Tuesday, July 31, 2012

The Rise Of The Novice

The dreams of the novice are pure.  He sees a world of possibilities lying bare at his fingertips.  Unencumbered by skills and knowledge, he practices the art of healing in it's most elemental form.  Caring for humanity entails a kind heart, an available ear, and a pat on the shoulder.  It is in these times, the seed is sown for an unswerving path.  An ending that far too often has no recognizable remnants of such a noble beginning.

The mind of the medical student is already entrenched in chains.  The subject is no longer humanity but a textbook of pathology.  Facts, diagnoses, and algorithms lead the wanderer to stray from his path.  To do no harm becomes the lifelong mantra that distracts the addled brain from the primary dictum.  What once was the domain of the soul becomes fodder for the intellectual capacities.  We learn the art of caring through a skill set, we subtract it from the core of our being.

The resident believes himself to be inching closer, not farther from the secret.  Competence is the line between survival and failure.  The punt, the turf, and the buff are perfected as if they were indeed the practice of medicine unto themselves.  Fear and the struggle for survival detract from the ultimate goal. The distortion of the carnival fun house is almost complete.

The practicing physician wears a lab coat of many colors.  One part businessman, one part computer technician, his role changes based on the needs of a complex and rigid system.  He is both the keeper of facts as well as the follower of guidelines.  He is the supervisor and the grunt at the end of the line.  His loyalties are so divided between society and patient, that he has become utterly ineffective.

The secret is shockingly simple.

The novice was more adept in the art of healing than the byproduct of this dehumanizing process.

We must start again.

We must return to the beginning.

Sunday, July 29, 2012

Whose Burden Is It Anyway?

I mean, we're all kind of dying a little bit.  Certainly we've had our dark moments.  It's one of the hazards of the profession.  What do we expect after seeing so much pain and suffering, pain and longing?  It would be quite audacious to suppose that it doesn't affect us.  That we can waltz into the exam room and leave our personal feelings and scars behind, the idea is laughable.

We are human.  And as human beings we cope the best we can.  Some have more mature mechanisms, others not so much.  So when I enter the office on a bad day, I  may feel a little bit distant, maybe cold.  Occasionally I might be downright mean.  It's not personal.  Fresh scars are often surrounded by fleshy, more sensitive tissue.

Over the years I have been cursed, threatened with malpractice, and left waiting for patients who have never shown.  I have been mistreated in almost every imaginable way by my clients.  Most of the time, I accept this type of behavior.  When faced with fear, illness, or death, it is common to lash out at the bearer of bad news.  Part of my job is to place my patient's behavior in context and react accordingly.  Often the worst actors are the first to apologize when their situation improves.

I try to give each patient the benefit of the doubt.  Yet it pains me to see how the public reacts to physician's poor behavior.  We have been accused of being aloof, distant, and angry.  I suspect that in reality most doctors are none of these things by nature.  Like anyone faced with fear and destruction, we're in pain.

You see doctors and patients aren't that different in reality.  We all hurt on the inside.  Why do you suppose we suffer alone?

I wonder if we could share this burden.

Saturday, July 28, 2012

Eating Crow

I mentally rolled my eyes. The twenty something sitting in front of me was trying his best to influence my plan, but the clinical decision making was quite straight forward. He had no fever, no shortness of breath, and looked nontoxic. His lungs were clear and he was healthy. It seemed like a no brainer. I tried to explain.

We don't treat bronchitis with antibiotics. Especially someone as healthy as you.

I could tell he wasn't buying my explanation even though he had little choice. I recommended hydration, rest, and to call me in a few days or sooner if his symptoms worsened. Then I shut the door and moved on to my next patient. I hardly though about him after that.

It was with considerable shock that I answered the phone call from the emergency room a few days later. He was septic and hypotensive. His xray showed a dense pneumonia and he needed to be admitted to the ICU. I rushed over to the hospital, and climbed the steps to the second floor with trepidation. By the time I reached his bed, his blood pressure was coming up and the color was returning to his face. He scowled as I walked in the door.

I carefully chose my words expressing regret that he had gotten so sick, without making reference to my decision making process. I was wrong. He didn't get better with rest and fluids. But I had taken the right coarse of action based on current guidelines and knowledge.

Sometimes, that just isn't enough.

As physicians we find ourselves wrong all the time. With the complexity of human physiology and the inadequacy of current medical knowledge, it's a miracle that we bat greater than five hundred. Complicating this fact, is that our profession must answer to a number of impatient mistresses.

The government and health care reform have now erected a monument to parsimony. So sometimes even when you right, your wrong because you utilized too many resources. The critical eye of malpractice lawyers also effects our decision process. Forget parsimony, rightness is defined by leaving no stone unturned no matter how small or remote.

At the end of the day, we have many hands pulling at us.   Even when every patient is home tucked in bed safely,

we still feel like we're eating crow.

Thursday, July 26, 2012

"Let's Waste Medicare's Money"

Narrator: And now folks it's time to play "Let's Waste Medicare's Money", the game show that shines a light on abuse with a complement of perverse incentives.  Today we have three contestants.  Say hello to Ida Mae, The Colonel, and Wild Bill.  In a moment our lovely guests will each recount how, with the help of their doctors and bureaucratic red tape, they have single handedly bankrupted our health care system.  But first, an explanation of how the game is played.  You, the audience members, decide the winner.  At the end of the show you vote based on who you think wasted more of the governments dollar.  The grand prize will be a full months stay at the contestants nursing home of choice, all expenses covered (that is, of course, unless medicare picks up the tab)!

Narrator: Let's start with contestant one, Ida Mae, how are you doing today?

Ida: Oy!  I'm so tired.  My legs hurt.  And my back, my back...do you happen to have any of those vicodin pills?

Narrator: No Ida.  I was just being polite.  I didn't really want to know how you're doing.  Tell us your story.

Ida: Well I was watching Dr. OZ on TV (he's so cute!) and he said that all diabetics should see the foot doctor.  So I asked my friend Sally, and she gave me the name of her specialist.  The podiatrist thought my feet looked fine, but noticed my legs were swollen. 

I hadn't noticed my legs were swollen.  Who knew?

Narrator: Quite a predicament!

Ida: So he says to me.  You better call your cardiologist.  And I call, but he's busy seeing patients.  His nurse answers the phone instead.  She asks if I'm feeling short of breath.  I say of course.  I been short of breath since nineteen sixty three when I gained that fifty pounds after carrying my last child.  The nurse became all excited. She told me I had to go to the emergency room immediately.  So I says there's no one available to drive me.  She says: call an ambulance right away

Once I got to the emergency room,  there were all these doctors I didn't know.  They admitted me over night and ordered a stress test and echocardiogram.

The hospital doctor came the next day and discharged me.  He said my heart was fine.  I told him I already knew that, but wanted to know why my legs were swollen.

Narrator: And what did he say?

Ida: He didn't know.  He thought that that was something my outpatient doctors should figure out!

Narrator: Very nice.  Now let's move to contestant two.  Colonel, can you top that.

The Colonel: Yes sir.  On Monday at 0800 hours I started having pain in my chest.  It was severe and pressure like.  I called my doctor and he sent me to the hospital.  In the emergency room it was decided I would stay over night.  On Tuesday, some case coordinator came to see me and said they were changing my admission to observation.  She said something about hospital readmissions and how this wouldn't count.  I was feeling tired and confused already, and so just went along with whatever she suggested.  Later that night, I spiked a fever.  The next day I was diagnosed with pneumonia.  By then, I was as weak as a wet noodle.  I couldn't get out of bed.  By Friday my doctor told me I needed to go to the nursing home, but they couldn't send me because of my observation status, medicare wouldn't cover it. Finally he agrees to change me to a full admission, but I had to stay in the hospital three extra nights so that medicare would pay for my nursing home.  He told me I could leave sooner,  but then I would foot the bill.  I said: heck no!  I would rather stay in the hospital hotel

Narrator: Quite nice accommodations they have there!  OK Wild Bill, your up.

Wild Bill: Well I was out riden my hoarsey when my back started to hurt.  I got off the hoarse and crawled into the ranch.  After searchin on the Internet, I decided I need to go see a neurosurgeon.  I called the doctor but his secretary said that Dr. Back Whisperer won't see anyone without having an MRI done first.  So I asked for a referral from my pcp.  Since my whole back was hurting, he ordered three MRI's to cover everything. 

Narrator: sounds logical.

Wild Bill: When I got in that MRI machine, I felt like a pig in too small a pen.  I had to stop after thirty minutes.  So my PCP called in a prescription for valium so I could retake the test.  The Valium worked alright.  I was so dizzy getting off the table I fell and broke my hip.  Six months later I'm finally recovered but I haven't road my hoarsey since.

Narrator: And how's your back?

Wild Bill: My back?  That felt better before I even took the MRI.

Narrator: Well, there you have it folks.  Which contestant gets your vote?  Who is the winner?  Or better yet, are there any winners?

It certainly isn't us,

the American public.

Tuesday, July 24, 2012

Unrealistic Expectations

I've cowered behind my gray coat as my hands fidgeted and my mouth sputtered an apology.

I've stood above the body of a dying patient and questioned every single decision.

These are the moments that blacken the soul.  These are the bleeding scars of one who attempts perfection and yet is destined to suffer the realities of being mortal.  I have accepted the weight of these burdens as I will carry them to my grave.  But sometimes it is the subtleties that chip away the edifice of confidence and expose the flesh, weak and unprotected.

Albert hobbled into the office six months after the death of his beloved wife.  Within weeks of developing a cough, she succumbed to lung cancer.  His eighty year old body was healthy, but his posture stooped with grief.  His eyes focused on the ground as he answered my questions in monosyllables.  When he did speak in sentences, he talked of his daughter who was paralyzed in a state of  perpetual mourning.

I examined his gaunt frame.  His blood pressure was good and his pulse steady.  His lungs were clear and his heart lub-dubbed methodically.  We reviewed his medications and recent lab tests.  There was nothing to be done.  I paused and closed the chart on my computer screen.

We stared at each other.

Albert cleared his throat and the light in his eyes extinguished.

She died so quickly!

His head shot back toward the ground, but it was too late.  In the brief second of contact, I saw a window into the depths of his heart.  He might not have even known it himself, but he blamed me.  I could hear the words although he wasn't speaking them.

You should have caught the cancer faster.  You should have saved her life.  No one should traverse between life and death with such minuscule warning.

Like a ton of bricks crashing down on my head, I realized that the only reason he was still coming to my office was that his kids were forcing him to.  I can't explain how I knew all this from one sentence, one look, but I was as sure of it as I was the reflection in the mirror.

He left the room.  My spirit drained, I couldn't muster the appropriate sentiments.  I certainly wasn't going to try to defend myself, although I was certain that I had done everything correctly.

Sometimes, I wish patients understood what physicians experiance.  Not only do we bear the overwhelming guilt when we perform below our own expectations, we often suffer the venom of unrealistic expectations.

Yet to point this out to a grieving family member is to belittle the mourning process in the first place.

We must walk this road alone.

Monday, July 23, 2012

And Now A Word From Our Sponsor

I live in a world of words.

The elderly man leans against the locked door of the dementia unit.  His bottom half pushes against the barrier while his upper flails freely toward the nursing station.  His is more passing the time than agitated.  The tenor of his voice rises and falls.  I discern a cadence, a military march.  His eyes are glazed, far away, in another land.

My secretary coos on the phone to the crying patient.  She placates, she soothes, she checks the schedule.  I can hear the lilt in her voice, the one that signals genuine empathy.  She fields such calls with a  certain expertise.  Her tone, the exact mix of warmth and graciousness, begins the healing process miles before the patient actually enters the exam room.

My son chitters away in the direction of my daughter.  Sometimes my children's voices are like songs, others they are squawking ravens pecking at my feet.  Every word is filled with emotion.  Every sentence ends with an exclamation point.

But words fall empty when there is no audience.  Only the keen observer will note that the demented man in the nursing home is a retired army colonel, or that the secretary has just lost her own mother, or that behind the children's nagging is the overwhelming request to be loved.

I have spent countless hours staring at this blank screen as it reflects back a mangled version  of myself.  My pitiful, misspelled words collide into fragmented sentences.  Thoughts come randomly and build, crescendo and decrescendo.  Purpose languishes in the shackles of rudimentary delivery.

Yet you, my reader, come faithfully without beckoning.  You comment, and retweet, and click like on facebook.  You turn the bald, pragmatic glyphs on page, to something more than ephemera.

You give my words context.

And in that, you bestow upon me the greatest kindness.

Thank You.


Sunday, July 22, 2012

Drawing A Line

I never liked it that much anyway.  My son was the one who came home with the idea in his head. Before I knew it, I was signing a waiver at the information session and writing a check.  After all, it was an extra curricular activity, and I was impressed with his verve.

Months later after attending a few meetings, it was my wife who sounded the alarm.  She had already supported a petition, but the recent public announcement was just too much.  How could I keep my son in Cub Scouts?  How could I look my community and my patients in the face?  What type of a role model was I becoming for my children?

My son is understandably upset, but we're working on him.  At eight years old, he doesn't yet know how often he will be asked to compromise his morals for ease, personal gain, or a myriad of other reasons.

It is our job to teach him.  It is our job to stand up and take a stance when ugliness and bigotry encroach on our lives.

We are just a few small people drawing a line in the sand, facing a Goliath.

And boy, does it feel good.   

Saturday, July 21, 2012

Primary Care Shrugged

I remember reading Ayn Rand's Fountainhead as a senior in high school.  I voraciously lapped up every word, every movement of her protagonist, Howard Roark.  My adolescent yearning for identity and integrity meshed well with the book's message.  The black and white morality fit well for one who was unable recognize shades of gray.

My freshman year of college, I read Atlas Shrugged.  And again, I found that Rand's words reverberated deeply in my soul.  I so wanted to believe that the able few drove the motor of the world.  For the rest of the poor slobs, it was either put up or get out of the way.  I was young and very impressionable.

As I grew older and experienced more, I began to change.  The simplistic morality play in Rand's novels started to feel crude.  Sometimes the poor and uneducated suffer their lot in life despite their best intentions.  Sometimes will and ability are just not good enough.  And luck often prevails over skill.  I became an adult and my sensibilities changed.

Strangely, as we talk about the state of health care in America, I find myself coming full circle.  There is whispering about a Primary Care revolution.  The pundits are already starting to critique the next steps of the movement.  Primary Care will arise again and become the lynch pin of a new era.  Affordable, practical, evidence based medicine will follow shortly over the horizon.  We are saved!

But if you ask me.  I think a little differently.

I think Primary Care shrugged long ago.  We just now are beginning to see the effects.

How else do we explain the drop in training in outpatient medicine and family practice?  What other forces explain the overuse of diagnostic testing and high utilization of referrals instead of deep thinking?

Many may have stayed in practice because of economic necessity,

but the heart of the speciality is gone.

Thursday, July 19, 2012

In Memoriam

It was a beautiful cool day much like this morning. I pulled into the parking spot recklessly. I was running late, but if I hurried, I might just make it. I grabbed my backpack and slammed the door shut without a second thought. Then my stomach sank. I heard the calm hum of the motor as I reached back for the door. Locked.

I felt the panic swell inside. My sixteen years of experience hadn't yet taught me how to deal with such things as overwhelming embarrassment. How could I have locked the keys in the car with the motor still running? As I stood frozen trying to find a way out of the situation, I heard footsteps behind me.

The women paused momentarily and gently placed her arm on my shoulder.

A little bit of a predicament...huh?

She had known me since birth. Her eldest child was my age. She was friends with my parents. And she had been kind enough to allow me to park at her house because I wasn't old enough to get a parking permit from my high school.

I remember her from childhood. At that time we lived on the same block. Her smile was always comforting. Motherly. And her kitchen usually smelled of something good. Her son and I were best friends once. But time and distance had taken their toll. Now we only ran into each other sparingly.

I was no longer a child, although I felt like a five year old parked in her kitchen waiting for my mom to come pick me up. I felt helpless as she called the police to have my car door opened. She made me hot chocolate while we waited. She neither teased nor chided. When I left she offered to write a note for my teacher. But I refused. I wanted to maintain the little pride I still had.

Over the next 15 years our paths crossed occasionally. My mom would update me on what was going on with her family.

I was busy with college, then medical school, then residency. I finished my training and returned to be a hospitalist at a local hospital. I was feeling young an important,competent, and ready to tackle the world.

I had known that she was diagnosed with lung cancer. Never a smoker, she was one of the unlucky ones.  From time to time I would stop by her room to chat when she was admitted for chemotherapy. We discussed her fears and anxieties. We talked about old times. I was just a friendly visitor to pass the hours.

The last time she was admitted, I made a point of coming early. She was in the hospice program and was dying quickly. I knocked gently on the door and let myself in. I expected to find a room full of people, but instead it was empty. Her family had stepped out briefly for a cup of coffee.

She was resting quietly. She was unconscious and breathing deeply. She had a look that I recognized-the look of someone who was walking her lasts steps through life's unexpected maze. I knew her time was fleeting.

So I sat next to her bed and let her know that I was there. Speaking softly, I leaned forward towards her. I told her that I was sorry for what she was going through. I told her that it was a pleasure knowing her. And then I said goodbye. I placed her hand in mine and promised that I would always remember.

I left the room before the family returned. She died later that day. Inexplicably, I didn't go to the funeral.

I run into her son every now and then. Our lives have taken such different paths, but we still share history. Unlike the people he now meets today, I knew his mother. And this means something.

I don't know why these thoughts came to me this morning as I got out of my car. Why such randomness pops into my head. But I am thankful for them nonetheless.

I will keep the promise I made to her that day.

I will always remember.

Tuesday, July 17, 2012


Daddy, daddy.

My daughter greets me at the door with a wiffle ball cradled in both hands.  My son follows closely with his fingers wrapped around the thin plastic stem below the fat end of a bat.  My wife slips past and kisses me on the cheek as she makes a beeline towards the garage to run errands.  I persuade the kids to follow up the stairs so I can change my rounding clothes for more comfortable shorts.  It's a sunny Saturday morning and the air is still cool.

I clip my pager onto my pants, and curl the blue tooth around my ear.  We rush out the door, and my son and daughter fight over the bat.  They have no interest in the hollow white sphere with the three air holes at the top.  I wait for a moment before intervening.  As I am about to jump between them my pager starts to buzz.

I sit down on the deck and dial the the number to the ICU hesitantly.  I lean on my left hand as my right clenches the ball.  A nurse answers the phone.  After my visit a few hours ago, the patient's blood pressure started to drop and the temperature rise.  I bark a few orders before being interrupted by call waiting and my vibrating pager simultaneously.

I click the call waiting and watch my children.  My daughter has dropped the bat and is now digging in the dirt with a child size trow.  My son has turned on the hose and is sloppily watering the plants.  The pulmonologist is worried.  The lactic acid is elevated and they are about to intubate.  We agree that I should call the cardiologist.  I leave a message with the answering service and dial the ignored number from my pager.

The patient's daughter is frantic.  Her fear and anger are evident in the vibrations of her voice as I strain to hear over my son who is yelling past the fence to the next door neighbor.  I pin the ball under my hand and push downward with increasing power as it rolls forward to escape the compressive force.

We talk about end of life wishes.  We talk of signs and symptoms, probabilities and prognosis.  The out come is too unclear at the moment.  I click over and leave her waiting as I answer the call back from the cardiologist.  He's in the building and will be in the ICU shortly.  They might need to open up the cath lab.

The sweat drips down my brow as the sun rises and the temperature creeps higher.  My son and daughter are crouched in the corner.  I can't see the extent of their mischief.  The ball has picked up dirt from the deck, and is taking on a  brownish black hue.  I throw it against the floor violently, and catch it as it comes racing  towards me.  The patient's daughter has surrendered the phone to the nurse.  The pressure is stabilizing but the sats are starting to drop despite intubation.  The X-Ray tech is on  the way from radiology. 

The nurse then gives the phone to the patient's son.  My daughter has snuck behind me and sticks her finger under my arm.  She laughs devilishly.  I pull back and stare at her malevolently.  I shoe her away with the ball glued to my hand like a a magnet stuck to metal.

The patient's son is despondent.  He wants to withdraw life support.  I ask if his sister is in agreement.  Again, I excuse myself to answer call waiting.

The cardiologist says that it's a no go. 

She's way too unstable.

I click back to the son.  Everyone is in agreement.  Seconds later, I give the nurse orders for a morphine drip.  The tube is removed.  My son is tugging at my arm.  I speak to him distractedly as I look helplessly towards the sky.

Hold on, I'm almost done!

The nurse reports that the monitor has flat lined.  I speak soothingly to the daughter.  My son is becoming more persistent.  He is really pulling on my arm now.

Dad!  Dad!

I hang up the phone and explode in his direction.

What's so important?

I'm frustrated and sweaty, sad and emotionally worn out.  My child becomes sheepish while his sister joins him on the deck.  He won't look me in the eyes. He speaks quietly, almost in a whisper.

Your bleeding!

The wiffle ball has torn open at the seems, and my finger is stuck on the inside.   A trickle of blood stains the pristine white edges.

I look at the precious angelic faces in front of me.

It's been an hour and a half, and I haven't noticed that the temperature has risen to a hundred.  I only now see that my daughter's face is smeared with dirt instead of sunscreen.

It's another Saturday,

and once again I've ignored my children.

Sunday, July 15, 2012

Meaningful Abuse

Undoubtedly the most difficult challenge of practicing medicine is the complexity.  There are both elements of IQ as well as EQ.  Because of this, the process of training is marked by a number of hurdles and weeding out periods.  Only a certain number of people pass the premed curriculum.  Those who succeed can get tripped up on MCAT testing.  If ones score are acceptable, so begins the interview process.

Those lucky enough to matriculate into medical school are pushed on every level.  Hours of classes and studying are followed by repeated skills assessments in which a certain percentage always fails.  The clinical years are marked by grueling physical and mental endurance.  The harsh realities of sickness and death, as well as the intense pressure cause not an insubstantial number of students to drop out.

And of course, once the weary student actually graduates, they get plunked on the head by residency.  When a patient enters the office of an attending physician, they step into the workshop of one whose abilities have repeatedly been stretched to the breaking point.  Yet still, few who inhabit the exam room would be called true masters.  In medicine, mastery and perfection are unreachable ideals.

This is why so many of our best and brightest enter the field.  It is like food to the hungry, water to the desert.

So it would take a truly twisted soul to suggest that what's needed in modern day medicine is more complexity.  Somehow, however, this is exactly what the government and reformers are suggesting.

Instead of searching through computer screens, we should be looking people in the eye.

Instead of trying to remember meaningful use criteria, we should be thinking deeply about our patients.

We are taking infinitely complex processes and adding new layers.  We are wasting our scarce resource, brain power, on paper work.  Our numbers may look great, but care is suffering.

That's the funny thing about the term "meaningful".

Perspective is everything.

Friday, July 13, 2012

The Clock Is Ticking

He reclines in his office with his shirt unkempt and bulging from his low riding trousers.  His cup of coffee sits on the desk, but if you look from exactly the right angle, you may imagine it floating from the bulbous pannus that abuts the blotter.  His lab coat is frayed and creased.  A stain lies below the breast pocket, the remnants of a malfunctioning pen.

His voice is confident and gruff.  The steadiness makes one sure that he is used to giving orders without apology.  He fiddles with the phone and taps his feet impatiently.  His eyes role towards the ceiling as he absentmindedly interrupts the inferior voice on the other side of the line.

He blows his stack often.  In fact, so often that his staff makes sure his blood pressure pills are awaiting at his desk every morning.  He has had a heart attack, or angioplasty, or CABG.  Even though he has survived his own health catastrophe, he still asks the drug reps to bring greasy fried food.

He remembers a time when during residency his attending put a cigarette out on a ventilator while discussing a patient.  Maybe, he even did it himself.

He is a curmudgeon.  He is a relic.

It is easy for today's society to turn our heads embarrassingly away from such a caricature.  Yet for decades his patients swore by his accuracy and skill.  His rough exterior melted away when confronted with a sickly grandparent, or holding the hand of a grieving family member.

He is a man of contradictions.  He is a dying breed.

Take a close look if you will.  Whether you think he is a work of art, or a reflection of our jaded history is totally irrelevant

His day has passed

Thursday, July 12, 2012

Sofia Was A Win

Sofia was a win.  She came to my office because she felt that her previous doctor was not careful enough.  And indeed, upon perusing her past medical records, I noticed a blip on her cat scan that he had failed to follow up.  Months later after surgery and chemotherapy, she returned with a broad smile on her face.  The oncologist and surgeon told her that I saved her life.  They explained that the only reason she survived this cancer was because of such early detection.

I basked in the glow of Sofia's success.  As physicians, we face death and destruction on a daily basis.  It feels quite gratifying when outcomes are better than expected.  Over the years, and many visits, we formed a bond based on trust and familiarity.  We struggled with some issues, and sailed through others.

It would have never occurred to me to describe Sofia as anything other than a highly satisfied patient.  So when I decided to change practices and physically move twenty five minutes north, I had no doubt that she would follow me.  After all, I had one hundred year olds willing to hobble along on their walkers to make the extra trip.

I remember the last time I saw Sofia in the office.  She took my new business card and told me that she would call in a  few months.  She never did.  Eventually, realizing her absence, I left a message on her voice mail.  Several calls later, her husband picked up and explained that the twenty five minute drive was too far.  She would rather see one of my old partners at my previous location.  I was stunned.

There are dark times in medicine.  Times when I sit in my office long after all the patients and staff have left.  Alone at my desk in the solitude, I occasionally torture myself with the existential calculus of a life lived in service.  I tabulate the wins and losses in neat but strikingly asymmetric columns.  Everybody dies eventually.

Years later Sofia's face often comes to mind. 

With a pang of sadness it always ceases to be professional,

and becomes overwhelmingly personal.

Tuesday, July 10, 2012

A Tragedy Based On Administrative Decisions

I gently rotated his arm as the beads of sweat formed on his forehead.  The pain came in waves.  His face contorted and relaxed in repetitive spasms.  I wondered if my exam was in vane.  The cancer had spread from his lungs to his liver and into his bones.  Once the blood stream had been tainted, the aggressive cells took flight and landed in various organ systems. 

We already had the conversation.  I checked the boxes off on the POLST form. 

X Do Not Resuscitate
X Do Not Hospitalize
X No Artifical Nutrition

Yet the hospice team had come and gone, and he refused to sign the papers.  He looked me forcefully in the eyes as he spoke.

You'll take care of it!

But I was starting to feel his confidence was misplaced.  Day after day, I returned to the nursing home to find that our plan was failing to control his late afternoon pain.  Escalating his narcotic dose only provided incremental benefit.  Topical therapy, heat, and message were adding little.

It was only after a week of failed attempts that he pulled me aside and quietly explained his hypothesis.

It's the physical therapy, they're pushing me too hard in physical therapy!

What? I almost fell off my chair. I couldn't help my voice rising in frustration.

Why the heck are you doing physical therapy?

He took a deep breath before answering.  I could tell he was getting tired of my daft intellect.

Because the hospice people told me if I stopped doing physical therapy, I would be dropped from my medicare days and would have to pay my own room and bored.  And then the physical therapy people told me if they don't push me hard enough, I will fail to make enough progress and will also lose my funding.

And like a blind man whose cataracts had just been removed, I once was lost but now could see.  He would live out his last hours struggling through futile physical therapy and in constant pain.  But he would labor selflessly to spare his family the financial burden.  He would expend more of medicare's resources than if he had just been covered under hospice, and would die sooner and in greater pain.

A tragedy based on administrative decisions made by nonclinical staff working for the government.  The pleas of those in the trenches have been ignored.

These silly rules are killing us:

financially and physically.

Sunday, July 8, 2012

The Moments That Test Us

In the process of becoming a physician, I've seen unspeakable horrors.  I watched as the ER trauma bays filled with mangled bodies fresh from a multiple car pile up on the expressway.  I felt the splatter of blood on my surgical gown as an abdomen was opened to expose a bleeder.  I have been vomited on, urinated on, and spit on.  We in the medical profession expect such things.

The physical trauma can only be matched by mental anguish.  After countless hours of uninterrupted work, I have looked into the eyes of a family member and delivered bad news.  Each evening of my career has been punctuated with a series of "what ifs".  Sleep becomes a temporary respite, a relief from the repetitive stressful moments of every day.

So it is safe to say that after a decade in the business, there really is very little that shakes me.  I find it laughable when a patient apologizes for unshaven legs or bad breath.  Most of the time I don't even notice.  Certainly it doesn't have a lasting effect.  

But I will never forget the day that almost broke me.  I shudder, shudder as I put these words on the page.

Her name was Alice and she was a slightly spacey, if not a harmless middle aged woman. She worked as a secretary in a business a mile away from my building.  Although she had a car, she often liked to walk to my office as a form of exercise.  A somewhat harmless, if not healthy life choice, it was almost the cause of my very real demise.

It was a scorching hot day in the middle of July.  Alice, who had gotten delayed in her office, slipped off her high heals and quickly laced up a pair of gym shoes for the trip  to our appointment.  She paused briefly when she realized that she forgot a pair of socks, she would have to do without them.

It only took a few minutes of walking briskly under the unfaltering sun for the sweat to pour from her slightly rotund body.  It wended its way down her legs and settled into the cheap canvas that held in her bulging feet.  She reflexively wiped at her forehead with a tissue as she made her way into my building.

A few minutes later, my medical assistant knocked on the door and let me know that Alice was ready.  She chuckled and her mouth twisted into a smirk.

Good luck.

Upon entering the room, I felt my nostrils start to twitch.  I inhaled briefly and then the air caught in my nose.  I began to choke.  The fetid smell of sweaty feet wrapped in musty cloth hit me and knocked me over.  I grabbed at my face and stepped quickly out of the room.  By this time, my medical assistant was standing down the hall.  She giggled and pointed at me with the secretary.  I took two deep breaths and then walked back into the room.  I sat at the desk and spoke carefully trying not to inhale.

Hello Alice, what can I do for you today?

My mind raced as I waited for her response.  Please be a sore throat!  Please be a runny nose!  She looked at me coyly.

I have an itch. Down there!

I almost fell off the chair.  Any physician out there will know that doing a pelvic exam is one thing, but putting her on the exam table and placing her bare feet in stirrups right on the level of my nose...

Let's just say I can't talk about what happened next.  It's locked and buried deeply in that place in my psyche that I don't allow myself to go.   I tried to escape to my happy place, but now I can't go there ever again.

She had a yeast infection.

The moral of my story is a simple one.  Your doctor doesn't care what you look like, whether you are groomed, or what kind of clothes you are wearing.

But if your feet evoke more fear than your privates,

please wash them before coming into the office!

Saturday, July 7, 2012

Dying Of The Light

I read the letter incredulously.  The writer was a medical school administrator and had seen my poem published in The Annals Of Internal Medicine.  He was hoping I would send a few dozen signed reprints for him to share with the medical ethics class he taught at the local university.  I carefully fingered the paper and then threw it onto a pile of unsorted mail.  I felt a mixture of excitement and shame pulse through my body.  Somehow I knew that I would never send the reprints.  I would make up some lame excuse like I didn't have the time, or didn't want to spend the money on the prints.  But in reality, I knew the truth.  I felt a strange sense of awkwardness about acknowledging such naked praise. I hate making a spectacle of myself.

As a child, I remember trying to avoid the limelight.  Nothing made me more uncomfortable than my own birthday or graduation party.  Growing up in a large gregarious household, I felt best when I was observing from the corner, away from the spotlight. With the passage of time, I learned to raise my voice and assert myself.  Yet, I still felt shame discussing my own accomplishments.

Years later, I realize, that for a person with such qualities, becoming a physician was a perfect fit.  In what other field does one so naturally sublimate their own identity?  We seek not the praise of our accomplishments but the health of our patients.  At the beginning of our careers we take an oath not to forward our own personal needs but rather to do no harm.

Even in training, we learn the art of self abrogation.  We abandon our families to spend countless hours in the hospital for minimal wages in the service of humanity and the learning of tradition.  We donate our time and energies to staff free clinics and provide for those who are less fortunate.

And when we hang out our shingle and become engrossed in the business as well as the practice of medicine, the majority of us still feel a certain sense of humility.  We take a loss on various procedures because it is the right thing to do.  We write off our patients debt when they are too poor to pay their bills.  And it is a rare day that a truly needy patient is turned away at the door, despite the inconvenience it causes.

We imagine ourselves as servants regardless of society's point of view.

So it comes with little surprise that the heads of physicians are on the chopping block in today's health care reform climate.  Indeed, physician advocacy groups applauded the supreme court's recent decision to uphold the ACA even though it may well sound the death knell for the modern practitioner.  How indeed could the AMA or the ACP deny a plan that would bring health insurance to countless millions of uncovered lives.  It would be down right unphysician like.

Yet strangely, we require such a greater burden of proof for our own medical treatments in contrast to the sweeping changes that reform promises.  We accept accountable care organizations and patient centered medical homes without a shred of evidence that they are beneficial.  We defile the doctor-patient relationship and bastardize the residency training process because it's easier to accept than to stand up and advocate for ourselves. 

It is easier to let the nobility of our profession melt away than to call attention to our own needs.

The politicians and insurance companies don't have such qualms.  The pharmaceutical companies and leagues of government administrators don't face such psychic doubts.

We are witnessing the dying of the light.

And we have no one but ourselves to blame for it.

Friday, July 6, 2012

Lawrence Spann Review Of My Chapbook "Primary Care"

I was honored to have Lawrence Spann review my chapbook, "Primary Care".  Because of technical issues, his words were not included on the publisher's website or on the cover.  His time and commitment are much appreciated.  Without further ado:

There is no one else writing like Jordan Grumet today. And how desperately we need a physician who humanely approaches doctoring through his eyes with moral sensitivity and the surgical language of a poet. My question is how does he do it? I know many doctors and work with them everyday. I felt the same way some years back when I came upon Jordan Grumet's poem "Fake" in the Journal of the American Medical Association. I published it in an anthology because I though it spoke so clearly to my own experienced working with physicians. How delighted I was to read his new book and find indeed that this theme is central to his work. Dr. Grumet exposes the heart of the American Physician. He allows us to hear the inner workings and strain. He allows us to enter into what it takes to keep a doctor going to work each day. Dr. Grumet is a rare find, like Celine or like Camus' s Dr. Bernard Rieux who endeavors to relieve human suffering in spite of the odds.

To order a copy, please email me at grumetjordan(at)yahoo(dot)com.

Thursday, July 5, 2012

A Blink Of The Eye

What does a young doctor know?

You scowl at me across the examining table suspiciously.  And indeed, the occasional spasms of pain that jolt my back are nothing in comparison to the strangling vines that form a vice grip around your lumbar spine.  I have diagnosed stenosis thousands of times, but never tasted the bitterness of singed nerves roasted on burning coals.

You hold your chest in agony, and I can only compare to the fleeting fire of bronchitis.  I have studied the inflections of countless electrocardiograms, but coronary artery disease for me is still just a conception.  I can't really tell you how it feels.

Yet there are things that you don't know.  I have endured loss in all it's various manifestations.  I stood by while death snuck up and smite it's foe with little warning.  I paused for what seemed like years as the grim reaper danced a slow and elegant waltz in my direction.  I have been acquainted with almost every form of pain and suffering.  And unlike you who lived all those years in sweet oblivion, I know exactly what awaits me.

We all walk down the same narrow precipice.  Although the paths may vary, missteps are common and many vines are dressed with thorns.  You may be a blink of the eye ahead and I a foot fall behind, but none of us escapes unscathed.  None of us.

Maybe it would lessen your burden to know that we are all in this together.  Maybe you will see the situation as I do.

The difference in years need not form an insurmountable divide.

You and I are much the same.

Wednesday, July 4, 2012

Some Thoughts On The 4Th Of July

I don't remember my father's birthday.   I don't remember the date of his death.  These are secrets that are locked away in the heart of a little boy.  But there is one day, each year, that I wake up thinking of my dad.  Every July 4th I spend the day lost in a cloud of nostalgia.  It is not only the recollection of parades and cookouts, but also connected to some of the few memories I have left of my short time with him.

Every year in Evanston, Central Street is roped off for a mile and a half stretch between Bent Park and the Northwestern football stadium for the annual parade.  I remember as a five year old driving from lamp post to lamp post down the street with my dad.  On each block, he would get out of the car and stand a ladder against the post.  I would hand him the two large flags, and he would climb up and perch them above the street.

Later that year, after the parade, the kids gathered in the back yard for fireworks smuggled in from Wisconsin.  After a few small ones, my dad lit what looked like a small bomb, and ran to the corner of the yard.  The blast was so loud and the power so great that it blew the glasses right off his face.


Year after year, I make the pilgrimage to the Central Street Parade with my family for at least a few minutes.  I won't lie, I have occasionally missed here and there.  But every morning, I wake up with a clear plan in my mind.

This year will be different.  My son is now old enough to be busy with various after school and summer activities, and for one of these, we both have been asked to walk in the parade. Although I have promised him I would, I can't say I'm excited about it.  The ninety degree heat and soaking humidity notwithstanding, I feel a certain sense of betrayal towards my father.  This is not how we celebrated!

The indignity of death is that memories fade.  Now as a father myself, I will create new traditions with my son and daughter.  I fear that as I grow older, when I think of July 4th, I'll remember the day I walked in the parade with my son and not the fleeting moments I have left of my dad.

When you become a parent you learn to sublimate your own needs.  You let go of a bit of your dreams to help your hapless offspring fulfill theirs.  As I walk the parade with my son this afternoon, maybe I will have more in common with my father than before..

Maybe, I will be even closer to him.

Tuesday, July 3, 2012

The Depths Of The Ocean

I could taste the frustration and anger.  I walked out of the room instead of saying something I would regret.  My patient was dying.  She had cancer riddled throughout her body.  Her kidneys and liver were failing.  Every ounce of medical knowledge told me that she would be gone in days.  But she refused to hear it.  She didn't care if it was futile, she wanted to go to the hospital. She wanted IV's and cat scans, chemotherapy, and radiation.  It mattered little the physical and emotional toll it would take on her.

My anger quickly transformed into shame and guilt.  Could I blame her for hoping to prolong the inevitable?  Just as I couldn't see the world through her eyes, she couldn't step into my shoes.  She had no idea the horrors that awaited her.  She had not watched helplessly by the bedside as torture upon torture was practiced on a beloved patient.  But I had, and it scarred me.


We talk of burnout as if it is a single event.  One day the doctor was happily rounding at the hospital and the next day boom...he turned bitter.  But those of us who have trudged through medical education know the fallacy of such arguments.  Our profession struggles not with the ebb and flow of the current but rather with the depths of the ocean.

The process of becoming a physician is marked by the diminution of the stress response.  We become so overwhelmed by intense, prolonged stimulation that the signals our patients send are no longer recognized as abnormal.  We are habituated to pain, dulled to suffering, and downright unsympathetic at times.  We have lost the ability to walk a moment in someonelse's shoes.

And in some ways, I truly believe that this is the pound of flesh that is extracted for the privilege of wearing the stethoscope.  But this loss comes at a price.  Physicians become depressed, leave the profession, or continue to practice on auto pilot.


One day, I woke up and realized that my brains are full of knowledge, my hands full of skill, and yet a small part of my soul is gone.

And sadly, it was that part that drove me to medicine,

that part that used to make me feel so special in the first place.

Sunday, July 1, 2012

A Post #TheWalkingGallery, @ReginaHolliday

We walk.

Sometimes we crawl.
Through surgery, chemotherapy, innattention, mistakes,
and the moans of our loved ones.
Bent over, we carry the load on our backs,
hunched, we cover the scars with cloth.

We walk.

Somwetimes we run.
Through hospital corridors and exam rooms.
We carry our patient's pain in our shoulders,
hidden underneath the lanky arms of lab coats.

We walk.

Sometimes we jump.  Our heads held
high in advocacy.  We blog, we tweet,
we shout.  Until others cover their ears.

We walk.

Our bodies as poetry in motion.
We no longer carry our hearts on our sleeves.
We carry them on our backs.

We Are The Walking Gallery