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"