Monday, December 31, 2012

Most Viewed Posts Of 2012

Here are my most viewed posts of 2012.

1. Black Friday Repost
2. Pretty Pretty Please
3. Medicine's Public Relations Problem
4. Is Social Media The New Doctor's Lounge?
5. In Praise Of Mothers

And my personal favorite of the year...

I Forgive You.


Saturday, December 29, 2012

A Price Above Rubies

He spent a few hundred dollars on pizza and soft drinks.  The setting was a little more lavish than usual, the servings more heaping.  As I settled down with a piece of deep dish, he started his pitch.

Healthcare is changing.  The little guys are joining hospital systems right and left.  Regulation is getting out of hand.  Why keep playing the same unsuccessful game?  He offered a few hundred thousand to renovate the office, he would handle all the billing and staff, my only job would be caring for the patient.  The perfect concierge practice. 

His goal was to focus on the healthy and wealthy.  No hospital work, no elderly or complicated.  I would work less and make more.  Of course, constant phone coverage would be necessary, and patients would have to be seen within twenty four hours.  But the pay would be better, and the hassles would be minimal.  Patients would be offered a cadre of services including full body CT scans and stress testing, but physician time would be mostly restricted to one hour evaluations. 

Although I clearly had no interest in such a model, I had one important question.

Minus all the bells and whistles, what would I be offering that I don't offer them already?

He was more than prepared for this query.  He rattled off a canned answer: same day appointments, rapid phone call return, personal attention, and a program that places a stress on wellness. 

I thanked him kindly for lunch, and took a copy of his brochure.  I perused it for a few minutes before jumping into my afternoon schedule.

I guess I just don't get this concierge thing.  I already guarantee my patients same day appointments for almost anything.  I return phone calls within thirty minutes.  I take care of all my patients in both the hospital and nursing home.  And I spend heaps of time concentrating on health and wellness, as well as death and dying.

The truth is, I don't know what I would add to my service to justify the costs required by most concierge practices. 

I would just be asking them to pay me more.  Pay me more to stay the same.

But believe it or not, in this ever changing healthcare system, this may be exactly what people crave.

Who can find a virtuous woman? for her price is far above rubies. The heart of her husband does safely trust in her, so that he shall have no need of spoil. She will do him good and not evil all the days of her life.

Wednesday, December 26, 2012

What's Good For The Goose

I never said I didn't like the guy.  In fact, the opposite was true.  I respected Thomas for his career choice.  Instead of residency or fellowship, he went to business school.  Instead of hanging up a shingle, he worked towards a masters in public health.

Far be it from me to criticize his expertise.  We need people like Thomas.  The kind who expose the waste and absence of thrift.  Maybe I rolled my eyes occasionally when he threw around Berwickian acronyms or sang the praises of the patient centered medical home.  We are all entitled to our opinions; to use our knowledge to make a living.

So when Thomas limped into my office wincing in pain, I looked forward to interacting with this engaged and empowered patient.  After taking a history and performing a physical exam, I felt fairly certain that he was suffering from a herniated disk.  I sat at my desk across from the examining table and began to discuss the options.  Seconds into my explanation, Thomas interrupted me.

I want an MRI!

I tried to explain that in absence of worrisome signs and symptoms, we could hold off on such testing until we got to the point of considering injections or surgery.  I thought a man of his knowledge and outspoken views on parsimony would surely understand.  There were a number of simple treatments to try first.  Thomas wasted no time in responding.

I don't want surgery, but let's do the MRI just in case.

Would it surprise you to know that I spent the next twenty minutes trying to dissuade him?  The MRI showed a herniated disk as expected.  After a steroid dose pack and a few sessions of physical therapy, he was feeling better.

He strode into my office effortlessly two weeks later.  His pain was gone.  I gently chided, and asked if the MRI had been ultimately necessary.  His smile barely quivered as he skirted the question, and reasserted his glorious improvement.

Apparently physical and emotional distress can alter one's beliefs about appropriateness.

Apparently what's good for the goose is not always good for the gander.

Saturday, December 22, 2012

What's Old Is New Again; The Plateau Of Hospitalism

Wait long enough, and what's considered old will be new again.

The other day I was talking to a shrewd hospital administrator about the upcoming changes to our health care system.  His eyes shown brightly as he proclaimed that now the name of the game was integration, enhanced communication.  Why, in a matter of months the hospital would connect their EMR to the EMR of a number of skilled nursing facilities.  Not only would that help the hospital qualify for meaningful use, it would usher in an era of higher quality and vertical integration.

Following his arguments, I wondered out loud.  Although talking EMRs are wonderful, something is lost in translation when care is handed from one physician in one institution to a completely different physician in another.  What if the hospitalists rotated through the local nursing homes and continued care in the post hospital setting.  The administrator carried it even further, maybe those same hospitalists could also have a few hours of clinic time each week to follow up with newly discharged patients.  That way, continuity and communication could be maintained through the whole spectrum of care.

He was really excited now, and started to dream about how his institution could rocket past his competitors into a new, efficient, quality driven model with zero voltage drop and minimal hand offs.  The foibles of EMR generated communication gaps would be solved.  Why mess around with making these huge, complex, voluminous systems talk when the real knowledge could remain in one or a small number of physicians heads.  The ultimate accountable care organization.

I couldn't help laugh as I pretended to seriously ponder his suggestion.

You mean...the same doctor would take care of the patient in the hospital, nursing home, and outpatient settings?

He nodded his head vigorously as I continued.

You mean, like the system we had before the invention of hospitalists?

It took only moments to realize that I was teasing him.  But as I walked away, I could see the confused look on his face as he pondered the reality of what I had just convinced him of.

The truth is, few people still believe that hospitalists provide more efficient or cost effective care.  When taken as a whole, the studies suggest that when the costs of hospital and post hospital care are added, it comes out a wash.  So why do we continue with the hospitalists model?  Simple:

1)Hospitalists are great at implementing quality control initiatives and populating the EMR.
2)Hospitalists make eveyone's life easier, and allow primary care physicians an out from the arduous work of inpatient care.
3)Young physicians want to be hospitalists because of work life balance and the ease of having no long term responsibilities to patients.  When your shift is over, your pager gets turned off.

I don't think the hospitalist movement is going anywhere.  For better or worse, it is a model that is here to stay.  But I think it's reached it's plateau.  The new political goal is integrative care over multiple settings.

No one beats the primary care physicians of old at that game.

Wednesday, December 19, 2012


No one escapes this life unscathed

To the mother caring for the sickly child, his eyes will always be the sparkling iridescence of the school boy attending his first day of class.  Although decades have passed and she is nearly eighty years old herself, he is not the middle aged man battling cancer, he is her son.  Some parts of us are so delicate that even the mere threat of storm clouds can send us fleeing to safer climes.  And when the unbreakable lies shattered at the feet of the mourning soul, we realize the frailty of love.  We painstakingly relinquish the promise of dreams.

To the husband lying fetal on the death bed of his beloved, she is not the ancient beguiled by the failings of time.  She is the sorority girl inching tepidly down the sweeping stairs unsure of the blind date that awaits below.  The wrinkles only outline his vision of the porcelain skin from a time long ago.  Souls may be inseparable, but bodies no longer cling with such great avidity.

Happiness is a goal to be strived for, yet pain is a much more reliable bedfellow.  So we wander this earth half heartedly embracing the depths of our inner desires, half petrified of finding what we're looking for.

Sometimes I feel like I stand at a crossroads.  I watch the misery play out around me.  Such strength and such sadness.

As a physician, as a human being, I can't help but feel this burden.

I'm not always sure what to do with it.

Sunday, December 16, 2012

Determination Of Need

I have come to terms with making difficult decisions.  I accept  the possibility of committing a mistake that will cost a life.  But I never signed on to bankrupting my patients.   Never!

I had been up all night tossing and turning.  The stat cat scan was deemed unnecessary by the insurance company.  My patient called crying saying he couldn't afford the thousands of dollars in charges.  Never mind the fact that the results suggested two life altering diagnoses.  Feeling horrible, I called the hot line immediately and was told that the consulting physician would not be available till the next morning.  Meanwhile, my patient was set up for an emergency consultation with the appropriate specialists.

My blood pressure began to rise the next day when my staff was still unable to reach the appointed doctor, the judge and jury deciding my patient's economic fate.  I replayed the decisional process in my mind.  Of course I could have done a chest xray and an ultrasound first.  But given the acuity of the symptoms, I didn't feel like I could wait.
And indeed, the scan did exactly what it was meant to.  It answered the pertinent question and allowed for immediate, possible life saving, action.  But as I finally picked up the phone to argue my case, I felt my heart beating out of my chest.  If I didn't perform, if I didn't say the right things, my patient would be saddled with unmanageable debt. 

My vocal cords shaking, I answered the questions as best as I could.  The businesslike voice on the other side of the line was steady and devoid of emotion.

But why a Cat Scan?

I again described how the acute shortness of breath, abdominal pain, and surprising physical exam mixed with the recent history of cancer was troubling.  I waited in between long pauses for a verdict.  Eventually, I was told that the interview was over.  Helplessly, I sputtered out the question that rested so heavily on my brain cells for the last twenty four hours.

So are you going to cover it?

Impatiently,  he explained that he wasn't able to give me a determination over the phone.  The nurse coordinator would call my office back.  As the words left his mouth a female voice chimed in who, unknown to me, had been monitoring our conversation.

Thank you Doctor for your time.

A few minutes later we received the call telling us that the cat scan would be covered. 

This time. 

I breathed a sigh of relief.  Now, I could go back to dealing with the fact that his life and health would never be the same again.  He was my next appointment. 

It was time to break the news.

Wednesday, December 12, 2012

The Clock Is Ticking

Justin had but one wish.

He dreamed that his newborn child could sink comfortably into his beloved Grandpa Joe's arms.  Months before the delivery, however, Joe suffered a debilitating stroke and his once mild dementia became catastrophic.  He now wasted away in a nursing home.  Unable to speak, feed himself, or dress, there was no sign of higher brain functioning.

Justin visited the home every weekend.  He brought his growing son along hoping to spark a twinkle of life in his dying forebears eyes.  The boy became a fixture in the home.  The orderlies cooed and peek a booed as they found random reasons to engage him.

Justin was distraught.  He missed the companionship of his grandfather dearly.  The joy of parenthood, stained with the blemish of his suffering loved one, had lost its tarnish.  If Joe could only speak to him.  If only his baritone laugh could ring out like it once had when a young Justin took his sweet time.

The clock is ticking!


Early one morning as the baby played on a small area rug, a new doctor entered the room and approached Justin.  He stood quietly and appraised the situation.  His gray lab coat was wrinkled with the collar hiding his obscure complexion and darting eyes. 

Quite a quandary.

He spoke without introducing himself.  Justin strained to see his lips moving behind the fabric of the upturned collar.  He  nodded his head slowly, unsure what to make of this dark figure who abruptly entered his space.  The doctor lowered his voice and spoke in a raspy whisper as he stared at the door.

What if it could all be different?

He took his right hand out of his pocket and produced a large oval pill. Justin grabbed the offering and examined it.  It shimmered in the light of the adjacent desk lamp.  It was plain, devoid of writing.  The doctor instructed that if given to Grandpa Joe, he would wake up from the fog of dementia and become himself again.  But the effect would be fleeting.  The mysterious figure was already half way out the door before delivering the final pronouncement.

Three hours after taking the pill, he will fall back into his current state.  Then he will die!

By the time he looked up, the doctor was gone. 

Justin rolled the pill between his fingers and peered down at his son playing happily on the rug.  Without hesitation, he slipped the pill into Joe's mouth and gently placed the water cup hoping the primitive swallow reflex remained.

And then he waited.


Moments later Grandpa Joe was alive!  He hugged Justin and jumped out of bed to embrace his great grandson.  As the child bounced in and out of his lap, he talked incessantly as if a long dead battery had been replaced somewhere deep in his bosom.

It will not serve the story to tell of all the things that were said in those three hours.  The plans that were made.  The promises that were kept.  The unspoken words that suddenly found an outlet in reality.

But exactly three hours later, Joe got back into the bed seconds before his heart stopped.


Standing at the lectern reading the eulogy, Justin took a moment to survey the crowd of friends and family.  Like with Grandpa Joe, he realized his time with each and every one of them was limited.  As he finished his speech, he vowed to slow down and become better at being with those he loves.  It was his grandfathers parting lesson.

Joe's voice echoed in Justin's ear while stepping down from the podium.  His baritone laugh and mocking voice breaking the silence of the somber room.

The clock is ticking!

Sunday, December 9, 2012

The Nobility Of A Profession

The dictates of human kindness are fickle.

The eruption of papers fluttered to the linoleum floor of the bustling hospital corridor.  Important persons with grey pressed coats and stethoscopes bouncing against clavicles rushed by without rotating necks downwards to notice.  Loosely fitting scrubs clung to contracting muscles, and pudgy abdomens directed bodies hurriedly around the corner with a misplaced sense of purpose.

And the poor woman bent down helplessly, and struggled to collate the papers that had once fit nicely into her carrying case.  Was she a hospital administrator? A researcher?  A family member, back from the library, trying to study up on her loved one's illness?

No one took the time to find out.

A transporter pushing a gurney sped by and trampled an errant artifact that had flown away from the safety of the herd.  The women wiped the sweat off her face, and blotted a tear with a crumpled hankie.

I was no less guilty.  A few steps past, my mind swirling with one patient conundrum or another, I stopped mid stride.  I turned around and silently knelt toward the ground.  I gathered what was left on the floor and feebly handed it to the struggling woman.  She looked up with injected conjunctiva and smiled anemically before I raised from the floor and moved on.

Am I any better?  I have given myself a pass.  I have used the nobility of a profession to deny the basic humility of grass roots kindness.  How many times have I refused a donation to some odd cause or another by thinking: haven't I given enough?

Yet there is a strange lightness of heart that comes from the unrequired act of selflessness.

We health care professionals must remember that it doesn' take years of education or fancy gear to help our fellow man.

We must relearn how to practice basic kindness. 

Wednesday, December 5, 2012

Only Words

Sometimes words are like rain drops, tears, that bounce off the umbrella and splash to the ground fraudulently. 

Some barriers are unable to be breached.


He was intense.  His arms swung rapidly in opposite directions as he talked.  Words whizzed out of his mouth like formula one cars, shooting past me and often missing their target.  His physical presence was far smaller than his spiritual.  Yet he was an immense man.  His brutish exterior hid a much kinder and gentler soul.

He was rough around the edges.

He tolerated the antibiotics just fine, but this was his third bout of diverticulitis.  The last was particularly severe.  I wrote the referral for the surgeon, and placed it in front of him.  He read the name quietly and looked up at me.

Surgeon, why do I need a surgeon?

I carefully explained how the nature of his recurrent infections necessitated surgery.  His posture changed dramatically after the "s" word parted my lips.  His colorful face mimicked his language as he spouted uncontrollably. 

Surgery, surgery...Fuck You!

I could see the look of surprise and regret before he sputtered a pressured apology.


It was really rather offhanded.

I had called to relay the latest results of her daughter's blood tests.  Everything looked fine.  She breathed a sigh of relief.  The hospitalization of her twenty year old child was enough to send her over the edge. 

But she survived.  They survived.  And likely this was the end of a trying but hopefully not scarring episode in their lives.  We chatted for a few minutes before hanging up.  I had taken care of one or another family member for the last decade. There was a certain familiarity.

As we went to say our parting goodbyes, she paused for a moment. 

Doctor G, you know we really love you!

I thanked her and hung up the phone.  My mobile was ringing, the front desk was over heading me, and the computer was flashing. 

Drip, drip, drip.

And down to the ground.

Saturday, December 1, 2012

A Tipping Point

It was really a rather arrogant presumption so early in my career.

The secret sauce of medicine, I figured, was becoming an excellent diagnostician.  I devotedly memorized the signs and symptoms, the pathways and algorithms.  I strained to differentiate the pain in the chest due to suffocating myocardial cells from the stretching of the pleura or the lack of serotonin in the brain.  I cut my teeth on those early patient encounters.  Each experience was like a bookmark, a highlighted passage from a sacred tome.

I was blindsided by the realization that there was something else.  Something just as important.  And to my dismay, the art of prognostication proved to be just as complicated.  When I talk of the master prognostician, I'm not referencing one skilled at matching diagnoses to life expectancy charts.  This is the work of the accountant, the actuary.

I'm referring to the innate ability to understand when a person is dying.  Without such knowledge, our profession becomes the fodder of technicians.  Hands meant for healing can also do great harm.  How are such hands restrained?

There is a tipping point. Once past this imaginary line, aggressive intervention heightens pain and decreases quality and duration of life.  There is a reversal of physiology. Cure becomes the poisonous draught of good intentions.

We suffer a blindness to the important skill of prognostication.  We don't recognize or acknowledge the tipping point.  We hang on hope and deny reality.  It's easier that way.

Chemotherapy drip drips.

Scalpels snip snip.

Overzealous hands provide underwhelming outcomes.

It's an uncertain skill.  It can't be gleaned from text books or defined by lab values.  We learn through experience.  A strange mixture of clinical information, familiarity, and intuition makes some better than others.

But if you really want to help your patients, learn how to recognize death's distant footsteps.

Suffering at the end of life is not a requirement.

Wednesday, November 28, 2012

My Son Is Crying

My son is crying.

Not the "I'm in so much pain" cry but more like the "who just pulled the rug out from under me?" cry.  His face contorts into abstract gyrations mirroring the profound melancholy vibrating through his innards. 

He's not in physical pain.  He didn't just lose his favorite toy.  This calamity is far more subtle.  After a thanksgiving full of cousins and joy, it is time to return back to normal life.  His cousins have left for the airport and he feels empty; consumed by longing for togetherness.

My son is sensitive.  Normal emotions that others brush off, he feels to the core of his soul.  It is part of the unbridled uniqueness that he brings to the world.  He fills me with such pride and envy, yet I worry.  But should I?

Am I not also a protege of Achilles?  Being in tune to the morass of humanity has allowed me to be a father, writer, and physician.  It is such qualities that fight the unbearable indifference facing any monumental task. 

Except, I am not my son.

My sensitivities have a limit.  The pain only goes so far.  I do not feel things the way he does.  Or maybe I should preface such statements with the qualifier: anymore.  The death of my father at the age of eight has had untold consequences.  I can only imagine the hardness of heart such things require the soul to imbibe.

He is more than a father could ask from a son.

So why am I so afraid?

Saturday, November 24, 2012

The Old Ways

It's funny that I happened to see it on Thanksgiving morning.

Sarah Liston was well into her eighties when she walked into my office for the first time.  Her legal blindness was only a small impediment to her daily functioning.  She breezed through the door with calm and confidence.  Her monthly visits became a unique pleasure in my busy schedule.  Over the years I realized I was one in a small number of connections to the outside world.

She had a few friends here and there.  She had long since stopped visiting her ophthalmologist formerly, but they lunched on a regular basis.  Painfully past trying to fix her vision, the much younger woman offered companionship instead.

As Sarah became more and more debilitated with age, I worried about who would take care of her.  She had no children or relatives.  Her husband died decades ago.  We spent time talking about what would become of her things when she was gone.  She had a luxurious house and a comfortable bank account with no one to leave it to. 

Once Sarah remarked how she had given an expensive peace of jewelry to her ophthalmologist.  At first feeling unseemly, I eventually warmed to the idea.  The young woman had become more a friend than a physician.  And in some ways, I was learning to fulfill the same role.  Only with experience was I becoming aware that the greatest gift we give others, patients or friends, is the love and respect that resides in our hearts.

Sarah's health was turning.  We planned for her death as if it were a trip yet to be taken.  When the time came, she was comfortable.  A few weeks prior she had my nurse take a picture of us in the exam room.  She framed it and sent it over with one of her caregivers.  I was staring at the picture when the call came.

Five years to the date, on Thanksgiving morning, I was thumbing through the financials of my local hospital system (that comes in the mail annually).  I scanned through the donor information looking for names of people I know.  And there it was at the top.  Five hundred thousand dollars given by the Sarah Liston memorial fund.

I guess Sarah figured out what to do with her money after all. 

On this of all days, I felt like she was thanking me.  Thanking me for being the face of this medical system for which she decided to donate her life savings.

Better yet, she was sending a late reminder. She was pushing me to ignore the current upheaval faced by our backwards health care system. 

Mocking me. 

Tempting me to hold on to the old ways.

Thursday, November 22, 2012

Black Friday Repost

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 just carted away a belligerent man and his wheel chair bound daughter. There was 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!

Tuesday, November 20, 2012

Proper Vocalization

Even at the age of fifty, he was still her little boy.  And she tried to embrace him in a protectionist cocoon.  She could create calm and warmth in the almost cozy hospital room, but she couldn't undo the turmoil inside his body.  Her son was dying.  Indeed, of the millions of breaths that had left his mouth over half a century, his remaining expirations would be few.  The cancer had spread.  The counts dropped.  The fever mounted and the skin grew sallow.

The strength of her voice misleading for an octogenarian, her arthritic knees buckled as she ambled towards me.  Her questions were focused and deliberate.  The emotion spent on her her contorted posture, her words came out in a dead monotone.

How long does he have?
What will you give for pain?
Is there anything for anxiety?

Her questions, like afterthoughts, came slowly and painfully after prolonged pauses.  The irony of watching her adult child die was not lost on one who was old enough to inhabit the next bed over.  Many times I reached for the door, and yet was pulled back by another halting statement.

Eventually, I left the room to chart at the nursing station.  Moments later, I noticed her limping towards me. She waited patiently as I finished scribbling in the chart.  She started to speak, but then grew silent.  I could feel her needs leap like a lion from her chest in the absence of proper vocalization.  She was struggling.

You know...

I cradled her with my eyes.

I'll take care of him.

Her heart splintered and the aged blood pooled on the floor at her feet.

Yes. Yes.

She smiled feebly.

And then went back to sit with her dying son.

Wednesday, November 14, 2012

Shifting Paradigms

It's my only memory of religious school.  I must have been about ten years old.  The poor teacher really had little chance.  The moment the conversation turned, I pounced.

What do you mean the chosen ones?

Such propaganda seemed anathema to a young upstart in the mid eighties in a town like Evanston, Illinois.  A town where people of different races and colors were bussed into my neighborhood to integrate the school system.  I remember using a child's words to described how divisive these beliefs could be.  My rant began to gain steam as my voice rose.  Eventually the flustered teacher lead me out of the classroom, and made me sit on a bench in the hallway for the rest of the period.

He must have felt bad about it.  Because the next weekend he suspended the morning lesson and took us all to McDonald's for breakfast.  It was my first and last tussle with religion.  Spiritual by nature, I rarely subscribed to any specific teaching or creed.  I believed our actions could be meaningful and holy without reciting incantations or bowing to an embellished deity.  I never really gave it much more thought.

That is, until recently.

As I voyage deeper into end of life care, I find myself more apt to openly discuss religion with my patients and their families.  When the cards are down and the answers are few, it helps the suffering to have a higher power to raise their hands and release their fate to.  More than once, I have slumped next to a grieving family member and spoken words that seemed foreign as they left my tongue.

It's in God's hands now.

Seeing the comfort and relief, I no longer feel like a hypocrite.  While never my personal path, clearly religion brings solace to many.  Because of these experiences, I believe I have reached a sort of truce.

And this evolution largely parallels the truce we as physicians must reach with death in general.  The great bain of the modern American physician, it has taken a paradigmal shift to convince some of us of the true value of palliation and hospice care.

Like religion, we don't have to love it.

We don't have to strive towards it.

But we must learn how to embrace it to ease the great suffering of our patients.

Sunday, November 11, 2012

The Keepers

The agent stands above his victim thoughtfully.  The white walls and the sterility of the room are mocked by the spatters of old blood on his frayed laboratory jacket.  The tools of torture lie restlessly on the counter: a probe for the rectum and genitals, a tube to be shoved down the nostrils, various needles and catheters, electric current.  Behind him, in a chest, potions and truth serums ache for acknowledgement.

The memory of the agent's humanity had been submerged long ago under the weight of a brutal apprenticeship.  Loathing and despair were squashed with surgical precision.  This is the price of the health of a nation.  The currency of the cloak and dagger is not to be glamorized. 

These are not subjects discussed in the genteel parlors of the aristocracy.  Nay, silence is the virtue that binds the keepers of societies dirty little secrets.  And rightfully so, the backroom deals and ugliness of the puppeteer does not necessarily need to be disclosed to the innocent little puppets.

The body writhes on the table.  Vomit and stool stain the loosely fit clothing.  The agent is practiced and calm.  He studies the victim and makes adjustments.  An assistant leans over the counter and and repositions a probe before leaving the room silently.  Light floods the eyes and the ears are assaulted by various beepings and ringings. 

If there ever was a hell on earth, than this would be it.

The agent looks up at the clock and then rushes toward the glass door.  His shift is over and his family awaits.  His son and daughter want to see their father.

He exits the hospital.

His life's work put on hold till another day, till another sad soul with shaky voice whispers the secret code that sets his diabolical training in action.

Do everything.

Wednesday, November 7, 2012

The Beat Goes On

The man steps up to the podium.  He is no longer a candidate.  His voice is hoarse and cracks as he begins to speak.  One can only imagine what the last twenty four hours have felt like.  Heart racing, pulse thumping, and the lack of sleep have taken their toll.  The victorious pause will be momentary.  Today is a fleeting oasis, the challenges of tomorrow a certainty.

My body crumpled underneath a blanket, I try to keep my eyes open with the rest of the nation.  The daunting hurdles of the last call cycle still washing over my listless spirit.  I saw thirty five patients.  Some by choice, most by necessity.  As a nation travelled to the polls, I rounded in the hospital.  I tended to diabetes, hypertension, colds, and various other illnesses in the office.

I helped two patients die.  Or more accurately, I struggled to use primitive tools to enhance the quality of what little life was left.  I talked to their families, huddled with the nurses, and signed all the orders. 

I answered phone calls.  In the exam room, in the car, in the bathroom.  I signed papers, hundreds and hundreds of papers.  So many papers that my hand began to cramp and my signature became an eligible scrawl.

I will awake tomorrow and do it all again.  The pundits will speculate, a president will return to the business of a nation, and the people will go back to the minutia that fills our overcrowded lives.

And the beat goes on.

Saturday, November 3, 2012

The Rise Of The Extended Care Facilitator

Once the red headed step child of the care giving continuum, nursing homes are playing a more significant role in today's health care environment.  The aging of the population, the rise in hospital as well as outpatient acuity, and the focus on rehospitalization rates are driving forces shaping the need and quality of such institutions. 

The modern nursing home is nothing like the barren images of the past.  Ornate buildings with state of the art rehab facilities, parlors, and resident amenities are now the rule.  The beautified facilities, however, hide a more technical and intensive milieu of clinical care.  Total parenteral nutrition, patient controlled anesthesia, and the placement of central venous catheters all take place in extended care facilities on any given day.  Acute care, chronic disease management, and end of life palliation are now the expectation.

While the capabilities and quality have increased, the future of the nursing home as a soft landing place from acute hospitalization depends on an ever increasing clinical skill set.  Once the purview of administrators and directors of nursing, to create centers of excellence a new breed of physicians must rise to meet these challenges.

I propose the extended care facilitator.  These are physicians schooled both in intensive hospital care as well as outpatient medicine.  Leaders who are willing to spend hours a day rounding and problem solving.  The nursing home doctor of tomorrow needs to be agile at acute diagnosis, chronic disease management, as well as understand hospice and palliative care.

These facilitators will have innumerable benefits.  Nursing homes will deliver higher quality care and their numbers will swell as unexpected discharges fall.  Hospitals will experience better integration and lower rehospitalization rates.  Patients will receive state of the art care in comfortable surroundings.  And lastly, physicians will administer advanced medicine to a ready supply of patients without worrying about having enough to support their small businesses.

Its a win, win, win, win situation.

Tuesday, October 30, 2012

Some Things Must Be Learned On One's Own

In first grade, I was quite the athlete.  Mr. Thomas emptied a bag of soccer balls and I maneuvered around my classmates nimbly.  I dribbled up and down the court.  I weaved in an out of the orange triangles without losing step.  I could feel the pride wash over my shoulders as the other students stared on admiringly.

At one point, Mr. Thomas praised my performance and bayed the other children to come watch.  I was a star.  For a few days at least.  But eventually all the first graders combined for gym class, and I quickly faded into the background.  There was Jimmy, his father was once a professional player and he had obviously inherited skills.   Leslie was surprisingly fast and agile for a girl. 

The truth was that I was good, not great.  It was the first in a series of heartbreaking realizations.  I wasn't the fastest, strongest, or even the smartest.  In fact, I seemed to hide in a cloud of mediocrity for so many years.  It wasn't for a lack of trying.  I once spent a whole summer training for a basketball squad to be cut in the first round of tryouts.

It was only years later, that I realized that the painful fits and starts of childhood were the building blocks of becoming a successful adult.  It was in failure that I found the most sound master.

I try to remember this as I watch my children struggle to leap over the hurdles of youth.  I know that each flubbed performance or sub par grade stings them much more than I.  Yet, I struggle, like most parents on when to intervene.  How does one know when to rip the bandage off quickly or to peel slowly and feel the burn?  I survived and became stronger.  Will they?

In some ways doctoring resembles parenting.  My patients are far from children, but the casual similarity remains.  I have the benefit of experience to guide them through situations they are unequipped to manage on their own.

Strangely enough, I still question when to intervene.

Some things have to be learned on one's own.

Sunday, October 28, 2012

Stand Up And Deliver

I never considered becoming a surgeon.  I knew that I didn't posses the three dimensional sense to perform at the highest levels. I would have been mediocre at best. And, in general, I don't regret this decision. There are times, however, when I feel unbridled jealousy.  When the abdomen quivers with acute appendicitis, I so wish I could wield the scalpel and with a few trusty thrusts rid the body of the diseased organ.  Or when the breast is invaded by misguided cells, I could extirpate the cancer with strong arm and unrepentant soul. 

It's not that surgery is easy, un-messy, or for the weak of mind.  We all know that it is actually a thinking mans sport.  But there are times when the answer is actionable and the pathway is clean and decisive.  Did I go into the wrong field?

General Internal medicine (like surgery in general) is anything but straight forward.  The common cold can turn into life threatening influenza, the tingling of pain in the chest can be a heart attack or the first signs of a perforated esophagus.  You never know what's lurking behind the exam room door and complacency of the routine can be shattered at any moment.

Yet, strangely enough, the certainty I crave has become more apparent as I delve further into end of life care.  Unlike many of my colleagues, it mostly seems quite obvious when a patient is dying.  Maybe its the weakness of voice, durability of diagnosis, or just a hunch.  Usually I can tell when the time is coming and help prepare as best as possible.

Once all parties accept that death is the realistic outcome, I become like the surgeon operating on a fiery appendix.  The dance becomes much more choreographed, the decision tree much less complex.  This is where I thrive. 

And maybe this is why we are failing in medicine.  The dizzying myriad of treatments and options sometimes clouds our minds to the obvious reality.  If we could just foretell death better we could surely save a world of suffering and unnecessary treatments.

I think the knowledge is out there.  Like the surgeon, we need to learn to stand our ground.

We need to deliver in both life and death.

Tuesday, October 23, 2012

The Secretary Executives

I strained to keep from rolling my eyes as I looked at Sheila's paperwork.  The surgeon was requesting an inordinate amount of preop testing for a straightforward surgery.  Of course I would clear her, but he wanted me to do a urine culture, chest xray, and protime as part of the work up.  I was well versed in the literature surrounding preoperative testing, I knew there was no scientific data to support this drivel.  But what was I to do?  Tell the surgeon that I refuse and watch as he cancelled the surgery.  I had seen it before.  Reluctantly, I signed the lab and radiology orders and sent Sheila down the hall.

She returned a short time later.  The tech asked her to sign an advanced beneficiary notice, and explained medicare would no longer cover this testing under the guise of preop necessity.  Sheila seeing the possibility of hundreds of dollars of uncovered services, stomped back to my office angrily.  She caught my attention as I was walking a patient to the door.

Can't you find another diagnosis to code it under?  I can't afford this.

I ushered Sheila back into the exam room and explained the sad truth.  No, I couldn't change the code without committing medicare fraud.  No, I had no other justifiable reason to order such superfluous testing.  And no, I didn't actually feel that I needed this information to clear her for surgery.  As she left my office thirty minutes later, I marveled at the teaming exam rooms full of people waiting to be seen. 

Yet again, the primary care physician is the red headed step child of the medical system.

We are forced by specialists to order useless tests without scientific backing.

We are hung out to dry by medicare, and uncompensated for hours of explaining her erstwhile policies.

We have become everything we aimed to avoid,

the secretary executives of a failing system.

Saturday, October 20, 2012

Work And Life Enmeshed

It's my fault.  I didn't have to go into private practice.  Or join a group that quickly became just the two of us.  I didn't have to take on so much nursing home work.  And certainly giving out my cell phone number went far beyond expectations.  But the patients were so complicated that my coverage started to send them to the emergency room every night.  Practically, taking my own phone calls on the weekend just made sense.

So my friends and family have become used to me walking around with a mobile phone attached to my ear.  I accept the fact the I'm never really free (unless I leave the country).  Vacations, weddings and even the children's party today got interrupted.  Between choruses of Happy Birthday I was hashing out a case of chest pain with a frightened octogenarian.

Younger physicians talk of work life balance.  For me, the seams have thoroughly faded.  Work and life enmesh.  I never leave the house without my mobile phone and car charger.  I rarely consume more than one alcoholic beverage at a time lest I receive an important page.

I'm present in my spouses and kids life.  I go to every parent teacher conference.  I rarely miss a family dinner.  But we all are aware of the mobile leash that binds me to my non filial responsibilities.

My job has become my life's work. 

I'm not sure how else to fulfill the covenant I've agreed to.

Wednesday, October 17, 2012

Dream Catcher

The heat rushed into my cheeks and a frog caught in my throat.  I knew the woman approaching me. Years ago, I sat at the bedside and watched her mother take her last breaths.  It had been the end of an emotionally cruel and grueling year in which we ultimately decided on hospice.  Her mother was one of my first patients.  It was an intimate experience.

Back then, this woman and I talked dozens of times.  I stood by her during a difficult period of life.  Yet as she reached out her hand for mine, I couldn't recall her or her mother's name. We exchanged pleasantries and eventually moved on.  She likely didn't detect my mental lapse.

When I became a physician, I promised that I would remember each and every patient and family who lived and died under my care.  As the years pass, my vessel has become so full that the details often run over.  After being a part of countless life altering experiences, the emotional muscle memory loses it's resilience.

And thus the irony of being a physician.  Your face becomes seared in the brains of many who must be forgotten to make room for the needs of those who remain.  You become a dream catcher, catching the peaceful sleeper's nightmares and holding them till the sun washes away all the specifics.  But something remains.

It is in the ashes of those remnants that my writing takes form. 

I try to capture the gift.

The gift that each soul has left behind.

Monday, October 15, 2012

You Plant Tulips

There was no question that after the hearing incident, my wife and I became a tad more nervous.  My daughter developed congestion, fever, and ear pain.  The fevers lasted for a week.  Burned by our last few encounters with pediatricians, we were hesitant to bring her in.  Ear infections came and went.  We were weary to expose her to more antibiotics. 

Eventually she got better.  The mucous dried and the fevers resolved.  But over the next few months we noticed something disturbing.  Our three year old daughter was having trouble hearing.  She kept asking "what" and turning toward her right side to hear better.

The ENT examined her and felt the ear drum looked good.  No signs of scarring or damage from infection.  Thus we were surprised when the audiometry testing showed neural damage and complete hearing loss on the left side.   It must have been the high fevers.  One never knows.

Shell shocked and feeling responsible for our daughters new found disability, we spent the next few years questioning ourselves.  Each fever or cold became a testament to our parenting abilities.  Would we miss something again (even though the ENT assured us that it was not infection that damaged her ears)?

So when she developed fevers and ear pain again, we couldn't help but be a little nervous.  Our regular pediatrician wasn't available, and we hesitantly made an appointment with the doctor on call. 

We had been warned about the older doctors in the practice from friends and family.  We were told that they were outdated and curmudgeonly.  I admit, that when the aging fellow with the tattered coat came in, my heart fell.  His pockets were empty and he didn't carry a computer like all the other docs in the practice.  In fact, the one accoutrement in his lab jacket was a single ballpoint pen in his breast pocket.

It took less than a second for everything to change.

He bent towards my timid daughter and got on his knees.  He stared at her lovingly, and his eyes smiled as he addressed her directly.

Do you know how special you are?  Does your mommy and daddy tell you how special you are?

My daughters eyes lit up.  Her shyness disappeared, and she laughed and played happily as he examined her.  Her ears looked fine.  It was likely a virus.  The doctor spoke gently to us reassuring that everything would be okay.  He looked at my daughter and then my wife.

You plant tulips.  You get tulips.

We went home elated.  For once, I felt like I had actually been to see the doctor.  You know, the kind who isn't hiding behind a computer screen.

The kind who you entrust the lives of your children to.

Saturday, October 13, 2012


Saul knew his numbers.  He knew his HDL.  He knew his LDL.  In fact, he kept track of just about every measurable parameter.  Daily weights, mean body temperature, blood pressure, blood sugar, nothing was left to chance.

He bounced into my office with spreadsheets in hand.  He highlighted the numbers and pointed out peaks and valleys, trends and outliers.  He had every lab value graphed to the most detailed minutia.  He once called me to discuss a change in percentage of neutrophils from his complete blood count.

Saul wasn't crazy, he was afraid.  He was hoping that by tracking his own physiology he could escape the inevitable. Unfortunately, his fears had driven him to obsession.  He spent more and more time and energy pouring over measurements.  It eventually became unhealthy.

When a message flashed across my EMR to call Saul immediately, I was unperturbed.  Likely he found another minor aberrancy needing an explanation.  I listened to the dial tone, and waited patiently for him to pick up the phone.  Recognizing my number on the caller ID, he began speaking immediately.

Dr. G, I'm having chest pain!

Thirty minutes later, I was walking into the emergency room.  His EKG screamed the diagnosis before I physically evaluated him: acute myocardial infarction.  I grasped his hand as he was being whisked off to the cardiac catheterization lab.

You're gonna be just fine!

And he was.  But it all makes me wonder.  This quantified self movement is nothing new.  Whether it be blood pressure or blood sugars, there have always been those with an interest in self knowledge through technology and self-tracking.

The better question is what do we do with the data once we obtain it?  How do we know what measures are meaningful and which are complete rubbish?  And what are the mental and emotional consequences of such vague self knowledge?

I think if your goal is to be healthy, my advice is to concentrate on the unquantifiable.

Eat well.


Don't smoke.

Drink a little alcohol everyday.

Cut down on stress.


Do something selfless to further mankind.

Wednesday, October 10, 2012

Mistaken Youth

I could feel the burn arise from my throat. I had been talking for hours.  My first day back after a short trip to give grand rounds at the Carolinas Medical Center, I was overwhelmed.  Only gone for two days, I was feeling a week behind.  My calves ached and my shoulders were heavy.

I knew I was coming down with something.  Likely a virus of some sort or another.  I packed up the computer, and gathered my papers to rush off to the nursing home.  The administrator had a four alarm fire that had been building in my absence.  It had to be put out.

My secretary caught me just as I was slipping on my jacket to leave.

Mr Preston's daughter was wondering if you had a moment for her.

I glanced up at the clock and nodded in assent.  It was a hard decision to to take Mr. Preston off life support, one steeped in years of conversations and familiarity between father and daughter, patient and doctor.  It was anything but easy. 

She wanted to thank me for caring for her father.  She found great value in the speed I returned phone calls, and the direct manner in which I explained difficult situations.  She hoped that time would not erase my sensitive nature.

I almost laughed at the unspoken assumption that I was new to doctoring. She must have thought that I was a recent graduate at great risk for losing my idealism.  I decided not to correct her, and basked in the glory of being mistaken for someone more youthful.  I thanked her profusely as she left the office. 

Moments later, I was bounding down the stairs to my car parked at the far end of the lot.  My lungs constricted, my nose clogged, and my ears plugged.

I could feel the last ten years surge through me like pints of blood coursing through thirsty vessels.  Not quite forty, I'd become keenly aware of the foibles of the aging human body.

A decade after graduating residency, I felt old.

Physically and emotionally.

Sunday, October 7, 2012

Who Needs Us Anyway?

What's this?

My four year old daughter was staring quizzically at her right knee.  I bent down and squinted to get a better look.  Sticking out from her flesh was a small pearly growth.  She had a wart.

My wife and I bought a role of duct tape and religiously placed a piece on her knee every night.  It seemed to get smaller, but never went away completely.  My daughter was indifferent.  She neither complained or shied away from showing it.  It was a part of her.

Eventually we decided that something had to be done.  I contemplated making an appointment with a local dermatologist.  But who wanted to spend a hundred dollars (deductible) on such a little thing?

In a strange turn of irony, I did that which I always criticized my patients for.  I ignored it.  I turned a blind eye to the festering imperfection that seemed to grow a little every day.  If I just put it off.  if I just ignored it, maybe it would go away.

Time passed.  We continued with our busy lives in denial of this small but annoying problem.  Until yesterday.  Yesterday, my daughter tripped while running on the side walk.  As I swooped down to pick her up, I noticed a small flesh wound on her knee.  And there on the cement lay her wart.  Decapitated.

The lonely parasite stared up at me smugly.  It mocked me.

You doctors think your so important!

Who needs you anyway?

Saturday, October 6, 2012

Wisdom, Action, And Planning

Drip. Drip. Drip.

The drops of chocalate ice cream cascaded down the cone and landed impetously on the ground.  They formed a line for about fifty feet tracing the path of the shopping cart with the infant dangling in the front.  The mess facing the checkout counter didn't go unnoticed for long.  Seconds later, a team of teenage Target employees swarmed with their red shirts and faded khakis.  Shoppers unknowingly steered back and forth through the gelatinous puddles.

I expected the whole thing to take seconds.  I could see the paper towels dangling from their hands.  But strangely, the flurry of action was delayed.  The young mouths moved and words were exchanged.  I stepped closer to hear what was being said.

Apparently calculations were being made.  A young man tried to triangulate where the offending drops had come from.  A brief discussion was held about which direction was the correct starting place.  All the while, the streaks of chocolate were being disrupted by the wheels of carts and unwitting footsteps.  Within moments, the problem multiplied.

Eventually the team split up and attacked from multiple directions.  One woman got on her hands and knees and scrubbed while a boy placed his paper towel on the floor and pushed it carelessly forward with his shoe.

The job got done, albeit inefficiently.  Sticky sneakers could be heard making the pilgrimage to the front door.  And I couldn't help but think of our health care system. 

A generation of doers has been replaced with teams of measurers.  As communities bleed, the new mangers tabulate and plot, calculate and proportion.  But sometimes action is more timely than planning.  Sometimes the guy on the floor scrubbing is the only one fast enough to prevent widespread disaster.

Planning and action.  Action and planning.

Have we lost the wisdom to discern the difference?

Thursday, October 4, 2012

Maybe She Was Right

It's not that I have a problem with big box cancer centers.  I just feel like we have some great specialists in our neck of the woods.  So I rarely suggest my patients cross state lines for care. 

From time to time it happens anyway.

I didn't blame Sarah for going to the far away Mecca for treatment.  Her colon cancer, routine as it was, was still a big deal.  She could afford to put her life on hold, rent a hotel room, and get the very best her bank account could afford.  As she said on the visit before leaving:

I'm not taking any chances!

Sarah was a youngish sixty year old who was in the prime of her career.  She entered the office wearing the latest fashions and exited the parking lot in flashy new cars.  Her cancer was found on routine screening.  The stage and pathology were favorable.

Her treatment plan was carried out flawlessly.  She returned to pre cancer life a bit more cautious, but otherwise no worse for wear.  Every year she made the pilgrimage back for her annual checkup.

And every year I rolled my eyes as I read through the gracious consult note that arrived on my desk a few weeks later.  But this year was different.  I skimmed through the first few lines.

Sarah is doing well.  She has no signs or symptoms of recurrent cancer.  She recently welcomed the birth of her first grandchild (Nora!).

It was the name that caught my attention.  I could no longer push this off as some distant big box cancer center staffed by arrogant clinicians.  This physician had taken the time to learn about Sarah's life and rejoice in her triumphs.  From these few sentences it was abundantly clear that she was not just another case, another number. 

She was truly being cared for.

Wednesday, October 3, 2012

Let Sleeping Dogs Lie

I'm sorry!

I really am!  No one deserves breast cancer.  Especially the kind that spreads to your liver, lungs and brain.  The fact that you lived to your eighth decade doesn't detract from the sadness.  You deserve to live.  I can't blame you for not being ready to go.

I apologize that our meeting was so abrupt.  I was consulted to see you in the nursing home to address various issues.  I swept in the door, and introduced myself to you and your daughter. I explained what the word "palliative" means, and why I was asked to see you.  Although I saw a full hospice consult in the hospital chart, you both stared at me blankly as if this was the first time you heard of such things.

I asked if you were in pain.  I asked about your breathing as I watched your chest move back and forth laboriously, and your dreadfully weak body sink into the gigantic hospital bed.  Finally, I tried to discuss prognosis. 

You mentioned how your oncologist said that "we can get it all".  You placed great hope in the upcoming brain radiation.  When I pushed further, you had vague ideas about seeing your grandson's wedding that was slated for next fall.

Your skin sallow, your breath heavy, there was absolutely no way you were going to be alive for that wedding.   I had doubts about the weekend.  When I started to express my concerns that your expectations were unrealistic, the conversation turned.  Your daughter shook her head and her glance shot arrows through my chest.  You became angry and shooed my out of the room.  I was asked not to return.

I thought of a million ways I could have done better.  I should have approached the situation differently.  I could have brought these subjects up over many visits and allowed you to come to conclusions on your own.

But for some reason, I felt a great sense of urgency.  Rounding the next morning in the nursing home, I found your bed empty.  You coded an hour after I saw you.  The ambulance came, life support was initiated, and now you lie half dead in the local ICU.  Your daughter is left to make the horrible decision of when to pull the plug, if ever at all.  You will not recover.

Some may think that I write this post to gloat; to say I told you so.  The truth is agonizingly more complex.  I wish I could do this one over.  I wish I could have left you in your mist of denial, and taken a more simple approach.  I could have held your hand, said I was sorry, and let sleeping dogs lie.  Your weren't going to listen to me anyway.

Now, I am stuck with the great possibility that your daughter will see my visit as the straw that broke the camel's back.  And you, your last memory before dying, will be of some young pompous doctor who walked into the room,

and told you he was giving up on you.

Monday, October 1, 2012

What Happened To Hope?

I scratched my head as I pulled into the parking lot of the hospital clinic.  There were quite a number of cars for a Sunday morning.  I watched a young woman and man (I presumed husband and wife) making their way towards the front entrance.  There was a certain hope in their movements. 

Of course!  It must have been the fertility clinic weekend.  About once a month, dozens of couples come to be artificially inseminated.  Or at least that's what I figure.  I've never actually asked what goes on in the clinic.  I'm just guessing.

This rush of optimistic people seemed strangely peculiar amongst the back drop of the gloomy, voluminous hospital.  Enclosed in the concrete walls of this massive building was almost every type of pain and suffering imaginable. 

I began to wonder, what happened to hope?

It seems that medical centers should feel like spaces of great opportunity.  It's where you go to have your disease cured, your broken arm set, or your life saved.  And when the outcomes will be more dire, it's the place to have your pain palliated,  your hand held, and where you come to die embraced in the compassionate bosom of those who have dedicated their lives to doing such work.

Sound a little pie in the sky?  Maybe it shouldn't! I've been a great component of physicians re branding.  I think it's time we started to tell our stories about what happens behind the stethoscope in an attempt to humanize; to inoculate our patients against the growing furor against us.

Hospitals are facing the same crisis.  Under Medicare's gun and hounded by malpractice lawyers, the loss of identity is staggering.  Once a pillar of the community, today's medical center is under increasing fire.

There are such great opportunities, and so much room for improvement.  Let's get back to practicing high quality, patient centered, no strings attached care of our community.

Do we have to wait for some guy in a suit with an MBA to spur us to change?

Saturday, September 29, 2012

The Sun Will Rise

My Daughter was afraid of the dark.  So she climbed in bed with my son and he read her a story.  As he closed the book, he realized that she had fallen asleep.  Like any sweet, kind older brother, he wandered off to her room and crawled into the unoccupied bed.

Chaos, of course, ensued at three in the morning when my daughter awoke in the wrong room, and grasped for her absent teddy bear and blanky.  It took Katie and I fifteen minutes to calm her down.  I barely closed my eyes before the alarm clock blared.

Four forty five on a Saturday morning. 

Thirty minutes later I was closing the door, and striding toward the garage.  Four admissions to three different nursing homes last night.  One of which was spiking a fever to 102.  Another patient tucked into the hospital yesterday afternoon.

The roads were less quiet than you would expect.  The sun had not yet risen, and most of the store fronts on Central Street were hidden in shadows.  I stopped for a red light at the same corner which I always seemed to time imperfectly.  To my left, a beacon of light emanated from the bakery.  Inside a middle aged man bustled to and fro directing four or five others. 

Every morning I marveled at the hurried flurry of activity.  The bakers and I, the only souls in the universe silly enough to be rushing around at such an hour.  The owner kneaded dough relentlessly while his workers lifted, carried, stacked, and arranged.  Although the light already turned green, I lingered a moment to watch before pressing down on the gas.

The patient at the nursing home had stabilized, her fever was gone.  On the way out, I grabbed a few pens and a reflex hammer for the kids.  They always enjoyed such little trinkets.  I stopped by the hospital and eventually landed in the office. 

Saturday morning clinic is refreshingly slow.

Sometime between patients, Katie called to tell me to meet her and the kids for lunch.  I finished my paperwork and shut down the computer.  The afternoon sun was a stark contrast to the somber morning haze.

Passing by the bakery on the way home was a different experience.  It failed to stand out under the glare of the sun.  The middle aged man was now helping customers.  The store was no longer clean and tidy.  The remnants of heavy foot traffic had brought in the dust and dirt.  The loaves of bread in the display counter were either absent or jarred to the extent that they no longer sat neatly in the case.

Time will pass, and the store owner will gray and his movements will slow.  Driving by from day to day, the changes will be so subtle that I'll probably not even notice. 

My children will grow up. 

In the brief moments alone before I park the car and jump out to meet my family, it hits me that this is a life. 

The sun will rise.
The bakers will bake.
And I will father.

And doctor.

Thursday, September 27, 2012

In The Midst Of Tragedy

At first it's a little daunting.  A friend or colleague approaches you to take care of their parent. You pause for just a second before accepting.  Do you really want to get involved in this person's life?  But it is a compliment after all.  They are entrusting the well being of their loved one in your hands.

You tread lightly.  You spend extra time teasing out the symptoms.  You explain each diagnostic test and medication.  Days or years go by. Usually they get better, sometimes they don't.  But eventually tragedy ensues.

And you're calling your colleague or friend in the middle of the night.  You don't mince words, you tell them the end is near.  Physician to physician, friend to friend, there must be a level of truth and certainty. 

The appropriate orders are written.  Morphine and ativan.  Hopefully you can avoid the IV's and diagnostic tests.  While looking into the teary eyes of the family you again question whether you should have gotten involved.

The truth is, you will honor your friendship.  You will bath their relative in a cocoon of loving care.  Because you owe at least that much.  Because you will do it better than others.  Because you will be there to comfort and explain patiently in the midst of tragedy.

We do these things for acquaintances.

In fact, we do these things for complete strangers also.  Every patient eventually becomes like family.  We care for them as if their sons and daughters were our best friends.  We shower them with the best we have to offer because that is the covenant we make when we usher them through our exam room doors.

It's an intimate relationship between doctor and patient.

Even more intimate than with friends and colleagues.

Tuesday, September 25, 2012

Would You Do It All Again?

I suspect I would have changed anyway.  It's not just medicine, but life itself that distributes it's share of blows.  Battered and bruised, the body adapts. Unfortunately the mind also adjusts. The softer, more sensitive parts, are often the first victims.  We become hardened to the difficulties of reality.

There is no doubt that medical education is particularly aggressive.  The ego, like a scab picked over and over, maintains a solid exterior .  The skin becomes leathery and tough.  Our behavior subtlety changes.  A patient is quietly castigated or a child is allowed to whimper without the benefit of our empathic touch.  There is an attempt to assault the victim.  Instead of facing the difficulties and harsh realities of dumb luck, it's easier to cogitate blame. 

If they had just exercised more and eaten better!

There is an urge to cower and protect oneself.  In residency, many imagine that they are under siege.  They devise a plot where the world is out to get them.  The poor CHF'er in the emergency room on thanksgiving morning no longer becomes the wounded soul in need of healing, he becomes an agent of torture.

Those who read my writing will scoff.  They will say that I exaggerate, and point to the ideas expressed on this blog as proof. But I will counter.  Words on a page are much easier than real life. They are more safe and require less action.  I have known the coldness and bitterness that goes along with doctoring.  Accusations find their target on my chest from time to time.  And often they are deserved.

So it comes as little surprise that I paused when asked by the exuberant young college student if I would do it all again.  Her eyes scrunched together and her lips pursed in anticipation as she waited impatiently for my response.

Ultimately, the answer is yes.  But it's a calculated and often unsteady answer.  I would do it differently.

I would hold on to my idealism more tightly.

I would try not to protect myself so much.

Saturday, September 22, 2012

Superman's Burden

I mean, your like superman.  You fly into the room with your white lab coat.  You might not bend steel, but you do something more important.  You save lives.  I wish I could do for a living what you do.

Superman. Hmm.  I guess it's been so long I forgot.  It use to feel like that!

Use to?  What happened?  Are you no longer a doctor?  You're a hero in my eyes.  There are so many people who wander around this planet aimlessly.  They bounce from job to job, firm to firm, and year after year they toil without making a shred of difference.  They touch not one life.  Their footprint is wiped away the minute they take the next step. 

It's funny how it stops feeling that way.  Sure, the first time you help someone, the first time you save a life there is a certain rush.  But you finish medical school and enter residency, and that rush disappears.  You may help hundreds, but it no longer feels special or different.  It just feels like your job.

Yet you become acutely aware of those times when you can't help, when your skills are not enough.  You suffer through every failure.  You remember every death until the day comes when there are so many that you can't possibly hold on any longer.  And then you forget.  The worst part is when a name disappears and all you have left is a face imprinted in the depths of your subconscious.

You don't blame yourself, do you?  You try your best.  What else can be expected of you?

The funny thing is that even superman doesn't feel like superman all the time.  I bet sometimes he wishes he were batman or wonder woman.  Sometimes he feels that there is a pile of kryptonite waiting around every corner.

And sometimes, he finds that helping an old lady cross the street is a heck of a lot more gratifying,

than the death defying acts of bravery that everybody expects of him.

Friday, September 21, 2012

Social Media's Fun House Mirror

I like to think that I would write like this anyway.  I like to think that the breath, depth, and quantity of my output would be the same regardless.  I always say that I do this for myself.  Of course, the occasional comment and retweet are gratifying.  Can you blame me for basking in the joy of being heard?   But there is a certain danger in notoriety.  When does hoopla replace the primacy of the writing process?

I have started and stopped a million times.  The record laid forward in my blog history is marked by periods of great productivity interspersed with vast deserts of low yielding crops.  The ebb and flow of my emotion crests and falls with motivation.  I write and write and write, then stop.  These dry periods can last days or years.  There's no way to tell.

Never in my life have I produced as consistently as in the last year.  Never have I blogged so much.  When I look back at the last three hundred posts, I feel great pride.  Some are better than others.  Some have barely been read.  But they all are an accurate reflection of who I have become (spelling errors and all).

I don't know how long this fruitful period will last.  Maybe I will push the publish button and disappear for a month, maybe not.  Your guess is as good as mine.

The one thing that is abundantly clear, is this period began when I linked my blog to Facebook and Twitter.  Is it a random coincidence?  Or has the process of social media altered me.

I look into social media's fun house mirror.

In the reflection, I see the writer I was so hoping to be.

But better.

Wednesday, September 19, 2012

Without Succor

If my car was ninety years old, I would have thrown it away a long time ago.

She speaks nonchalantly as she appraises the wrinkles that bunch together on the back of her hand and collect at the base of her knuckles.  The skin hangs from her once muscular biceps.  She is neither bitter nor sad.  Acceptance oozes from her brow like the drops of sweat that collected during her labored walk into the office.  She is tired.

We talk of her shortness of breath.  Even as I offer a plethora of tests to draw back nature's curtain,  she shakes her head quietly.  For her, the betrayal of the body is simply the unassailable progression of tempermant.  She would no more try to fight it, than attempt to manually disassemble the second hand of a clock. 

Time passes regardless of whether it is measured. 

She will slip away delicately.  Inch by inch, pound by pound she will succumb without succor.  There will be no protestations, and no proclamations.  One day the phone will ring and I will be informed that she is gone.  Likely, found cold in her bed by a neighbor who noticed the mail piling unnaturally at the front door.

And as she hobbles out of the office, I can't help but think there is some important lesson to be learned.  Why do some die angry, regretful deaths while others pass gently without fanfare? 

It is said that we die as we live.

And we live as we die.

Tuesday, September 18, 2012

Room 2413

I could've sworn the hospital operator said room 2413. But as I wandered the halls, a perplexing look came over my face.  I searched above each door: 2411..2412...2414.  I stopped a smartly dressed nurse rushing past with a cup full of pills.

Where's 2413?

She laughed, and called over her shoulder as an after thought.

There's no 2413, 3413, or 4413 for that matter!

I started to protest, but it was too late.  She was long gone.  And the truth was, I didn't need an explanation.  How many buildings skipped from the twelfth to the fourteenth floor?  How many room numbers had been intentionally changed?

It was a myth.  Superstition and folklore permeated even the most holy of scientific grails, the hospital.  As an institution we failed the most basic test of identity.  And I started to wonder what other myths pervade our culture.

This won't hurt a bit!

How often do we knowingly mislead or water down the truth? Furthermore, how do we justify this charade in light of the dictum "to do no harm"? 

Sadly, I think the answer reveals the worst kind of ugliness.  We would rather defer to ease, than accurately interpret the reflection in the mirror.

Don't worry, we'll do everything!

Because the truth is much more difficult.  Patients die regardless of the room number.  The procedures we perform are often hurtful. 

And "doing everything" can be more than just dangerous.

It can be cruel.

Saturday, September 15, 2012

I Forgive You

Staring into the tiny mirror perched above the bathroom sink, he started his morning in the same fashion he had done every day for the past thirty years.  He winced from the splash of aftershave on his face, he straightened his bow tie one last time, and he studied his own steely gray eyes in the reflection in front of him.  His lips barely moved as he softly pronounced the words to no one in particular.

I forgive you!

The drive to the hospital took less than five minutes.  The walk from the doctor's parking lot to the physician's lounge was half that.  He picked up his lab coat from the hanger next to the mail boxes and rushed up the stairs to see his first young patient. 

Matt was just a teenager if calculated in years.  But in view of his multiple rounds of chemotherapy and failed bone marrow transplant, he had traversed several long and difficult lives.  And even in death, he evaded the immaturity and self centeredness of many of those his age.  He had one last request of the doctor who had navigated his medical care so expertly, to help explain his last decision to his parents. 

The family meeting lasted a full hour.  He left Matt curled with his mother and father on the hospital bed, and raced to the office.  The methodical pace of the clinic helped take his mind off the tragedy.  In each child's eyes he saw the pain that Matt suffered.  The pain he was still suffering.  And in each parental tone of concern he remembered the anguish of the two individuals whose hearts were breaking at the very moment.

By the end of the day, Matt's situation worsened.  Countless family members huddled at the bedside.  On the desk lay a school yearbook with signatures and well wishes written in bubbly and careless lettering.  He sat at a distance fingering his bow tie and clearing his throat from time to time.  Years of experience had taught him that it wasn't words that families sought at such difficult times,  it was the mere act of being present that brought comfort.

He ambled home at eight o'clock.  His wife had left dinner for him on the stove.  He sat quietly and picked at the food as he leafed through a throw away journal his beloved placed on the table.  He wasn't particularly hungry.

The call alerting him of Matt's death came in the early morning hours.  He fumbled while putting the phone back on the receiver in an attempt to spare his snoring wife from the inconvenience of her husband's chosen profession.  He woke up a few hours later without the benefit of an alarm clock.

He bounded out of bed.  He brushed his teeth, shaved, and took a shower in usual fashion.  He winced from the aftershave, and straightened his bow tie.

I forgive you!

A younger man may have been repenting for his own imperfections as a physician.  An angrier man may have been letting his patients off the hook for the intense frailty of the human condition.  But a wise man, he had long outgrown this type of immature frivolity

No.  He was absolving the universe of such random and abject cruelty.  He was purging all malice toward a higher being who could allow Matt and his parents to suffer so.

For him to continue, year after year, in a profession that inflicted deep wounds,

he had to lay his burden down.

It was a large heart with lots of hearts growing smaller inside, and piercing from the outside rim to the smallest heart was an arrow. Momma said, “Sister, that’s right pretty.” Then she turned back to the Store and resumed, “Glory, glory, hallelujah, when I lay my burden down.” *

*When I Lay My Burden Down , from I Know Why the Caged Bird Sings, Maya Angelou

A Day In The Life

My cup runneth over.  No, really, my cup runneth over, and over, and over!

I spent a few hours sitting in on a meeting for the board of directors of a local home health company.  I listened intently as the discussion turned to strategies for dealing with medicare's 2013 readmission rules.  Most home care companies are positioning themselves to woo local hospitals with promises of tighter care and lower rehospitalization rates. The discussion ended with an invitation to Las Vegas.  Vegas?   Who has time for Vegas?

Next, a stop at the nursing home for a pow wow on our palliative care program.  We have assembled a group of nurses, social workers, and recently added a psychologist.  While the program is up and running and serving our patients, what we really need is to codify the data.  What impact has the program had?  Are pain scores better? Is satisfaction higher?  And oh by the way, could I cover hospice consults at the local hospital next week?

After rounding on half a dozen patients and doing a few new palliative care consults, it was off to the post office to drop a copy of my book in the mail to someone who had bought it over the Internet.  Then I had a few minutes to start to prepare for my upcoming grand rounds at the Carolinas Medical Center on social media in October.

Did I mention that I had a blog post that was itching to be written?

I spent the afternoon seeing patients in the office.  It was a slow schedule-just a few late Friday stragglers.  But I felt a certain joy in the process.  I concentrated on each patient.  I took the time to address every concern and fear.  I made sure they walked out of the office satisfied.

What a great way to finish the week.  This is why I went into medicine.  The buzz of my pager reminded me that I had one more admit to see in dialysis,

before returning to my family and ushering in the long awaited weekend.

Thursday, September 13, 2012


She must have stood at least six feet tall.  Walking past me in the parking lot towards the breast center, I couldn't help but solicitously stare.  Her sinewy torso caused ripples in the abdomen of her t-shirt.  She was elegantly thin.  One would never have used the word gaunt.

Her jeans clung to her body like a glove.  Her strides were long and confident.  Maybe a touch of midriff was showing.  I dared not look too closely for fear of being discovered.  She was ageless.  At first I thought youngish, or possibly middle aged?  She defied classification.

She walked with the apathy of a model, and the decisiveness of a warrior.  There was no doubt her taut muscles were contracting towards battle.  She led with her chest, supporting the swan like elongation of her neck.  Her head was perfectly perched atop.  Her recently shorn scalp added to the sleekness of her sculpted facade.

The timber of my voice humbled, I mouthed the word in an anemic attempt to be heard.


This wasn't a woman to be crossed.

Certainly not by a self indulgent doctor,

nor some trifling cancer.

Wednesday, September 12, 2012

Efficiency, Value, And Unexpected Consequences

I bounded down the stairs of my office to the cafe on the first floor of the hospital owned building.  I could taste the early morning coffee before it even touched my lips.  I charged right to the front of the line, and handed over my credit card. Already familiar with my order, she swiped away and handed it back to me.  A few steps later, I was standing at the coffee station.

Something was strangely wrong.  The cascade of various sized cups was still resting by the beverage dispenser, but the sugar was all the way on the other side of the counter.  I shuffled over to get a few packets (which is always my first step).  I shook vigorously, than tore off the tops of three at once.  I gently shook downwards and waited.

Then it hit me.  The little hole in the granite for trash was gone, or at least covered up.  I crinkled the waste in my hand and secured it between my pinkie and ring finger.  Unperturbed, I reached my arm out for the half and half to no avail.  It took a few seconds of searching to realize that it was across the room in the refrigerated section.  I carried my cup in my left hand, my trash in my right, and paused as I tried to figure where to set my cup to pour from the decanter.  There was no flat surface.

Finally I walked back to the coffee station and pumped the nozzle.  Later, I fumbled with the sleeve which was stored in a particularly awkward place, and spilled my coffee on the counter when I reached up to grab the stir.  Lastly, I collected all the trash and walked around the corner to throw it away.

Thoroughly discombobulated, I sauntered back to the register and caught the woman's attention.

Who messed up the coffee station?

She stared at me for a moment, and then peered cautiously over both shoulders before speaking.

The hospital sent some kind of efficiency expert over yesterday.  He changed everything.

Although nonfunctional, apparently the display now looked more appetizing.  Plus, by making the cream and sugar less accessible, the cafe was expected to save thousands of dollars in supplies.  Ditto for the awkward placement of the stirs and cup sleeves.

As I walked towards the stairs, I looked one last time at the my beloved coffee station.  Trash had collected on the counter because there was no where to dispose of it.  Puddles of liquid had accumulated from knocked over drinks.  And a line of people had formed at the register, waiting for the poor employee who had left her counter to clean up the now unkemt beverage area.

I shook my head. I figured any money saved on sugar and cream was being lost on cleaning supplies and wasted napkins.

I settled into my morning routine, but couldn't shake the feeling that something was wrong.  I sipped on my coffee and enjoyed the pleasant taste and woody aroma.  I was seriously thinking of going to Starbucks next time instead.

I entered the exam room to find my first patient anxiously clenching the exam table.  Before I could open the chart, he began to sputter.

Doc, my chest is really hurting!

I half listened to his complaint through the fog of my disruptive EMR.  When I went to open his chart, an annoying pop up window wouldn't let me proceed.  I cursed my front desk employees for failing to follow the meaningful use questionnaire, and interrupted the patient as he was repeating himself in an even more forceful manner.

I'm sorry, I have to fill out this field before I am allowed to continue.  Could you just answer one quick question?

What race do you consider yourself?