Thursday, May 31, 2012

Perpetual Striving

We all yearn for something.  We strive for that which is just out of reach.

The dreams of childhood are infinite.  Unhindered by the shackles of the adult brain, the young mind believes that if it can be imagined, then it can be done.  My son's room becomes a library with shelves of homemade books and irregular paper check out cards.  The backyard will be my daughter's swimming pool and she digs relentlessly at the ground in front of  the garage.  For every barricade there is an alternate route.  This is the joyous frolic of the first decade.   The exuberance of youth is undeterred by the adult concept of possibility.

The yearnings of the middle aged are restless and hurried.  We contemplate our accomplishments and recognize that we are young no more.  The blood flows through our chest hungrily.  The time to make our mark is receding as the sands of the hour glass mercilessly make their pilgrimage.  We are vaguely aware of the nagging voices that follow us into our bed at night.  They whisper.  That book is still unwritten.  That promotion will go to someone else.  That inheritance is fading into the slop of a bad economy.  This is a time of unfulfilled potential.

The sorrow of the elderly is palpable as they walk into my office.  Under the weight of their failing bodies lies the discontent of moments lost.  It is too late to reconnect with that unrequited love or mend the fence that was so carelessly broken.  The heart, however, refuses to lie dormant.  The promise of better health, new accomplishments, and continued adoration refuses to pause for human frailty.

To live is to hope.
To hope is to dream.
To dream is to breath.

I have watched people die.  I have hovered in doorways and sat at bedsides as the humanness has faded leaving a mass of inanimate tissue.  There is a time of struggle where breaths are uneven and labored.  Voices are raspy and mouths are dry.  This may last for minutes or days.

Yet, without a doubt, at the pinnacle of the dying process there is often a moment of calm.  The chest moves evenly and the facial muscles unclench.  It is in this moment that I wonder if we can let go of the persistent longing of the living.  The sickly pause for clarity and peace before they pass on to the unknown.  For once they are still and become one with their surroundings.

Maybe this is the message of the dying.  That in letting going of perpetual striving, we may find the acceptance that so eludes us in life.

As I leave the room to write the death note, I vow that I will learn the secret of stillness.  But in the seconds that follow, I smirk at my own folly.

Even in this I am still very much alive,

for I have started to strive again.

Wednesday, May 30, 2012

I'm Not A Doctor, But I Play One On TV

If the government was a physician, it wouldn't be an ordinary doctor like you or I. It would be a sexy actor like the ones we see on those medical melodramas that have become so popular over the last few years.  His hair quafed, his jacket pressed and free of stains, and his manor confident he would rush into the trauma bay.  As the beeping moniter flat lines, he would sweep the nurses and residents out of the way, grab the paddles, and shock the poor patients heart back to life.  The wife and children would rush in and profess love to their newly awakened father.  And the super cute head nurse would glance appreciatively at our hero and wink with not so subtle romantic overtones. 

Of course, any one remotely involved in health care knows that this is a farse.  Wipe away the syrupy made for TV moment and what we are left with is one simple medical fact.  You don't shock asystole, it's useless.  Such subtleties are often lost on those who shape today's health care policy.  And who could blame them?  Most are politicians, administrators, or physicians who have long forgotten the practice of medicine.

Given the set of circumstances, the ACA is more sophisticated than it first appears.  In fact, much credit must be given for the emphasis on demonstration projects.  This is basic scientific method at it's best.  Try a bunch of ideas and see which stick.  I couldn't be more in agreement.

To Medicare's great embarrassment, recent demonstration projects have shown little measurable benefit for the lynch pins of health care reform: pay for performance and patient centered medical homes.  There is no doubt in my mind that the same will eventually occur with ACO's.  The problem arises, however, that in Washington, political expedience often carries more weight than courage.  In other words, it may be of no benefit whatsoever to shock asystole, but when the film is rolling, the defibrillator paddles are charged and ready.  It's a million dollar fundraising moment.  Politicians like these.

But when the lights are turned down and the cameras shut off, we are left with a doctor who knows nothing of the practice of medicine and a health care system wrought with perverse incentives.

We need the real thing. 

Not just someone who plays a doctor on TV.

Monday, May 28, 2012

The Roles We Play

The last time Charlie's grandmother called before a visit, it was to let me know that he had a "special" friend.  She might not of said it directly, but I knew it was time to have a talk about the birds and the bees, STD's, and birth control.  He may have been in his mid thirties, but he functioned like a teenager. 

Charlie never really knew his parents.  His father jumped ship when his mental shortcomings began to manifest during elementary school.  A short time later his mother died from pneumonia, and he moved in with his grandparents.  There were a few years of independent living in an apartment complex, but he returned to help around the house when his grandfather passed away.

Years ago, Charlie was labeled as "slow" before we had the nomenclature for the complex range of mentally challenging diseases that exists today.  An accordingly, anyone who spent a few minutes talking to him could tell that something was different.  A longer conversation, however, would reveal that a thinking, feeling person was present behind the facade that he had been labeled with.  He held a job at the local grocery store for more than a decade, and was even named employee of the year a few times.  He was fiercely protective of his grandmother and was a loyal friend.

Taking care of Charlie was a pleasure.  He came to see me regularly and followed directions when given.  He had a plethora of minor problems which we dealt with on an ongoing basis.  It was the kind of visit I looked forward to.

Charlie entered the exam room in a button down shirt and blushed as he handed me the neck tie.  His grandmother's vision had become to poor to help him do such things anymore.  I stood a few inches behind him as we stared into the mirror.  I took his hands in mine and gently guided him through the motions.  By the end of the fifteen minute appointment, he could tie it by himself.  I made him promise to take pictures and bring them to the next visit.

As a physician, I fulfill many roles for my patients.  To some, I am like a son doting over his parent's every ache or pain.  To others, I am a comrade who lends an ear during difficult times. 

And occasionally, momentarily, I get to fill the space of a father who left long ago.

Being the product of a single parent family, it's a role I particular cherish. 

Saturday, May 26, 2012

The Shores Of My Insides

I have always been able to sense pain and suffering.  As a child I visioned it as a light that emanated from others bosoms and I was the beacon.  It was not something I saw so much as felt.

I wonder if I got that from my father.  The poor soul, he knew he would die young.  I, on the other hand, have always innately felt that I would die at an old age after witnessing the passing of all those I cared for.  It was not that I felt this a burden, it was just the load that I was uniquely built to carry.

As I've grown older, I've honed my skills.  Conversations with strangers end in tears as I am able to divine what they need from me.  My choice of career is fitting when seen through this lens.  But even in medicine, I have migrated away from the young and healthy and have landed square in the middle of illness and dying.

Sometimes I have delusions of grandeur.  I picture many like me have been placed among our populations.  We act like vessels accepting the pain and suffering that others must deposit.  Unlike those others, I am not destroyed by this sadness.  Conversely, it fills me up.  As the raging waves of the ocean crash against the shores of my insides, the waters eventually calm and the tide recedes.

And I am empty once again.

Like a banker without money, waiting for the next deposit. 

Friday, May 25, 2012

The Opacification Of Intent

There was a time when the humble physician traveled to each patients home.  Care was rendered at poorly lit bedsides with a stethoscope, a pat on the back, and whatever medications could be fit into a small black bag.  Payment was cash, or barter, or services were provided for free.  As the doctor packed his tools and left the house a few ticks past midnight, there was no questioning the nature of the man who walked through the door.  The intentions of the profession were abundantly clear.

Years later, medical science has advanced far past the boundaries of these so called dark ages.  People are living longer, healthier lives.  Although the scourge of disease is being successfully battled on every front, the doctor-patient relationship is more fractured than ever.  We have lost the position of our brother's keeper.  Suspicion and anger have become empathy's uncomfortable bedfellow.

So what has changed?  The doe eyed medical student who cautiously peers into the room of her first hospital patient is lauded.  This poor soul has emptied her bank account and devoted countless hours to master the self serving mistress of knowledge.  The frail, emaciated, cancer riddled patient reaches his hand out to her, even as his body is failing.  For they are comrades who struggle and suffer together.  No one doubts what drives the student's heart.

As one advances into practice, a metamorphosis occurs, and thus begins the opacification of intent.  A geographic barrier is formed when a patient has to travel to the physician's office.  Medicare and the modern insurance complex cause an economic barrier as the patient is required to disclose payment information even before an appointment is made.  A physical barrier is placed between doctor and patient as we hide behind our electronic medical record and use technology in place of touch.

We have allowed for the institutionalization of empathy and we suffer the consequences.

Yet I still believe our intentions are pure.

Thursday, May 24, 2012

Disruption, I See Great Change

We talk of disruptive change in health care as a tectonic cataclysm.  We're hanging by the moment for that one innovation that will flip flop the practice of medicine and bring better, more efficient care.  But if you ask the poor lowly physician struggling on the front lines, we might tell you something different.  We are suffering through a sustained, insidious, devolution.  I see great change.

Reform takes place in fits and sputters.  Regulations are made and then remade.  The product of the governmental assault on the cost of health care is a series of forms and check marks.  Who better to be responsible for such minutia then the wayward primary care physician.  The same beleaguered professional whose numbers are dwindling in direct relation to their pay and inversely related to their work load.  With the passage of the ACA the paperwork has already increased.  The time spent typing away at a computer is multiplying.  Is care any better?

I see great change.  Physicians are looking for a way out.  They are becoming businessman, social media entrepreneurs and commentators, writers, reformers,  and career coaches.  They are retiring early and cutting their hours.  I spend less time in the clinic than ever before.  Each year I replace some of my office time with non clinical revenue generating activities.  The joy of patient care is being overshadowed by regulation.  We are quietly and incrementally bowing out.

The patient narrative is fracturing.  Primary care physicians are using hospitalists.  Patient centered medical homes and large medical groups are favoring speed of access over continuity of care.  A patient no longer has one physician but a team of doctors working on their behalf.  Unfortunately, as opposed to group think, what usually happens is that each provider knows strikingly little about the patient.  Tests are repeated, stories are retold  and modified, there is no longer a holder of knowledge.  A persons narrative not only heard but experienced over years of joint interactions and communications.  We are losing our connection.  Care is suffering.

In reality, the disruption we are looking for has been occuring in a sustained fashion for years.

Are we ready to deal with the consequences?

Wednesday, May 23, 2012


It was a laughably small amount-something like ten or fifteen dollars.  But when the customer service agent for the local phone company told me that she wouldn't refund my money, something snapped.  My heart started to race like a turbine engine, and I could feel the warmth rising up through my face and landing square into my temples.  My hands curled around the pager strapped to my belt loop, and the sweat began to drip down my forehead.

As I jumped off the bed and began to pace, my wife stared up at me from the other side of the room.  A rumble started in the bowels of my chest and regurgitated through my mouth.  At first the words sputtered out in in a measured but gruff tone.  Although the operator was trying to back down, the eruption, once begun, was becoming uncontrollable.  I was a pit bull.

My voice shook with anger as I delivered a series of high pitched verbal barks.  The sentences became paragraphs, the paragraphs pages, and the pages congealed into a verbally abusive story.  My body split in half.  The calm side watching the explosion and picturing some poor operator sitting with the phone purposefully turned away from her ear.  The other side, fire and brimstone, was too busy blathering at the mouth to recognize the absurdity of the situation.

This might have gone on for hours if I hadn't paused to take a breath.  My bloated face, sweaty brow, and bulging eyes did nothing to diminish the acuity of my hearing.  In the brief moment of silence between curses, I heard the most small and inconsequential sound.  A sniffle.  A gasp. The delicate weeping of a stranger.

Six months into residency, I had become a radically different person.  Many would blame the transformation on the brutality of our training programs.  But I think we are missing the point.  The uncontrollable rage comes from somewhere more primal.  It's more endemic to the professional as a whole.  we bang our heads against the wall to knock on the door because our hands can be so useless.

I lost a little part of my soul that day.  And the price?

A ten dollar refund from the telephone company.

Monday, May 21, 2012

Non Clinical Revenue Generation

Although I mostly expound on the trials and tribulations of practicing medicine, when Freelance MD asked me to pen a guest post, I decided to write about being a small businessman.  Running a successful private practice can be both difficult and time consuming.  With the recent passage of health care reform, many physicians fear the security of their current income streams.  As primary care doctors, we face the ultimate catch twenty two.  The better job we do, the less outpatient visits and hospitalizations are necessary, the less money that flows through our doors.  Talk about perverse incentives!  Many have thrown their hands up in the air and joined the local hospital or medical group.  For some of us though, the loss of personal freedom is a major concern. 

So what is the burgeoning physician/entrepreneur to do?  How do we continue to be captain of a ship that faces a tsunami of change?  For me, the simple answer lies in maximizing non clinical revenue generation. 

Over the years, I have established myself as a medical expert, nursing home director, and writer.  Each of these activities provides consulting fees that are more lucrative than patient visits, require little or no overhead, and develop new personal goals and interests.By diversifying my skill set, I have created a more stable and enjoyable practice environment.  Furthermore, my time spent in the clinic is more concentrated and busier than ever.  I no longer need to try to actively recruit new patients.

There are many different nonclinical revenue streams available to physicians.  Besides those mentioned above, there are opportunities with pharma, chart review, and biotech to name a few.  Either way, I no longer worry about the traffic through my exam room door.  Most importantly, I am able to practice parsimonious, appropriate care and still bring home a salary that I'm proud of. 

And I learn something new each day.

Sunday, May 20, 2012

Have You Compromised Yourself?

It took only a moment to convince himself that it was no big deal.  If he used a black ball point pen he could change the two into a three.  This would give him just enough vicodin to calm the ache is his ankle, and still have a few left over for his thirtieth birthday party.  Or maybe he would sell some to the kid down the street.  He could always use the extra money.  If any hesitation existed, it was gone before he got up to search the desk for a pen.  Who would know anyway?

It took only a moment to convince himself it was no big deal.  No one could blame him for ordering the EKG.  It wasn't exactly standard practice, but he had seen other physicians do it before.  Anyway, if his numbers didn't increase soon, there would be no office left.  The bills were piling up faster then medicare could cut checks.  With the economy slumping, the traffic in and out of the exam room had fallen off precipitously.  If any hesitation existed, it was gone before he placed the chit on the super bill.  His patient was waiting.

It took only a moment to convince herself that it was no big deal.  Of course she had noticed that a disproportionate number of his catheterizations resulted in interventions.  But he was a rainmaker, and as CEO of the hospital she could hardly afford to lose him.  The budget was tight and the board was constantly on her back.  It would be ill advised to alienate one of the biggest revenue generators.  If any hesitation existed, it was gone before she signed off on the pseudoinvestigation that found no wrong doing. 

It took only a moment to convince himself that it was no big deal.  Word had come down from the nose bleeds that too many claims were getting through.  Deny first and ask questions later.  The secret motto was whispered with winks and nods during training all those years ago.  At first he tried to resist, but he was all to aware of which colleagues were getting promotions.  If he wanted to move up in the world he had to dance the dance.  If any hesitation existed, it was gone by the time he rubber stamped the pages with the word "DENIAL" glaring back at him in all caps. 

It took only a moment to convince himself that it was no big deal.  Without the promised lobbyist money, there was no way he would have enough to win his reelection.  So he would have to vote against his conscience on one medicare bill.  What was the big deal?  He had no doubt that it would eventually be overturned anyway.  If any hesitation existed, it was gone by the time he closed the draft of the proposed bill after only reading the first page.

It only takes a moment to compromise oneself.  But it's happening at all levels.  It's time we stopped pointing fingers.

And took a look at the reflection in the mirror.

Saturday, May 19, 2012


Do I resonate?

Have you ever heard such self indulgent blather from a blogger?

There was a time when such a question was irrelevant.  I grew up feeling like I was spawned secretly from another planet.  My alien thoughts and perspectives not only did not jive with my cohorts, I felt like a mime debuting on a radio station.  I was different.  I was misunderstood.  I was speaking in a foreign tongue.

It's amazing how this internal separateness became a normal part of reality.  I could no more deny it than I could remove the scar above my eye from the stitches I received in first grade.  Being an anomaly, I learned rather quickly how to minimize my differences.  It became much easier to shake my head in mock agreement than to explain that to me the sky was white and the clouds were blue.

But something happens as one gets older.  Society's chains are no match for the chaffing, sputtering mind as it matures.  Ideas germinate and take root strangling ones innards as words come flying through fingertips and attach themselves to web pages.

At times those words stick and posts are showered with comments and repeated and retweated.  And there are those occasions when sentences lose their form and dance stubbornly in the eye of the reader till the blurr becomes meaningless static.

I still feel like the outsider.  Post after post appears on my blog, but the seat of comfort refuses to adjust to the fidelity of the echo that bounces back at me.

Do I resonate?

Even if I did,

would it matter?

Thursday, May 17, 2012

Cogs And Gears

William was rather brutish.  Although his large beefy hands rested quietly at his side for the moment, they danced around the room when he began to talk.  At first look, one could mistake him for slow, an oaf.  But this was miles from the truth.  A skilled engineer, he made a living building complex machinery.

William understood cogs and gears.  He understood the complex interrelationship between moving parts.  So to talk with him about the pathophysiology of diabetes or the mechanics of a heart valve was natural.  It took months, however, to breach the issue of depression.  After a prolonged divorce and layoff, his mood was slumping.  Yet only recently was I able to convince him to start an antidepressant.

A few weeks later, his spirits were gently rising.  The cloud around his humongous cranium had started to part, and the rains had contracted to an infinitesimal pitter patter.  The visit started on a high note, but quickly became contentious.  When I mentioned the referral to a therapist, I felt like William chewed on my words and spit them out on the side of his chair. 

Doc, I solve problems with my hands, not my mouth!

Of course, I knew that this was not true.  His profession required on the spot thinking and innovation every day.  But William didn't feel these things came from his mind.  It was as if his limbs had their own master control center and worked independently from the rest of his body.  I thought for a moment before speaking. 

Depression is like being stuck in a hole twenty feet below the ground.

William's eyes narrowed but I caught a sparkle of recognition.  I could see that my analogy resonated.  He shifted in his seat and waited for me to continue.  I paused for effect.

Antidepressant medication is like having someone lower a ladder down to you.

Again I watched and waited for him to react.  His chest moved up and down but the rest of his body was still.  He was soaking in my words and allowing them to wash over him.  I wasn't sure yet whether he was buying my pitch, but I wasn't going to stop now.

You see the ladder and feel a burst of hope, but your not sure if you can make it all the way up.

I stopped.  I wanted to make sure I finished the analogy correctly.  I figured I had one shot to convince William.  There would be no second or third chances.

Therapy teaches you how to climb the ladder.

Without it,

your still a man stuck in a hole. 

Tuesday, May 15, 2012

Second Act

By his mid sixties, Collin had traveled many of life's winding roads.  The majority, like his decision to become a financial planner, were guided by the delicate hand of fortune.  The only job offered to him after college became his singular passion.  His financial wizardry allowed for both comfort and acclaim.

So it was with great irony that Collin awoke one morning to find himself swallowing the dust with his face smashed into the cold pavement.  The night before, he epically celebrated his retirement with family and friends.  The envy of the crowd, he was leaving the game with decades of life left to explore.

But destiny was a fickle mistress.  Once Collin drank freely from her sparkling trough, now he would learn to live with drought.  The first thing he felt upon awakening was a strange numbness over the left side of his face.  He tried to get out of bed but his right arm refused to move.  His right leg felt like a tree trunk.  When he lifted his head and called out to his wife, she came running from the bathroom.  He was slurring his speech.

A few hours later, Collin sat helplessly in the stroke unit of a local university hospital.  He listened morosely to the irritating beeps and clicks of the machinery surrounding him  His limbs may have been dead, but his ears were crystal clear.  There were no medicines to fix this predicament.  There were no financial formulas or tax shelters to hide under.

Collin's path had taken a nasty detour.


Just a few weeks after his famed retirement, Collin found himself in the fight of his life.  Each day started the same.  He woke up at seven and showered before starting the relentless therapy schedule.  Physical therapy before lunch, occupational and speech afterwards.  The pace of the rehab facility was brisk.  Every spare moment was filled with a physical obstacle to stumble over. 

As with most conquests, Collin was doing better than expected.  He was using a walker, and was ready to try a cane.  While his body ached and was overcome by exhaustion, his mind was suffering the most.  The intense decline of his physical acumen contrasted the clarity of his mental processes.  There was no nice way to say it; he was bored.

It was therefore quite natural, when he heard his roommates wife mention their financial distress, to offer advice.  He perused the hospital bills and financial statements voraciously, glad to be flexing a muscle that had been lying dormant for what seemed like centuries.

It took a few hours, but when Collin explained to the man and his wife, he felt the rumblings of power well up in his chest for the first time since the stroke.  It was not only the knowledge obtained after years of financial planning, but also understanding the physical devastation of disease.

For once, Collin could offer his clients more than just sound advice, he could walk a day in their shoes.


By the time he finished rehab, he not only acquired much needed strength and dexterity, he had also embarked on his next voyage.  Armed with knowledge and real life experience, Collin had become a patient advocate and financial liaison.

The bumps in the road had left scars.  And those scars marked his body like his limp marked his gait.

He would celebrate his imperfection as he journeyed down a new road.

It was time for the curatin to rise.

Act Two was about to begin.

Sunday, May 13, 2012

My Father's Son

There are pilgrimages that are finite.  The kind documented in diaries with color photographs and blurbs scribbled with ballpoint pens in black ink.  Then there are the ephemeral journeys that we stumble upon over lifetimes.  Where conclusions are sparse and understanding brings more pressing questions.

For the first seven years of my life, I took my father's presence for granted.  I have spent the last thirty one trying to find him.  Even though I have lost and found myself several times in the process, I am no closer than when I first started.  Unfortunenately my empirical premise is flawed.  I am no more my father than my son is me.   How could I be?  His father didn't leave him when he was a little boy.  Yet I choke on the similarities.  My life's choices are peppered with filial flavorings. 

I have followed his footsteps in so many ways.  I coapted his profession.  Yet I am a much different physician.  While I may have never known the man, I am intimately acquainted with the doctor.  I studied his notebooks and hob knobbed with his colleagues.  We could not be more different.  An oncologist by trade, he was a master of the science of medicine.  His writings are littered with miniscule data and detailed tables and figures.  My eyes glaze over.

The art of medicine has always been more captivating to me.  I would trade the textbooks any day for a touch of the hand, a glint of an eye, or the subconscious tells that each patient manifests.  My wanderings have lead me to end of life care.  Who better to translate the dance of mortality than one caught in the cross hairs for a few odd decades.

And my travels continue deep into the heart of hospice and palliative medicine.  Stuck in the imaginings of a little boy, I strive to bring the peace to families and undo the death that befell me so early.  But no matter how many people I help depart, I can't rewrite my own past.

I struggle.  I am flawed.  I attempt to appreciate the beauty of my own mortal wounds. 

There are pilgrimages that are finite.  And there are those we stumble upon over lifetimes.  Conclusions are sparse. 

And understanding brings more pressing questions.

Saturday, May 12, 2012

Face Off

I'm not exactly sure when my body turned against me.  I first became aware about six months ago, while rounding at one of my facilities, the director of nursing pulled me into a corner and whispered softly.

What happened to you?

I ducked out of the hallway and entered the bathroom to look in a mirror.  Two large red lesions had sprouted on my face.  One on each cheek.  I had acne!  With hope I tipped down my head and inspected my scalp in the reflection.  I figured since I was reverting to my teenage years, maybe I had also sprouted a few more strands of hair.  No luck-unfortunately my bald spot was as sparse as ever. 

Over the next few weeks the large pearly parasites began to recede, but to my absolute horror, new ones came quickly.  There was no geography that was left untouched: my forehead, my eyebrows, the stubble above my lip.  Although I pictured myself a rather self confident guy, I was starting to feel like the big breasted girl in high school.  I watched as eyes shifted  and glazed over mid conversation as they landed on the freshly formed Himalayas on my face.  I contemplated making one of those snarky shirts.

I'm up here dummy!

But then realized that I would have to wear it on my chin to have the proper effect.

My wife was the first to offer a solution.

What you need is a facial.

She lunged at my with her fists clenched and two thumbs sticking out like talons ready to pounce.  I ducked out of the room and made some excuse about being late for work.  The next morning, however, I sat in front of her makeup case and lifted a tube of concealer up to my eyes to appraise the color.  As luck would have it, she walked by the open door of the bathroom at that exact moment.  She stopped and stared at me with glee.

I have a nice lipstick and eye liner that would look fabulous with that color!

The advice began to role in from all sectors.  My mother in law snatched the box of raisins out of my hand and scolded me for eating the wrong kinds of food.  My elderly hypochondriac interrupted her litany of complaints and stared at me with her mouth open.  It was the first quiet moment I had ever experienced with her in the exam room .

It's stress, my doctor has too much stress.  Don't have a heart attack !  Who will take care of me?

So I bought an expensive facial cleanser and scrubbed relentlessly. I changed shampoos and splurged on a loofah.

And believe it or not, the red tide has started to abate.  Although you wouldn't know it from my partner's reaction the other day.  As we bumped into each other in the hospital he interrupted shop talk for a sprinkling of personal advice.

You know, we have some good dermatologists around here.

I shrugged.  If eyes are the window into the soul, then the face is an invitation for comment.  I looked off into the heavens exasperatedly and replied while turning to walk away.

I really don't like going to the doctor.

Thursday, May 10, 2012

It Startles The Soul


It was the only question the frail elderly woman asked as she cradled the head of her fallen son. Her wrinkled hand caressed his cheek and her osteoporotic spine bent over him longingly.  He was too far gone.  His respirations were shallow and labored.   His lips mouthed a few words and his eyes fluttered.

Maybe if there had been enough time, other questions would have surfaced.

How could this have been prevented?
Who is at fault?
Why didn't you know that he was at risk for this?

But that's the thing about sudden and immense grief.  It startles the soul.  It turns full sentences into piddly words.  Ideas become stuck and hang in the cobwebs of the stunned mind.  Within a moment the weight of the years becomes apparent in the stillness of the figure standing at the bedside.

I have learned and forgotten many things in this short career.  I hunched over textbooks unravelling the mysteries of disease.  I walked from room to room with learned professors demonstrating living and breathing pathology.  I passed thousands of hours in the exam room listening intently to words whispered in somber tones.

I have less answers than the day I began this journey.  I am painfully aware of my personal as well as my professions flaws.  We are limited by our anatomy and pathophysiology.  Maybe we are asking the wrong questions.  Maybe we should have spent a few semesters in seminary.

Why? Why? Why? Why? Why?

I choke on the bitterness of my own simplicity.

Tuesday, May 8, 2012

Dying In America

I've seen people die poorly.  I've watched as the family struggled to decipher the writing on the wall as the medical system sucked the marrow out of their unconsciouss loved one and then spit it out indignantly.  We are losing the war against futility.

But how to stem the tide when demented centarians are newly started on dialysis?  How do we explain that chemotherapy will not help when metastatic disease runs rampant and bodies are confined to beds?  I usually start by considering death as a given, then work backwards. 

If I were to tell you that you only had two weeks more to live, how would you want to spend those last days.

Often as the words role down my lips, I can see the stages of grief pass before my eyes.  A family member spits and turns his head in anger.  A husband sputters that the oncologist said years, and I wonder is this denial or just bad advice.  Sometimes a patient falls off the grid and lands squarely on accusation.

Doctor, if only you had checked my labs sooner.

And in my mind I continue the if only game.  If only the cancer wasn't metastatic.  If only you were strong enough to get out of bed.  If only we could live forever.

If death is a tsunami, then futility is the collateral damage.  Cars are upended, houses are flooded, and bodies lay ravaged on the streets.

We've got a problem.

The process of dying in America is seriously flawed.

Sunday, May 6, 2012

One More Thing

Lisa was my mid day physical.  A new patient, I eyed her cautiously as she walked through the door.  She was a youngish looking thirty something.  She wore a bag slung over her right shoulder which no doubt carried a computer.  Her left hand clutched what appeared to be a few inches of computer printouts.  I mentally rolled my eyes.  It was not that I didn't like my patients well informed, I was just hoping to get through the physical without spending hours undoing whatever calamity her Internet search had produced.

My fears about Lisa faded quickly.  She was respectful and to the point.  The interview and exam flowed smoothly.  Of course there was some issues here and there, but we talked through each without confrontation.  She accepted my suggestions with minimal push back.  I glanced at the printed pages on the desk as I finished my notes.  They were just far enough away for me to be unable to make out the typed words.

I  waited for a moment for Lisa to ask any other questions.   I couldn't help but wishing every new patient was like her.  Smart, organized, and ready to listen.  When she assured me that there were none, I got up to leave and reached for the door knob.  And that's when the feared bomb dropped.

Oh...Dr. Grumet, one more thing.  I wanted to show you this!

I turned to find her thrusting the ream of papers towards me.  I moved forward hesitantly and accepted the package with feigned indifference.  I scanned the top of the page. 

In My Humble Opinion

It was my blog.  She handed me a copy of my most recent blog posts.  I looked up to find Lisa smiling.

I just wanted you to know why I chose you to be my doctor.

Friday, May 4, 2012

The House That Medicine Built

The medical system doesn't care about you. It cares for you. Of course if you go to the local hospital you might get treated to frilly curtains and a large screen TV. In reality, your nothing but another piece of meat. Pure, fine, grade A-but meat nonetheless. There's a vested interest in preserving your integrity en route to market. Yet no one escapes the system without being tussled, pushed, and manhandled to the point of bruising. Permanent damage, however, is strictly discouraged.

Occasionally a cut of meat gets uppity and fashions itself steak instead of ground beef. The medical system doesn't tolerate such hubris. Even VIP's are fashioned in gowns that fly open in the back. The rectal exam is ignorant of traditional class warfare. The indignity of disease lashes out against all comers.

We talk of modern health care as a living , breathing, sentient organism that expands and contracts intelligently. The truth is much more nuanced. Our medical system is a series of ill conceived systems that interact mindlessly and react intuitively. As processes collide, the bull headed survive.

Your visit to the hospital may be a nightmare. A ream of disjointed information will fly into your face at warp speed. Buried under a sea of nonsensical medical jargon, hurried staff will rush in and out of your room and pause impatiently when asked questions.

But this is the house that medicine built.

You want things to be better?

Incent time.

Cut governmental paperwork and red tape.

Destroy the nonsensical and time consuming coding and payment system.

Bring the joy back to practicing medicine.

That is all.

Thursday, May 3, 2012

The Temple Of Medicine

I woke up this morning at the usual time.   But instead of driving to work, I waltzed out the front door and walked toward the station.  Ten minutes later, I was rocking gently back and forth with the motion of a train car. I was looking forward to wandering around the city, although, in reality, my path would be just a short hop to the testing center.  I was taking my Maintenance of Certification exam for Internal Medicine.

Ten years ago, I had taken a similar test.  I was fresh out of residency, and had just started practicing as an attending physician.  I was used to being tested back then.  It seemed like every year there was a Step I or Step II.  But now I'm out of practice.  After the original board certification the tests had ended.

As I sat down at the computer to begin, I couldn' help but feel a strong sense of nostalgia.  A decade has passed and my life has changed.  Two jobs and a couple of kids later, I'm a different person.  I remember how pure my intentions were then.  I bowed at the temple of my profession.  I still held the mistaken belief that most problems were solvable, most diseases curable.  I was naive, but happy.  There was no field I would have rather studied.

Years later, medicine has lost it's luster.  An imperfect devil, she laughs as we inferiorly toil at her feet.  Unlike the test questions flashing up on the screen, real life is much more messy.  The answers are less clean and the consequences more apparent.  You never killed anyone by missing a question here or there.

The test is woefully unlike the real practice of medicine.  There is no multiple choice on what to do when the chronic debilitated back pain patient uses up all her medicare days and only qualifies as an observation stay.  There are no useful suggestions on how to stave off the fears of malpractice that whisper in your ear when your are trying to sleep late at night.  Apparently such skills as anger management, grief counseling, and maintaining calm when being insulted, are to difficult to test.

I finished the exam a few hours early.  It was challenging, but I'm sure I passed. 

It now feels like I have a love hate relationship with my profession.  When it's good, there's absolutely nothing like it.  But most of the time, it's like seeing a beautiful car in the distance.  As you get closer, your eyes adjust, and you notice the paint is chipped, the bumper is dented, and the exhaust pipe is barely hanging on and rattling against the ground.

It was never that fine in the first place. 

Your mind was just playing tricks on you.