Friday, September 30, 2011

The Ties That Bind

I saw a familiar face amongst the crowd of children dusting the snow off their boots and replacing them with soccer shoes. My wife and I stood in the corner and watched our daughter run into the middle of the gym and socialize with a group of little girls.

As the woman approached I realized she was a former patient. After a brief exchange of greetings her eyes opened wide and she developed a lump in her throat. She turned to my wife.

Your husband saved my life!

She then excused herself to fetch her parents who were helping her daughter get changed for practice. She wanted them to meet me.


I will never forget the early morning during residency when I struggled into the hospital with the stomach flu. Between each patient I had to run to the bathroom to vomit. It was one of the hardest days of my career.

Or the time when one of my fellow residents showed up for a weekend on call yellow. Literally yellow from jaundice. It took several hours to convince him to go to the emergency room. Fortunately it was just a bad case of Mononucleosis.

So when Sheri arrived for her ICU shift with a severe headache, she sucked it up like everybody else. As the night progressed, however, she knew something was wrong. Her vision became blurry. Her speech started to slur.

The nurses put her in a wheel chair and sped her through the maze of passages to the emergency room. Upon arriving she had her first of several seizures. Two weeks later she would leave the hospital for a rehab facility with a diagnosis of terminal brain cancer and a fresh scar on her head to prove it.

Sheri struggled over the next few months. She measured life's ups and downs with little triumphs. By the time she walked down the isle with her long time boyfriend, she used only a cane.

A year later she was rounding with the rheumatology consult service. She was no longer a resident but she didn't want to abandon her life's work. She missed every other day for chemotherapy, or radiation, or doctors appointments.

Her life had been extended but her clock was still ticking.

Each resident regarded Sheri in a different manner. Some ignored her. Others acted like nothing had happened. And some of us struggled to treat her as if she was anyone else going through something horrible. We walked the tightrope between caring and melodrama.

After leaving residency I would never hear of Sheri again. A decade later I assume she is dead.


As the soccer game began my wife stood by my side smirking. She knew how uncomfortable I was with public recognition.

After all, I didn't really do that much for the woman. She came to me with a mild case of post partum depression. We talked about medications and therapy. But mostly we just talked. I was also a new parent. Like her, I was exhausted and overwhelmed. I was tired all the time.

For brief moments, during our visits, we felt like fellow soldiers in a an arduous battle. Apparently, for her, the personal connection did more then medications or therapy could.

And I thought of my residency program. I thought of my years as an attending. As physicians we spurn our own personal illness as if it does not exist. We stand above it as if we are superhuman. Our patients may get sick but not us. We try to lift ourselves out of the fray.

But what if our own mortality serves a purpose?

What if our frailty is neither embarrassing nor an Achilles heal?

Maybe. Just maybe.

It is the tie that binds.

Thursday, September 29, 2011

The Place Between Grief and Guilt

When Donna spoke of the "old bag" it took a moment to realize that she was not being self referencing. Although her left arm laid limply at her side, her right hand clutched a small purse. It was old but sturdy. I imagined it was from the 1920's. One of the handles was slightly eschew and had recently been repaired. Her fingers moved across the fabric rhythmically, absentmindedly.

She explained that the purse belonged to her mother. It was stowed away until Jessica, her granddaughter, came upon it while foraging through the closet. Since that time the two were inseparable.

Jessica would race around the house with the bag tucked under her arm. She refused to carry it properly because the handle was dangling by a thread and she didn't want it to break.

The bag followed her everywhere. When Jessica and her brother would sleep in the guest room, Donna would see the bag standing proudly on the side table basking in the glow of the moonlight.


As I examined Donna, I thought about how similar she was to the adornment that sat next to her on the examining table. She was well into her seventies. Fine stitching and excellent craftsmanship. A repair here and there, but generally in good shape.

I took a look at her left arm. The surgical site was clean. Her strength and range of motion were perfect. Her stitches had long been removed but her scars remained. Although functionally proper, the arm fell back lifeless by her side. Donna looked the other way as if it didn't exist.

Memories from the accident were starting to return.


Donna remembered waking up confused. She was grasping the small purse that was last in Jessica's hand. The strap was broken and it was speckled with blood. Her grandson was screaming in the back seat.

She remembers the orthopaedist leaving the room after placing her cast. The emergency room doctor returning with eyes shining with empathy. He held her hand and told her that Jessica was gone.

Donna remmebered how the room suddenly became still. How instead of screaming or crying out in anger, she felt she had to concentrate very carefully. She heard the words but she couldn't understand the meaning.

But her brother sitting next to her...not a scratch.

The doctor's eyes became cold and distant. He turned his head away as he continued.

When the back of the car was crushed.....

Donna was no longer on my examining table. Her eyes were blank and looked up towards the ceiling.

She was lost in the place between grief and guilt.

Her words were monotone and spoken into the air as if to no one in particular.

Unlike that old purse and I, Jessica's sins were shockingly innocent.

As most girls of a certain age, she was just a little bit

too tall.

Tuesday, September 27, 2011


My son is standing in a crooked line of students with violins dangling from their chins awkwardly. As all beginners, they don't yet know what to do. They fidget uncomfortably and wait for the teacher to approach. She appraises each separately. Lifting the chin of one. Lowering the arm of another. The parents sit in desks in the back corner. We search our children for hidden signs of excellence. I wonder who will be the next virtuoso?

I contemplate mastery.


The white coat is finely pressed and stiff. It slides over my shoulders but refuses to conform to the shape of my torso. I take the stethoscope out of the pocket. It gleams in the sunlight. It is perfect. Free of blemishes or scuffs. It has not been used yet.

I feel like an untrained actor in a play for which I don't know the lines. I neither understand the posture nor the rhythm. Doctoring, at this point, is an elaborate game. The work of children.

I stand with my fellow students and recite an oath. We are being inculcated into a culture although we are still foreigners in a foreign land.


Bows have now been tightened and rosin applied. Ten sets of horse hairs meet ten strings. Each moves back and forth across the body of the violin. Squeaks and squeals emanate as parents look as if they want to plug their ears.

This is practice. The place where beginners start on the rode to mastery. The violin produces music but it is immature, tentative. Movement is neither novel nor comfortable.

Practice is an evolution. In can last lifetimes. Some will never leave this forsaken phase. Some will reach mastery for moments. They will perfect one composition or set. But they will continue to struggle.


My short white coat has been replaced with a longer one. My stethoscope dangles around my neck. The ear pieces no longer sting when placed correctly. My blue scrubs are warn and have black pen scrawled in various places for later use.

The hospital has become a second home. I walk with confidence because I know my surroundings. But I am still maturing. History and physical, labs and x-rays, assessments and plans. They are separate sections which need to be assembled and rejiggered. There is a lack of fluidity. A loss of buoyancy.


The teacher picks up her violin. The room becomes silent as she begins to play. Her posture lacks the tension of the beginners. Instead of playing separate notes she performs the composition as a whole. There are no pieces...just raw sound.


After years of practicing I feel closer to mastery. The tools of my trade are no longer foreign or separate; it is as if my stethoscope has become another extremity.

Doctoring has evolved from a process of parts. There is only the whole. The dance between care giver and patient.

I think in terms of composition. Less history and physical and more rise and fall. My mind spurns process. It is free to expand and contract.

Science has transformed into art. Each encounter its own small performance littered with both structure and free style riffs.


We run a risk when we interfere with mastery. When we replace the intuitive with the laborious.

The process experts will tell you that it is OK to add extra steps. An electronic medical record here, a check list there. Adding and subtracting tick marks.

We must remember that these experts understand composition no better then my young son understands how to play violin. They have an inkling. Their knowledge allows them to see the parts.

But their lack of mastery is blinding

and they can't see past them.

Monday, September 26, 2011

The Stories Of Our Lives

Lisa clutched at the tissue dangling from her hand as we settled into an awkward silence. The only sound in the room came from her seven year old son obliviously sitting in the corner. He violently smashed two toys together and then made laughable siren noises while reaching behind to grab a miniature police car.

We stared in his direction content to have a distraction from the intensity of our conversation. In the lull that followed my thoughts wandered back to childhood. I remembered the day my father died.


My mother is lying in bed. Her head is barely visible hidden under floppy curls of disheveled hair. She is thirty seven years old. My childish body struggles to climb over the ledge as I flop onto her comforter. My older brothers are busy entertaining the crowd of people who wander in and out of the house at random intervals.

I watch as her body heaves up and down slowly. She is weeping. I place my hand on the part of the blanket that is covering her shoulder. I know that there is something wrong but at seven years old I don't have the intellectual capacity to understand.

I feel the faint excitement of missing school but I am distressed by my mother's grief. I coax her gently.

Mommy. Lets go out and play.

She lifts her head and looks over in my direction. She smiles faintly.

Maybe in a few minutes honey.

The adult in me wishes I could reach back and comfort her. Tell her that although happiness had left us, it would return eventually. Assure her that her boys would grow up to be successful men. Touched by their father's death but not destroyed by it.

Remind her that our greatest gifts are bestowed upon us not only by our triumphs but also by our sufferings.


The police car has now pulled up to the fake crash seen. Lisa gasps as she realizes that her son is using toys to reenact her husbands fatal accident. Her eyes fill with tears as she turns her head towards me. She is drowning.

I have already accepted my fate. But him...

She gently motions her head toward the shy boy playing in the corner. She can't finish the sentence.

I open my mouth to speak but have trouble conveying a lifetime of experience in a coherent manner. I want her to know that I am her son. That my father died and yet despite this tragedy my life has beauty and meaning. That I am a doctor, a husband, and a father.

I want her to know that her beloveds death will become part of the vast fabric of her son's experience. But his life will forever guide her son's future. She doesn't yet know that she will have the strength and fortitude to provide for his well being.

Eventually the words come to me.

We tell ourselves the stories about our lives that make it bearable. Or better yet magical, mystical. At forty years old part of your own story is already written. But your son. Your son sits in front of you an open book.

The pen is in your hands.

Write from your heart.

Sunday, September 25, 2011

Some Thoughts On Quality

Sonia struggled to express herself through broken English. Her lively facial expressions and exuberance betrayed by her inability to string the words together fluently. One hand gesticulated widely while the other rested gently on the elderly woman's hair.

She somehow managed to coo quietly in her companions ear, calming her, as she continued the conversation with me. Sonia's eyes opened and closed in an exaggerated blinking manner as she questioned me further. Although she understood my words, she doubted their meaning.


Sonia moved to the United states five years ago to build a life with her fiancee. She took a job as a caregiver for an elderly woman with Alzheimer's. Over the years her love affair with her beau dissipated but her relationship with her employer flourished.

She quickly became the primary care taker. She ran the house and finances. She spent every waking moment feeding, cleaning, and nurturing. Her patient...her employer had become her friend.


There was absolutely no doubt her friend was dying. She walked a slow and relentless march to the grave. She no longer spoke. She couldn't feed herself. Such simple tasks as bathing or dressing had become as complicated as quantum physics.

Sonia choked on each word.

But I can't just let her die!

I explained that for her friend, death was no longer the feared outcome; no longer the emergency. It was suffering that was anathema. We would work together to make her comfortable. We would steer her away from the hospital and manage complications from home. Eventually she would slip away quietly and without fuss or fight.

I could see the transformation in Sonia's posture. She understood. Her head bowed as she whispered up towards me. The tone of her statement rose at completion as if she was asking a question.

So we will no longer try to save her.

I could see the internal struggle as she paused. Her arms stopped moving and fell to her side. Nothing in her former life prepared her for this moment. It was as if I erased a large part of her essence with a sweeping motion of my hand.


Sonia and I would talk multiple times over the next few months. Eventually her friend would die quietly in her own bed. Sonia's hand on her forehead with a wet cloth clutched by her side. Her lasts breaths peaceful. Her lasts moments enveloped in selfless love.

She visited me one more time before she drove to the airport and got on a plane back to Poland. She thanked me profusely and handed me a box of chocolates.

As I watched her walk out of my office I thought about the state of our country.

We talk about healthcare and quality as if they are quantities that can be hung in IV bags in high tech hospitals garnished with radiology suites and cancer centers. We cherish magazines that outline the best hospitals and the best doctors as we read through the best advertisements effacing each of their pages.

But if you really want to search for the highest quality you have to look further. You have to wend your way through the living rooms and parlors of our people. To the quiet places where the ill and beleaguered are being tended to moment by moment with careful hands and open hearts.

You have to look to our caregivers... to our families.

When are we going to start learning from them?

Saturday, September 24, 2011

The Prodigal Son

I walked into Sarah's room like the prodigal son. Her husband stood above her holding a glass of thick liquids in one hand and a spoon full of pureed food in the other. She lay defiantly on the bed in front of us. Her left arm dangling over the sheets would occasionally move in a semi purposeful manner. Her right side was painfully still.

She looked nothing like the other fifty year olds in my practice. The ravages of cerebrovascular disease had devastated her body. Her mind was clear but her lips struggled through garbled musculature.

I greeted her husband with a firm handshake. A brief flash of relief quickly gave way to a sheepish hesitancy. We hadn't seen each other in a year since he requested his wife's medical records and disappeared without an explanation. I fained ignorance as I stepped passed him and placed my hand on her shoulder. Her lips curved upward in a crooked half smile.

Long time no see, stranger.

I pulled a chair forward in order to keep both husband and wife in view. As I flipped through the hospital chart we caught up on what I missed in the last year.

Her husband's brow had furrowed with new wrinkles since our previous encounter. His hairline had receded slightly farther. His tone was quiet but belayed the struggle and torture of the last few months. There had been a number of hospitalizations. Medicines came and went with many side effects but few benefits.

As I got up to leave I couldn't help but ask what was on my mind since I got the call from the emergency room.

So why did you come back.

He swayed uncomfortably in his chair and then stood up and strode forward. I could see him mentally rehearsing his answer as he cleared his throat to speak.

You see Doc. I don't really believe in what you do. What any of you do. It's all the same to me. God has a plan for my wife and there isn't a thing you or I can do about it.

But're different. You answer my questions. You return my phone calls. And all those other doctors got angry every time they walked into our room.

You are like a breath of fresh air. You don't blame us at all for what has happened.

You seem to actually like Sarah.

Friday, September 23, 2011

Our Relationship Was Difficult

Our relationship was difficult. I dare say strained at times.

I internally gasped as I listened to my own words as if they had come out of someone else's mouth. The walls closed in on the little office as the three men lingered by the door. They each appraised me differently. The oldest nodded his head in agreement while the middle stared at me blankly. The youngest twisted his mouth in a scornful grin.

There was no doubt about the elephant in the room. They wanted to know why their mother suffered six months before dying. Why the pain and weight loss could only be attributed to cancer in the last moments of life.

I had no clear explanations for why I, the oncologist, and the pulmonologist couldn't make a proper diagnosis. It mattered little that her emphysema was severe or that her heart was already failing. It calmed few nerves to assure that even if the cancer had been diagnosed she wouldn't have tolerated surgery or chemotherapy.

I can see the youngest squirm

But she said you were always rushing out of the room. That you never had time for her.

And she was right. She was the kind of patient who needed everything done in triplicate. She would pick apart each sentence. Forty five minutes later she would look up and accuse you of not explaining and want to start over again.

Most of her doctors had thrown their arms up in the air and given up. They abandoned her when the appointments began to prolapse into their other commitments.

Yes. At times your mother's needs were overwhelming and I'm sure she felt like I was rushing.

I wasn't going to hide the truth. I wasn't going sugar coat.

I handed over a copy of the medical records without being prompted. I urged them to take a close look. Talk it over with family and call me back with questions.

They slowly filed out of my office, the youngest clinging to the stack of papers.

I never saw or heard from them again.

I would love to end this blog post with something pithy or profound like my others. I would love to say that some greater truth evolved that brought peace to the family or made me a better physician.

But I would be telling a lie. The doctor patient relationship can be difficult and complicated. Each side comes to the table with inherent biases and personality disorders.

Sometimes it works and sometimes it doesn't.

It ain't always a bed of roses.

Thursday, September 22, 2011

A Love Letter To My Patients

If I can explain it will you understand?

Will you understand the wave and roll of the belly upon waking every morning of residency. The overwhelming nausea not caused by anxiety or fear (both of which are present)but by lack of sleep accumulated over months.

Or the shear panic of getting up after an hour of rest to an incomprehensible day chocked full of lectures, rounding, and an overwhelming amount of patient care to deliver. And realizing that returning home will only occur in twelve hours after each task is completed.

Will you understand a training that stresses pushiness, impatience, and bullying to such an extent that softness and empathy turn from a golden star to an Achilles heal. How one learns to yell, scream, and shake fists as a matter of course. As if these are things that normal people do in normal professions.

Until the outer skin becomes so tough and protective that not only can't sadness and pain get in but love and joy can't escape out. And a spouse sitting across the table watching as words sputter and a head bobs forward in mid sentence, wonders if it is worth it.

Would you understand the distant look as you describe the pain from your fracture, your migraine, or your gout. The mind cluttered and reeling from the last patient who was told that she was dying as her husband groaned and sobbed by her side. The brain numb from a torrent of paper, and forms, and phone calls accumulating on the desk in the adjacent office.

Has anyone ever told you that physicians are skilled at building barriers? On bad days we carry a mortar and trawl.

Can you see that I am trying to carry a sledge hammer here?

Wednesday, September 21, 2011


I sat dejectedly at the nurses station with my head buried in a chart to hide my tears. I felt a hand on my shoulder but didn't look up.

If you practice long enough, Jordan, there will be a small graveyard with your name on it.

I recognized the voice as that of a veteran cardiologist I often worked with.

We never spoke of this again.


It took a moment to integrate the melancholy of the words coming from the pretty young woman who sat on my examining table. Her face was bright and expressive. She neither smiled nor grinned. She spoke evenly without hesitation or stutter.

She recounted the events that changed her life. The morning she, a careless twenty year old, got into her car to drive to school. She would return home a drastically different person.

Of course she hadn't meant any harm. She would never hurt another human least on purpose. Her parents had warned her about drinking and driving. No one ever told her, however, of the dangers of cell phones. After all, she could text with her eyes closed.

She never forgot the feeling of the body as it bounced against her car. The blood that soaked her shoes as she jumped out to investigate. Or the look of the poor child's parents in court.

These are the kind of things that stay with you.


I was fascinated as she continued with her story. I felt not only great sympathy but a strange sense of camaraderie.

After the accident she took stock of her life. She neither granted forgiveness nor wallowed in self pity. But she did change just about everything.

A few years later she was a national spokesperson. She lectured around the country. The loss of one life ignited the courage to save countless others. A young self absorbed child had now become a world citizen.

She transformed her graveyard with its single inhabitant into a lively garden.


As she left I paused momentarily in the examining room. I could hear the phone ringing. The secretary chatted amiably as new patients checked in. The medical assistants scurried back and forth between hallways.

I contemplated that little place carefully buried in the deepest recesses of my soul. How many headstones had accumulated with names that long ago had become unreadable.

Maybe it's time to face my demons.

Maybe it's time for me to do a little landscaping.

Tuesday, September 20, 2011

Why Social Media?

The voice on other other end of the phone shook with volume and power. I could envision her fists shaking, her brow sweating, and her eyes bulging as if I was watching a bad reality show on TV. She was not just insinuating. She was outright accusing me of doctoring her medical record for my own personal gain.

I calmly listened to her fowl mouthed diatribe and waited for a moment to interrupt as she caught her breath. Should I tell her it was a hard day in the office? Explain that a patient was dying in the hospital? Would she have understood that I was just trying to follow government mandates and had been distracted by my first attempt at eprescribe?

So Yes...I did miss that my front desk employee had placed the wrong chart on my schedule. The names were so close. And I asked about her insurance status not to profile her but to decide whether to use eprescrbe or not.

In my heart I realized that she didn't want explanations. She was convinced that I was trying to harm her and I wasn't going to change her mind. It didn't matter that I correctly diagnosed her with pneumonia. She, in fact, got her antibiotic a few hours late but was feeling perfectly well now. But none of that mattered.

The truth is as physicians we are suffering from poor PR. Between the loss o faith from To Err is Human and the political wrangling of the PPACA we have gone from knights to knaves.

In the public eye the empathic physician has been replaced by the miserly clod who clumsily dances through doctoring in order to drive home in his BMW and trade stocks online.

We are looked at as greedy. We spend to much. We order too many tests. We make to many errors.

If those darn doctors would just do what they were trained to do!

Many physicians who struggle on the front lines see a very different picture. We are consumed by our career. We fight for our patent's well being as if they were family members. And we get burned over and over again by the oversimplification purveyed by catchy headlines and enthusiastic politicians.

In order to reverse the egregious harm done to our profession we have but one choice. We have to take our fight to the people.

Why do I use social media? I see it as a profound and effective way to communicate to our patients who we are. To re brand us back to the knights we strive to be.

Only then will they know our commitment. Only then will they have a window into our souls. Only then will they know that although we may not be lying with them on the operating table.....

we still bleed.

Sunday, September 18, 2011

What Do You Want?

I sat uneasily staring at the young man sitting across from me. He winced and painstakingly adjusted in his seat to find a comfortable position. His face gray and withered had taken on the look of the nursing home surrounding us. Drabness pervaded.

At thirty eight he was much too young to be incarcerated in such a manner. He was a victim of biology's cruel misfortune. He had usurped the privileges of age prematurely. He was dying of cancer.

His legs were paralyzed since undergoing surgery to remove tumor from his spine. His lungs, stifled by nodules, gurgled and sputtered with every breath. His hands clenched with each movement. The pain was debilitating.

His doctor discharged him from the hospital with instructions to get stronger. A few weeks of therapy and you'll be ready for your next round of chemo...your next back surgery.

I listened to his explanations and begrudgingly hid the doubt and disgust that percolated through my brain. What kind of physician encourages his dying patient to waste his last hours of life doing physical therapy?

I focused my thoughts for a moment. If I impose my will on him am I any better then the doctor who exhorted physical therapy? Could I recommend hospice with a clear conscience?

So what do you think of all this?

As I waited I searched him for direction. He paused. He closed his eyes and took a deep breath. A tear formed and rolled down his cheek.

I think I'm dying!

I reached over to the desk and handed him a tissue. I thought of my wife and children. How would I handle his situation? Would I except the harshness of reality or would I fight impossible odds?

What do you want?

His eyes, which had been focusing on the floor, shot up to meet mine.

I want this to be over. I want to be out of pain.

His face brightened. The grayness disappeared and he smiled and started to laugh. I asked what was so amusing.

What I want?

No one has ever asked me that before!

Saturday, September 17, 2011

The Kind Of Doctor Who Takes Care Of Colds

It was my favorite kind of gathering. The room was filled with young attractive non medical people. Most carried a cocktail effortlessly as they stood in their best Friday night apparel. The tempo of the conversations rose and fell.

I caught a glimpse of my wife standing across the room with a small group of friends. I watched her hand gestures and the shift in her posture. I had just enough alcohol to amuse myself by conjuring up mock details of their conversation. Boy Sally I love that purse but those shoes are just dreadful!

I cradled a Corona in my right hand as a distant acquaintance wandered forward in my direction. He was well dressed. A business type if I remembered correctly. He was a friend of a friend.

We chatted amiably for a few moments. Quickly running through our list of polite conversational topics before a look of excitement flashed across his face. Hey...your a doctor right? What do you practice?

I felt a twinge of disappointment and embarrassment. I really didn't like talking about my profession in public. I paused for a moment and then explained that I am an Internist.

An Internist? Like a primary care doctor? The kind of doctor who takes care of colds right?

I probably would have taken offense to his comment if his words hadn't transported me back to the struggles of the last week. My eyes glazed over.

I signed four death certificates last week. Each patient was in hospice. One in the hospital. One at home, and two in a hospice unit. Three I had known for years. The fourth was a young man who I just met. I spent hours counseling each one of them.

I admitted ten people to the hospital. Some got better. Some got worse. A few ended up in the ICU.

I was on call half the week and hadn't slept most of those nights. I returned each morning dutifully to see patients in clinic. I struggled as always to sort out the bio-psycho-social causes of illness. I diagnosed a case or two of gout. Saw a patient with erythema chronica migrans whose Lyme titers were markedly positive. I told a young woman she has cancer.

I worried. I paced. I stressed. I ignored my children nagging at my feet as I returned the deluge of phone calls from the nursing home.

I held hands. I teared up several times. And I the hospital, in the exam room, at home. I laughed even when sometimes I felt like I wanted to cry.

I woke up from my haze to see that my companion was now waving his hand in front of my face. For a moment I focused on him before I purposefully walked in the direction of my wife.

Yes. The kind of doctor who takes care of colds.

Friday, September 16, 2011

For Safe Keeping

He skated into my room with his hair disheveled and his hands waving wildly. For a moment I thought he was Kramer from an old a Seinfeld episode. His lips moved erratically as he gasped for breath.

Doc...doc you got a help me!

I motioned him into a chair. As his backside was about to touch the seat he bolted upright. He stood with one arm resting on his hip and the other holding him steady against the desk. His eyes squinted in pain. A drop of sweat formed at his hairline.

What happened to you?

As I asked his face turned from pain to humiliation. His voice lowered and he strained to lean closer. He looked up at the door cautiously to make sure that it was closed.

Doc I got a chicken bone!

He must of recognized the confusion in my facial expression because his eyebrows furrowed in frustration. He looked like a poor school teacher forced to explain yet again to his substandard students the difference between a noun and a verb.

Jeeeeeez, I got a chicken bone stuck up my ass.

I almost fell off my chair. I turned my head and bit my lip. Anything to avoid breaking into peels of laughter.

Upon regaining composure I turned back toward him again.

Surely your wrong! A hemorrhoid? An abscess? Some left over toilet paper?

He was losing patience quickly. He gritted his teeth in a last effort to control his emotions.

I know what I know. Last night I ate chicken and this morning I got a chicken bone stuck up my ass. Are you going to take it out or what?

With that he dropped his pants, turned around, and leaned forward against the exam table. I cleared my throat and took a step backwards.

Um...Um....I better get some gloves for this one.

I adjusted the exam light over his behind and pulled my stool closer to take a peak. Apparently he enjoyed the warmth because he moved his torso from side to side in mock pleasure.

And there it was. A minuscule shaft of pearly bone with a forking arm wedged perfectly in his rectum. With forceps in hand I gently coaxed the obstruction free. I could hear the sigh of relief escape form the other side of of my precariously perched patient.

I laid the product of my excavation indignantly on the tray and turned to leave the exam room.

No more chicken for you I called over my shoulder as I gathered my computer and raced toward the door. Out of the corner of my eye I could see him grab a tissue and grasp the bone between two fingers.

He then put it into his pocket...

for safe keeping.

Tuesday, September 13, 2011

Why I Write And Some Medical Blogosphere History

It was the sitemeter. The damn sitemeter. I couldn't take my mind off of it as I sped down the highway to the hospital. The sun inched over the horizon and a blur of headlights swarmed and then passed my car.

I should have never put a sitemeter on my blog. I didn't need to stare down the barrel of cold incontrovertible proof. I already knew that my posts disappeared into the ether as fast as I pushed the publish button. But I sure didn't need confirmation.


I remember back to when I started blogging. I built a web site selling artwork. I called it Fine Art Doctor. It was a hobby to fulfill the emptiness from those early years of practice.

The blog was a companion to the web site. I wrote about various art related topics. But I was flat. Uninflamed by the controversies of the art world I searched the Internet for more.

What I came across was a well known blogger named Gruntdoc. When I surfed his site I knew I was onto something. I left a comment on one of his posts and started to change the direction of my blog to focus on medical topics.

It was 2006 and the Grand Dame of the medical blogosphere was a woman named Moof (I know your lurking out there somewhere!). Moof followed from Gruntdoc and introduced me along with Doctor Anonymous (Mike Sevilla) to the community.

It was an inspiring time. I remember reading the likes of Charity Doc and Doctor Charles (before he left and then came back). TBTAM was on hiatus. KevinMD still rained supreme but in a slightly lesser way.


I turned the radio up as Adele was playing in the background. Her voice, sweet and soft, was becoming bigger and more powerful each second.

In the beginning I had quite a following. I started with medical narratives and poetry. Eventually I graduated to writing fictional stories. I celebrated with each comment. Sometimes I got as many as ten per post.

I felt creative and liberated. Like part of a community. I even got some face time on KevinMD. Sure I would sometimes fall off the bandwagon and go days without posting. Maybe even weeks. But I would always come back.

That is until the morning I had a car accident. I wasn't hurt but I was shaken. And then I arrived at my office to turn on the computer and find that my blog was gone. A word press glitch.

I finally got the content back weeks later but it was imported to a new web address.

With the snap of a finger I lost my blog. I lost my community. I lost my voice.


Adele is now barely audible. Her voice vibrates with charisma but soft...emotional.

I migrated over to blogger with little fanfare and little following. I would have loved to be able to brag about my stamina but I couldn't. My blog had been mute for weeks or sometimes months at a time. Posts came and went. Sometimes barely audible.

So why did I do it. Why did I keep writing in such a public way to an audience that had all but disappeared?


My mind slowed. My shoulders relaxed and I listened to the music:

I hate to turn up out of the blue uninvited.
But I couldn't stay away I couldn't fight it.
I'd hoped you'd see my face & that you'd be reminded
That for me it isn't over.

As I listened to the lyrics my emotions swelled. A few words masterfully twisted and tangled with a little melody brought up such vivid feelings. Snapshots. Memories. It reminded me why.


I write because I envy people like Adele. I envy the master craftsman who with a twist and flourish can reach down deep into our souls and produce something different in each and every one of us.

I yearn to use a few words to paint a million pictures on each reader's private canvas. To pull out from them that which they secretly want to expose but hold fiercely close to their hearts. To teach. To learn.

I would write if there was no blog, or paper, or pen. I would scrawl my awkward musings in the sand with a stick.

I would write because I have to.

Even if no one is listening.

Sunday, September 11, 2011

A Hospice Story

If cats have nine lives surely Paul had at least two. There was the one he led for his first thirty years. Lonely and introspective he struggled with a secret that was far too large for his conservative Catholic upbringing. So he closeted his feelings. He closeted his hopes and dreams. And he closeted his sexual orientation.

His second life began on his thirty first birthday when he confessed his heart to his parents and sister. A heated argument ensued which caught Paul completely by surprise. He left his childhood home in the tony Chicago suburbs and never looked back.

A decade later I stood next to his bed my body shading the stream of light pouring in from the east facing window of his room. I fidgeted uncomfortably as I asked if there was something I could do. It was my first day on the hospice unit. His partner nodded slowly. They wanted to see the chaplain.


My earliest clinical experiences occurred during the first year of medical school as a hospice volunteer. Each week I would leave the cloistered environment of the library and anatomy lab and wend my way through the hospital to the hospice ward. It was the mid nineties and people were still dying of AIDS.

Paul had withstood every cruel manifestation of an emotionally and physically disfiguring disease. Lymphoma, Kaposi's Sarcoma, pneumocystis pneumonia. He was tired. And for the most part he was ready to die.

As dying people go, Paul had it all. A caring partner. A slew of friends that visited him constantly, and a kind and generous demeanor. He rarely complained of physical pain. He, however, could not overcome the internal unrest that snatched the dream of a peaceful death from his frail clutches.

Paul had not spoken to his family in over ten years. They had no idea that he was sick or dying in the hospital. He called once six months prior. But his father hung up before he could explain his situation. He yearned to see his father and mother once hug his baby sister.


On a sunny October morning the chaplain sat down at the nurses station to call Paul's parents. His mother answered the phone cheerily. The chaplain gently explained who he was and why he was calling.

A barricade that took a decade to traverse emotionally melted away in minutes as his family rushed the short distance from the suburbs to the city hospital. By the time they entered his room, he was unconscious.

I watched as Paul's father, mother, and sister sat attentively at the bedside for a few minutes. Then they would leave and his partner and friends would enter to take their rightful place. This back and forth continued for hours.

As Paul's breathing slowed the chaplain approached his family and beckoned them to come. They joined the others standing in his room. Each family member jockeyed amongst the crowd to get one last look. Touch his body one last time.

The chaplain asked that they hold hands to say a prayer. And there stood Paul's loves ones. His father holding his partner's hand. His mother and sister interspersed among his friends.

Paul's eyes opened briefly before he took his last breath. As he looked up a faint smile formed at the corner of his lips.

He had found peace. He could die now.

The two parts of his life...

had finally come together.

Saturday, September 10, 2011

Sexual Dysfunction And Hearing Loss..A Story

As I barged into the exam room I could feel my cape catching on the door knob as the few strands of hair left on my balding head blew luxuriously in the wind. I halted a moment to catch my breath. you must help me.

My thoughts raced. Could it be a heart attack. A stroke. Hemorrhoids? I strode through the door and sat down on the edge of the chair. I was prepared for anything.

You see's an emergency. I went to sleep three days ago and when I woke I couldn't hear out of my left ear.

His mouth twisted as he chocked out the last sentence. My keen medical mind surveyed the situation. He was in moderate distress. His head swayed back and forth with each word as if trying to position his right ear for better volume control. His brow was damp. His hands shook with excitement and fear.

He began to explain the dilemma further but I lifted my hand dismissively. Quiet man...I don't need to know such insignificant details.

I propped him up on the exam table with one hand as I pulled my trusty otoscope of the wall. I agiley placed the tip in his left ear.

First line: AECD. Second: QSTR

He waited for a moment and confusedly blurted out: what...what are you saying?

Oh nothing. I replied nonchalantly. I was just reading the eye chart on the other side of your head. Just as I expected! Even through the otoscope I have perfect vision!

He swayed in his chair as I finished the exam.

It appears you have an obstruction. Nurse...nurse...get me the irrigation tray.

I filled the syringe with scalding water and draped his shoulders with a gown. After five or six vigorous sprays a small blue pill fell out of his ear and onto the exam table.

I picked it up and examined it. Why it's a Viagra pill!

His eyes grew big and his jaw dropped. So that's where it went...I've been looking for that all over.

My eyebrows rose quizzically as he fidgeted and blurted out an explanation.

You see wife was trying to be all sexy like and leave a pill on my pillow. But I got so tired I didn't even see it. I laid down on my left side as usual to take a nap...

By then I had turned to leave the exam room. There was another life to save the next door over. Hearing loss as a side effect of Viagra. You better believe I was going to report that adverse event to the FDA. more thing. He thrust his hand toward me. Can I have the pill back.

Those things are expensive.

Friday, September 9, 2011


They were like two peas in a pod. The pod a sterile deodorized nursing home and the peas withered and wrinkled.

I remember the first time I made the trip to the end of the hall and turned a sharp left into their room. I felt as if transported from a frigid blustery Chicago day into a cozy den. The fire crackling. The smokey smell of home.

I would later recognize this warmth as the rapturous, indignant heat of unrequited love. But for now it welcomed me into their surroundings. Bayed me to come. Spoke to me. Sit down and talk awhile.


Her medicine list was as long as an elephant's trunk. Her litany of diseases filled the tomes of her disheveled chart. Papers hung loosely to the binder perilously close to breaking free.

He was the more healthy of the two. Eighty five years old on dialysis with heart disease. They were the poster children for our healthcare system. Death was no longer an endpoint but more a bothersome tick, a flea. Annoying but something that could be dealt with.

I followed her in and out of the hospital. Seizures, heart attacks, strokes...she suffered them all. And each time she would return to their little room together. He doting over her with the patience and anxiety of a father watching his sickly child.

The love in the room was palpable. So much so that one day I asked how long they had been married. I expected five or six decades. Instead he answered quietly: Twenty five years.

I, shocked by his answer, pulled up a chair and placed it at the edge of the beds.

Tell me about it.

She looked over in his direction. Her eyes silently encouraging. You explain to him. You always tell it so well!


They dated in college. On graduation night spurred by the confidence of alcohol he asked for her hand in marriage. At this point in the story she averted her eyes in faux embarrassment. For some reason she declined.

Fast forward thirty years, two divorces, and five children later. Destiny brought them back together. As he said this a devilish glimmer momentarily flittered across his face. The subtlety was not lost on me. He likely engineered the meeting. Maybe she knew....maybe she didn't.

They lived happily together, of course, till illness brought turmoil to their lives. She was losing strength. Her will to live was faltering. And he was suffering.

He pleaded with me every visit. Please doctor...please. Don't let her die! I couldn't live without her!

Despite my best intentions. Intravenous fluids and antibiotics. Steroids and chemotherapy. Despite all I humbly had to offer. I received the call one morning. She was unresponsive. I arrived at the same time as the paramedics.

We were too late. I sat with him in a vacant room as the nurses prepared her body for transport. I held his hand and tried to stop it from shaking. He was silent. He was empty.

The next few weeks were difficult. He struggled with depression and pain. He was afraid to be alone. His family tried to comfort him.

One morning a medical assistant walked into his room and found him dead. His body finally reaching his soul.


As I sat in my office filling out his death certificate I felt both sorrow and triumph. I would later learn that he died on the morning of his beloveds birthday. She would have been eighty years old.

With unusual candor I filled out the rest of the death certificate. But my mind was elsewhere.

We doctors are like little Napoleons. We annex the human body as if unclaimed territory. We grapple as if we have any control over human fecundity.

I dropped the paper in the fax bin. A few minutes later the funeral home sent a fresh certificate with a note attached:

Dear Dr. Grumet,

Please repopulate the "cause of death" field on the attached form.

Your previous answer: "A Broken Heart"

is unacceptable

Wednesday, September 7, 2011

A Moment Of Clarity

Although the name on the chart was oddly familiar I couldn't place her. I was covering for a partner who was on vacation. It felt like my day would never end.

When she bopped into the office I knew immediately. We went to school together. Years ago. She sat down quietly on the exam table typing away on her mobile phone. I approached cautiously my mind musing on occupational hazards. I wondered if she would recognize me.

As I introduced myself I searched her countenance for signs of familiarity. I quickly realized that she was too busy talking to even notice. She was a classic example of today's connected youth. She grew up in the email/text message generation. Conversations were more a one way soliloquy then a rational bidirectional exchange of information.

I found myself only half listening as she continued to harangue me with unimportant non sequiturs. Please be a a low back pain.

I awoke from my reverie horrified by the one phrase that struck terror down to the core of my being.... I'm having a little itch and the way do we know each other?.

I brushed off her question and entered doctor mode. This is what I trained for. If I could run a code and make life changing decisions I certainly could pretend I didn't know a young woman I was doing a pelvic on. (Wow...did I really just write that!)

I handed her a gown and left the room to collect an assistant. This was one exam I wouldn't be doing solo.

When I returned the technician had placed her on the exam table. Her legs were up in stirrups and her gown was folded over. Smack dab in the center of the commotion was the chair of honor reserved for yours truly. I donned a pair of gloves and inspected the speculum. As I sat down my medical assistant stood above me...ready.

And their laid our patient. Fingers tapping away at her cell phone as she continued to talk at random. She urgently chewed a piece of gum that appeared in her mouth as quickly as her clothes came off.

While placing the speculum and collecting samples I froze. Oh...I know! We went to high school together!

All of the sudden the room became unbearably hot. My face burned a shade of crimson. The medical assistant bit her lip and squeezed my shoulder tightly in order to stem the tide of laughter. Yes....yes...maybe.

I quickly finished the pelvic and left the room to send the specimens to the lab. Upon returning my patient had fully dressed. As I explained my findings I could barely look her in the eyes. With great embarrassment I gave her a script to treat a yeast infection and rushed out the door.

As she left I could hear her chatting away with the receptionist without a care in the world. I fled to my office and closed the door. I took a few deep breaths. A drop of sweat raced down the side of my face.

And then I had a moment of clarity.

It was like she was the doctor.

and I...befuddled, afraid, and powerless...

was the patient.

Tuesday, September 6, 2011

This Is Not One Of Those

My dream is always the same...

It’s just another day in hell. I stand on the Bone Marrow Transplant unit. There are no windows. Suddenly the building starts to shake. The ceiling cracks letting in rays of sunlight. The ground rumbles below.

Sadness, grief, and despair spew from the floor. They rise as black lava erupting from the innards of the building and drag me to the street. I am swept forward as black death encompasses the earth and moves to envelop the sun. It carries me to the east…..always to the east.


I've never thrown a punch. Never been in a fight or carried a gun. So if you ask me what it is like to do battle…I only have a limited set of experiences to draw from.

I did, however, catch a glimpse of the desperation of war during residency when I spent a month in the Bone Marrow Transplant unit. I felt continuously under fire, attacked from all sides, desperate. I experienced death every day.

It wasn't just the was also the young. Mothers, fathers, children…no one was spared!


The Bone Marrow Transplant program during residency was large. There were fifty patients on the unit and then twenty to thirty scattered amongst the oncology floors.
We had ten admissions a day and the same number of discharges. On average one patient died every 24 hours.

The job of taking care of these patients fell on two fellows, two residents, one attending physician, and countless dedicated nurses.

There are many beautiful life affirming stories that occur on a Bone Marrow Transplant floor.

This is not one of those.


I remember my last day on the unit. I spent the morning avoiding ambush. There were no codes. All our patients survived the night.

I stepped into Mrs. P’s room gingerly. Mrs. P had been in the hospital for over 6 months. She had a stubborn lymphoma that persisted despite treatment. She knew that she would never return home.

She knitted every morning as she watched the news. As with so many patients, our conversation moved from cordial greetings to a discussion of world events. I went through the motions of my examination as she recounted the most recent atrocities. They were particularly horrible today.

We did this every morning. She telling me who recently died, or was killed, or robbed. And I feigning interest although in reality I had lost touch with life outside the unit. The world could fall apart around me but I was too busy…scurrying after labs, running codes, talking to family members. Secretly trying to protect myself from the death and destruction that surrounded me.

If you listened closely to the discussions that we had every morning the essence of what was said would sound something like this…

“Doctor, I watch TV and see that in the world things are happening, and I am still here”. And dutifully I would respond, “yes, yes, bad things are happening in the world and yet, thankfully, you are still here!”

Mrs. P’s days were limited. And my days on the unit were almost over. I worked 12 hours a day, every day, for a month. My time at home, in-between shifts, was surreal. I would sleep, eat, have conversations. Mostly exhausted bridges to my next stint on the unit.

I had become a robot, a zombie.

I was withdrawing.


It was just another day in hell.

I sat down for rounds that morning. Mrs. P was right...things were happening in the world and strangely I couldn't’t relate. The TV above us was blaring the latest news. My attending was sitting down with his daily Tab and being prepped by the other residents.

The hum of the nursing station had reached a fevered pitch. I glanced at my progress notes and realized that I forgot to add the date and time. I looked at the clock on my pager:

10:45 AM

The world had instantly changed.

And it would take a good deal of time and spiritual healing to realize that it wasn’t just another day..

of death and destruction on the unit.

Sunday, September 4, 2011

Mary's Disease Was Not Measured In CT Scans

You killed my patient.

His words were like venom. He spit them in the direction of the phone held by his left hand which bobbed in front of his face.

You mean the one with the metastatic lung cancer? The one whose finger like tumor strangled her esophagus making the act of swallowing similar to trying to fit a hamburger through a closed vice grip?

I could feel the heat emanate through the line as his temperature rose. I could sense the amplitude of his body shaking as his words came out an uneven staccato.

Yes the one whose disease burden had noticeably shrunk on last nights cat scan.

I felt calm. I had watched from the periphery as Mary's physical and mental condition declined dramatically. Although she was my partner's patient, I grew fond of her during a recent hospitalization.

She struggled to comprehend the changes overtaking her. She was lost in a whirlwind of chemotherapy and radiation, medication and complications. Her oncologist spoke of the future as if it was already written. Full of hope...he never mentioned prognosis. Never talked of life expectancy.

He managed her disease on a cellular level. He thought in terms of tumor growing...tumor shrinking. But Mary's disease was not measured in ct scans or labs tests. One look revealed life's harshest reality. She could no longer walk. She could no longer eat. She was dying.

Two weeks ago Mary developed a fever. She became confused. And she refused to get out of bed. Her family brought her to the oncologist who prescribed antibiotics. Her physical state improved initially but was now receding. Mary's family, overwhelmed and afraid, brought her to the emergency room.

The ICU nurse woke me form a sound sleep. There was no DNR order and Mary needed to be intubated. The oncologist had already given the order to ventilate but the nursing staff was reticent. Lack of familiarity added clarity to their perspective. There was no history or personal involvement to falsely color the obvious.

I quietly spoke to Mary's husband.

What would she say if she could see what is happening?
She'd be horrified!
Would she want to be on a ventilator?
Should we just make her comfortable?

I asked for the nurse and ordered a morphine drip and ativan. When I arrived the next morning I found a crowd huddled at the bedside. Mary was peacefully unconscious. Her husband was somber yet relieved.

She died and hour later.

The oncologist lit into me mercilessly. She had pneumonia. We could have treated her. You let her die.

I took a deep breath and paused.

All of our patients die. We have no control over that.

If we are lucky we can allow for a little dignity. Perhaps help them control how and when.

Upon finishing I realized that the oncologist missed my last sentence. The sound of the dial tone on the other end confirmed..

he had already hung up.

Friday, September 2, 2011

It's Complicated

My son glances up at me with those stunning brown eyes as his fingers pull at the sides of my pant leg. His head plunges downward and he clasps his hands behind his back. He is working up the courage to ask. His feet sway side to side. I know what's next....daddy, can I come with you to the hospital?

My heart sinks and then bounces back into my throat hampering my voice. How do I explain to a seven year old and keep him from becoming enamored? Should I tell him being a doctor is not just about pagers and fancy phones? Blue tooths, reflex hammers, and pens with shiny pharmaceutical logos?


He is shimmying back and forth in his booster as I turn down the car radio to answer a page. How do I explain my life's work? The all consuming task that has swallowed my youth. Ground me into pieces and spit me out...ragged and torn.

What do I tell a little boy about uncertainty? About the irrational complexity of the human body and the self inflicted torture of those who willfully try to master it. Or of consequences. Could I explain how it feels to be responsible for the loss of anther's life?


As we enter the hospital he marvels at the balloons in the gift shop. For him, the wards are a carnival of grandparents with kind words and smiling nurses offering sweet treats. But does he see the beaten and haggard bent over their rosary beads in the ICU waiting room? Or hear the mindless hum of the ventilator? Or notice the fetid smell of sterility that permeates the hallways?

Can I explain to him that a doctors career is series of battles which are all inevitably lost. And that victory occurs in crowded exam rooms were quiet desperation is met not with miracles but humanity and humility. A kind smile, a generous hand, and a partnership built on difficult decisions.

How...I ask I protect him from a profession fraught with such difficulty?

How do I elevate him to a life that offers so much?