Monday, April 30, 2012


We all know what happens when you make assumptions. 

And the truth is, labels are no better.  Yet as physicians we make them all the time.  The label is less about the person and more the feeling they invoke inside of you.  When you like a patient they become "friendly" or "easy".  When the relationship is more strained, they are "complicated" or just plain "crazy".

Labels not only color the interaction between doctor and patient, they also are intimately tied to clinical decision making.  We live and die by our own sword.  But occasionally we draw a faulty cover for the book we pick up to read.  The result is chaos, and poor medical care.


Allison was a difficult patient.  A striking middle aged woman, she strode into the exam room with the same confidence that she entered board meetings.  Her control over her appearance and profession, however, were in stark contrast to her personal life.

Allison was a mess.  Full of anxiety and inner loathing, she bounced from one tumultuous relationship to another.  Men and women passed in and out of her life quickly.  She was unable to maintain even the simplest bond whether platonic or otherwise.  Because of this, she spent an extraordinary amount of time in her therapist's office.

The stress and loneliness manifested itself in the form of somatic complaints.  Years ago, when we first met, it was headaches.  She later progressed to myalgias.  Her most recent issue was chronic abdominal pain.  Her labs, cat scans, and scopes were all normal.  Yet her pain was unrelieved.

My relationship with Allison had it's ups and downs.  Although she was nice enough, I couldn't help getting that sinking feeling when she showed up on my schedule.  After countless attempts to solve her problems, I often came up with the big zero.  Undoubtedly patients like Allison make physicians question their professional relevance.  There is nothing worse then striking out every time at bat.


When Allison entered my office this morning, I figured I was in store for yet another fruitless workup.  But today was different.  She walked into the room with her head held low, and a slouching posture that I had never seen before.  The confidence was gone.  As she sat down on the examining table, she lifted her head to speak.  The left side of her upper lip was swollen and her left eye was black and blue.

I stood quietly and touched her face, palpating the cheek bones and orbits for signs of fracture.  Then I sat back down on my stool, and decided not to ask any questions.  We stared at each other, and I waited for her to talk.  A few moments later she began to speak.

In a fit of anger, her latest boyfriend punched her in the face.  Allison picked herself off the floor and left his house immediately.  She then called the police.  I was saddened by her story, but glad that she had the presence of mind to protect herself in this horrible situation.  I told her that I was proud of her while being careful not to be condescending.  Allison looked up more defiantly this time.

I would never go through that shit again!

My mind caught on the word "again" as I waited for her to explain.  Apparently Allison had been removed from her home by social services as a child.  She had been a victim of abuse and neglect.  She moved from home to home as a child.  Some times her caretakers were good, other times not so much.  She was raped by the teenage son of one of her foster parents.

My mind  was spinning as she continued to tell her story.  I clicked over to the social history section of the electronic medical record and read in horror.  One lazy sentence.

Adopted, family history unknown.


Things have changed between Allison and I.  I look forward to her visits, even though I still often can't fix the emotional and physical problems that plague her.  I now recognize that  the "difficult" moniker is more appropriate for her experiences and less so for her intentions or personality.

In fact, I've found an altogether different label for Allison now:


Saturday, April 28, 2012

A Movie Without A Soundtrack

I wouldn't call myself a music snob. Sure there were years in high school where I bought tapes and Cd's. I pictured myself a suburban outcast. The titles lining my bookshelf represented a smattering of rap, R + B, and soul. I can still hear the haunting rhymes of Chuck D and KRS-1 run through my mind at random times.

As the years passed, I listened to music regularly although I was no longer a consumer. I spun the dial on the car radio and settled on syrupy, upbeat top 40. And that's where I stayed. To this day, the younger members of my office staff are surprised when I recognize the stylings of the newest radio stars. I catch their pop culture references and shoot a few back at them. What else is a guy going to do while driving a few hours a day?

A few months ago, I felt my self inundated with noxious stimuli and searched for something a little more calming on my daily commute. Like an answer to my prayers, I happened upon National Public Radio. Each morning, I listened to the smooth calming diction of NPR's announcers. The programming was informative and stimulating. The afternoon doldrums were interrupted by the latest news and interviews. For the first time in my life, I felt well informed.

But something else subtle was beginning to happen after this seismic shift. I began to struggle with my writing. The blog posts became slower and more labored. The depth and breath of my emotion began to fade. I sat down many mornings and started to write, but ended up staring at a blank screen. My mood began to sour and my enjoyment in work was fading. It was like I had lost my internal rhythm.

This morning while running errands, my kids convinced me to turn off the "boring" talk radio and play some music. As I cruised down the highway, I started to feel myself shift. My body unconsciously bounced to the melodic drumbeats coming from the speakers.

A flood of memories returned to me. Memories of driving quiet mornings before the sun came up. It was during these lonely moments where the impetus to write welled up in my chest. Inspiration was not the monotonous chatter nor the informative stories of talk radio, but rather the booming of base, the riff of the guitar, and  the soul of lyrics.

Without music, I was lost. I had become a movie without a soundtrack.

Thursday, April 26, 2012

Whose Team Are You On?

It couldn't have been worse. The complaints in the office were unsolvable. The regulars came late to their appointments. The "oh, by the way doctor" questions required more then cursory explanations offered from the doorway. I sat down during a stolen moment for lunch only to be harassed by a call from the emergency department that needed urgent attention.

It was the kind of day where office visits were interrupted by mobile phone calls that were interrupted by a beeping pager. By the end of clinic, I was ready to hang up my stethoscope. I was physically and emotionally exhausted. These were the times that tested one's will to be a physician.

As I crawled into my car for the drive home, my phone started to ring. I read the display before picking up. It was another call from the nursing home. Mr. G was being admitted after a prolonged hospitalization. I remembered Mr. G well.

I took care of him a few years ago after a hip replacement. He had been assigned to my case load because his primary care doctor didn't come to the facility. He was a large, gruff, strapping sixty year old at the time. After a few weeks, he fired me because I refused to give him an antibiotic for a mild respiratory infection.

One moment I was in charge of his care, the next I wasn't allowed into his room. I have forgotten many of the hundreds of patients I have taken care of in nursing homes over the years, but I'll always remember the faces of those who have fired me. I still take it personally.

Although I was itching to get home, I pulled into the parking lot a few minutes later. I suspected Mr. G would take one look at me and remember our colored history. I braced for a confrontation.

When I walked into his room, I couldn't have been more surprised. Mr. G was a shadow of the man he used to be. His face was drawn, and his frail body rested listlessly on the hospital bed. His dialysis catheter was taped neatly on his chest wall.

He didn't even remember me.

When I finished questioning, I silently examined Mr. G. How much had changed over the last few years. Although I entered the room like a lion, I left like a lamb. After seeing him, I couldn't help but wonder when the doctor-patient relationship became a confrontational one.  We have so much in common.

We both agonize over the limitations of the human body. We suffer with life's unexpected turns. And we face our own limitations every day while gazing in the mirror.

Maybe it's time to allow humility to remind us,

we're playing for the same team.

Tuesday, April 24, 2012

Dropping The Ball?

I love Juggling. I started when I was a little kid. Originally my brother learned from reading a book. But I had to be better than him. I taught myself. I started with one ball and tossed it back and forth from hand to hand. I did this for weeks till I had mastered the skill. I could do it with my eyes closed.

Next I added a second ball. Two balls are a little more tricky. The juggler's concentration is split. The chief process is still similar. Throw the ball up with one hand and catch with the other; except now two hands are both engaged at the same time.

Months later, I was ready to try three, and then four. The trick to juggling is to be able to give the appropriate amount of attention to each ball at the right time, while being generally aware of all the rest. It is a dance performed by the hands, but mastered by the eyes. The more balls one has in the air, the quicker and more intense one must focus on each ball, and then move on. Once concentration is lost, everything tumbles to the ground.


Medicine is a lot like juggling. The doctor must have razor sharp focus on each patient at times, but also be aware of thousands of others in the background. It's a balancing act. One in which we struggle to keep all balls up in the air at one time. This is becoming more difficult. Even in the last year, the number of distractions facing the lowly generalist are increasing.

Five years ago, the paperwork and hassles were less. There was no such thing as face to face encounter forms to fill out, or med reconciliation forms. Pre authorization was slightly less rampant. Electronical medical records are dutifully adding to time spent on charting. While all of these may have some beneficial impacts (emphasis on "may"), there are consequences also.

The struggling primary care doctor can no longer keep up with all the balls in the air. Attention and focus are being nudged away by paperwork. One would argue that maybe the physician should start to focus on fewer balls. But with decreasing reimbursements and increasing need in the community, that's just not likely to happen.

So the question is no longer whether physicians are dropping the ball,

it's why?

Sunday, April 22, 2012

For The First Time

My son sits quietly as the train clanks from track to track. The morning sun streams into the the mostly empty car. We both squint and stare as the cityscape passes by. The suburban scenery is quickly replaced by advancing urban sprawl.

With each stop, more passengers pile into the sliding metal doors. Apartment buildings and unlucky homes rush by. A hurd of satellite dishes lopes past at the blink of an eye. Signage marks the borders of each neighborhood. First comes Arabic, which quickly gives rise to Vietnamese glyphs. A mix of Spanish and English signals yet another enclave. The stores are more authentic here. Glaringly absent are the cartoonish donkeys or the boasting burritos.

The air grows thick as seats fill. A businessman dressed in an Armani suite sits uncomfortably next to a disheveled homeless man. The clean tailored jacket clings to its owner as if aware of its unkempt neighbor. A Student sits across from us with her head buried in a series of photocopied pages stapled together at the corner. Her eyes dart back and forth between occasional page turns.

Young and old intermix and intertwine. Porcelain skin confronts wrinkles. The athletic youth in workout clothes stands and offers his seat to the elderly woman limping through the aisle as the train begins to lurch forward.

Hands are weighted down by shopping bags, back packs, and electronic paraphernalia. Eyes stare at mobile phones, or Ipads. Heads bob up and down and side to side revealing small white cords leaving the ears and wending their way down into jackets and disappearing out of site.

Over decades the details have changed but the feelings are the same. How long has it been since I took the train? My son doesn't notice that my attention has turned to him. He's too busy inebriated by the sites and sounds of a lazy weekend. My thoughts return to the window, and the world awaiting on the other side.

It's like, for just a moment I can experience the world through his eyes,

and see everything for the first time.

Friday, April 20, 2012

Swan Song

He rushed out of the elevator bank and made a b-line to the first patient room at the edge of the nursing station. His smart clothing and athletic build did little to portray his age. He looked about sixty, at least one or two decades younger then reality. We had discussed, plotted, and strategized in the past. But this morning he didn't even notice me buried under the weight of a computer screen. He was a thousand miles away.

I continued with the clean, unemotional tone of the note that I was writing. I thought I would give him a few moments alone.

I was called by the nursing staff at approximately 6am to evaluate for obtundation. Patient was unresponsive to voice or stimulation. Breath and heart tones were absent.

I marveled at how plain the words could be. How the last markings on the chart could be so similar for each patient who passed. We all live such varied lives. Yet we all die the same. Every chart is buffed and polished with the same cold, objective wording. I pulled away from the computer screen and ambled over to the door. I waited before entering.

His movements were jerky and unnatural. He bounced around the room picking through her belongings and stuffing occasional articles in a shopping bag. He had planned for this moment. He watched the months slip by as her condition worsened. Death hovered at her bedside in continuous battle. She finally waved the white flag.

I entered and put my hand on his shoulder. There was no place for words. I slipped the bag out of his hand and walked him over to a chair adjacent the hospital bed. He sat for a time by his wife's body. But both of us new that her essence was gone. Only inanimate limbs and tissue remained.

After a few minutes he got up and left the room. He would make funeral arrangements and call family.

His companion of sixty years was gone. Everything in his life had changed. But in the end he had no choice.

He would reenter the world of the living.

Wednesday, April 18, 2012

Minor Trauma

My daughter is crying uncontrollably. One hand is pressing her head as the other gestures wildly. Through angry sobs she attempts to articulate her pain.

My head!

I try to hold her close, but she pushes away. I settle for clinging to her hand. Nothing irks a parent more then listening to his child shriek in pain. I can feel the bile rise in my chest as I split in half. The emotional parent wants to rush to the phone and call an ambulance. The objective clinician sees a child who is upset, but shows no signs of real distress.


I've seen children die. I have watched the stillness that accompanies mortality. I will never forget the cat scan with the big sphere of blood entombed by such a small skull. I remember taking slow steps down the long hallway to meet the family in the crisis room.

I am not the same person I was before I started medical school. My eyes have been torn open and forced to watch the cruelty of human existence. The marks have left stains on my soul in much the same way the spatter has marked my lab coats.

I am broken.

I am empty.

I am less than when I started.

Yet I have been placed on this earth to protect these children. My love and knowledge must be enough to shield them from the abyss.


Thirty minutes later my daughter is calm. After wiping away her tears, we begin the real work of talking about what upset her. She doesn't have a brain bleed, or meningitis, or an aneurysm. She is simply a victim of minor bullying at school.

After she falls soundly asleep, I tip toe out of the room. She will recover from these minor traumas.

The better question, I guess, is will I?

Monday, April 16, 2012

From Zero To Med Reconciliation

The policeman was two cars in front of me. I meandered down the road cautiously adjusting my speed a few ticks above the limit. I lamented the forced, measured pace as the road lazily formed a long straight path. The clock refused to slow for my new found law abiding citizenry.

A sports car motored around a curve and flew past us unawares. The cop switched on his lights and tried to pull a U-turn, but couldn't clear the curb. By the time I realized what had happened, I was screeching to a stop to avoid the break lights that blinked on in front of me.

In the midst of trying to make the roads safer, our friendly neighborhood officer had almost caused a major accident. I wiped the sweat from my brow and reluctantly took my foot off the break petal.

It was a fitting end to a trying day.


My hospital emigrated from paper to an electronic medical record today. They eschewed a stepped approach and went from zero to med reconciliation with the tick of a second hand.

Aware of the chaos, I dragged myself into the hospital at 5:45 in the morning. Nurses scurried back and forth. Already the musical chairs had begun. Getting your hands on a computer was like happening upon a stash of meds long lost to shortage. Superusers walked the floors over confidently with their heads held high, their skills still building towards maturity.

Rounding took and extra hour and a half. No one seemed know how to discharge a patient. The labs were late. After returning to my office, I spent the rest of the day trying to communicate with the hospital staff. Phone lines were busy. Nurses were befuddled and seemed confused about which patients they were taking care of. Some orders were never carried out, others were continued long after they had been stricken from the record.

And somewhere amidst the chaos of this hectic day, patient care became secondary to the process of filling out the medical record. Critical patient decisions were being hampered by confused staff, tardy labs, and cumbersome rules set forth by nonclinical administrators.

While this was just one day, my experience with other hospitals is that things will only improve somewhat. Process wins over product once again. As the sun sets on this exasperating day, I'm still trying to put out a few fires.

I hope as the books close on this gigantic Go Live, we providers remember why we're ultimately here.

To protect and serve.

Saturday, April 14, 2012

A Simple Stitch

As eighteen year olds tend to be, Jake was lanky and awkward. His thick hands and muscular shoulders revealed a body far surpassing the maturity of his developing mind. But I could tell he was a good kid. He fidgeted in his chair as I walked through the door. We shook hands before I sat down to start the appointment. I looked up and waited for him to begin.

I have a lump, down there.

Hi eyes averted towards the ground. Many appointments have started this way. But unlucky for Jake, he actually had testicular cancer. After an ultrasound and a visit with his oncologist, he was back in my office.

After the surgery, will I be able to...

He swallowed hard.

You know.

Treatment was successful. By the time summer was over, he was ready to go to college. Over the next few years, we saw each other periodically. He would stop by for a physical during spring break. We chatted from time to time. Occasionally he would call from out of town to update me on one issue or another.

Jake was a cancer survivor, but he was young and healthy. He had his whole life in front of him.


Four years later, Jake walked into my office with a swagger I had never seen in him before. As we chatted, I noticed how the tone of his voice belayed a new sense of confidence. In the midst of talking, he interrupted me.

I've met someone!

After the obligatory talk about safe sex, I waited for him to continue. He told me about how it felt to be in love, about how his heart was full for the first time. I watched quietly like a father listening to his son. After a prolonged and hurried soliloquy, he eventually stopped and took a deep breath. I ventured forward cautiously.

So what brings you in today?

His eyes started to laugh before his lips could catch up.

That. Just to tell you that!


No matter how much the government tries to stomp on us, there will always be physicians. It's not the life and death that keeps people going into this profession. It's the time in between.

Day after day we open our doors to the details of the souls that pass through our examining rooms. We are present for the good, and the bad. If we are lucky, we play a small part.

We become a stitch, a simple knot.

In the fabric of someones life.

Friday, April 13, 2012

Does Your Physician Live In A Silo?

By 8am I had rounded on all of the hospitalized patients and stopped at the nursing home. As I settled down to paperwork before the clinic doors opened, I took a moment to organize my day. I had two critical patient issues that needed to be resolved as soon as possible. The solutions centered on contacting three different specialists and discussing the cases.

So I dialed the operator and had each physician paged. I waited fifteen minutes and no response. Undaunted, I called the offices individually. None of them had arrived yet, but their secretaries were kind enough to re page them. Over the next few hours, while I ran from room to room seeing patients, my medical assistants dutifully tried to make contact. One doctor was out of town, the other was in the OR, and the third had lost his pager.

At 1 pm, a full 5 hours later, I finally was able to reach all three. Our conversations were short, but I was able to negotiate these critical care issues with little difficulty. It would have been nice if it hadn't taken so long. Thank God these were issues that could wait while I spent time tracking down the right people.

You may wonder if there is something that ties these slow responders together. Is there a sentinel characteristic that binds?

Like most places around the country, private practitioners are closing their doors and joining hospital systems and large medical groups. The economic and regulatory climate has changed to favor such arrangements. The problem is, something happens to physicians when they transform into company men. They become lackadaisical. All of the sudden there pagers are nonfunctional, and consults take greater then twenty four hours to attended to.

It's not just physicians, hospital and nursing staff are taking on similar attitudes. This morning I called a medical floor to relay important information to a nurse. After waiting on hold for five minutes, the secretary informed me that she was not available because she was in the middle of report.

Please call back in thirty minutes.


Let's talk hypotheticals. Why is it that a pedestrian walking a dark alley who comes upon a mugging will call the police, yet hundreds of onlookers will do nothing while an innocent gets jumped outside their building? Group think leads to group paralysis. Decentralized decision making promotes a loss of culpability.

What threatens to topple our medical system is the disappearance of individual actors. When your down and out, what you want is that guy standing alone in the alley. The one who thinks that if he doesn't make the call, no one will.


I've been accused of living in a silo. But standing alone in that empty room gives me a lot of time to think. When the hearts fibrillating, the blood pressure drops, and the white count rises, you better believe that I'll be doing my best. I'll be making that phone call, checking those labs, and consulting the literature. Because the truth is, I take sole responsibility for each and every person who walks into my office. There is no group to lean on.

And maybe, just maybe, that isn't so bad.

Thursday, April 12, 2012

Are Your Bags Packed?

I told Sam he was dying one quiet morning as he lay in the over sized hospital bed. His girlfriend sat by his side. Her glassy eyes contrasted the steel blueish gray of his. The bone marrow transplant failed and the white count was increasing. He had been through both chemo and radiation in the past. The cancer cells were stubborn, much like the middle aged body they lived in.

Sam stared at me with the same mocking look that I had seen so many times in the office. It was as if I had just told him that he had gout or pneumonia. I could hear the unspoken scoff and visualize the mischievous grin that had yet to form on his face.

The phone started to ring on the table. Sam ignored it. A few seconds later his mobile began to buzz. He snatched it up and looked at the screen. He answered briefly and told the caller he would have to get back to them later.

His movements were steady and purposeful. This was just another day, another set back, another hurdle to vault over. His gaze met mine. He paused for a moment before speaking.

But Doc, I don't have time for this right now!

He then burst into a loud spasm of laughter. His girlfriend couldn't turn back the smile that fought through her tears.


Sam went home with hospice. I stopped most of his medications but continued pills for pain, a steroid, and antibiotics for his pneumonia. When I waved goodbye from the hospital room door, I had a feeling it would be the last time I would see him.

Weeks passed and I heard nothing. I started to worry that he died, and no one told me. When I had a few spare moments between patients, I perused his contact information and started to work down the list of phone numbers.

There was no answer at home. His mobile went to voice mail on the first ring. Eventually I tracked down his son at work. I could here his father's laughter in his voice.

Dad. He's in New Orleans. He went to Mardi Gras!

Apparently he was feeling better. Later that day I talked to his hospice nurse. Sam gained weight and stopped the antibiotics. He had been on quite a few trips since being discharged form the hospital. He was eating out, going to the opera, and living it up.

I was flabbergasted. Surely his white count must have been in the hundreds by now.


I tried to reach Sam various over the next few weeks. Usually I got his voice mail, and didn't want to bother him with a message. It was only the arrival of his death certificate that notified me of his passing.

I called his girlfriend on her mobile. Sam died alone in the middle of the night. She came to check on him the next morning, and found him lying in bed peacefully. When she leaned over to call the hospice nurse, she noticed a single suitcase resting quietly on the floor. She opened it to find that Sam had packed his favorite suite, lucky shirt, and a brand new pair of shoes. This was odd since they hadn't planned any more trips.

As I hung up the phone I realized that Sam was sending us all a message. To him, death was just another adventure.

And he wanted to make sure his bag was packed.

Tuesday, April 10, 2012


There were battles large and small. There were years littered with highs and lows. And there were days; dark, dark days.

Simon didn't ask for the genetic hand that he was dealt. He didn't drink, smoke, or idle about the house. He was strong and active. In fact, his first heart attack struck while on the treadmill. His second, when in bed. We forgot about what he was doing during the third and fourth.

Yet, after open heart surgery and multiple angioplasties, Simon was still having chest pain. His medication regimen was maximized. He attended cardiac rehab regularly.

Day after day, week after week, he came to my office. We fiddled with his med list. We searched for creative diets. We explored yoga, meditation, and acupuncture. Each intervention brought such high hopes that tumbled to the ground and shattered into tiny little pieces with each hospitalization. The leak of cardiac markers felt like the oozing spurt of unrequited blood vessels as the cup of life slowly emptied.

I once apologized to Simon for my own ineptitude. The current state of medicine was unable to solve the ruthless riddle that was unhinging the squeeze of his heart. As his lungs filled with frothy waves, his body began to sink in the great vast ocean.

And I was beginning sink with him. My confidence waining in the sturdiness of the concrete wall I called medicine. The cracks were large and disfiguring.

I sat one morning at his bedside and stared at the remnants of a body transformed over the last few years. The ventilator was removed and the room was still. The second hand on the clock marched forward refusing to bend to the will of misplaced hope.


No one ever warned me about this in medical school.

Monday, April 9, 2012


If you've been there before, you know. Although a decade has passed, I remember it like it was yesterday. My wife was driving. It was a few years before car seats cluttered our vehicles. It had been a long day of errands and dinner at my parents. I yawned as we pulled into the ally. The sun had set long ago and the beams of headlights bounced up and down our poorly lit neighborhood. My wife reached for the garage door opener on the visor, and then stopped and hit the breaks.

I turned my head just in time to catch the darkly dressed figure slink out of our back door. Before I knew what was happening, we had passed the house and were in hot pursuit. I pulled out my cell phone and called the police. I described the suspect as we followed him down the street.

An hour later the police had come and gone. Even though the perpetrator was eventually arrested, we never recovered the majority of our stuff. The financial and physical damage was minimal, but the episode did take an emotional toll.

Years later our kids are forced to wander into our bedroom every morning before going downstairs to play.

They have to ask us to turn off the alarm.


Sheri had lost her glow. An athletic forty year old, she completed at least one marathon a year. She ate well, she meditated, and she took care of herself both outside and in. So when she felt a small lump in her breast, she originally was fairly unconcerned. A woman with such poise and control of her life couldn't help but feel a little invincible.

Sheri called her gynecologist and scheduled an appointment. Two weeks, one mammogram, and a biopsy later she was devastated to hear that she had cancer. As with every other challenge in life, Sheri faced surgery, chemo, and radiation like an expert.

A year later she sat in my office with her head hanging down. She had just received a call from her oncologist. Her latest exam and xrays showed that she was "cured". But Sheri couldn't wrap her head around the concept. She had spent so much emotional energy on fighting, she now found herself strangely lost. She stared up at me as the tears began to well in her eyes.

What do I do now?

It was a difficult question. One with many possible answers.


What do you do when you body has been burglarized? How do you recover that which has been stolen from your soul?

The traumas we face mark us and litter our insides with scars that are slow to heal. The threat of our own vulnerability becomes more overwhelming than the Achilles heal itself.

Sheri will eventually return to her previous life, although her uneasiness will likely remain. I have counseled many people through this type of situation. I have seen a myriad of different responses: anger, depression, denial. I have held their hands and told them that it would get better.

All the while, I still awake occasionally in the middle of the night in a cold sweat wondering if I was dreaming.

Or did I actually hear the beeping of the alarm system downstairs?

Saturday, April 7, 2012

The Fulminant Scourge

Zeke had once been told that he was named after a great medical reformer. He assumed it was some figure from before the Great Automation in the early 20's. Before then, Data Entry Recorders (DER's) were called Physicians and were required to undergo a rigorous training process before being allowed to practice.

The discovery of the Automaton changed everything. Medical school was shortened from four to two years and post graduate training was abolished. This was before the great naming convention. Thousands of useless medical terms were organized into a hundred simple categories. In fact, the makers of the Automaton had long ago dropped the archaic nomenclature and replaced each disease with simple numbers.

After the great revolution, death from antiquated diseases such as heart failure and cancer became unheard of. The speed and accuracy of the Automaton was no match for such human failings. In fact, if it hadn't been for the perilous scourge of Virus Fulmentis (VF), life expectancy would have skyrocketed. Instead, most people were lucky to make it past the sixth decade. VF was a hundred percent fatal.

Zeke was proud of his medical training. His two years of medical school were arduous. He spent countless hours learning how to connect the probes in just the right fashion. During his clinicals, he read almost all hundred numbers off his Automaton's monitor. In fact, he sent quite a few fifty two's right to the micro dissector.

But no matter how many times the results flashed on the screen, Zeke would never get used to the large VF that occasionally popped up unexpectedly. The only disease not indicated by a numerical value, VF struck terror in the hearts of DERs in training. Although the presenting symptoms could be anything: cough, chest pain, a lump in the belly; the treatment was always the same. The patient was whisked away from their family and isolated in a dark, damp, holding center in the basement of the hopspital. First line therapy included trials of forced starvation which had been shown to prolong life weeks more than conventional cyanide replacement.

Occasionally, patients with VF would escape the hospital or office before security could escort them to a treatment center. Often they sought out alternative medical practitioners who trained in pre revolution doctrines in secret schools throughout Europe. Zeke refered to them as Witch Doctors (WDs). There was a WD who lived a few blocks down from him. He was an elderly gentleman who must have been a little boy at the time of The Great Automation. Although Zeke had half a mind to report him to the Health Alliance, he couldn't bare to see the poor old man carted away in hand cuffs. Like everybody else in the neighborhood, he kept his mouth shut.

Zeke would occasionally see wayward grifters entering and leaving the WD's house. There was no mistaking the look of desperation in their eyes. The comings and goings would continue all hours of the day and night. Zeke dared not get to close. He was afraid of catching the virus. Strangely, it had never occurred to him why he hadn't met a WD with VF. In fact, he hadn't seen a WD in his office or in medical school, not once!

Zeke's daily work was occasionally interrupted by sickness. Like everybody else, he would sometimes lay in bed and fight a bad thirty nine or seventy six. Once a twenty four caused him to miss work a whole week. So when his chest started to hurt one day, Zeke assumed it was something minor.

He had meant to strap himself up to the Automaton a hundred times, but he kept getting side tracked by one patient issue or another. On one particular morning when the pain became unbearable, Zeke cleared a half an hour from his schedule and locked the exam room door. He place the probes gingerly on his own body (which is no simple task when one considers the central back lead) and hit the analyze button.

After a moment of whizzing and whirring the machine became quiet. Zeke unhooked the leads and turned the monitor carefully to visualize the screen. With great shock, he glanced uncomprehendingly at the large letters flashing in front of him.


He stared at the neon figures and squinted as if he could somehow transform them to numbers by cocking his head in just the right manner. A moment later he jumped off his chair and flipped the switch on the monitor. He knew he had just minutes before the internal alarm informed security that another VF patient was in the building.

Zeke grabbed his bag and charged out the room. As he sped past the nursing station and flew out the doors, he could hear the high pitched alarm screech in the background. He momentarily sprinted towards the garage, but then realized that he would never make it through security.

His only hope was to go on foot to his house before the authorities could question him. His chest pain had become severe now. He could taste the burning sensation arise from his belly and twist its way up to his throat. By the time he turned the corner to his block, he could see the sirens. The Health Authority had already staked out his house.

Zeke only had one choice. He turned away from the squad cars and paced a hundred yards to the WD's front entrance. The door slid open, and he was beckoned to come in before he had the chance to knock. The elderly WD looked him up and down.

I never thought I'd see you here!

He asked Zeke a number of questions and then took out an ancient looking piece of metal and plastic from his pocket. He placed one end in his ears and put the other on Zeke's chest and then back. The WD then pushed and prodded on his belly.

You have something we used to call gastroesophageal reflux.

He reached into his pocket and pulled out a bottle full of unmarked pills.

Take one of these now and then repeat every twenty four hours. I suggest you avoid the authorities for one full day and then turn yourself in. Repeat Automaton testing will be normal.

Zeke stumbled out of the WD's house and looked down the street. The authorities were gone. For a moment he regretted swallowing the pill that the old man had thrust upon him. Strangely, his chest pain was already feeling better. He remembered that he had an extra set of camping gear in the garage. He could hide out there if he had to.

Maybe he didn't have VF after all!

Thursday, April 5, 2012

Process vs Product

Okay, It's time to be unpopular. Mind you, I'm not trying to spit in the eye of my new found friends. But I think we're missing the boat. I read day in and day out about how physicians not involved in social media are doomed, falling behind, or will be lost in the future. As much as I'd like to pat myself on the back for becoming a utilizer, I think we're overstating our own importance.

Yes. Social media is brilliant, powerful, and can improve the delivery of our healthcare system. There's no doubt about it. But it's not a game changer. It's a process, not an end unto itself.

For some reason we keep confusing process with product. Quality healthcare is a product. It's not an electronic medical record. It's not a Twitter feed or Facebook timeline. These are tools.

I know many brilliant physicians who do not use social media. Their skills are supreme, their offices are packed, and there reputations are spotless. If their inability to adapt to todays information superhighway renders them obsolete, then only patients will lose.

I applaud those providers who are using social media to blaze new trails. I envy and imitate them.

However, when I'm unexpectedly lying on the operating table for an emergent procedure, I pray my surgeon is swift of hand, agile of mind, and well trained.

I could care less if she's on Twitter!

Wednesday, April 4, 2012

Getting Dumped

We all lose patients. I'm not talking about death. More like the ones who leave the office cursing or call and harangue you over the phone. These cases are more clear cut. You evaluate the anger and the circumstances and then try to draw conclusions.

That guy was just crazy!
Boy she totally misunderstood me!
I could have done better!

Patients have left me for all sorts of reasons. Anything form my age, to my demeanor. Once a woman left my practice because her physical therapist didn't agree with my my diagnosis of coronary artery disease. This was a few weeks after her first heart attack.

I usually take these loses in stride. You can't please everyone after all. But I can't say it doesn't bother me. I question myself each and every time.

Sometimes the transition is more ominous. A relationship starts out intense and then suddenly disappears. Often it is only months later that I become aware of the absence. An errant pharmacy request for a medicine refill reminds me that I haven't seen a certain someone in quite along time.

With sadness, I realize that I have become a victim of the fade away. Unhappy with my services, I was dumped without even the kindness of a Dear John letter.

And as I sit at my desk and stare at the chart on the computer screen, I contemplate calling. Do I dispute the end of the relationship like a castaway lover? Or do I walk away with my tail between my legs?

Usually, I have my staff contact the patient and offer to forward the medical records. Experience has taught me that confronting the situation myself only leads to awkwardness and apologies.

When I was younger, I so badly wanted to learn from such experiences. But now, I no longer have the taste for hearing how I seemed distracted that day (I was dealing with a crises), or how I took too many calls from the ICU while I was in the examining room.

Furthermore, I admit that I am often not at my best. Some days I am cold, or distracted, or downright curmudgeonly. I still haven't mastered the trick of being open, attentive, and unhurried all the time.

Yet I do mourn these loses. Often more than the deaths. Surrendering to disease is about inevitability.

This, is about character.

Tuesday, April 3, 2012

Social Media As Aggregator

Although a pile of clothes sits in the corner, my son is not in the bathtub. Instead, a naked body darts passed me chasing after a remote control motorcycle that skitters across the floor. In the excitement and adoration of his new play thing, he has forgotten to be embarrassed of his own nudity. He turns around and stands with his left hand by his side and his right clutching the remote.

Daddy, daddy...I'll never be bored again!

Now I imagine this is how most of my readers picture me after discovering twitter for the first time (Insert appropriate emoticon here-something that expresses eew). But in reality, I was a late adaptor. As much as I wanted to promote my writing, I was reticent to jump into social media. Facebook and twitter were interesting, but really seemed like just a little too much work.

So what changed my mind? After years of collecting journals, going to lectures, and browsing web sites, I realized that there had to be an easier way to stay up to date. Enter Facebook and Twitter.

By far the greatest power of social media is aggregation. Want to be the smartest guy on your block? Easy.

Sign up for Twitter. Find the two hundred most sophisticated people and journals related to what your interested in. Check your feed a few times a day.

And comment when appropriate.

Sunday, April 1, 2012


Even as I write these words, I feel as if my head will split and the contents will pour out. Not exactly a migraine, but more the kind of headache that comes from concentrating too much. The neck muscles contract and the shoulders tense forming a ray of lightning that shoots up the nape and explodes just above the forehead. I am tired.

The contractor said that he couldn't quite figure out how to assemble the vanity. So my brother and I studied the mounted shell, and tried to make sense of the diagram heavy instructions. Eventually we had to wing it. After multiple failed attempts, we realized the scaffolding for the drawers was uneven. After correcting, we still struggled to angle at just the right degree till we heard the fabulous clicking sound.

We quickly realized that the back of the bottom drawer would have to be rejiggered to make space for the the sinks hardware that was jutting out of the wall. A half an hour later, my brother made the measured cuts with a hand saw and reinforced the slats with a piece of leftover scrap.

The victory dance, when the drawers were appropriately mounted, was short lived. I joined my wife in the basement and sprayed the surface mold with vinegar for awhile. Then I climbed carefully on top of garbage left over in the garage to re program the door opener.

A few more glitches were then worked out with the contractor. My wife devised a brilliant plan to shortcut a lighting problem. And finally it was time to hang up the overalls for the day.

After a quick dinner and putting the kids to sleep, I've collapsed on the couch. I'm exhausted.


My inexperience with home improvement is basically a fluency issue. I grew up in a female centered household where the majority of repairs were farmed out. By the time my mom remarried, I had lost interest in such things. As my step father toiled around the house devising fixes, my mind wandered, I did homework, or watched TV.

Years ago when I became a homeowner, I realized that my lack of literacy was a deficit that needed to be corrected. But trying to decipher a foreign language can be difficult. I find that it takes great amounts of time and brain power. I can get the job done, but it usually drives the gas tank down to empty.


On days like these, as my writing waxes philosophical, I really feel for my patients. They lie in hospital beds or await worriedly in their own homes. Each day can bring a dizzying flurry of data that can be impossible to interpret. They are harangued by various physicians, specialists, and nurses. The problems are complex and can change at the drop of a dime. And the consequences are sometimes deadly.

Unlike the problem solving involved in my remodeling follies, medicine is often unknowable. The systems are infinite and intricate. The headache I feel pails in comparison to what patients and families face every day.

I will sleep well tonight. My lack of fluency may slow me down, but I will live to fight another day.

I can only hope the same is true for my patients.