Monday, October 31, 2011

Agents of Torture

I don't know when I became the angel of death. It was never my plan to be the patron saint of hospice. In fact, I started my career dealing with much less terminal illness. But as I spend more and more time in nursing homes, end of life discussions are a large portion of what I do.


I had multiple admissions to the facility this weekend. Of course, there were the occasional rehab patients recovering from hip and knee replacements. I was shocked, however, to see how many people rolled through our doors with end stage illnesses. The expectation was that they were coming for rehab.

There were metastatic cancers, devastating cerebrovascular accidents, and centenarians newly started on dialysis. As I sorted through the admissions paperwork, I started to see familiar patterns.

Peg tube placed for malnutrition. Dialysis initiated for failing kidneys. Chemotherapy scheduled for lung cancer with diffuse metastases.

Since there was no documentation of detailed end of life discussions, I made a point of asking each patient and family member a few questions:

How do you think treatment is going?
Has anyone told you about prognosis?
What are your goals?

Surprisingly, many of these questions had never been asked or answered. I found my patients and families to be largely oblivious. Many of their responses were shockingly uninformed.


I don't know how we got to this place. I understand that we as a profession need to make money. That gastroenterologists need to place peg tubes, that oncologists need to give chemo, that internists need to rack up visits.

I accept these facts. But when did it become okay to practice futile medicine and batter our patients?

How did we become agents of torture?

Saturday, October 29, 2011

Breaking Up

As I walk out of the building, I wonder if I will ever step through these doors again. I feel a faint ache in my chest and my eyes tear up. We had a few good years-the building and I.

How many mornings had I rushed in at 6AM to evaluate and ailing patient? How many afternoons had I sat at the nursing station writing in charts and chatting with residents and staff?

My letter of resignation was an abrupt and unexpected end to an emotional connection.

I could no longer come to the facility.


There was a time, in my career, where I pictured myself a superhero. I swooped into patients rooms in the nick of time. It was a one sided arrangement.

As I matured as a physician, I realized that the doctor-patient relationship is much more complicated. It's more like a dance. Sometimes our steps are in unison. Other times it is as if we are listening to completely different music. But it's two sided. Like most relationships it is messy and complex. Each party has both needs and gifts that require nurturing.

How could I not be changed by my years at the nursing home? I think of the resident who would accost me while I was charting at the desk. How often we talked about baseball and the Cubs. I never had the courage to tell him that I knew nothing of such things. But with time, I came to expect this camaraderie. I learn to look forward to these encounters.


It's hard for a physician, nay a person, to admit that we can no longer meet other people's needs. Or better yet, that meeting these needs will encroach on our own.

As we grow and change, we take on these transitions with little thought. We leave practices and hospitals. We move to different cities or change careers. And for the most part, we are oblivious to all that we have left behind.

But today I will be cognizant. I will say goodbye to years of hard work and countless relationships built on blood, sweat, and even tears. I will not be ashamed of my sadness, nor deny that I am leaving behind some who truly need me.

I will also admit that my absence will not be a contradiction to the fact that I need them too. I will not pretend that this is just another day. I will not pretend.

That breaking up isn't hard to do.

Wednesday, October 26, 2011


I'm not sure when I lost my humanity-at least for the most part. Maybe it was the hazing in medical school or the unending nights of residency. I prefer to speculate it was the dull thud of yet another pile of papers dropped on my desk.

Whatever the excuse, it happened. The soft, compassionate, eager student who started this journey is morphing. My skin withers and thickens into sheets of heavy chain mail. My eyes turn a colder shade of grey. My hands become dry and leathery in the midst of the frosty Chicago weather.

My body and soul adapt to form a protective shell. My heart battered and bruised beats in it's restless cage.

But sometimes, for just a moment, I remember the former strength of my innards. How my heart stood front and center. Occasionally knocked by the harshest of realities but never backing down.

Those days seem so far away now.


I gently rock back and forth as I stand at the nursing station. Three racks of charts rest beside me. Every few minutes I close one chart, place it back in it's holder, and pull another. I am acutely aware of the ticking clock on the adjacent wall.

My billing sheets collect dust in a pile next to me. I'm tired. For two hours I roamed the hall of the nursing home, interviewing its inhabitants. I put out fires. I calmed angry family members. And I am about to finish documenting, when a young woman walks up to the desk and waits quietly for my attention.

Are you Doctor G? I was wondering if you could come talk to my father.

I glance at the chart the nurse placed on the counter next me and feel an odd sense of relief.

Your father is not my patient. You should call his doctor.

She taps her feet impatiently and looks slightly annoyed.

Well the nurses told me you're covering for Dr. K who is out of town.

I vaguely remember that I offered to manage Dr. K's patients while he is gone. My heart falls. I'm already late and the last thing I want to do is walk into the care of a train wreck.

The woman watches my response closely. She senses hesitation. She's angry

Look! If you don't want to help...

She turns away and stalks down the hallway.


I walk into the room with my tail tucked between my legs. A kind elderly man lies in the bed in the center of the room. He is surrounded by his wife and daughters who fawn over him to adjust his bedding. None of the fangs that I witnessed earlier are now apparent.

Their needs are minimal. A simple explanation. Some interpretation of tests. Mostly they are looking for attention. They search for a sign that someone is commanding the ship through the relentless tempest of illness that they bravely face.

And I remember back to a time before my mind was clouded by all this "education". When I would give myself freely to sit with an ailing patient and provide the sort of "doctoring" that now has been squeezed out of me.

I started on this path to provide service to my fellow man.

How have I wandered so far off course?

Tuesday, October 25, 2011

Actively Dying

The group of students walking behind me move uneasily through the bustling hospital halls. Their crisp clean coats stand in stark contrast to the faded linoleum and stained wallpaper. Doctors and nurses dart quickly to avoid slowing down behind the ambling herd.

I pause for a moment at the end of the hall, think better of it, and walk on. I turn quickly toward the group as my legs propel me forward mechanically. Our next stop is just three doors away. I check to make sure the hallway is empty before addressing the group.

I think we'll skip room 214. She's "actively dying."

A few steps later, it dawns on me that such a term is likely confusing to a third year student. I stop abruptly in front of our next patients room.

So who can tell me the definition of "actively dying"?

The row of faces look up quizzically, but I am already lost in thought.


My mom's voice sounded shaky over the phone. I could hear my grandmother breathing heavily in the background. Her silence spoke volumes. I adjusted the receiver and took a deep breath.

How's she doing?

My mom's answer was almost imperceptible. I felt, for a moment, like I was talking to a child.


I strained to interpret her uneasiness as I calculated the distance between St. Louis and Chicago. If I left immediately, I could reach the assisted living in six hours.

Is she still talking to you?

Instead of answering, my mother lifted the phone to my grandma's ear and coaxed her to speak. I listened to each struggling gasp. The prolonged breaths were punctuated by pauses.

My mind clicked. As a second year resident, I'd dealt with this before. I slammed down the phone and rushed to my bedroom to pack a few things before leaving the house.

The roads were dark as I sped down the highway.

Time was running out.


Six hours later, I walked into my grandmother's room. I was oblivious to the grime and sweat caked on my body. I had driven all night. I knelt next to the bed and placed her hand in mine. My mother and father sat quietly in the corner.

Her breathing had slowed since the night before. The pauses were more apparent. I leaned over and kissed her forehead. I whispered into her ear.

It's OK. You can go now!

I placed the radio on the nightstand and put on the My Fair Lady CD.

Grandma's chest moved up and down slowly with the rhythm. Each rise and fall more gentle till the energy in the room palpably changed.

Her body was still.

Her soul had left us.


After a reflective moment, I answer my own question.

"Actively dying" is the final phase of life. The short interlude in which the dying process takes place. It often lasts between twelve and twenty four hours. Patients are usually unconscious and exhibit cheyne stokes breathing.

I can see the puzzlement wash over the student's faces. A few raise their hands as if we are in a classroom. One speaks up.

So what do we do when this happens?

The first thing that comes to mind is my mom's face. She still can't talk about that day without breaking into tears.

We comfort the family.

They are the ones who will carry the scars.

Monday, October 24, 2011

Memories Of My Father

So it happened again the other day. I was admitting a patient with kidney failure and his potassium came back at 6.9. I quickly got on the phone and dialed the patient’s nephrologist. He was an older gentleman who I rarely worked with. His secretary kindly took my information and replied,

“OK Dr. Grumet, I'll let him know you’re holding”.

After a minute he picked up the phone:


It took me aback for a moment although it shouldn’t have. It’s already happened a few times since I moved to Highland Park.

“High Dr. H, this is Jordan Grumet. Jerry (Gerald) was my father”

"Of course, Of course, Jerry died years ago. I knew your father well. Hell of a physician. We worked together at Northwestern”

Although my father died in the early eighties, i’t sometimes seems that he is still alive and well, roaming the halls of the hospital. No matter where I practice, someone goes out of their way to tell me what a wonderful physician he was. One day it will be a colleague and the next a nurse. A few of my patients even knew him.

And yes, I still get called “Jerry” all the time. I have mixed feelings about this. On one hand, I am extremely proud that twenty plus years after his death his memory is still strong. That he was a great physician and people carry his kindness and wisdom with them. On the other, I'm getting to the point in my career where I am no longer content to be known as the son of a great physician. Sometimes I want to be acknowledged for my own achievements and merit.

But the truth is, when I reread the last paragraph, I guess I'm lying to myself. Because what really burns is that all these people have a piece of my father that I will never own. They knew him as a physician.

And there have been times when I really needed to know that aspect of him. When I was struggling in residency after countless sleepless nights, I could have used his encouragement. When I did my best and watched my patients die anyway, I so yearned for his support. When I became disillusioned with medicine and felt like leaving, it would have been helpful to know that he went through the same thing. And when a colleague accidentally picks up the phone and calls me “Jerry” it would be nice to hear his laughter as he slaps me on the back and exclaims,

“if only I was half as good a physician as you are at your age!”

Because at the core, stripped of the years of education and medical degrees, I am still just a little boy trying his best to gain the respect and love of his father.

And sadly, I am all to aware, that thirty years after his death...

that is no longer possible.

Saturday, October 22, 2011

Ode To The Computer Guy

The computer guy (our trainer) is starting to look stressed. The sweat roles down his forehead as he hunches over the lab top. A cell phone is perched between his shoulder and ear. A line of people are standing behind him. He tries to inconspicuously look at his watch while he waits for a response on the telephone line. Only a few more minutes till quitting time.

Our "go live" has ended horribly. It's the close of day two, and there are still major glitches in the system. The eprescribe functionality is missing in action. Scanning of external documents is restricted and the auto fax is nonoperational.

My partner, who hadn't bothered to peruse the online learning modules, runs after the trainer between each patient. He struggles to input precious information that swirls randomly in and out of his consciousness.

My office manager is perturbed. Half the staff aren't up to speed. The other half are threatening to quit.

It's a miracle that any medical care has actually taken place in the last few days.


I feel strangely above the fray as I observe the seen unfolding in front of me. I can't help but harboring a touch of scorn for the computer technician.

He thinks he's stressed!

At the moment I have a patient in the nursing home dying of lung cancer. He's in severe respiratory distress. His family crowds around as he struggles to suck short wisps of air through fibrotic lungs. He is like a fish out of water. I order intravenous morphine and ativan around the clock.

A nurse just called to report that my psychotic patient who ripped open his scrotum spiked a fever. A moment ago, the lab informed me that my demented patient with "non cardiac" chest pain has positive markers.

I'm thirty minutes behind in the schedule and my last patient managed to vomit on the medical assistant

Yet, I haven't broken a sweat. I manage these, as well as all other crises, with an air of confidence. This is a typical Friday afternoon. I feel completely at home in the midst of chaos.


But maybe I'm not giving the technician enough credit. Maybe he is wiser then I. His job is methodical and orderly. He finishes with one problem, and then moves to the next. At the end of the day he's done.

Physicians, on the other hand, have let their profession get out of hand. We have lost control of our most important commodity-time.

It probably happened decades ago when the pressure of paying for overhead spurred us to become more efficient. Take on more cases. See more patients.

Now we manage thousands of lives. We takes histories, answer overhead pages, and tend to our cell phones simultaneously.

As our heads spin, our hearts palpitate, and our blood pressures rise, we find our internal rhythms changing. We become over-caffeinated. We concentrate intensely in small spurts.

We live in a facebook/twitter society. One blink and everything changes.

But wouldn't it be nice, for once, to be like the computer guy. To greet each patient as if there aren't four other crises or five other people trying to get our attention.

As if the patient sitting in front of us is the only one.

The only one who exists in the world.

Friday, October 21, 2011

Hospice and The Way Of The Master Diagnostician

I had the privilege of giving the keynote address for the Amedysis Hospice Strategy Summit last week in Louisville, Kentucky. Below find an abridged version of my comments.

Hospice and The Way Of The Master Diagnostician

We are facing a crisis in our healthcare system. If you listen to the politicians, two forces are growing that are diametrically opposed. On one side, the right composed mostly of Republicans. On the other, the liberal left and Democrats.

Although they never seem to agree, if you listen closely, we are all searching for the same thing. Our arguments, when distilled to their basic tenets, are similar.

We have to define the most salient indicators of quality and learn how to motivate our practitioners to adhere to them.

Quality and motivation. It sounds simple. But in reality it is anything but.


Defining quality, in our current healthcare system, is often a struggle. If you ask my colleagues what makes a "good doctor", we will likely mumble something about excellent care. But if you push us further, you'll mostly get blank stares.

Our progress, to date, in aspiring towards quality has been limited to measurement of indicators. We ask ourselves over and over again. What are the indicators of optimal care.

Anyone who understands Goodhart's law, however, knows that we are probably off base. Goodhart's law is an economic principal that simply states:

When an indicator becomes a target, it loses its quality as a measure.

A fun example is Soviet Russia. The government tried to incentivize nail factories to create more product by paying personel according to the number of nails produced. The employees ingeniously increased production by thousands a day by making small ineffective nails.

A more sobering example is the four hour pneumonia rule. Researchers found that patients hospitalized with pneumonia who received antibiotics within four hours of admission to the emergency room fared better. But when they incentivized EDs to give antibiotic faster, their were disastrous results. Over use of medications in inappropriate patients caused worse outcomes and higher costs.

This is Goodhart's law.


So even if we could identify the indicators of quality health care, how would we motivate our practitioners to follow them?

The government espouses pay for performance and the carrot and stick method. But one wonders if this flies in the face of motivational theory.

Self determination theory says that we shouldn't try to externally motivate behaviors that should be internally motivated. It never works.

Picture growing up in a crowded neighborhood. The kids on the block run roughshod on all the beautiful lawns. One day the smart guy on the corner lot says to the children:

Please....I'll pay you ten dollars a day. Come play on my lawn.

A week later he returns and scolds the children for doing a poor job and decreases their "wages" to five dollars a day. Another week later he returns and tells them he no longer will pay. When he asks them to play on his lawn they smirk. And they never step foot on his grass again!

This story may sound far fetched until you realize that the UK has been using pay for performance since 2000. A study in the British Medical Journal recently found that the carrot and stick method had no effect whatsoever on blood pressure control or hypertension related morbidity and mortality.

It appears that for people to become internally motivated to perform a complicated task, they need to feel autonomous, competent, and connected. Although it sounds hard to believe, having a central authority dictate your actions can have negative effects on such feelings.


I have come here today to tell you that we don't know how to measure quality, and even if we did, we are poor at motivating such behavior.

So we might as well give up, right?

Well, I have an idea that there is a better way. It's the way of the master diagnostician.

Our current healthcare model is a biological one. We focus on genes and diseases, symptoms and treatments. The problem is although we are 99.9% similar genetically, each one of us is very different. We react to stress differently. We get sick differently. And we respond to treatment differently.

The master diagnostician not only recognizes the biologic aspects of health, but also understands biologic variability, the psychological, social, and spiritual components of well being. In other words, the master diagnostician excels at giving each individual patient exactly what they need.

Take, for instance, two patients with coronary chest pain. One is fifty five years and otherwise healthy. The other is ninety five and has end stage cancer.

My fifty five year old will get maximal aggressive hospital care. My ninety five year old will get nitro, morphine, and be told to take it easy at home. Both patients will get appropriate care.

There are no quality indicators or carrots and sticks that can easily accomadate both of the above scenarios.


The master diagnostician learns to focus on what each patient needs and not necessarily what they want. The thirty year old with constipation does not need a cat scan of the abdomen. He might want it. He might believe that it will be the only way to calm the fear in his heart. But the risks and likelihood of incidentalomas is too great.

The master diagnostician also realizes that medical care has to respect each individuals right to make decisions. Although everyone should get a screening colonoscopy at age fifty, some patients just don't want one. And that's OK as long as full disclosure of risks and benefits has occurred.

The theory is simple. Give people all that medicine has to offer, but also search each patient for what they really need. Patient centered care that is tailored to each individual's circumstances.


I believe if we go the way of the master diagnostician we will achieve the penultimate heathcare reform trifecta. We will increase survival, decrease costs, and improve quality.

I not only believe this, I know it.

How do I know it? Because their are master diagnosticians among us who practice truly patient centered care. They are one of a kind, and their numbers are growing.

They are hospice and palliative medicine practitioners.

Hospice medicine is the only field that has resisted getting stuck on biologic necessity, and has learned to evaluate the psychological, social, and spiritual components of health.

To the hospice and palliative medicine team your cancer is only one concern. They also want to control your pain, prepare your family, and even make sure your dog is taken care of after you die. And why do they focus on such inane things....because that's what the patient tells them to. They look to help each and every soul receive exactly what they need.


Earlier I boasted that the master diagnostician theory would bring about the healthcare reform trifecta. That longer survival, lower costs, and increased quality of life are achievable.

I you look at recent data, hospice and palliative medicine have conquered all three goals.

Data from a New England Journal of Medicine article from 2010 showed that patients with metastatic lung cancer lived three months longer if given a palliative care consultation at the time of diagnosis. Data out of Duke in 2007 showed that being on hospice saved medicare roughly $2903 per patient. And finally, too many studies to count have shown that people who die in hospice suffer less pain, are more likely to have their needs met, and their families reported calmer deaths.


For all these reasons, I believe we are entering the golden age of hospice. These master diagnosticians are standing as shining examples of what we need to achieve to usher in the age of true healthcare reform.

In order for the movement to continue, two obstacles need to be overcome. First we need to rebrand the movement. The term "hospice" is too old and misunderstood. It no longer serves.

Second, hospice and palliative medicine need to become an earlier part of the health care continuum. Too often, they are relegated to "end of life care". The true power lies in early intervention.

Thank you for listening

Thursday, October 20, 2011

We All Need To Slow Down

Oh shoot!

I looked up from the computer and glanced in my wife's direction. She was standing over a pot with the last drops of milk pouring out of the carton.

We're out of milk.

As straightforward as the statement sounded, I knew the alternate meaning. I would be running to the store shortly. I pouted pathetically.

Come on. You know they need to have chocolate milk before they go to bed.

If I left immediately, I could be home in time for dinner. I walked over to the mud room and struggled to get my shoes on quickly. When I looked up, two sets of small feet blocked my way to the door.

Can I come too?

They both spoke in unison as if they belonged to some sort of synchronized cult. In the blink of an eye, both kids were somehow decked out in boots and rain coats. I paused. My eyes moved from the clock to their quizzical faces.

Daddy is just running out for a moment. I will be right back.

Their smiles turned into frowns. My three year old daughter started to cry. I pushed my way out the door while they followed in tow. They stopped on the porch and waved as I opened the garage door. A sheet of rain separated me from their pitiful little figures.


While driving to the grocery store, I couldn't help thinking about the office. Today was the "go live" for our new electronic medical record. As expected, the stress in the air was palpable.

My patients stared glassy eyed as I fiddled with the computer. I repeated myself. I interrupted them. I was distracted. My agenda clearly wasn't their well being.

And strangely, it felt similar to what just happened with my kids.

I was going to the store for their benefit. But my children didn't really care about milk. They just wanted a ride with their father. If I listened to their opinion, I probably wouldn't be alone in the car at the moment. And that's how our patients must feel.

We're moving so fast with meaningful use, ACO's, and patient centered medical homes. We're punishing hospitals for re admissions and collecting "quality" data on our doctors.

We say that we are doing this for the "good" of our community. We talk about "patient centeredness" as if we own the term. But is anyone asking their opinion? Or are our patients left standing in the cold in raincoats and boots like little children?


When I arrived at the grocery store, I sprinted through the isles. I quickly grabbed two gallons of milk, and tapped my feet impatiently at the check out counter. I reached for the wallet in my back pocket, and was shocked at what I found. Or better yet, what I didn't find.

I left in such a hurry I forgot my wallet. It was the law of unintended consequences.

Has anyone explained to the government that you can't buy milk If you hastily forget your money?

I think we all need to slow down!


I left the store and drove back home. I picked up my wallet and kids, and we all went together on an adventure.

Our destination was the grocery store.

Wednesday, October 19, 2011

A Physician's Prayer

As I sit down to drink coffee tomarrow morning and type away at the computer, I will do something quite uncomfortable for a non religious person.

I will pray.

I will pray that my children make it safely to school

That the weather is good and the sidewalks are not slick.

That their feet will be steady and their minds alert to the dangers that lurk in any suburban neighborhood.

That my wife will have an excellent day.

That she will face the uncertainties of being a mother and a professional with her usual grace and certitude.

I will pray that I am a humble physician.

That I will be a beacon of strength and hope to those who choose to walk through my door.

That I will garner the right mix of compassion and authority to guide those who seek answers. Mourn with those who receive them, and rejoice in the human condition.

I will pray that the EMR upgrade in my office will be flawless.

That the new platform is indeed a major improvement and not just another money maker for some corporation.

That the emotional distance placed by increasingly complex computer systems will melt away as does the physical distance when I reach for my stehoscope.

That the creators of HIPAA will turn their heads as I sneak out of the exam room in order to ask a trainer the correct way to enter "hemorrhoidectomy" .

That the patients hue of crimson, as they walk past the trainers desk and towards the checkout counter, will be short lived.

I will pray that this government has been wise.

That penalizing me for not checking off the "race" box on the EMR will indeed be the one missing ingredient that will help mollify the pain of the patient with chronic pancreatitis.

Or stem the the sadness of the family watching their loved one fade away from Alzheimers.

I will pray because it seems that this space we call healthcare has denigrated from rational debate and scientific method to an orgy of magical thinking.

And I want to make sure the central authority knows not to penalize me.

That I'm on board.

Monday, October 17, 2011

My Career As A Hospitalist

George's mind was spinning. The surgeon described how he would make a hole in his wife's skull. The procedure was called a "hemicraniotomy" but to George the words made little sense. All he knew was that his wife had been dancing in his arms two hours before.

At first, when she collapsed, he thought she was pretending. But then she didn't get up. He saw her chest moving up and down. But she wouldn't respond.

The ambulance came quickly. The paramedics gathered up his wife and placed a breathing tube down her throat. They whisked her off to the hospital.

Two hours later, George sat in a conference room with the neurosurgeon. His wife suffered a devastating stroke. The swelling had already caused sgnificant damage to her thirty five year old brain.


I shifted uncomfortably in my seat as I listened to the neurosurgeon. He would offer George's wife a procedure. It would release the pressure on her brain. But there was no mincing words. She was unlikely to recover fully.

After the surgeon left the room, George and I talked for a few moments. I gently pushed him to consider what his wife would say if she could speak for herself.

He rocked back and forth in his chair. In the main ER the PA system called a doctor overhead. The monotone voice of the page operator broke the silence.

She would want to be there to see her kids grow up.

There was little certainty in his statement. It was more a question than a declaration.

I reached out to put my hand on George's shoulder but was surprised to see him pull away. I was neither a trusted advisor nor a long time friend. I was a stranger newly assigned to the case.

It was precisely at that moment that my thoughts began to crystallize.

My career as a hospitalist would be short lived.

Sunday, October 16, 2011

A Physician's Credo

There was only one point to the Morbidity and Mortality conference. We ordered the xray. We could have looked at the result sooner. But how was I supposed to know? I was in my first week of internship and had no idea why my resident wanted an xray of a cellulitic leg.

The next day it became clear. The film showed pockets of gas. She had necrotizing fascitis. Within minutes the antibiotics were infusing. Within hours she was on her way to the OR. My fellow interns and I lined up at the back of the operating room. It was a particularly slow call day and there weren't any medicine patients to admit.

We watched as the surgeon expertly filleted opened her thigh. First pus and then black necrotic tissue. He took wide margins and then packed the wound. He didn't close up. He knew he would return to the OR multiple times in the next few days.

Miraculously she survived. Even with the delay, we evaluated and treated her infection far faster then the national average. A number of residents gathered at the door the day they wheeled her out of the hospital. Over her three month incarceration, many of us had taken care of her.


She bounced in and out of the hospital over the next year. After her original surgery, she developed bouts of intractable nausea and vomiting and would need to be admitted for intravenous fluids. She accepted each visit with serenity and calm. Her children and grandchildren surrounded her in the Emergency Room. It was as if she knew she was operating on borrowed time. Maybe the grim reaper had missed his chance once. But now he was circling in on his pray.

Between hospitalizations she came to see my partner in the residents clinic. She was physically fragile but mentally strong. She beamed as she talked about her family. Her blood sugars were atrocious. She spent most of her time in a wheel chair. But she was happy.

She returned to our clinic one last time. She had just been discharged from an outside hospital. Dangling from her neck was a central IV catheter that someone forgot to remove. The resident cut the sutures free with a scissor. He advised her to bear down as he pulled the length of the catheter out of her neck. She looked up and her eyes went blank. She took a deep breath and then fell over in her chair.

She was dead. Nothing about the next thirty minutes of resuscitation would change that. Father death had found a weakness in the fabric of her life and moved in swiftly. She may have escaped her fate once, but not twice.


As the years pass, I often think of her staring up at the resident as she was getting ready to have the catheter removed. An autopsy would later reveal no obvious cause of death.

As physicians, we have much less control of our patients destinies than we would like to admit. Sometimes, we are like a strong wind that blows the hand of fate inches in either direction.

Other times, we are like a gentle breeze bringing momentary relief to the fevered battle front, but rarely making an impact on the outcome.

So we try to be gentle and humble in our dealings with fate.

Often our true power comes not from altering that which we can't control but controlling that which we can.

We offer a kind heart, open arms,

and a devotion to those we serve.

Friday, October 14, 2011


I don't know when I lost my sentimentality.


With a thud the fish stops flopping up and down. It lays still on the floor of the boat. My camp counselor, a tanned college student, carefully places the paddle on the seat and cuts the fishing line. The hook remains dangling from the lifeless mouth.

He grabs the fish with his bare hand and throws it back into the water. He talks slightly above a whisper. I don't know if his words are directed at me or into the air.

Couldn't get the hook out of that one. He would have never survived!


My son and daughter sit on the curb in front of our house, stunned. The car pulls over as the dog's owner sprints around the corner. She stops a few paces away and screams.

The animal's chest heaves up and down slowly, but he is otherwise incapacitated. My daughter looks up at me quizzically?

Can we call an ambulance? Can we take him to the hospital?

I don't respond at first. The owner is now leaning over her beloved pet. She strokes his head and whispers softly into his ear. She is crying.

No honey. The dog is dying. There's nothing we can do

My son instinctively grabs my daughter's hand. They sit silently and watch as the dog's respirations slow.

I feel a strong urge to cover their eyes and walk them into the house. But I don't. I put my arms around my children and wait.

We all just wait.


So you're putting 421 on hospice?

The nurse leans over my shoulder as I write orders. It's been a long day and I don't feel like talking. I'm starting to drift.


Sometimes I dream that all those fish are swimming after me. The hooks wag back and forth in their mouths as they pull IV poles behind them.

Her primary sent her here to get therapy. She's due for another round of chemo next week.

The nurse persists even though my mind is clearly elsewhere. She's starting to get on my nerves.

You know, most docs let the oncologist take care of this stuff.

Now I'm angry. I growl as I look up at her, but then think better of it. I turn my head back to the chart.

I mutter under my breath...

just loud enough to make sure she understands.

I wouldn't treat a dog that way!

Thursday, October 13, 2011

Departures and Arrivals

The woman sitting across from me is sniffling. Her chin is tucked into her neck, and a small tear barely leaves her eye before she wipes it away with a tissue. She balances her cell phone under her ear. She talks quietly. Her face contorts as she struggles to control her expression. As I watch, I listen to another flight begin to board.

We are in an airport. I can't help but wonder who this poor woman is talking to. I am a voyeur. I turn my head with embarrassment in the opposite direction, but against my will I glance back.

How often does human drama unravel in places like this? Is she breaking up with a boyfriend? Has she just been to a funeral? Did she say her last goodbye to a favorite aunt or uncle who is dying?


Sometimes my office also feels like an airport. There are many arrivals and departures. Each person comes on a different schedule. Occasionally many at once. Other times just a few stragglers.

And they bring their baggage. Usually I am more a helper and less a voyeur. I may procure a larger bag or help them rearrange their contents. Often a few things get discarded.

Before long they are running back to the gate to catch their plane. Waving goodbye until our next visit.

Where we will do the same thing all over again.


The woman is boarding her flight. By the time she leaves, the tears are gone. Maybe it was simply a bad day. She smiles as she hands her pass to the man at the counter.

And I remain in my chair, waiting. An elderly gentleman is talking on the phone a few seats away. I catch the last few sentences of his conversation.

Shingles....shingles you say.

Tuesday, October 11, 2011

My Keynote Address

My son's hand shoots skyward. The teacher appraises the group of students and then motions him to the front of the room. He smiles as he skips forward. All sense of trepidation is lacking. He is aware of the other students, the parents, and the teacher. But he seems unconcerned.

He gently lifts his bow to the strings. The piano starts with an introduction. And he plays. The bow screeches awkwardly at first. A few notes in, he catches his stride. His eyes close slightly.

Seconds later he is finished. He puts his violin in rest position and bows deeply. The crowd claps. He skips back to his seat with a smile on his face. He knows his performance is imperfect.

He doesn't care.


Tomorrow I will wake up early and leave my family. I will take a taxi to the airport where I will board a plane to Louisville, Kentucky.

I will attend the Amedysis Strategy Summit. On the second day I will step on stage in front of hundreds of people. My voice will be my bow. My knowledge, my instrument.

And I will play. With a little more trepidation than my son and likely a greater measure of imperfection.

But my joy,

my joy will be the same.

Monday, October 10, 2011

A Brave New World?

As I walked up the stairs I thought about the history of the building I was about to enter. Although the foundation was the same, almost everything else had changed. The hallways were updated. The patient rooms decked out with comfortable furniture and fancy televisions. I even marveled at the bathroom as I answered nature's calling. I could have been in a fancy hotel.

Yes. Things were different than when I started as medical director. Back then, no one doubted upon walking into the entrance that they were in a nursing home. The five senses exploded with unwanted stimuli. The moans and groans, the smell, and the faded, run down facade.

They were "the good old days". Hindered by appearances, we felt we had to provide excellence beyond compare. The patients were old, demented, and psychotic. But they were ours. The names rolled off our tongues with an ethnic flavor. We took care of our neighbors. Before the boundaries blurred. We were part of the community

There was something about being the red headed step child, the underdog. It created a strange sense of identity. We knew who we were.


With an infusion of money, the construction trucks trampled in. The act of breaking ground was an affirmation of survival. But it was also the beginning of a new era.

Staff changed. Our patients changed. No longer constrained by second hand clothes the facility attracted a new clientele. We didn't need the support of our community, we expanded against it.

I looked at my patient roster. So many names were holdouts from a time long passed. But there were also new names. New responsibilities.

It was time for me to say goodbye. I was no longer captain of this boat. My ship had sailed and I didn't belong. It was as if it was I, and not the building that was antiquated.


We are entering a new era of healthcare. Old ways are being replaced at a staggering pace. The cracked and crumbling facade of our institutions has given way to the technological marvels of modern day society.

But sometimes I feel like a lonely ship floating in the ocean. As I struggle against the seismic change of tides, I wonder whether I will drift along with the waves or be swallowed whole.

We have changed our outsides. We have slapped lipstick on the pig. But on the inside are we really any different?

Can we, as physicians, survive the new world that is being foist upon us?

Sunday, October 9, 2011

Poor Role Models

He was cocky and arrogant. The kind of attending every medical student feared. I heard the rumors before his arrival. But I was hoping that reality was less harsh then word of mouth. I had only one week left in my Internal Medicine rotation. So far, I received glowing reviews from my residents and attendings. Seven more days and I would clinch the sacred "honors" grade that I needed to be eligible for the top residency programs. A "pass" would just about eliminate all the highly competitive options.

It was the beginning of my third year of medical school and I had chosen general medicine as my first rotation. I was already signed up for the early subinterniship like many of the other students who were entering the field.

As he walked into the resident's room for the first time, I waited cautiously. He scanned our faces briefly before flopping in a chair beside us. There was no formal introduction. No exchanging of names or titles. He nodded at the third year resident and spoke to no one particular.

So what do you got for me?


The rest of the week went similarly. He spoke only to the residents and barely looked in the direction of the students. His condescending demeanor dripped with sarcasm and contempt.

Occasionally he accompanied the team to the bedside. He rarely asked the patient questions or spoke to them directly. His statements were curse and robotic.

Unfortunately, he was brilliant. He was able to pick apart a patient presentation and pull out the relevant facts with ease. His skills were adroit. There was no doubt his presence was highly valued by the university. He spent ninety percent of his time in the lab. Likely some administrator relegated his minute clinical duties to the VA to minimize his ability to do harm.


On the last day of the rotation he walked into the lounge with a smirk on his face. He would return in the afternoon to watch each student perform a blind history and physical.

My resident scrambled to find an appropriate patient. He looked for someone who could tell a good story, and had a problem befitting a third year medical students fund of knowledge and abilities.

The attending returned later that day and we walked quietly to the patients room. To our surprise, when we entered, the room was empty. She had gone for a stress test.

Looking mildly annoyed, he asked the head nurse for another suitable patient to examine. She, of course, not realizing the purpose of the interview chose a complex medical patient with a rare disease. She thought it would be a good learning experience.


The interview was a disaster. The patient was demented and confused. His self described pneumonia was, in reality, a pulmonary embolism. He also had empty sella syndrome.

I absolutely flopped. And to add injury to insult, after I finished the attending performed a superb history and physical and elicited everything I missed.

He later sat me down and berated me for half an hour. He was disappointed in my abilities. That morning he had been ready to give me honors, but now...

My final grade for internal medicine was "pass".

Although I aced many other rotations as well as my subinternship, I would not be offered interviews at many of the top residency programs that I applied for.

Years later, as I look back on the experience, I realize that that hour changed my life.

I would never have been motivated to become the teacher that I am today

if I hadn't started with such a poor role model.

Friday, October 7, 2011

Mortally Wounded

I remember it.

As the call room door closed behind me, all semblance of light disappeared. I felt no guilt about missing rounds. I stumbled to the bed and sat down. Cradling my head in my hands, I waited for the gush of tears. They never came. Neither did the gut wrenching nausea or the searing pain in the chest. Nothing.

I felt absolutely nothing.

And that's when I knew I was lost.


I was overwhelmed within the first few minutes of internship. I clutched my stethoscope with sweaty hands as I followed the chief resident from ward to ward. He chattered incessantly listing a series of do's and dont's. I was barely listening.

The nurses bustled to and fro as I loitered by the chart rack. Eventually the chief returned with another resident in tow.

This is Jim. It's his last day of residency. He can't be hurt anymore!

My mind reeled. What did that mean..."can't be hurt anymore". Hurt by whom?

My question never made it to my lips. Jim quickly sputtered off a list of patients for me to follow. He handed me his pager and placed his arm around my shoulder.

Good Luck!

Sometimes, in the lonely moments over the next few years, I would wonder how Jim became invincible.


It's not like patients never died before. As a second year resident, I manned the ICU on my own. But this one was different.

Maybe I was a little to cavalier when I decided to intubate. Maybe not. But the damn tube wouldn't go down. And then Anaesthesia never showed up. We kept on paging and paging.

I finally got the tube in and within moments, he coded. We worked on him for thirty minutes.

When I called his wife, she seemed strangely distant. She came at 2am to sign the papers and make funeral arrangements. She didn't ask any questions.

With a heavy heart I worked through the rest of the night. There were too many sick patients to stop and mourn. To process. It was only later that it hit my like a ton of bricks.


The first daughter phoned from out of state. She explained that she didn't talk to her stepmother and was wondering how her father was doing. Moments later she was screaming at me.

The second daughter called from the road and would be arriving in a few hours. Her crying horrified me. It never stopped. After a few minutes the line went dead.

I told the last daughter in person.

She collapsed into my arms.


I would never hear from any of these women again. But they changed me.

Their grief left an indelible mark on my soul that would last long after residency.

By the time I handed my pager to a brand new intern I was mortally wounded. I was dead.

I guess I couldn't be hurt anymore either.

Thursday, October 6, 2011

I Was Still The Apprentice

Dr. G was like the Jedi master of our residency program. He was board certified in multiple specialities. But it wasn't the training that set him apart. He was just brilliant. An educator at heart. No nonsense. He told you how it was and he was right most of the time.

The residents actively searched for cases to stump Dr. G. We connived to present to him at case conference, something he had never seen before. But mostly we sat back and enjoyed watching the mind of a master clinician at work.

He taught us lessons about being a physician. He hammered us on deductive reasoning. I can still here his raspy voice scolding me in the exam room when I'm struggling to put the pieces together:

Be the detective.


While Dr. G could expound on almost any topic, he was known as an expert in one disease in particular: Hereditary Hemorrhagic Telangectasia (HHT). An autosomal dominant disease, HHT was widely recognized among our residents. Patients came from far and wide to see Dr. G in his clinic. By the time I finished training, I treated at least ten patients with this rare problem.

Although years later my mind is fuzzy on the details, every time I see a person with chronic nose bleeds I think of HHT. Often when I hear hoof beats I think of this zebra.


I watched in the ER as my patient rolled back from xray. She was thirty five years old and plagued by anemia. She had been admitted to the hospital five times over the last decade for transfusions. She showed up at our door when fatigue and shortness of breath had become unbearable.

The laboratory values confirmed it. She lost quite a bit of blood. Given her good pressure and pulse rate it was likely that this occurred over several months. I introduced myself and started to question her.

As the details unfolded I became excited. Apparently she had nose bleeds since childhood. There was no other cause of blood loss. I examined her. When she opened her mouth I saw a few small red dots on her tongue. Telangectasias! The hallmark of HHT.

As I explained the diagnosis, I informed her that I knew one of the world's experts on this disease. We would transfuse her blood. Have her see an ENT to help with the nose bleeds. If she was willing to travel the few hours to St. Louis, she could even see Dr. G. himself.


As the phone rang I felt like I was in residency again. I was calling Dr. G to tell him about another patient. Could I stump him?

After exchanging pleasantries, I informed him that this was not a social call. I had a patient to discuss. I was about to begin with the details when he interrupted me.

What's the patients name?

I stammered. Epi...Mrs Epi Staxis

He laughed a deep belly laugh. I felt small. Like I was a student again.

Another HHT case!

I was taken by surprise. did you know?

He paused. Well I take care of at least ten different people from the Staxis family! Didn't she tell you she comes from St. Louis?

I felt a growing sense of embarrassment. Dr. G. made the diagnosis without even hearing a single detail of the patient presentation. He was still the Jedi Master. I was still the apprentice.

Didn't we teach you anything hear in St. Louis?

You gotta take a thorough Family History!

Wednesday, October 5, 2011

What The Undertaker Said

I bolted upright with the sound of the alarm. The first thing I noticed was intense jaw and head pain. My wife sleepily looked up at me.

You were grinding your teeth again last night.

Thirty minutes later I was in the car half way to the hospital. I rubbed my jaw with one hand as I steered with the other. Damn TMJ. It had come back recently as my stress levels increased. One of the physicians left our practice, and my partner and I had to pick up the slack.

I was on call every other day. Every other weekend. The nursing homes were packed and the phone kept ringing. Not to mention that I had taken on other administrative responsibilities and a few speaking engagements.

And of course my son and daughter were getting older. Each day filled with a new activity for me to supervise. Violin practice, homework, dance class. For the first time I felt truly overloaded.


I'm not afraid of death.

The gentleman sat on my exam table with a jovial smile. He was strangely at ease in the doctor's office. I suspect this was due to his fifty years as a funeral director. When you spend so much time among the recently deceased, the specter of illness is less a demon and more an old friend.

He liked to take the last appointment before lunch. Countless times he watched as I raced out of the office to go to the nursing home. He would show up early to give me a little extra time. He was all to aware of my tight schedule.

As I finished my exam, I typed the last few sentences into the emr. I would have just enough time to avoid construction and breeze into my noon lecture. After that, I would visit nursing home patients and then rush home to make dinner, feed the kids, and take my son to violin.

I vaguely listened as he started to tell a story. At the funeral home he had an employee who was always bugging him for a promotion. The employee did a good job but was exceedingly slow. So slow, in fact, that he usually had to stay late into the night to finish his daily responsibilities.

That guy just needs to speed up!

I listened to his exclamation as I tried to nonchalantly look at the clock on the wall behind him. If I left immediately, I could make it in time.

He noticed my glance. Unexpectedly he placed his hand on my shoulder and looked me dead in the eyes.

And you, you kid have to slow down!

I paused. It's not everyday that the undertaker offers unsolicited advice.

But even now, as I quickly put the final flourishes on this blog post before facing the onslaught of patients in my waiting room, I wonder.

Will I listen?

Tuesday, October 4, 2011

Why I Moved To Private Practice

Chief of Medicine
Evanston Hospital
October 23, 2005

To whom it may concern,

I would like to take a moment to express my deep displeasure with one of the interactions I had with a physician in the Church Street location. I use the term "interaction" loosely since the doctor in question, Dr. Jordan, never actually saw me. Apparently he was too busy.

Last Thursday I was shopping in downtown Evanston when I felt the sudden onset of severe abdominal cramps. I ran into the nearest restaurant and spent the next thirty minutes on the toilet. After finishing I felt much better and packed up to leave. As I exited the restaurant, I noticed your clinic across the street.

Thinking that this was my lucky day, I entered the waiting room and asked for an appointment. Since this was my first time in the office, I was asked to fill out numerous forms. A few minutes later a nurse brought me back to an exam room.

She asked a lot of questions about my diarrhea and abdominal pain and then examined me. She then left the room for a few minutes. When she returned she explained that Dr. Jordan was the only doctor in the office and currently seeing other patients. The nurse made up some excuse about another doctor calling in sick. He could see me but it would have to be at the end of the day.

My jaw dropped. That would be like four hours later. Why couldn't I see him immediately? The nurse explained that she had evaluated me and my vitals signs were stable. She said my abdominal exam was normal. She then tried to shoo me away by saying that most diarrhea is self limited.

By now I was quite angry. I demanded that the nurse at least give me an antibiotic before I left. I could be dead by the the end of the day. The nurse left the room yet again and returned a few minutes later. Apparently Dr. Jordan felt that antibiotics are not usually indicated for most forms of diarrhea and he would prefer to examine me himself before he made that decision.

I stormed out of the clinic with my mind made up never to return to one of your facilities again. When I got home I took some amoxicillin which was left over from my root canal. I felt better within minutes.

I am lucky I had the antibiotic in the cabinet or I could have become very sick. I believe Dr. Jordan is a horrible physician and he brings down the quality of care that you are trying to provide. I hope you work to correct his attitude!


Disappointed Customer

Written in neat cursive on the side of the letter was a note from an administrator:

Dr. Grumet. Can you please call this patient and apologize. We definitely handled this one wrong.

Monday, October 3, 2011

My First Patient

It didn't really happen in the beginning. The atmosphere of awe and mystery was too great. In fact we barely spoke a word those first few sessions. Half the class was buried behind their books while a few students clutched at their scalpels wildly. I made a point of being the first to place blade against cold leathery skin.

As time passed, however, familiarity cut through the tension much like our scalpels. The air of humility was replaced by the buzz of students busily working through their lessons. The quietness was interrupted by voices: some laughing, some arguing, and others carrying on everyday conversations.


The inappropriateness was subtle. One day it would be a classmate holding a dismembered limb up to his own body. Or occasionally a group of students would gather around a tank to stare or snicker at a particular body part.

although, on the outside, we each had come to terms with the gruesome act of dissecting the human body, a process of internal hardening had begun.

I disdained my classmates for their lack of taste. I cowered in the corner with the dissector pretending not to notice. Ever dour, I was building my own walls of protectionism but I chose a slightly less infantile route. I abandoned the scalpel and retreated behind the anatomy primer. I would direct the dissection from afar. My hands would not get dirty.


There were days in the anatomy lab that seemed to last forever. The students developed back and shoulder pain as they huddled over their tanks. Their were a number of finger sticks. We all carried our scars.

The physical discomfort paled in comparison to the emotional. We didn't like to talk about it. But sometimes, in the middle of a session, the whole mood of the room would change. We sat helplessly as the whirr of the bone saw cut into our cadavers pelvis. The fetid smell of singed bone filled our nostrils and we wanted to vomit.

We carefully dissected the genitals in pure silence. For some, it was the idea of physical discomfort that made them wince. For others, it was the total obliteration of all semblance of privacy. There is a certain amount of human dignity that we expect, even for the dead.


My hardest day in the lab came towards the end. As we entered the room, we were confronted with the most human of body parts...the face. I found myself handing the dissector to my tank mate and grabbing a scalpel. It was my first foray into cutting since early in the semester.

As I started to peal layers of skin, I thought about the lady whose body laid below my fingers. I knew so few details. Just some demographics.

As I came to the cheek muscles I wondered how they contracted to form a smile when her grandchild walk into the room. Or how here eyes, now dead and distant, would shine when she was happy. How her tear ducts would create moisture when she was sad.

As the hours passed my neck grew stiff. My joints grew tired. A tank mate had offered to take over but I resisted. I couldn't bare the idea of someone else doing such a horrific and personal task. Certainly not one of those who had previously made fun of the cadavers.

As I finished the dissection my nose began to run underneath my mask. My eyes were tearing. I excused my self and ran to the bathroom

By the time I returned the tanks were closed and the room was empty.


She was my first patient.

I tried to give her in death that which I couldn't provide in life. I attended to her with the sanctity and dignity necessary for such an intimate task. To me she was a person, not just a bundle of bones and tissue.

I left the gross anatomy lab that day with a promise.

I protected my patient in death.

For each person who walked through my exam room doors in the future, I would work equally hard...

to protect them in life.

Saturday, October 1, 2011

Are You Listening?

I did what all good interns would do in the same situation. I rolled my eyes in the direction of the ER resident and waited for his response.

You have to be the sieve....the sieve.

We all did it. Stonewalled the ER in hopes that they would send our new admission packing. It rarely happened though. Somehow each admission always made it up to the floor. There was no turning back once the papers were filed and the bed was assigned.

Scottie was no different. His twenty year old body was fit and lean. His chest moved up and down in a rapid rhythm. I took my time examining him. As we talked his respiratory rate slowed. I placed my stethoscope on his chest. Maybe a few wheezing sounds but I had my suspicions that they came from his neck and not his lungs.

The paperwork classified him as an admission for asthma and bronchitis. My resident and I were doubtful. Scottie wanted, not needed, to be in the hospital. We just couldn't figure out why.


I spent the next three days trying to convince Scottie to go home. By day I would find him sleeping in bed with the covers pulled over his head. At night he awoke. His cell phone dangling from his tattooed arms. He teased the doctors and nurses. He convinced the dietary staff to bring him extra portions. He was king of the ward.

His charm was his greatest weapon. He smiled. He cajoled. He begged. But as another call day was approaching, my resident and I became more stern. We had to clear our census for the next onslaught of patients.

As I wrote the discharge prescriptions, Scottie tried again.

If I leave today I'll die out there. I just need more time!

By now I was immune to his pleas. His lungs sounded great and he was ready to be discharged. He pulled his hat over his eyes and his pants fell low on his waste. A few of the nurses gathered to wish him well. They whistled and catcalled as he disappeared through the hospital doors.


A few days later I was paged to the ER at three in the morning. As I yawned and rubbed the sleep from my eyes, A man dressed in sports coat approached from the door. He wore a cowboy hat and boots and I could see the outline of a gun tucked behind his coat.

He introduced himself as a detective from the St. Louis police department. He reached deep into one of his pockets and produced a tattered piece of paper. He held it up in front of my face. I squinted to read the writing. It was a set of discharge instructions with my signature at the bottom.

We found this in Scottie Pearson's back pocket. He was shot in the head and dumped in a field.


Scottie's story quickly spread among the physicians in our program. Everyone had a different idea of why he was hiding out in the hospital. Was it drugs? Gangs? Organized crime? A love triangle?

For many, Scottie became another memorable book mark in a series of odd and difficult experiences that marked our years in training. But as I get older, I think more about what he really had to teach me.

As so often happens in our lives, Scottie was trying to tell me exactly what he needed. Although I heard his words, I kept trying to interpret them based on my own point of view. Clearing my patient census for my next call rotation was more important to me then keeping him in the hospital. Sure I justified my actions by saying that he was healthy. But I never took the time to step outside of my own space to understand his.

Whether professionally or personally we all express our deepest needs to the people around us. Years ago, Scottie was trying to tell me his.

I just wasn't listening.