Tuesday, October 30, 2012

Some Things Must Be Learned On One's Own

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

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

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

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

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

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

Strangely enough, I still question when to intervene.

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

Sunday, October 28, 2012

Stand Up And Deliver

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

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

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

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

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

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

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

We need to deliver in both life and death.

Tuesday, October 23, 2012

The Secretary Executives

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

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

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

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

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

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

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

We have become everything we aimed to avoid,

the secretary executives of a failing system.

Saturday, October 20, 2012

Work And Life Enmeshed

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

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

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

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

My job has become my life's work. 

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

Wednesday, October 17, 2012

Dream Catcher

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

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

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

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

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

I try to capture the gift.

The gift that each soul has left behind.

Monday, October 15, 2012

You Plant Tulips

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

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

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

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

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

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

It took less than a second for everything to change.

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

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

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

You plant tulips.  You get tulips.

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

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

Saturday, October 13, 2012


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

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

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

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

Dr. G, I'm having chest pain!

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

You're gonna be just fine!

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

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

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

Eat well.


Don't smoke.

Drink a little alcohol everyday.

Cut down on stress.


Do something selfless to further mankind.

Wednesday, October 10, 2012

Mistaken Youth

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

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

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

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

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

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

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

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

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

A decade after graduating residency, I felt old.

Physically and emotionally.

Sunday, October 7, 2012

Who Needs Us Anyway?

What's this?

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

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

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

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

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

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

You doctors think your so important!

Who needs you anyway?

Saturday, October 6, 2012

Wisdom, Action, And Planning

Drip. Drip. Drip.

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

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

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

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

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

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

Planning and action.  Action and planning.

Have we lost the wisdom to discern the difference?

Thursday, October 4, 2012

Maybe She Was Right

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

From time to time it happens anyway.

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

I'm not taking any chances!

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

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

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

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

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

She was truly being cared for.

Wednesday, October 3, 2012

Let Sleeping Dogs Lie

I'm sorry!

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

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

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

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

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

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

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

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

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

and told you he was giving up on you.

Monday, October 1, 2012

What Happened To Hope?

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

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

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

I began to wonder, what happened to hope?

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

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

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

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

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