Wednesday, November 30, 2011

A Cutter's Diary

The neon lights of the hospital corridor boldly contrast the bland gray of the morning mist creeping through over sized windows. My feet shuffle and then stumble as I absentmindedly propel myself toward the ICU. My eyes shudder, deflecting remnants of last nights sleep.

At this early hour, the hallway feels like a forgotten graveyard. My reverie is interrupted by a flurry of activity. Transport personnel wheel their patients in front of the door well that leads to the operating room. Family members scurry to give one last hug, say one last goodbye, before their loved ones are pushed through the swinging doors and into the unknown.

I can't help but stare at each face as they pass by. I recognize the strange mix of terror, hope, and desperation brought on by powerlessness.


If Dagny Taggart existed in real life she would have been a surgeon.

Josie is standing in a circle of men who don't usually take direction from a woman. They belong to an era of medicine that has long past. Like in the days of the giants, they stalk through the hospital indifferent to their surroundings. They are cardiothoracic surgeons.

Josie presents patients like a machine gun. Each diagnosis and vital sign sprays forth in rhythmic staccato. The appearance of her torso is lengthened by her unorthodox posture; one leg is a stilt while the other folds into a triangle. Her hair is slightly disheveled from missing a night of sleep.

I watch from the corner of the room with the other medical students. Josie is pretty but not in the classical sense. Her jaw juts forward and her body is sleek and thin. As she finishes her conversation with the attendings, she strides effortlessly in my direction.

Come with me. We're opening Mr. Simpson's chest.


Mr. Simpson is dying. His blood pressure is dropping and his anemia is worsening. His emergent coronary artery bypass, the night before, has kept Josie busy till daybreak.

She leans over her patient in the cardiothoracic ICU. He is too sick to take to the OR, so Josie scrubs and steriley drapes him in his room. She is on the front lines of a battlefield and has created MASH unit.

She expertly removes the sternal wires and opens the chest cavity. Her eyes survey the operative site. I watch from the corner mesmerized. Her hands move with ease and fluidity. She performs a complicated dance with the attending who is functioning as her first assist. They communicate through movement without the exchange of words.

The blood pressure stabilizes. The anesthesiologist transfuses another few units. Josie closes up and takes off her gown. Their are other patients to tend to.


I can't help but feel a touch of anxiety as I pass by the operating room doors every morning. Sometimes there is a rush of fear as if I am the one kissing my wife and saying goodbye.

But no patient enters this solemn and sterile world alone. They are accompanied by a surgeon like Josie. Someone who has sworn to protect and cure with the precision of a scalpel.

Surgeons have been called butchers and carpenters. They have been mythologized as goons and thugs.

But, if you ask me, It takes guts to willingly put another person's life in your hands. It takes skill and mastery.

I think we owe them a debt of grattitude.

Tuesday, November 29, 2011

Anatomy Of Dying

Two weeks ago I told a man that he was dying. We sat together in the mid afternoon haze. Puffs of snow meandered by the hospital window and wended their way down to the ground. The sun was lost behind winter's never ending clouds.

The tempo of my voice was steady, lacking variation in tenor and pitch. I clung to my lab coat as if I was floating outside the window and being blasted by the inclement conditions.

I waited coldly for a response. At first, he stared at me quizzically. His eyes asked so many questions but his lips remained still. He shook his head and sighed. I glanced above him at the ticking clock.

You're wrong. It's not my time yet!


Two days ago I entered the same room. I watched as my patients chest heaved up and down slowly. His laborious breathing like spikes piercing the insides of his family members. They sat somberly around his bed in a circle.

It won't be long now.

As the words slithered out, I realized that I failed to convey the proper warmth. My voice box robotic and stale. The phrase lost in a haze of familiarity.


Two minutes ago I pronounced him dead. The room still heavy with doubt and false expectations. The social workers and case managers huddle around the family as funeral plans are made.

And in two days, I will call his wife. I will express my condolences and ask if there is anything I can do.

Then, most likely, I will never speak to her again.


Two weeks from now I will tell a man he is going to die. He will sit calmly in my exam room as he shifts his weight from side to side. Although his hair has grayed and his body has weakened, his face will sparkle with youth and vibrance.

He'll stare deeply into my eyes and I'll detect a hint of mirth.

We're all dying my friend.

He will draw in a deep breath and put his hand on my shoulder.

The trick is learning how to live!

Monday, November 28, 2011

Is It Just Me?

I use the words "death" and "dying" so often that I sometimes forget that the majority of my life's work is focused on avoiding such things. In a geriatric population like mine, end of life issues are a part of everyday practice. Lately, however, there seems to be a rent in the fabric of my reality.

Where previously these conversations were nurturing and beneficial, recently they've turned quite negative. As hospice and palliative care are moving forward at a breakneck pace nationally, on the ground, there's more resistance than ever.

I'm finding that my relationships with patients and colleagues are souring around such issues. No one wants to acknowledge the elephant in the room.

Or is it just me?


I really hated you that day!

I see the anger migrate through her face as Agnes looks at her elderly parent. Her eyes soften when she walks over to the bed and gently combs her fingers through her mother's hair.

She is referring to when I told her that the dementia had progressed and that death was near. The evidence was incontrovertible. Her mother hadn't spoken in weeks. She wasn't eating and her weight had dropped significantly. Now her breaths were prolonged and erratic.

But the neurologist said she could live for years!

Tears drop slowly from Agnes's eyes and cling to her cheeks to avoid the perilous pull of gravity. I can see the question in her posture before her lips part to vocalize. I interrupt her softly.

A feeding tube would provide more harm then good.

Agnes stops mid sentence and her head bobs down toward the floor. Could I tell her that I don't agree with her neurologist? Should I explain that his reputation is to flog his patients well past the point of no return?

Maybe we should call the neurologist again. He says we should put in a feeding tube.

The same neurologist crucified me on the phone the week before for signing the DNR order.


Eventually Agnes sent her mother to the hospital for a feeding tube against my objections.

A few days later it fell out.

When her mother's heart eventually stopped, an ambulance was called.

CPR was performed to no avail.

Friday, November 25, 2011

Someone's Gettin Scoped! A Farce

Icicles shot down Lisa's back and into her left calf. Standing out in the cold, waiting in line, wasn't the best place for someone with severe sciatica. But this is how Black Friday had become. At least she could stand.

The police had just carted away a belligerent man and his wheel chair bound daughter. There had been a kerfuffle with a young couple standing in front of them. It had been whispered among the crowd that the girl had some sort of brain tumor.

The gold slips for the brain MRI's were going fast. Lisa was lucky. Her spine films were not in such great demand. Although she was easily the hundredth person in line, she would likely limp away with the coveted referral form.


Everything had changed since the great healthcare reform. No one had dreamed that hospitals would profit so handsomely. But the provision that allowed billing for uncovered services had unintended consequences.

Fettered by poor reimbursements from medicare and private insurance, the market took over. Every other commercial on the TV was hocking some uncovered medical procedure.

Mercy Hospital is going out of business. Everything must go! MRI's half off, CT-thirty percent discount, elective choleys starting at $5000.

Black Friday was the biggest day of all. The people would crawl out of their beds early Thanksgiving morning and push, wheel, or be carried to the nearest medical outlet to stand in line and hope for a bargain. Sure insurance covered many essential procedures, but like Lisa, the panel often denied basic requests. She knew her back surgery would never be payed for unless she obtained the MRI on her own. Once the results came back, it would be a gamble to see if the panel would OK her procedure. If not, the neurosurgeons down the street were having a buy one get one free sale for Christmas. Of course, Lisa would have to hire a lawyer to make the legal arrangements to find and share costs with a complete stranger (anyone no someone trustworthy looking for back surgery?).

Lisa sighed as she crept toward the front entrance. Her chances were good. She wondered if poor John was having as much luck.


John couldn't help but salivate as he watched Lisa and the kids slurp down turkey and stuffing for breakfast. Unlike his wife who would receive a referral to have her MRI at a later date, if John was successful he would be whisked off immediately for the procedure. And, of course, you couldn't eat the morning of an endoscopy.

After breakfast, Lisa's parents arrived to watch the kids and it was off to the races. Lisa dropped John at the GI suites, and then rushed to the radiology center. Luckily the parking lot was not yet full when she arrived.

Twelve hours later Lisa left the facility with her hand greedily clutching the thick gold referral form. She sent a quick text to John, but no answer. She hadn't heard from him in hours.

She clicked the Facebook Application on her smart phone. Amidst the pictures of Thanksgiving feasts and newly purchased flat screen TVs was a mobile upload from John.

He was siting on a gurney dressed in a skimpy gown with his black socks covering his dangling feet. He had a large smile on his face and was holding his thumbs up in mock triumph.

Lisa couldn't help but laugh out loud and exclaim to no one in particular.

Someone's gettin scoped!

Wednesday, November 23, 2011


As I pull out of the hospital parking lot, I feel nothing but gratitude. The cold Chicago morning has transformed from blustery to pleasantly sunny. I become acutely aware of the gifts bestowed upon me.

I have a mind to think, a body to work, and a heart to love.


I walk into the house to find my four year old daughter singing along to an old Squeeze CD.

Tempted by the fruit of another..

She hops back and forth as her button dress flies through the air. My wife stands over the stove, and the smell of Ghiradelli's brownies wafts through the kitchen. My son's face is stained red from the seeds of a pomegranate that he greedily grasps between his fingers.

I will answer phone calls tonight but how can I complain? I will round at the hospital tomorrow, but it is a small price to bear witness to humanity. To experience such profundity on a regular basis that I am often unable to choke out the words to describe my experiences. Instead I write to clumsily record that which I fail to express by other means.


And it is you my dear reader.

You have allowed my words to seep out of your computer or cell phone. You have followed me on facebook, twitter, or read my blog. You, who has given me the greatest honor and pleasure to awkwardly juxtapose my thoughts and phrases into something that pleases.

It is for you reading these words at this moment that I am thankful.

Happy Thanksgiving!

Tuesday, November 22, 2011

Missing The Boat

Arthur's voice rattled as if small bits of gravel were stuck in his throat. His words resonated over the phone and felt more like commandments then questions.

Lillie's coming back home?

By home, he was referring to the assisted living that they both had inhabited for the last few years. But Lillie developed a severe case of shingles and was transferred first to the emergency room and then to the nursing home.

She was like many of the other patients in the dementia unit. Her complaints of pain were both persistent and monotonous. When it was explained that her belly discomfort came form shingles, she would calm down and become quiet. Moments later, however, she would forget the explanation and start to moan all over again.

As the weeks passed, Arthur would call from time to time. The nurses rumored that he was abusive and controlling. Lillie's son mentioned that having them apart was not necessarily a bad idea.


So when Arthur made plans to move into the nursing home and sleep in a bed alongside his wife, there was a general uproar. The nurses scurried in and out nervously expecting his arrival. The administrator paced back and forth in her office. Lillie's son sat quietly in the room with his mom.

When Arthur arrived I was surprised that the small thin frame belonged to such a powerful voice. He barraged the staff with a series of demands. They shook their heads but dared not disobey.

The months passed and a routine was established. Every now and then Arthur would spew forth another unreasonable request. The nurses felt less trepidation and grew bold over time. They began to understand that his bark was much worse then his bite.


I walked into their room this morning for my monthly visit. Lillie was perched low in her wheel chair and Artur was stooped over her, sitting on his bed. The TV was on and they were holding hands.

I flipped through the chart as I talked to them. Lillie's use of pain medication had dropped seventy five percent since her husbands arrival. I asked Arthur about her tremor.

When her hands start to shake, I reach out and hold them. She then stops within a few seconds.

There was no signs of being overbearing here. There were no accusations of alleged abuse.


There is no doubt that as health care practitioners we need to make decisions based on slivers of information. We become like cameras. We store a series of snapshots and use them to tell a story.

Yet clearly we occupy such a small portion of our patients life. We miss 99.99% of their existence. But sometimes it is in those miniscule moments, when doors are shut, that we see a true window into their souls.

If we are lucky, we may get a chance to be a part one of those moments.

If we are not-we might just miss the boat.

Monday, November 21, 2011


The thud vibrated through my body as the pipe refused to budge against the sudden upward force. Damn crawl space! My eyes closed and bright shards of light shot through my visual field. I struggled out into the open and put my hand on my scalp. I could feel the lump beginning to form.

The vague pain in my head and neck lingered. I payed little attention as I continued to inspect the house. My thoughts limped forward as if caught in a deep haze. When I was finished, I slid into the passenger seat of the car and my wife began the long drive home.

My eyes felt heavy and my head woozy. A spasm of nausea started in my abdomen and worked its way up my throat. The saliva spilled into my mouth as I gulped to keep from vomiting.


It's just a concussion. It's just a concussion.

I kept repeating as I crawled into bed. The nausea abating only in complete stillness. My head was pulsating. My eyes felt heavy as they rotated to survey my surroundings.

I fell asleep hoping that I would feel well enough to make the long drive to work the next morning. Every few hours I awoke and choked back the uncomfortable feeling in my belly.

As morning came, I arose and walked down the stairs to get a Tylenol. I stumbled over the ledge. I felt like each step was another turn on a roller coaster. I walked past the bathroom but thought better and turned back quickly.

As I lay on the ground in front of the toilet my body heaved and convulsed rhythmically. Each wretch sent spasms of pain up my spine and down my forehead. After a few minutes I was able to get up and flush the toilet. I wandered up the stairs and woke up my wife. It was time to go to the emergency room.


The ER is such a different place seen through the eyes of a patient. I slumped in the chair at the front desk as the intake person took my insurance information. As she asked me questions, I tried my best to control the war that was raging in my abdomen.

I was walked quickly back to a bed. The gown was cold and the bed had neither sheets nor pillow. I laid flat and moved as little as possible. A nurse came in and placed an IV. The blood trickled down my arm as she applied pressure.

Sorry we hit a bleeder!

Zofran and ativan were pushed through my IV. The nurse dutifully scanned my wrist band after each new medication as If I was a box of cereal being checked out of the grocery.

The attending came in and checked me over. I fidgeted at the thought of the radiation of the suggested cat scan, but I felt too sick to argue. This is what I would have suggested for my patient.


The cat scan was negative and I was sent home with an anti emetic. After sleeping most of the day I finally feel well enough to sit up and write this blog.

Tomorrow I will return to work and forget this day as if nothing happened.

But maybe I'll be just a little bit more understanding of what it's like to be sent to the emergency room.

Maybe, from now on I'll avoid crawl spaces.

Saturday, November 19, 2011

False Intimacy

When I saw the name pop up on my schedule, I sighed deeply enough that the nurse and secretary both turned to stare. I ducked into my office. Mrs. Lange had just been double booked into my last opening of the day. I quickly perused my calender. The likelihood that I would make it on time to parent teacher conferences just plunged to zero.

Mrs. Lange was an old, crotchety, lady that belonged to my partner who was currently out of town. The cracks and crevices in her face formed chasms that only seem to deepen with each visit. Each clinical note began with same mirthful statement.

The patient is a ninety year old Caucasian female appearing older then her stated age.


As the day progressed, I felt a sense of dread in the pit of my stomach. Each visit with Mrs. Lange ended exactly the same. After a mind numbingly difficult history and physical, I would shoo her out of my office with a set of referrals and no likely explanations for her miriad symptoms.

Her testing always came back negative. By then her complaints were replaced by a new set of maladies.

And we danced this peculiar dance. Like fencers we sparred relentlessly. Each jab defended and countered in short order. Each match ending without the delivery of a fatal blow.

Mrs. Lange evoked in me the most difficult emotions as a doctor: anger, pity, frustration, and helplessness. She made me feel like a prisoner trapped behind the cold metal bars imposed by the exam room.

I left every appointment feeling beaten down and hopeless.


And this appointment was no different. I struggled through a dizzying list of nonsensical symptoms and signs. She spouted forth a complaint and I shot back an answer. Finally I convinced her to climb onto the examining table.

Her vital signs were normal. Her lungs and heart were regular. I lifted her sleeve to examine her elbow. My hands shook as I peered down at a patch of skin I hand never seen before.

Below her elbow, on her forearm, was a faded series of numbers. My heart fell into my abdomen as I realized that this was the branding of life's atrocities.

I must have been too hurried in the past to elicit a detailed social history.

She was a Holocaust survivor.


As physicans we suffer from false intimacy. We are given a pass to delve into the most delicate parts of people's lives. We see the best and worst of human nature.

But in reality, how well do we really know the innocents that sit before us? How often do we make snap decisions and judgements based on faulty and incomplete information?

Mrs. Lange taught me alot about making assumptions.

Every time I feel my temper rising and my patience ebbing I picture her ancient face.

And then I remember her arm.

Friday, November 18, 2011


As I opened the chart on the computer screen, my eyes glazed over. It was the third case of shortness of breath in a row. I combed through the records of yet another octogenarian: stress test (check), xray (check), echo (check), pulmonary function tests(check).

It wasn't even lunch time yet. I sat down quietly at my desk. The screen blinked reminding me that a patient was ready for assessment. The overhead pager system was calling my name. My cell phone started to ring.

I laid my head down on a stack of papers.

When did life become so complex?


I push the mop and bucket out behind the counter and move slowly as not to spill. Inching toward the smaller of the two dining areas, I stop at the entrance and remove the garbage can. As I dip the mop into the bucket of soapy water, I listen to a group of girls giggling at a table a few feet away. They look my age, maybe fifteen.

I glide from one end of the room to the next. Pausing to place the mop back in the bucket, I push a row of tables onto the newly mopped floor, before starting the process over again. My arms relax and contract and my hands grip tightly around the handle.

I enjoy this work. My thoughts are free to wander. I calculate how to complete my task more efficiently as I bounce to the music overhead. I think about my life, school, and work. My mind hums like a machine. It jumps from thought to thought without pause or interruption. The sweat roles down my back and the white ice cream parlor uniform clings to my sides.

My muscles ache from physical labor intermixed with occasional jaunts to the equipment room where the teenage employees do pull ups on an old rusted pipe. I am youthful and proud.

I finish the small dining room, and move a garbage can to block the entrance to the large one. I will sweep and mop. Then the bathroom, break room, and equipment room await me.


I leave the exam room with more questions then answers. Maybe it's just a bad case of sleep apnea, anxiety, or deconditioning.

I think back fondly to those days in the ice cream parlor. When, at the end of day, I could look out and see all that I had accomplished. I could peruse, contemplate, and record my inconsistencies.

But as time went on, life changed. With education comes complexity.

And as a physician, I spend most of my day flopping in a sea of the abstruse. There is so rarely a finite beginning and end. My work product is subjective and ephemeral.

But sometimes I dream of dropping it all, leaving my profession, and donning the apron once again.

I'm sure I would enjoy myself immensely,

for about a few hours!

Wednesday, November 16, 2011


As Sylvia swept through the door into the waiting room, the receptionist called out from behind the counter.

Dr. Kris, Dr. Kris, Mrs. Beckwith is on the phone. She's having back pain again!

Sylvia paused, the bag carrying her laptop propelled forward and then snapped back on the shoulder straps. Her laboratory jacket was folded neatly across one arm and the adjacent hand held a cell phone. She was about to call the Nanny. She pushed the power button on the phone and glanced at the display.

Technically, it's after four. Give it to Dr. Short, he's on call!

The secretary opened her mouth to explain that the covering physician wasn't familiar with Mrs. Beckwith, but then thought better of it.

It wouldn't have mattered anyway, the front door of the office had already slammed shut.

Sylvia was gone.


The choice of practices was perfect. Sylvia could work a full schedule and still have time to cart the kids back and forth to their various activities. Hospitalists had taken over the inpatient responsibilities. Call duties were light and spread among a large group of physicians. The clinic closed at four.

Sylvia congratulated herself on finding the perfect post residency job. The work-life balance was exactly what she and her classmates were looking for. At first, she had been worried about being able to handle the more difficult patients. But she quickley realized that there were always specialists to refer to, and she could send the sick ones to the ER. And when the clock struck four, they were someone elses problem.

As Sylvia bent down to place her bag into the passenger seat, she felt a faint twinge of pain radiate down her stomach and into her pelvis.

I wonder what that was?

She quickly walked around the side of the car and got into the driver seat. Her son would be finishing soccer practice soon, and she didn't want to be late.


Upon awakening, it took a moment for Sylvia to realize that she was about to vomit. As she jumped out of bed, she felt a sharp stabbing pain emanate from her epigastrium and spread into her chest. At first her mouth watered, and then she heaved violently. Her body spasmed over and over again until she had completely emptied the contents of her intestines.

She crawled back to bed and fumbled with the phone.

Hello...hello...I need to talk to Dr. Phillips immediately.

She silently prayed that her personal physician could give her some guidance. She felt alone in the large bed left absent by her traveling husband.

Dr. Stone is on call for Dr. Phillips. Please call back If you don't hear from him within the next half an hour.

Each minute seemed like an eternity. As Sylvia watched the clock desperately, she wondered if the phone would ever ring. When she walked into the bathroom to rinse her mouth, she was taken aback by her own reflection. The whites of her eyes had turned yellow.


Sylvia watched the nurses bustle back and forth in the emergency room. The dose of dilaudid had calmed her abdominal pain, but not her anxiety. She was all alone. Her husband was thousands of miles away. Her parents were sleeping in her guest room next to the children.

She reached over to the table to check her cell phone. Maybe Dr. Phillips had returned her call. Maybe he would walk through the exam room doors like Marcus Welby, and grasp her hand and tell her that everything would be okay.

Unfortunately, the only one who came was the Surgical PA. He explained in an emotionless tone that the ultrasound showed choleycystitis. In a matter of moments the antibiotic would finish running and then it was time for surgery.

Dr. Carson is on the way. The anesthesiologist will explain everything and then we'll put you under.

Sylvia grasped for words as she felt a sense of terror rise from her belly.

But don't I at least get to meet my surgeon.

The PA's back was turned and he was moving quickly toward the door.

Sure. After the procedure.


As the anesthesiologist placed the mask on Sylvia's face, her mind raced. First she thought of her husband and children. She wished that they were by her side.

Then she thought of her parents and how they used to comfort her as a child.

But as the intense feeling of fatigue washed over her body and she started to lose consciousness, she conjured up the face of poor Mrs. Beckwith. She imagined her sitting alone in a cold room with her arm retro flexed and her hand grasping her painful flank.

She recognized the fleeting sensation of empathy.

It was something she hadn't felt recently.

Not since the early days of medical school.

Tuesday, November 15, 2011

Having Your Story Told

Mrs. Fitz clasped her husbands dangling hand as her son and daughter sat in the empty chairs next to the examining table. The children had brilliant black hair with the beginning of gray streaks at the edges. The family waited quietly while I maneuvered the stool into the corner so I could interact with each member without craning my head. The daughter cleared her throat to speak and looked affectionately towards her father's wheel chair.

Since you are going to help my father die, we thought you should know his story.


The mustang glided easily under Captain Fitz's steady hand. The World War II era fighter was reserved for only the most advanced fliers. He was finishing a successful mission in enemy territory, when he noticed a flash out of the corner of his right eye. The staccato sound of gunfire was brief but ended in a large thudding sensation that he felt in his fingertips as he struggled to control the flubbing aircraft.

Seconds later he felt a heave of pressure on his chest as the cabin rolled. He fell into a tailspin. His body hurdled violently toward the ground as the unbearable g-forces lead to a loss of consciousness. As his eyes closed for what he believed to be the last time, he pictured the pale face of his fiancee waiting innocently for his return.

Like a bird suffering from a heart attack in midair, he tumbled lifelessly out of the sky. He later calculated that he fell at least forty thousand feet. He awoke expecting to meet his maker at the pearly gates.

Instead, his first recollection was searing pain coming from his right leg. He looked down to see the bottom half of his lower extremity shattered and bent disfiguringly under his thigh.

Three men stood above him speaking in a foreign tongue. One pointed a rifle in his direction and gesticulated wildly. The other two walked calmly over to the captain and lifted him onto a stretcher.

On the thirtieth anniversary of the crash, Captain Fitz would return to the exact site and be reunited with the three men who had had every intention of killing him. But in a strange twist of fate the men decided it would be a bad omen to kill a man who had survived such an incredible fall.


Captain Fitz was taken to a POW camp where a fellow prisoner happened to be an orthopaedic surgeon. His leg was meticulously cleaned and splinted. His extremity was spared but his luck was brief.

The Captain refused to speak of what happened in the camp. But he survived years of torture and forced labor. When the war was over he limped back across enemy lines.

He came home to find a fiancee who had already attended his funeral. Within months they were married and soon were expecting their first child. Captain Fitz became a proud father.

He returned to school and earned a PhD. His research would eventually have profound effects on modern medicine and biology. He would educate the next generation of researchers and physicians.

As he entered his eighties, the miracles would run out. Captain Fitz developed a progressive neurological disease that first stole his words and then his thoughts. Relegated to a wheel chair, his body failed in the same manner as his mind.

As Captain Fitz sat silently in front of me on that day, his daughter's eyes brimmed with tears. His son put his arm gently around his mother's shoulder.

I took a moment to enjoy the silence. We were all lost in thought.

Captain Fitz died a few months later. None of my subsequent visits were nearly as profound.


Sometimes part of dying is having your story told.

Sometimes being a healer is less about talking and more about listening.

Medicare has no way of measuring such things. There are no ICD-10 or CPT codes for this kind of interaction.

But ask anyone who spends their life taking care of others.

This is where the healing takes place.

Monday, November 14, 2011

If I Die Young

It's funny how a few words, a phrase, or music can bring back buried memories.

If I die young, bury me in satin
Lay me down on a, bed of roses
Sink me in the river, at dawn
Send me away with the words of a love song

The sharp knife of a short life, oh well
I've had just enough time

I heard this song on the radio this morning. A rush of memories flooded my brain in the form of the smiling face of a beautiful little girl.


Hola Flaco!

Hola Flaca!

A peel of giggles erupted from the small figure enveloped by the hospital bed. Her frame was lithe and frail but her eyes were large and luminous. Sparkles of light and fire shot forth when she honored me with her melodic laugh.

I was a third year medical student and unaccustomed to the wall building that accompanies most medical education. I had been assigned to the case because I was the only medical student on the team who spoke passable Spanish.

Although we sometimes had trouble communicating, the relationship had attained a certain level of fluidity. The family called me "flaco", the Spanish word for skinny, because I had started to work out during the rotation and lost ten pounds. My clothes were hanging uncomfortably off my body and my pants were barely held up by my overextended belt.

Although the miniature girl in the hospital bed was alive with passion and spirit, her body was dying. In better times, I referred to her as "flaca", the female version of my nickname. But, as the days passed, I became leery as she lost more weight and her illness progressed. Her rampant giggling reprimanded me for my political correctness and reminded me that it was just a small intimacy between inconvenient friends.


Flaca was struggling. Her energy was waining and her laboratory values told the story of a fairy tale that was coming to an end. Her body could no longer sustain the repeated insults of medication and dialysis.

One night toward the end of my pediatrics rotation, she spiked a fever. The nurses hurried to administer Tylenol and draw blood cultures but they were unsuccessful. As I walked into the room with a tourniquet and butterfly needle, Flaca's eyes turned cold.

I fumbled with words in both Spanish and English to explain why I needed to draw her blood. My resident stood above me tapping her foot in disapproval because she felt there was no time for explanations.

Flaca pulled her arm away from me and spit in anger. The fear in her parents eyes was overcome by determination. They nodded at the nurse who walked over and pinned Flaca's arm down against her struggling torso. I quickly grabbed the needle and jabbed her arm. As the blood flowed, we all gasped a sigh of relief.


Flaca would never speak to me again. When I entered the room she would turn her head in disapproval. The frailty of her body was betrayed by the unending strength of her anger. It was as if my face had become the form of all the hurt and sadness brought on by her terrible illness.

She died a few days later. And along with her a small part of myself.

I will always hold the greatest respect for those who take care of our ill and dying children.

But I could no longer be one of them.

Sunday, November 13, 2011


My son plays his violin. He practices every day. He attends group and private lessons multiple times a week. Occasionally he learns new pieces. Mostly he plays the same music over and over again. There are days when the music seems to glide sweetly from his hands with little effort. There are also days when screeching mangled notes seem more the norm.

It's a tiring process. Day after day and week after week, he struggles. He concentrates on his posture and fingering. He battles to hold the instrument in just the right manner. His fingers bend and contort. His hands cramp. His progress is measured in small increments.

And if he is lucky and persistent, he will improve. His practice will pay off. His notes will be more melodic and pleasing to the ear. He will graduate from one set of pieces and move to the next. The complexity and pace will increase.

Each time he studies a new composition, he will need extra hours of training. His arms will learn the exact twists and turns. He will repeat over and over until his mind no longer thinks of each separate movement, but learns to play as a whole.

But the violin is knowable. While there are some minor differences to each instrument, he will expect roughly the same sound from any violin he picks up. There are a finite number of sounds and notes to learn.

After countless years and thousands of hours of practice, he will approach mastery. Likely this will take decades of both persistence and luck. It is definitely possible. There are no short cuts. Some will reach mastery faster than others. Some will not reach it at all. But every one will have to put in the appropriate time.


I don't understand how we think we can short circuit medical education. Under the rubric of reform we are undermining our training programs.

Residents are being told that they must work shorter shifts and take call less often. As they finish their programs, they are entering their profession with less accrued experience. Their knowledge base is lacking and they learn to consult often, order more tests, and refer to the emergency room.

Primary care physicians are being replaced with nurse practitioners and physicians assistants without requiring the same requisite hours of training. While basic care is surviving, the art of the differential diagnosis and the treatment of the complex patient is being punted to specialists.

Yet my son continues to practice. In order to obtain mastery, he will be expected to study more them most residents and medical students, more then nurse practitioners and physician assistants. And he will learn this tiny instrument. With its four strings and single bow. With its countable number of pieces that move in finite and measurable ways.

No one would expect him to reach his goal without putting in the appropriate time.

Why don't we expect the same out of our medical professionals?

Thursday, November 10, 2011


The clanking of the wheel chair destroyed my memory of Tim's last visit.

He was healthy then. His long torso sat on top of spindly legs. He strode into the exam room confidently. Although he described burning in his chest, his gait and demeanor were unhindered. He seemed reassured that the work up in the hospital was unrevealing.

The cardiologist's report from the outside facility said that he had clean coronaries. He showed me the bandage on his groin to prove it. Eventually he was given the label of gastroesophageal reflux or anxiety.

His chest pain was worse then ever, but he could manage as long as it wasn't life threatening. He grinned at me as I took out my stethoscope. His exam was normal. I thumbed through the hospital records. His cardiac catheterization, chest xray, ekg, and lab reports were normal.

We discussed different treatment options and finally decided on watchful waiting. As I ushered him out of the office, I had no inkling of the torment that would soon befall him.

Hours later, he collapsed in his living room.


Ya, I know he has chest pain!

The caller annoyed me. I just saw Tim in the office. Why was he in the ER now?

The last thing I expected to hear was that he suffered a devastating heart attack, and was being resuscitated. I rushed to the hospital to find him in the Intensive Care Unit on a ventilator.

His status wavered from day to day. His wife and I talked about the poor prognosis and the likelihood of death. But as the days passed, Tim got stronger. When sedation was weaned, we removed the ventilator.

Tim's mind was as sharp as ever. But he couldn't talk, and he was having trouble moving his right leg. The lack of oxygen during the initial days in the ICU took its toll. Tim had suffered a stroke.

I wrote his discharge orders with a heavy heart. He was transferring to a rehab facility and then a nursing home. I didn't have privileges at either location, and I would have to surrender his care to another set of physicians.


Months later, Tim was leaving the nursing home and returned to my office to reestablish care. His eyes rested on the ground as his wife pushed him into the room. This was one of his bad days. I could sense the depression before I even talked to him.

I felt a great compulsion to apologize. I wanted to say that I deeply regretted not sending him to the emergency room. I wanted to explain that even when all the protocols are followed correctly, the body is a fickle master. Even the bravest of lion tamers occasionally gets bitten.

I couldn't feel the ache of the tooth marks nor the restraint cast upon his soul. It is only with great hubris that the physician pretends to understand the reality of illness.

So I sat silently next to the wheel chair and put my hand in his. A promise to unlock the bodies secrets would neither be offered nor accepted. Instead I looked him in the eyes, and gave the only thing I had left.

I'll be right here.

You're not alone!

Wednesday, November 9, 2011


The spasms of pain were gentle at first. The large muscles of the right side of my neck and shoulder would tense and then ease up. The pain radiated up my spine and ended in my right temple. I sat at the nursing station hunched over a desk with twenty charts sitting by my side. The chair was stuck on a low setting and I had to arch my back and shoulder to reach the desk. Apparently the environmental controls for the building had just two settings: hot and cold. Today it was hot.

I rushed to finish charting so I could drive home, feed the kids dinner, and get my son to his violin class. The pain in my head ebbed and flowed. Some moments severe, like when I turned my shoulders the wrong way, others bearable.

As I cleared the dinner plates, I could feel the nausea building. We hurried to the car and arrived just in time for the violin lesson. The squeaking of bow on string compounded the stress as my cell phone was abuzz with new admissions. As I walked outside to take a call, I perched the phone between my right shoulder and head. The jolt of pain lanced through my scalp and landed above my eye. I stepped into the cold air and took a few deep breaths.

By the time I arrived home, I was fidgeting with discomfort. My stomach was raw and bilious. I fumbled with the ibuprofen container and crawled into bed. I could hear my son and daughter screeching a floor below. My wife was vacuuming the floor.

As I laid in bed prostrate, I knew there was only one way to make the pain abate.


Without thinking, my mind began the process autonomously. I started with slow deep breaths as I tried to disassociate myself from the searing enemy. I mentally took stock of each muscle group and localized the pain. I concentrated first on neck and shoulders, then the intricate muscles of the face. I imagined the flexed, agitated, spindles as flaming red orbs.

As I had done so many times in the past, I completed the inventory and then started the process of relaxation. I isolated each inflamed muscle group. I systemically tightened and relaxed. All the while, I visualized the muscle fibers. I commanded them to let go of the tension.

My body swayed up and down rhythmically. My torso sunk into the bed below me. I finished the muscle work and moved on to my breathing. I felt as if a tight band had been released from my cranium. The nausea was gone.

As I tried to fight sleep, my mind drifted off to childhood.


I could hear my mom yelling frustratedly at my father behind the closed door.

But your the doctor, what is wrong with him.

We had been to some of the best clinics in the city. I had taken test after test. Xrays, cat scans, and blood work all came up negative. The pediatric neurologist was at a loss on how to cure my headaches.

My mom and dad were struggling. I complained daily of head pain. Some days were mild, others were severe. I was missing school on a regular basis. After months of failed attempts, my mother made an appointment for me to see a new type of doctor.

As the years pass, I can no longer remember his face, but his words stick with me. He wouldn't take any more tests or draw more blood. He simply wanted me to relax in his chair and listen.

We met weekly. He called his technique "self hypnosis". He explained that we have great power over our bodies if we know how to access it. This access is granted when we bring ourselves to a state of relaxation and visualize the changes we want to take place.

He gave me homework. Each day I sat in my room alone and practiced. At first I would lie flat in bed. But as I got better, I was able to do my relaxation exercises sitting up and with my eyes open.

Over the next few months my headaches disappeared. But more importantly, I learned a life skill. Although I no longer practice anymore, I return to biofeedback often. It has helped me with both physical and emotional pain. It has improved my performance academically as well as physically.

Biofeedback has centered me as a human being.


My voyage into medicine has been littered with positive role models and teachers. I have many people to thank for becoming the physician that I am today.

But the truth is, this amorphous man whose face I can no longer remember, taught me more about the human body then any gross anatomy professor.

Monday, November 7, 2011

On Cell Phones And Primary Care

For a brief interlude, the world moved in slow motion. I saw the cell phone leaving my hand and twist and turn wantonly in the air. It fell onto the pavement with a loud thud. I stared at the lifeless object. It's face hugged the ground. I cautiously bent down and turned it over in my palm.

With great horror, I looked at the distorted face. A large fissure splayed from the corner like children's fingers striving to frantically grasp the unreachable.

I felt a vague sense of discomfort vibrate through my body. What could I do now? The phone calls from the nursing homes would not stop for a broken phone. I pressed the power button. The display lit up, but half of the view was shrouded in black. The dial pad worked but the smart functions were unusable.

For the next few hours there would be no email, no twitter, no blue tooth, and no Internet access. I was in the middle of nowhere. In, of all places, Wisconsin.

And so the odyssey began.


I cut my trip short and drove to the Sprint store close to my house. I browsed for nearly an hour while I waited for the customer service agent. I impatiently explained that, as a doctor, I needed cell phone access restored as soon as possible. The calls were already piling up.

The room suddenly started to spin. I lifted my arm to wipe the sweat off my forehead and tapped my feet. Apparently, I had few options. I could buy a new phone for $500 or I could take it to their service center.

I stomped out of the store and drove twenty minutes to the Mecca of phone repair. By the time I walked into the building, my levels of agitation were rising. It had been hours already, and still no resolution.

The clerk at the front desk was courteous but unhelpful. He explained that although they had the capability, the service center wasn't authorized to fix trauma induced phone damage. As I turned to leave, he slipped me a piece of paper with the name of an independent repair company.

Shh. You didn't get that from me!

I slammed the door on my car and frantically dialed the number. After multiple rings the line went dead. I called back again. The same response.

It was Sunday afternoon. Come Monday morning, I would be faced with an onslaught of phone calls without blue tooth or hands free dialer. I only had use of half of the dialing pad. And I couldn't use twitter!

Needless to say, it was a sleepless night


As I explained to my office manager my predicament the next morning, my medical assistant chimed in on our conversation.

I know exactly what you need!

She made me an appointment to a repair shop close to my home. I struggled all day to use my nonfunctional phone. I pulled over three times on the highway to return pages.

By the time I walked into the shop, I was at the end of my rope. I was hungry and tired. I was grumpy. And I wanted my cell phone fixed.

The gentlemen who owned the store greeted me at the front door.

You've come to the right place. We'll have it fixed in no time.

They were kind and courteous. When they didn't have the right parts, they came up with a creative solution. At one point, they called Sprint themselves to fix my settings.

They were not only professional but empathetic. How many stressed out customers had walked through their doors with similar needs? One of the owners pulled out a bucket of broken cell phone parts.

This is just from today!

An hour later, I was on my way home. My phone was fixed for a third of the price I expected. My blue tooth was perched on my ear and my hands free dialer was reinstalled.

I felt the knots in my chest relaxing.

And then it dawned on me. I wonder how often patients walk out of my office feeling this cared for?

How did we PCP's lose our way?

Sunday, November 6, 2011

Medicare For All. Be Careful What You Wish For.

John's facial tick reminds me of a shark. His upper lip curls behind his teeth and he makes a hissing sound. He does this every time we talk about health care reform. He smiles and teases, but he's only half joking.

You doctors have it coming! Boy do you have it coming!

We banter back and forth as I examine him. John's muscular limbs are surprising for a ninety year old. His opinions offend, but only slightly. He belongs to the far left. He is most comfortable discussing universal health care and the public option. To him, medicare is the final answer.

Medicare for all!

He looks at me with both sincerity and pity. He realizes that my colleagues and I think this will be the death knell of modern medicine. But he doesn't care. He's fairly certain that we are wrong.


Although John's emphysema is much improved, his ankle is now swollen and painful. It's bruised and barely able to support his weight. He hobbles through the door with a cane. He is finished with the prednisone and levaquin, but now is suffering the consequences. His tendon has ruptured.

A week later his orthopaedist performs a short surgical procedure. He is discharged home hours later with detailed instructions. His only support is his eighty five year old spouse.

The next morning John's wife calls. Her voice trembles with panic.

John's too weak. He can't even get out of bed. We're bringing him to the nursing home.

I pause a moment. While I definitely think a skilled facility is a good idea, I'm doubtful that medicare will pay or it. I begin to verbalize my concerns, but John, who has now joined the line, interrupts.

Oh don't you worry. Medicare will take care of me.


Weeks later John is recovering at home. His physical therapy is going well. As he stoops to lower himself down on the chair in my office, he slams a stack of papers on the desk. I look up quizzically.

Five thousand dollars! Can you believe five thousand dollars of nursing home bills? And medicare won't pay a cent.

It is now I who looks at him with pity.

Medicare for all.

Be careful what you wish for!

Saturday, November 5, 2011

I Could

Adapted from the poem "I Could"
Cook County hospital 1998
Breast center

Who's next?

He calls to the residents, as if he is a bank teller waiting to accept his next deposit. He walks from room to room with the medical students trailing behind. He enters the cubicle without taking the time to introduce himself. He touches breast tissue with precision and tenderness. Yet to put his arm around the shoulder of a suffering patient would be considered to intimate.

How could you?

He stops momentarily to scan a mammogram. He is decisive and arrogant.

You will need a biopsy!

The crying woman looks up and her trembling finger points to the adjacent light box where last years mammogram sits uninspected.

Oh. Those calcifications were present before. I guess we can wait on the biopsy.

Her head is now in her hands. She doesn't look up.

How could you?

I wince as he shoves the needle into her breast. Her face contorts and a tear roles down her cheek. As he smirks, I find myself more worried about the amount of local anesthetic than the accuracy of his technique. He high fives the resident.

We got it

How could you?

A young woman sits on a chair with her two children playing on the floor with a set of checkers. He buries his head in her chart as he delivers bad news.

Your lymph nodes are positive.You will need chemotherapy.

He hands her a referral and leaves the room without waiting for questions.

How could you want to be a doctor?

He asks me in my dreams.

Because you will hurt for each and every patient who walks through your doors.

And in my dreams, I scream the answer, ablating his image from the depths of my being.

How could I not?

Thursday, November 3, 2011

A Calling

Would it surprise you to know that I often contemplate leaving medicine? That I awake some mornings with eyes drooping and jaw clenching. And I begin the day with the promise that it will be my last.

I have sworn off this profession more times than a bad habit. I have stormed out of the office with belly churning and head swimming in a migrainous ocean.

Each time, I feel more resolute then the last. Yet somehow I remain. I sit in my little office typing away on my lap top. The phone is ringing, my pager is buzzing, and the paperwork is piling up.

Yet, I'm still here.


Howie was like a tank. His thick muscular arms were covered in tattoos. His belly usually protruded proudly over his Harley as he drove into our parking lot. Needless to say, he wasn't the kind of guy who complained.

So it was with great surprise, that I watched him hobble into my office. His cherubic face was flaming red. Sweat soaked the front of his t-shirt. His left arm wrapped around his son, and they walked in unison as if they were participants in a three legged race.

I paused for a moment as Howie got settled on the examining table.

Doc. I think I'm dying

I was amazed at how this giant of a man had been transformed into a cowering mouse. I waited patiently as he explained the agony of the last few weeks. His knees were aching. His feet were swollen. He couldn't bare to walk or move. His pain was only tolerable if he remained perfectly still.

His trip to the ER had been fruitless. He was told that he didn't have blood clots in his legs, but was otherwise given no explanations. I surveyed the situation. His knees were warm and swollen with small circles of color radiating downward. He jumped with any attempt at manipulation. His ankles were also sensitive and edematous.

I diagnosed him with gout. I faxed a prescription for prednisone to his pharmacy and requested he come back the next day. He limped out of the office unconvinced.

Twenty four hours later, he strode through the hallway towards me a changed man. He walked confidently into the room. He smiled broadly showing his stained front teeth.

Doc. You saved my life!

I was about to disagree when he unexpectedly grabbed me around the shoulders and gave me a bear hug.

I didn't say a word. I was speechless.


Sometimes I feel that being a doctor is like fighting a pit bull. You scratch and claw against the vicious opponent in an attempt to survive. And when you finally pick yourself up off the ground in victory, the dogs owner walks over and kicks you in the groin.

Yet there are few professions that give back so much. Physicians are allowed a unique window into the lives of their fellow men. We help people live; we help them die. We bear witness to all that is laid at our doorstep.

We are treated as both kings and peasants. Our rewards are fleeting but much appreciated: a handshake, a pat on the back, a hug.

Years ago my parents asked me what I want to be when I grow up. I didn't know then what I know now. This profession is a calling. A loud, disruptive, unswerving calling.

And with every breath, of every moment, of every day,

I humbly answer it.

Wednesday, November 2, 2011

The Hand Holder

When the residents referred to Dr. Foster as a "hand holder" it wasn't meant as a term of endearment. In fact, we universally dreaded taking care of his patients. It wasn't just his wishy washy decision making, but also his syrupy bedside manner. Although the patients loved him, we often wanted to run out of the room and vomit.

I remember my last interaction with Dr. Foster. I was a third year resident and we were rounding together on a patient in the ICU. We examined the unfortunate gentleman. He was on a ventilator and his kidneys and heart were failing.

After methodically writing his note, Dr. Foster and I walked over to the waiting room to talk to the wife. Her eyes were stained with tears as she broke the news. The family had decided to withdraw life support.

Dr. Foster held her hand tightly as he looked deeply into her eyes. He begged her.

Don't give up yet. I feel like I could have done so much more!

The wife placed her hand on Dr. Foster's cheek and then embraced him.

Doctor. Don't blame yourself. You did all you could. It's time for him to go now.

I was disgusted. How had Dr. Foster become the center of attention. He should have been comforting the wife and not vice versa.

I would never see Dr. Foster again. But years later his memory would come clearly into focus at a most unexpected time.


Walter and Sarah were my favorite patients. Although their bodies had withered seventy years of abuse, their spirits were far younger. They bounced into my office with energy and kindness. They greeted the staff and physicians with equal measures of respect.

A year ago, Walter developed a persistent cough. After various remedies failed, a chest xray revealed a nodule in the lung. A cat scan was highly suspicious for cancer, and Walter's diagnosis was confirmed by lung resection.

He tolerated surgery well and was plugging along when a surveillance cat scan showed multiple new nodules. Months of chemotherapy and radiation followed. We met in the office frequently to discuss each new development. Sarah worried that her husband was dying. She agreed to the various treatments, but wondered if they were doing more harm then good.

Walter, for his part, put on a brave face and took his "medicine" as directed. He also knew that he was dying, but didn't want to leave Sarah behind.

As time passed, Walter's disease progressed. He was so weak that the oncologist cancelled all remaining appointments for chemotherapy. When he woke up one morning and couldn't get out of bed, Sarah took him to the hospital.

It was with great heaviness that I walked into Walter's room. Sarah was seated at his side. She held his hand as they talked. Sarah stood when she noticed me. I leaned over the bed. A faint smile came over Walter's face.

Doc. I think it's time to call it quits.

I felt the air leaving my lungs. I doubled over. As I opened my mouth to speak, I couldn't believe what I found myself saying.

I'm not ready for you to go!

Sarah was now standing next to me, her arm around my shoulder. The iconic image of Dr. Foster in the ICU waiting room came rushing back to me. Maybe I had been to harsh.

Sometimes when the cards are on the table, it's okay to let your guard down and allow this gentle act of submission. There is a time to transcend the doctor-patient relationship and to no longer be physician, patient, and family member.

We were just three human beings with deep emotional attachments.

And we were grieving.


Tuesday, November 1, 2011

Why I Blog Part 2

There's an ongoing struggle for the hearts and minds of the American people. The battle rages on quietly, but occasionally bubbles over into the public consciousness. One side is loud, veracious, and spits its tyrannical philosophy far and wide. The other is sheepish, and docile.

We all know that I'm talking about health care. There are those who feel that our system is undeniably broken. They think that we have journeyed so far off course that our moral fiber has eroded. They say our values languish under a system driven more by personal profit than public good. The detractors are a motley crew of journalists, politicians, policy wonks, and health care consultants.

They point their criticism at health care providers and coin new terms to describe the so called depravity. They talk about "accountability" as if they are the ones in the ICU having the family meetings. They pray at the alter of "quality" yet fail to define the specifics of such a term. They resent "over treatment" but never have suffered the consequences of not doing enough.

The veracity of one group of combatants is only equaled by the meekness of the other. Practicioners, actually providing the care in America, find themselves too busy to respond. They watch as the public's confidence erodes but feel overwhelmed by the complexity of patient care. Wasteful exercises in futility steel away their time: billing, coding, preauthorizations, meaningful use, electronic medical records.

It is a learned helplessness. The quiet rebellion continues. Doctors become businessman. Nurses become managers. We cling to new models like concierge and cash practices.

The public, inundated by the power and volume of our detractors message, has noticed our silence. Without a dissenting voice they are left to believe that what they are hearing is true. They are losing faith.

We as physicians and nurses, therapists and social workers, have but one choice left. We must recast the characters and rewrite the plot. We must repaint the fresco to be more airy and accurate.

We must tell our stories.