and residency that were hard. But now ten years later he was still w0rking maniacal hours. Still not sleeping at night. And still scrounging to make ends meet.

His mistake in retrospect was going into primary care. But who knew ten years ago how poorly it would pay? Darren also had no clue how deeply school would put him in debt. And now there was the wife and kids. House payments. If only he had gone into radiology. That's where the money is!

But maybe it wasn't even about money. It wasn't just the economics but the respect issue. Darren worked just as hard as his specialist friends. In fact he probably filled out more paperwork, took more late night phone calls, and yet still was looked at as the bottom of the totem pole. His judgement's questioned daily. After all....he was just the "pcp". An acronym Darren had grown to hate.

Don't be afraid

As Darren nodded of in his chair he heard his fathers words again. They were words he lived by. Although his father died long ago his words remained. Darren couldn't remember when he had given him this sage advice. Was it a dream or did it really happen? It didn't matter. Whenever times got tough he would hear those words eminate from his innerds. His dad may be gone but his soul remained.

And that's why Darren went to medical school. And that's why he chose primary care while his friends went into more lucrative fields. And that's why he continued to see his own patients in the hospital while everyone else used hospitalists. And thats why Darren was sitting in the ICU, as he did many nights missing his family, and wondering where his life went wrong.

And that's why Darren's wife was threatening to leave him.

Don't be afraid

Wednesday, October 1, 2008

Don't Be Afraid

Stephen reached for the shower door. He had no idea that his life would be over in seconds. As the bathroom door opened he looked up with surprise to see an unfamiliar face. The next thing he heard was a gunshot.

After a few moments Stephen stood up. He looked down to see his own crumpled body on the ground. With horror he thought of his wife and son who were still in the house. He neither felt sadness nor disdain. Anger nor suffering. His primary thoughts were on his loved ones. His movement towards the door was so quick that he became a flash of light. Into the hallway and towards his Son's room.

The man with the gun was standing over them. Susan huddled in the corner with Darren's 6 year old body bundled tightly in her arms. She was crying. She looked up to see a lightening bolt pass through her pursuer's chest and land between her arms on her son's torso.

The man with the gun smiled briefly. As Stephen passed through him he got a glimpse of the beauty he had taken from the earth. Beauty he himself had never been lucky enough to experience in his miserable life. And then the smile turned into a scowl with the horrifying realization of what he had done. He clutched his chest but it was too late. His heart had already stopped. He collapsed to the floor.....dead.

Darren hardly noticed that his mother was no longer holding him. Moments of fear and panic had been replaced by an awesome calm. He felt his whole body move as if the ocean had risen to knock him over but he remained still. His mind raced with primordial visions of his father. He saw his father's birth. He felt his anger as the other kids teased him on the playround. He experienced his father's joy and pain. His wedding day. The day he became a doctor. Countless moments of life and death. Sitting calmly holding a patient's hand. He saw his own birth and felt his father's pride and joy. And he heard his fathers words, not from his ears, but internally...

Darren....Darren.....Don't be afraid!

Darren's reverie was quickly broken by the schrill screams of his mother. She had raced into the bathroom and found his father....lying dead on the floor.