Monday, December 7, 2015

What I Believe The Public Should Know About Clinicians

The daughter of the patient walked out of the room livid.  She was convinced that the nurse had no business taking care of patients.  She seethed as she recounted all the supposed injuries and mistakes that had occurred.  I took a deep breath and paused for a moment, trying to collect my thoughts.

The daughter didn't know that I had watched this same nurse successfully perform CPR on a man the day before, and her quick thinking was one of the factors that save his life.  She had once recognized a rare side effect of a medication, and solved a clinical mystery that had hounded doctors, hospitals, and pharmacists for months.

In my mind, she was the best that clinical medicine had to offer.  Knowledgeable, kind, intuitive.

But this trend has been escalating over the last few years.  Patients and families wagging their fingers and nodding their heads angrily in the direction of clinicians.  Doctors, nurses, and therapists have been accused of being incompetent, lazy, or downright cruel.

There is a basic loss of faith in the ability of our healthcare practitioners.

I think that the Internet plays a role.  The ability to Google one's symptoms and come up with a host of diagnoses has made the populace feel that medicine is easy.  Furthermore, the lay press and some of our own physicians and administrators decry the system as befouled by errors.  They say that we account for as much death and disability as heart disease and cancer.

While I believe that medicine requires a continuous and stringent effort to improve itself, I also think that the populace is becoming progressively fooled and brain washed.

Here is what I think the public should know:

1)People die, for the most part, because they are sick.  Yes medical errors occur (even to healthy people).  But medical errors happen more often in deathly ill, hospitalized patients, with poor prognoses to start with.  The more ill the patient, the more complicated the care.  More medicines.  More tests.  More risky procedures.  More errors.  This doesn't mean that we must not strive to do better.  But all those articles about how "hospitals kill more patients than..." are ungenuine.
2)Complications are not errors.  A small percentage of people who get colonoscopies will have the unfortunate complication of perforation.  They may even die from it.  This is expected.  Same for post surgical deep venous thrombosis.  Same for deadly side effects of medications.  There is a cost/benefit ration.  We can do our best to mitigate risk, but we can't avoid poor outcomes altogether.  It's like a reverse lottery.  The grand majority do just fine, but occasionally there is a big loser.
3)A text book presentation of a disease is very rare in clinical medicine.  It happens infrequently.
4)Physicians are some of the most highly trained individuals in society.  Our education is arduous and can span more than a decade.
5)Medicine is one of the most researched fields known to man.  Billions are spent every year improving our clinical knowledge.  Our ability to treat cancer, heart disease, and injury is far better than it was even a decade ago.  Patient safety is, and has been, at the forefront of researchers minds for years.  We are making great improvements. Think anesthesia, hospital acquired infections, and surgical check lists.
6)physicians have active and time consuming requirements for continuing medical education and board certification. Greater, I believe, than almost any profession.
7)The legal system holds physicians to a high standard and the penalties can be life altering for the involved clinician.  The grand majority of physicians are sued at least once during their career.

In summary, medical practitioners are highly trained and skilled individuals who are plugged into an incredibly regulated and researched domain of human existence.

To treat them as if they are stupid or ignorant is unkind, to say the least.

Wednesday, November 25, 2015

The Anatomy Of A Home Death Without Hospice

Although his family was convinced that it was the metastatic prostate cancer that would eventually lead to his demise, I had my doubts.  His dementia had progressed to the point that he spent all his days in bed.  He could no longer navigate the most simple activities of daily living.   His caregiver fed him, dressed him, cleaned him up after he went to the bathroom.

I visited him in the home.  

We met eight months before his death.  His wife, two daughters, and I.  We discussed what dying looked like.  We talked of dignity, and what decisions he would make if he had the ability to rationalize his current situation.   We talked of dementia and how it eventually robbed it's victims of the ability to protect themselves from infection, aspiration, and bed soars.

They wanted him to continue seeing the oncologist and take the monthly shots that were possibly keeping the cancer at bay.  They wanted antibiotics and blood tests, but agreed to look over the POLSTt form that I brought them.  We discussed what would happened if his heart stopped, or he stopped breathing.

A few weeks later, I came back to look in on him.  The daughters were not present but his wife handed me the completed POLST form.  Heroic measures would not be necessary but antibiotics and lab tests were ok.

I examined my patient.  He no longer recognized me, but answered my questions as he was able.  His fingers had begun to contract, and there was the hint of a pressure sore on his back side.  I educated his caregiver on positioning techniques and placed the POLST form on the refrigerator where all could see.

Five months before his death, he became more confused and his urine developed a foul smell.  I came to his bedside and obtained his vitals.  The blood pressure was strong but the heart rate had risen.  We sat again, his family and I, in the living room and hashed out the details.

He had a urinary tract infection and was becoming septic.  We reviewed the options and eventually it was decided to try oral antibiotics at home.  Unlike his previous episodes, there would be no hospitalization this time.

Three months before his death his mental status became progressively worse.  He refused to take his medications and would often pass on meals.  He occasionally spit his food back at the caregiver.

Again we huddled in the living room.  They were not emotionally ready for hospice but yet were reticent to send him back to the hospital or check more tests.

He somehow made it to one more oncology visit.  His labs were strikingly normal.  He even woke up for the trip and put on a good show for his doctor.  But by this time he needed such extensive assistance to get out of bed and into the car, that even his daughter who was in quite a bit of denial about the current situation couldn't fail to see how far his state had progressed.

A few hours before his death his wife called to tell me he was having difficulty.  She held the phone up so I could hear the undeniable rattle of Cheyne-Stokes breathing.  I told her that he was dying.  That she had to make a decision to call an ambulance or to let him go peacefully at home.  I told her that this was what all our conversations had been building up to.

She hung up the phone and called her daughters.  A few minutes later, they were all by his side.  His daughters arrived in time to be present for his last breath.  Calm, quiet, uneventful.

I certainly wish they had allowed me to get hospice involved early, to make sure that appropriate meds and training had taken place.

But that was not their wish.

And it all turned out okay in the end.    

Tuesday, November 17, 2015

Be The Protagonist

I have said many times that we tell the stories about our own lives that make it bearable, or better yet magical, mystical.  I often use the death of my father as an example.  I was eight years old when he passed away.  Instead of embracing his premature demise as the greatest tragedy of my life, I credit this misfortune with my decision to pursue a career in medicine, and hopefully touch countless lives.  Reframing of my childhood has allowed me to feel like I grew up privileged.  Even lucky.

It has occurred to me recently that such story telling does not only have to be reserved for interpreting the past.  In fact, it is the present, and even the future that could also use a certain recalibration of lens.

I think that we, as human beings, struggle with happiness from day to day.  We bounce from stress to joy to tragedy.  We slog through our jobs, relationships, and financial issues and think little about how  our own thoughts lead to even greater distress.

I have decided to try to take a different path, and become the protagonist.

When facing the hardships of life, I am going to reframe my vantage point.  Like any good book or movie, most conflict can be distilled down (or blown up) into a battle between good and evil, right and wrong.

When you envision yourself the protagonist of this epic battle, you automatically view yourself in a different light.  For instance, the protagonist, from the outset, is innately good and virtuous.  It is the nature of the role even before any action takes place.

Furthermore, when you take on this persona, you hold yourself and your actions to a higher ethical standard.

No matter the outcome, win or lose, there is a certain glory in being the protagonist.  Success, against the odds, is expected.  And failure, even at it's worst, is filled with honor and humility.    

The role of protagonist could embody our best and most virtuous intentions.


Saturday, November 14, 2015


I have been thinking a lot lately about a dream I had as a first year medical student.

My father is standing besides my brothers.  We’re all building.  Putting the pieces together.  But I’m stuck and no longer making progress.  My mom stands besides me oblivious to my turmoil.

Does she know what I’m thinking?  This must be a dream because we are grown up now, and dad died when I was eight years old.

Although everyone’s building, I can’t.  I watch the way my father moves.  Somehow, I know this will be my last chance to see him again.  I’m afraid because over the decades his memory has faded so much.

But here he is in front of me.  I try to distill his essence, but it hurts.  I start to shake and bend over in pain.  I weep.

Mom turns to me and glares.  She’s the only one that notices.

”Tell him, tell him!” she urges and then turns away.

I crouch besides my dad while he continues to build.  I whisper softly in his ear.

”I will miss you dearly when you are gone”

These are words an eight year old never knew how to say.  But now, now I know

He turns around and smiles  He then holds me.

”I love you” he says

But I am too overwhelmed to speak.  Which really doesn’t matter.  He understands.

I hear voices, spirits, coming to take him away.  He holds my mom’s hand and she walks him to the door.  My brothers and I continue building.  But now we are joined by my wife and kids.

We continue building our lives.

As we work, I tell them we have to stick together .  We have to talk to each other.  My son and daughter look up inquisitively and ask me if I am okay.  I'm not a twenty two year old medical student anymore more but a forty two year old husband and father.  Yet with complete certainty, I answer the same way.

No.  No.  I am not okay.

I take a deep breath.  Put my head down.  Start all over.

And begin to build again.

Friday, November 6, 2015

For The Most Part, We Get It Right.

I have two refrigerators.

The full size, expensive version, sits in the usual location in the kitchen.  The small black one rests idly in the basement.  Excluding this morning, of course, when I dragged it up the steps and begrudgingly coaxed it back into action.  Let me explain.

Six months ago my old refrigerator started acting up.  Somewhere around year five, it’s motors groaned, its coolers moaned, and all the sudden the food started to smell.  So I called the repairman and hundreds of dollars later, it worked like a dream.

Until it didn’t.

The repairs held for all of a week.  I called the repairman back.  And we danced this dance a few more times.  In the meantime, I ran out to the local appliance store and bought a mini fridge to store my food.

I lived out of that little black fridge for weeks while workmen came and went.  Every time one problem was fixed, another popped up.  Eventually I bit the bullet, returned to the appliance store and brought a brand new, state of the art, full sized refrigerator to replace the old.

I happily returned the black fridge to the basement and thought little about it again.  For six months my new appliance worked exactly the way it should.  The ice bucket was always full.  Each zone maintained the correct temperature.  I had separate drawers for the fruits, vegetables, and dairy.

I thought I was truly on the pathway to appliance nirvana when the unexpected happened.  I awoke one morning to fine a horrible sound coming from my brand new refrigerator.  Hours later it was dead.  My ice cream melted and my vegetables wilted.

I called a different repairmen who showed up promptly, and fixed the problem in short order.  Money well spent, or so I thought, until the same exact scenario played itself out forty-eight hours later.  

Another trip to the basement, and the little black refrigerator has once again taken up residence in my kitchen.

This experience is nothing new.  I can’t count how many times a television has broken, an Ipad has malfunctioned, or a dishwasher latch has busted.  Each time I dutifully call an expert who sometimes gets the job done.  But often the repair  unravels or the machine is deemed DOA and unable to be fixed. 

This often makes me wonder why we expect so much out of our doctors.  The human body is far more complex than any electronic.  The number of moving parts measures in the millions.  And god knows how personal psychology plays into the range of pathology.

And for the most part, us doctors, get it right.  Eighty to ninety percent of the time.  Day after day, year after year.

I wish I could get this kind of service with my appliances.

Tuesday, October 27, 2015

Empathy: Are We Asking For Too Much?

As my daughter approached the stage toting her miniature violin, I could feel a flutter in my chest.  My palms were sweaty and my feet started to tremble.  I hesitated while she played the first note.  My heart soared with each rhythmic movement of her bow.  I caught my breath when she reached the most difficult portion, and exhaled calmly as she nailed it.  At the end, I elatedly stood and clapped with the rest of the crowd.

I have learned just about everything I know about empathy by being a husband and father.  In no other relationship have I so acutely felt the joys and pains of another person.  Triumph, despair, guilt, surprise.  Each emotion transcending the flesh and glomming on to those in closest proximity.

But empathy, like parenting, is hard.  You have little say over what befalls your children from day to day, yet feel each painful barb.  The loss of control can be maddening for those practiced in manipulating their surroundings.  You wear your heart on your sleeve unprotected.  I suspect this is one of the main reasons many decide not to procreate.

So I find it rather ironic that we stress empathy as a character trait to idealize in our physicians.  Few among us have the emotional fortitude to process such tumultuous emotions on a grand scale.  I dare say the majority of human beings would be paralyzed by the difficult and frequently overwhelming nature of illness.  Everyday.  With every patient.  All the time.

Empathy is an act of selflessness given as a gift to those we love most.

I think it is time to ask our doctors for what they are capable of.

Kindness, patience, humility.

And occasionally.  Very occasionally.


Tuesday, October 20, 2015


It was a little game we played.

My shoes squeaked quietly down the hallway of the nursing home as I approached her room.  I knocked gently trying to avoid any particular rhythm or dissonance.

Go away!

Her voice was at once stern, and then followed by peels of laughter.  She only saved such greetings for me.  And I tried to trip her up.  I varied my visits by time and pattern.  Sometimes I knocked, and others I would call out in a distorted voice.  She always knew.

She was recovering quickly and would be discharged soon.

The rest of my visits that day were not as positive.  The gentleman next door was concerned with service issues.  He decried the quality of the food, and demanded a faster response to his call light.  I didn't have the heart to explain that as the physician, I had little control over these issues.

The woman on the floor above was dying a slow, uncivilized death due to Alzheimer's.  I huddled with her family, and discussed the gruesome details.  Her body was fading away much in the same way as her mind.  She lost every ounce of extra weight.  Her voice had diminished to a nonsensical whisper.  She was no longer capable of making the difficult decisions that were left to her befuddled family.  They signed the necessary paperwork with both hope and sadness.  Hope that the end would ultimately be dignified, and sadness that her time was indeed near.

Cancer is an ugly term.  But it was chemotherapy that sickened the young man at the end of the hall.  He spent a week in the nursing home between hospitalizations.  His family couldn't manage the vomiting and intravenous fluids.  He peered through the window at the first ray of sunlight on a cold winter's day.  He didn't feel much like talking.

I left the facility two hours after stepping foot into the front atrium.  I felt as if I had already been working a full day.  But there was a certain lightness nonetheless.

Because just before leaving, I crept up to her door, knocked yet one more time, and waited gleefully.

Come in.

I paused for a moment and then joyously replied.


I could hear her laughter echo past me and through the hallway as I exited the building.  

Tuesday, October 13, 2015

Just Be

It all started with the tip of my tongue.  Really.  I was chewing on dark chocolate chocolate chips with a vigor that was maybe a touch inappropriate for such a snack.  I bit down firmly and felt immediate pain sear through my mouth where the tooth overzealously punctured the soft tissue.

I bit my tongue.

Which wouldn't have seemed so calamitous if it had not been one of many bodily malfunctions that had recently befallen me.  A growth the size of a marble called a chalazion has grown under my eye lid.  My hairline continues to recede.  All of the sudden, out of nowhere, I have acne far surpassing that which befuddled me as a teenager.

My joints hurt every time I exercise.  My ankle now makes a clicking noise while jogging.  The connective tissue holding my abdomen in place has started to falter.

Time is passing.  I am getting older.  Yet my mind has thankfully lagged behind my body.  I wake up each morning feeling like a much younger man.  There are a thousand tasks to be performed, a thousand opportunities, and I chase after each one of them.  Enthralled by the possibilities, I rarely stop running until the day is over and I collapse into bed.  Six hours later the alarm sounds, and it starts again.

This makes me happy.

For the most part.  The problem that comes with an awareness of the possibilities is the realization that time is finite.  There are projects that I will never finish.  Relationships that will never be rekindled.  The past is gone and the future diminishes even as these precious moments pass.

And just when I seem to have gotten myself into lather, I feel a soft tugging on my shirtsleeve.  I peer down into my daughter's soulful brown eyes.

Dad, dad, you're spacing out again.

My son is dancing a silent jig on the other side of me, listening to music that only he can hear.

They both need me so much right now.

Maybe it's time to give up on all this thinking.

And just be.

Tuesday, October 6, 2015


It hit me today while on hold with an insurance company to get a preauthorization.  The call took thirty minutes.  The medication was denied.  And I knew that I was going to get an earful from the patient when I delivered the bad news.  As I dialed the phone number, a disturbing and yet all to familiar feeling overtook me.

Helplessness, powerlessness, impotence.

I struggle with these feelings daily.  In the beginning of my career, they were spurred by the complexity of disease, the willfulness of bad luck.  Battling the human condition was a long, difficult slog fraught with trap doors and missteps.  Many patients improved, but others suffered.  And I often suffered with them.

Years of practice brought a hard earned humility, the wisdom of acceptance.  I learned to rejoice when interventions were beneficial, and comfort when a kind heart was all I had to offer.  I felt great peace in this middle ground.

These were the battle scars that I carried proudly.  My wariness was never a sign of failure, it was the toughness and patience developed by the skilled art of warfare.   I wore my badge proudly.

Yet these feelings have returned, even more powerful than before.

My enemy, however, is no longer the thoughtful, wily adversary of the past.  Instead of the foibles of humanity, I am hereangued with a litany of administrative tasks with no trace of nobility.  Preauthorizations, face to face, peer to peer, meaningful use, ICD, CPT.  The list goes on.

A long line of administrators, insurance employees, and government workers await my attention.  They tell me that my care plans are incorrect.  Improbable.  Not covered.  Out of the question.

And as my blood pressure rises and my temperature boils, I see no silver lining.  No lesson learned.  

I always expected that I would be bludgeoned by the awe-inspiring task of practicing medicine.

Not broken by a thousand, tiny, thoughtless insults.

Tuesday, September 29, 2015


He squeezed into the elevator just as the door was closing.  There was a lightness about him, an excitement.  His jacket was newly pressed and uncomfortably free of nicks or stains.   He stood at attention with perfect posture.  There was no sign that working at this early hour on a Sunday morning, nor even being awake, was something out of the ordinary.  Extraordinary.

He glanced over at my tattered lab jacket without trying to seem obvious.  I'd like to think that it was the gray color (as opposed to his white) that gave me away as an attending physician.  More likely it was the telltale signs of aging that I have been doing my best not to notice.  I slumped against the back wall and waited for the doors to open.  My eyes flickered and closed for a moment, but opened quickly.

I was drawn to him.  The energy emanated from his body, and pinned me into the deepest corners of the elevator.  I couldn't decide whether to envy or pity him.  A young intern, he was at the mere beginning of his medical journey.   He couldn't yet fathom the degree of wonderment and heartbreak he would experience over the next few years.  The joy and the guilt.  The triumph and the disappointment.

There is a whole world ahead of him.  A world I have become strangely accustomed to.  Racing into the hospital on a Sunday morning is no longer novel or extraordinary.  It is part of my weekly routine.  I get up early and round at the hospital and nursing homes in order to be back home before the kids awake.  There is no excitement.

No wonder.

Instead there is a gentle quietness.  A certainly that comes from years of sparring with health and disease.  An acceptance of both the hardships and joy involved in spending one's time contending with the human condition.

As the door opened, I awoke from my reverie, and sprung towards the hallway and the ICU.  I patted him firmly on the shoulder as I passed by.

I caught one last glimpse of him as I turned the corner.

He was still standing in the elevator doorway,

his face a strange mix of confusion and pride.  

Tuesday, September 22, 2015


It was a short trip from the hospital to the nursing home.  I luxuriated in the mid-morning sun.  Wisps of fresh air snuck through the cracks of my barely opened windows.  Although I had just gotten credentials at this particular facility, the path I drove was all to familiar.  I turned my head as I passed the elementary school that I had attended as a child.

As I stared at the playground, a long buried memory percolated to the forefront of my consciousness. I must have been around 8 years old, a little after my father died.  I am playing by myself on the jungle gym, and glance longingly at the street in front of me. I am overtaken by a great sense of loneliness.   I want to run down the street.  I want to go home. 

"Home", at that time, was the building I lived in. 

Many years later, my mom remarried and we moved from Evanston (the city I was born in) to the neighboring town of Winnetka.  A mere 13 years old, feeling myself the center of the universe, I resisted the move wholeheartedly.  For years I mourned the departure from my beloved city.  Only a few miles apart, the emotional distance seemed immense. 

I pined for my old neighborhood.  I dreamed of riding my bike down the old streets to my favorite places.  I was so in love, that years later, I returned to build a family.   

"Home", at that time, was the town I was born in. 

As I got older, I found solace not in places or things, but in people.  My interest turned to the amorphous task of building relationships.  Acquaintances, friends, lovers.  People and personalities became a currency by which to measure happiness.  I bathed in the luscious glow of humanity.  I gave and I took.  

"Home" became the people I surrounded myself with.

Recently, I have begun to believe that "home" is something much more personal, more internal.  Maybe it is a construct based on those people, places, and things that make us feel most connected, most safe.  

And driving by my childhood elementary school this sunny afternoon, on my way to the nursing facility, which will be followed by a jog with my wife, and then a walk to pick up the kids...

I feel as if, for possibly just this fleeting moment,

I have finally come home. 

Saturday, September 19, 2015


He had been educated at the finest universities.  He had graduated cum laude, or whatever the term is they use nowadays to signify distinction.  His pedigree was squeaky-clean.

But as he haltingly entered the dark building at the end of an otherwise unexceptional suburban street, he felt more like a criminal than a scholar.  His office was drab.  Each room a glow with the artificial light provided by an incandescent bulb.  He often wondered whether the lack of windows was to keep the light from piercing the imperturbable darkness or to trap the terror in.

He knew his place.  He was the last stop on a frightful train line that ended in horror.  There was no solace.  His clients never dreamed of needing his services, and yet they came.  Without fail, they averted their eyes to hide the excruciating pain and loss.  He met them in life's basement.  In a lonesome quagmire, he helped them wade through the morass.

In his younger years. his work clung to his back even outside the office.  He awoke from nightmares of the vilest kind.  Remnants of the day stuck to his clothing.  He tried to scrub and scrub but they refused to fade away.  A sort of blackness pervaded his waking hours.

It was in this acrid garden that a certain soullessness grew and flourished.  He found that he could approach his clients with a coldness that became rather comforting.  Empathy wouldn't pull them through the manure laden pit that they found themselves trapped in.  His voice, certain and clinical, could.

As the years passed, his body bent and his haired thinned.  Years of tumult left scars that were far passed the point of healing.  From time to time he found himself wandering through the office on the weekends, or in the evening when no one in particular was scheduled to visit.

He sometimes felt lost amongst his family and friends.  He occasionally had bouts of agoraphobia at home with all the light and windows.

He left the office cautiously everyday and found the outside world to be a place that was no longer black nor white but filled with incomprehensible shades of gray.

And that terrified him.

Most of all.

Monday, August 31, 2015

If We Fight For It

It occurred to me towards the end of our conversation that there was a large gaping hole.  We had talked about physician burnout, career choices, and his current plans.  He had drawn a map of his future.   It originally shot like a straight arrow towards clinical medicine, but now veered precipitously.  I took a moment to first clear my thoughts, and then my throat.

Medicine, I explained, is still as noble a profession as ever.  Every day I dip my toes tentatively into the current that swirls around me.  Often I am pulled violently into the depths.  My body bumps and sways in the mass of humanity.  Our rhythms join at times and depart at others.  Amongst the tumult my mind strains to unlock riddles, my hands reach forward pawing the Rubix Cube of disjointed anatomy laid bare on my table.

I am imperfect, and it is hard.  Maddening.  I sometimes curse my own feeble abilities.  Yet this profession offers the opportunity to be with our fellow humans.   Regardless of outcome.  It offers the ability to reach an imperfect hand towards a suffering soul.  Over and over again.  On weekends, on holidays, in the middle of the night.  When it's inconvenient.  When it really matters.

You become the beacon of light to someone's darkness.  The epitome of meaning, wrapped in a profession, crafted over years of practice.

There is nothing that I would rather due for a lifetime.  No profession more worthy.  No pastime more challenging.  No calling more sacred.

We suffer today not from a failure of training nor a mighty profession gone astray, but from the greedy, lecherous, and diabolical distortion foisted upon us,

We suffer from a government so mired in special interests that often the most simplified and logical tasks become overly burdensome.  Administrators with little knowledge of actual medical practice add layers of bureaucratic minutia on the backs of hapless workers.  Computer systems are generated with the wrongheaded idea of Big Data collection as they further warp severely strained processes.

We suffer from big business, hospitals, and insurers bent on squeezing every last cent from a system where they produce nothing.  They repackage the knowledge and ability of their clinicians, and slap a brand new inflated price tag.

And we suffer from ourselves. Our medical societies who pat our back with one hand while picking our pockets with the other.  Our physicians who have lost their way, and traded in this holy art for a chance to feast on the leftovers from the carcass of their debilitated brethren.  

The doctors who value bloat, cruelty, over-testing, and over-diagnosis to add to their wealth and not the health of their patients.

Medicine can still be noble and worthy.

If society allows it.

If we fight for it.

Friday, August 21, 2015

Being Your Doctor Is...You Pick

Being your doctor is exhilarating.

Everyday I wake up to a schedule brimmed with purpose.  The door of my office is a portal into the richness of the human experience.  I become a thread in the tapestry of other's lives.  I bear witness to the joy and pain, laughter and heartache,  and mundane daily routine.

I spend my days bouncing between art and science.  Paid to be the wily detective, my brain stumbles on detail.  Some cases are typical, quickly resolved with an adjustment here or there.  Others are more enduring, months are spent contemplating the possibilities until answers present themselves.  The sick become healthy.  The terminal are comforted and allowed a soft place to land.

A familiarity grows out of the wisdom of experience.  An acceptance of the limits of human knowledge.  Self acceptance soon follows.  The connection between me and my fellow man is the bedrock of my professional existence. I help people solve problems.

I make a good living.  My title still carries a certain amount of respect.  Job security is a good bet.  And my days are anything but boring.

Being your doctor is excruciating.

Everyday I stare into the abyss of humanity.  I become a party to every patient's agony and despair.   I have witnessed pain and loss that endure.  My mind is scarred from an invisible emotional battle much like the physical ailments of an infantryman.

I am haunted by countless decisions that profoundly affect other's lives.  The devil hides behind every dichotomy.  Poking out it's steely head, waiting to attack the supple underbelly.  I remember each battle lost, each face.  Until the next horrific calamity erases the last.  Over and over again.

I rarely sleep uninterrupted.  My phone rings while I'm taking a jog, in the shower, or on the toilet.  Occasionally a nursing home thinks my mobile is a fax number, and my phone rings over and over again in the middle of the night, waking my family.

I am constantly told that I am wrong by technicians, administrators, insurers, and the government.  I often have to fill out the same paperwork over and over again.  I sign thousands of papers a month for what appears to be no reason.

I often feel crushed by both the enormous responsibility and stupidity that the American healthcare system has placed on its doctors.

Being your doctor is...

Friday, August 14, 2015

Have We Lost Our Heart?

There was once a little boy who loved to draw.  He would wake up every morning, pull out his box of colored pencils, and let his hands explore the promise of a pristine sheet of blank paper.  For him, the canvas was anything but empty,  images and ideas exploded out of his mind and magically appeared on the pages in front of him.

His parents and teachers recognized his talent early in childhood.  Accordingly, he was afforded the luxury of the finest education.  His ability grew with each class and workshop.  He graduated college among the most gifted, and found work in one of the finest drawing shops in the country.

Here, surrounded by his friends and peers, he found his daily work to be anything but taxing.  Every morning he would role up his sleeves, open the very same box of colored pencils, and draw from the early morning to the late evening.  The time would pass by unnoticed as his mind wandered, and his hands dutifully followed suit.

Others would watch in astonishment as his creations took form.  They came from far and wide to witness the miracle.  Every drawing was lovingly produced for its exact purpose.  He was an expert.  A master whose skill was honed from countless years of repetition, innovation, and experience.

It was in this state that he toiled for many years, happily fulfilling his purpose, until the day the mandates started to roll in.  His shop was bought by another, management changed.  The first directive was annoying, but easy enough to comply with.

Straight lines were no longer acceptable.  Zigzags, however, were allowed.  So he substituted where he could.  He found that if he worked slowly and laboriously, he could make such small lines that from afar his zigzags looked straight.  A pain to say the least, but a fair approximation in the end.

Next came the war on green.  His boss appeared at his desk one day and fingered through his box of pencils, removing anything with a greenish hue.  Again, a work around was fashioned.  Blues and yellows were carefully mixed to create the right effect.  Some shades were easy, others could take hours to get just right.

As usual, the boy who had now become a man, refrained from raising his voice in defiance.

The directives flew out of the C-suite at a maddening pace.  Some were perfectly reasonable, others were odd and senseless.  All required an accelerating amount of time and concentration to be compliant, and yet still create a product that he could be proud of.

He no longer enjoyed his work.  He often left the office past midnight, and refrained from whistling on his walk home.  He even stopped drawing for fun.  He didn't have the energy or interest in reading up on new techniques.

And the sad truth was that his drawings were technically flawless.  They followed each directive expertly, but one couldn't help but notice that they had lost their purpose.

They had lost their heart.

His bosses shook their heads approvingly.

His customers turned their backs and mumbled,

and never returned to his office again.

Monday, August 3, 2015

On The Internet

Of course there are patient archetypes.  We all use them.  I mean, there is the old lady that is super sensitive to even the smallest dose of just about every medicine.  The psychiatric patient whose allergy list runs a mile long.  The drug seeking guy that swears his pills were stolen from his suitcase yet again.

My favorite is the widowed war hero.  His unrequited love for his deceased spouse pervades most visits.  He writes poetry and can carry a note to operatic proportions.  He is kind and humble.  He lives lost in a world of dreams and sweet memories.  He is both jovial and melancholy at the same time.

I have known many of these.  Taken care of them.  Watched them die.  They do so with a grace and determination which is nothing less than dignified.  They take their last breaths with a certainty and peace that I can't help but admire.  Maybe they know that they are one last gasp away from their lover's arms.

And I often contemplate whether they are right.

Perhaps we physicians also have our archetypes.  The arrogant and the too busy to be bothered.  The hand-holder.  The incompetent and the God-complex.  The automaton.

Then there's me.  I have seen myself in almost every archetype, good and bad.   And as with our patients,  these are poor constructs.  Because even though our most glaring attributes fit well into cubby holes, the reality is that human beings are so much more sloppy.

I am.

Maybe a bit introspective.


The kind of guy who writes about being a doctor to no one in particular.

On the Internet.  

Monday, July 20, 2015

The Sh$t You Read In The Newspaper

Jim almost convinced me.  The burning in his chest, after all, could have just been gastroesophageal reflux.  He assured me that the sensation was nothing new; that he got it from time to time after a large meal and took Tums.    I couldn't, however, ignore that it seemed to worsen with activity.  The pain was bothersome enough to drag him into my office, without taking the time to make an appointment.

Jim and I argued over the EKG.  He wanted to take his prescription and go home.  No hospitalization, no blood tests, no diagnostic studies.  I grabbed his shoulder, and did my best to convince him to reconsider.  He slowly turned back toward the exam room.  A few minutes later, I gulped as I looked down at the electrocardiogram.  He was having a heart attack.  Right there in my office.  We called an ambulance and rushed him to the ER.

Jim's story is nothing new.  I can recall countless episodes of personal beliefs contradicting my strongly held suspicions as a clinician.  I have begged, pleaded, and occasionally dragged unwilling patients back to the office or into the emergency room.

And occasionally I have saved their lives, or interrupted a malignant disease process before the effects could become irreversible.

Sometimes we are not so lucky. Many clinicians can recall a case in which they had been lulled into a false sense of security by a patient's own certainty.  There is nothing worse than a call from an emergency room, specialist, or coroner notifying you of a deadly misjudgement.

Conversely, everyday we face patients who are utterly convinced that they know what is wrong.  These beliefs, occasionally correct, but often heretical can be terribly difficult to dispel and lead to over-testing and over-diagnosis.

It's quite a slippery slope.

So when I read in the newspaper about the latest story of the mishap patient who was certain of the correct diagnosis, yet their pleas fell deaf on their doctor's ears, I kind of get it.

The layman's diagnosis is often wrong, but sporadically on target.  It takes great courage and concentration to accurately weigh the data, the patient's beliefs, and empiric science.  We actually get it right far more often than not.

We often listen to our patients, and take their beliefs into account.

But you mostly don't read about that in the newspapers.

Sunday, July 12, 2015

Are You Proud Of Your Patients?

It was only afterwords that I wondered if I had been condescending.  The words had come out so naturally.  We were sitting across from each other in the nursing home.  It didn't take a doctor to recognize that his leg was visibly less swollen.  I had seen him walking down the hallway with the physical therapist.  His face a mix of pain, concentration and triumph.

Each day had brought improvements.  The range of motion was returning.  His strength was growing.  His body balanced now with only the most minimal of assistive devices.  What had once been disability had transformed to normal physiologic functioning.  

In medicine we often talk in the most passive of manners.  We say that the knee is improving, or the wound is closing.  We talk as if healing is a mere act of God.  A blessing that is bestowed on the weary from time to time in a somewhat whimsical manner.   

And I am not a denier that randomness pervades our experience in hospitals and medical clinics.  But I have been trying to be more cognizant of the role that human will plays in the rehabilitation of both body and soul.  The force and strength, the sweat and tears, the physical act of becoming healthy.

So I said what was on my mind.

You know, I'm really proud of you!

Funny words coming from a middle aged doctor to his geriatric patient.  But his face lit up, and I could see that he was thankful for the recognition of the difficult road he had travelled and barriers that still lay ahead.  It wasn't condescending.  It was a truthful moment that transcended the artificial barriers between doctor and patient.  I was just an innocent bystander acknowledging the remarkable personal will it took to get better.

I feel both awe and pride, frequently, at the strength and endurance of those patients that fill my moment to moment existence.  

From time to time, when appropriate, I try to let them know that.   

Friday, July 3, 2015

Sticking It To The Man

Like two ships passing in the night, we sidled up to each other at the nursing station on the hospital telemetry ward.  I had already been home, ate with the kids, and returned, while he hadn't left floors all day.  We typed away at our computer stations, and chatted from time to time.

After we exchanged common pleasantries, we jumped into local politics.  We were hungry for news.  Battle worn and weary, we were searching for signs the tide was starting to turn.  The gossip was mostly pessimistic, but I saw a glimmer in his eye as he abandoned his screen and turned to face me.

I bet you haven't heard about...(fill in the name of your favorite academic medical center).

He was exited now.  The words came from his mouth faster than the keystrokes that disdainfully filled the electronic medical record that had become his slave master.  An academic center had taken over a hospital, and felt that it had every right to bully the large allied medical group.  The physicians, tired of being pushed around, silently vowed to steer their admissions to a local competitor.  Months later, the academic center was on it's knees with empty beds and an angry community to boot.

We both basked in the glow momentarily before returning to our respective tasks.  Although we wanted to go back home to our families,  there remained a need to share a fleeting moment with someone who could relate.  Someone who could understand.

And I imagine that conversations like these are taking place across the country where physicians congregate: hospitals, clinics, and doctor's lounges.

Meaningful Use, EHR, PQRS, ACA, ACO, Value, Quality, Patient centered Medical Home, Medicare Fraud, The Physician Sunshine Act.

A once humble profession is struggling desperately to find it's soul.

I find it rather disconcerting that a decade ago, colleagues used to revel in a recent save, discuss a difficult prognostic dilemma, or brag about a diagnosis of a rare ailment when happenstance caused their paths to cross in the middle of the night.

But now, now all we talk about is sticking it to the man.

And I wonder how those, at the moment, dying to find appropriate medical care,

are feeling about this.

Monday, June 29, 2015

Utility and Functionality

It is one of the most ancient stories wending it's way through modern history.  The hotheads of late have coined the term creative destruction.  But this concept of replacing old with new,  or innovation upending tradition, is no more novel than the concept of change itself.

There is nothing truly original in the world.

I ease off the gas pedal of my already outdated hybrid Prius.

My job will eventually fall prey to a computer named Watson.  My practice will be gobbled up by the nearest Goliath medical center as history scoffs at the arthritic physician bending over a doorbell with leather bag in hand.

There is no flash of glory here.  No smart technology.

The echo vibrates through cracks in the sidewalk and drags me unwillingly forward to the unkempt house at the end of the block.

Adapt or perish.

I open the door without knocking and find a decrepit figure slumped into a reclining chair in front of the television.  His car keys were long ago taken by some relative or another.  He waits for nothing in particular.  Scraps of food have been left on the side table by a home health aid.

There are memories of being gainfully employed.  Road trips across barren lands and such.  His son is now grown up and makes decisions on his behalf.  A nursing home is a far safer environment than this empty old house.

My visits to the end of the road are numbered.

Old is replaced by new.

Utility and functionality apparently are relative terms.  

And by and by something is lost.

Saturday, June 13, 2015

Why I Disagree With The Government And Use Antipsychotics Anyway. It's Good Palliative Care!

The outcry over antipsychotics has ranged far and wide.  Every one from governmental agencies to senior advocacy organizations have pointed to the abysmal data.  Antipsychotics have a negative impact on morbidity and mortality.  They say we are chemically restraining those who are too fragile to stick up for themselves.  They say we are sedating instead of treating.

And I disagree wholeheartedly.

I manage a large group of moderately to severely demented nursing home patients.  They are agitated and delirious on a regular basis.  Often searches for infections, pain, constipation, depression, and other inciting factors come up empty.  Their behavior is disruptive, dangerous, and heart-breaking for their loved ones.

The correct treatment: impeccable environmental controls, one-to-one supervision, and extensive counseling for the patient and family are often not available or too expensive.  Our choices become limited.

We have moved away from physical restraints in the skilled nursing facility environment.  They are dangerous, inhumane, and often add to agitation.

Sedatives (the benzodiazepine class: ativan, xanax, clonazepam) can increase agitation and are frowned upon among geriatricians.

Leaving patients floridly delirious without treatment is unduly burdensome to the family and nursing staff, pulls clinical support away from others who need help on the unit, and leaves patients upset and suffering.

Antipsychotics are effective.  They calm quickly with few physical side effects.

Using antipsychotics in a demented person suffering delirium is a prime example of palliative care.  They are prescribed for patients with moderate to severe dementia who have a low quality existence.

This is what defines palliative care.  We trade quality for quantity in a patient population that suffers deeply, and often is only obliquely aware of their surroundings.

It's good for patients.  Good for families.

It's excellent palliative care.

Thursday, June 4, 2015

Those Dumb Physicians Aren't Getting The Job Done

The insurance company insisted that they would be saving money in the end.  So they sent the PA (physicians assistant) to my patient's house.  They didn't take in to consideration that I was just there a week before.  Or that I made home visits on a regular basis.  In fact, they didn't even inform me about the appointment.

My patient later told me that the exam was exhaustive.  The PA, who incidentally graduated school the day before and had never seen an actual patient as a licensed practitioner,  poked and prodded the ninety year old woman for over an hour.  He asked her about drugs and sexually transmitted diseases.  He examined every joint and performed a Babinski test.

A few days later I received a call from him.  He tried to leave a message with my secretary, but I intercepted the call.

He had two recommendations.  He thought I should do a better job of addressing the patient's knee pain.  When I asked if he thought it was a result of her polymyalgia, rheumatoid, or osteoarthritis, he had no idea.  When I mentioned that the pain had been treated in the past with various medications (and physical therapy) and the patient had stopped them all due to fatigue (even Tylenol), he was surprised.  When we discussed that she was in the hospital multiple times for pain control before I met her, and now had avoided hospitalization because of better symptom control, he said he was unaware.

His other recommendation was to start the patient on Detrol for overactive bladder.  He, of course, had no idea that her urologist had tried the same thing a few years back and she had become dizzy and broke her hip.

It wasn't the poor PA's fault.  There was no way he could have known what I gleaned from a year's worth of hospital, nursing facility, and home visits.

He just didn't know the patient as well as I did.

Which, of course, brings us back to the insurance company.  They believe that complex problems can be solved with simple solutions.

Just get some PA to go over there and make recommendations.

Those dumb physicians aren't getting the job done.

Tuesday, June 2, 2015

Till Death Do Us Part

Even though they were such carelessly spoken words back then, Jill took her vows seriously. Till death do us part.
She was just a child when she married Tim. He, a few years her senior, was like a father figure. But they grew together: first professionally and then personally. 
When the kids came, everything changed. He spent late nights at the office, and she transitioned her schedule to part-time so she could be home in the afternoons. 
Jill’s love grew and expanded. Of course the romance was still there, but what she valued as she grew older was the companionship. Her and Tim were partners in every sense of the word. They traversed life’s paths together, avoiding roadblocks, and choosing carefully for their little family. 
The kids were well into high school when Tim developed the numbness and tingling. Jill wasn’t concerned in the beginning, until his symptoms progressed. A flurry of doctor’s appointments later, they held hands in the neurologist’s office and listened attentively to his description of multiple sclerosis....

Read the rest of this post at The Medical Bag.

Tuesday, May 26, 2015

Safe Zone

When I first began the practice of medicine, I used to think of the entranceway to the exam room in mystical terms.  How else could I explain my patient's willingness to suspend all social rules and norms upon passing through those magical doors?  They would sit down in front of their baby faced-doctor and talk about things.  Private things.  Scary things.

Conversations occurred that would be unthinkable if two strangers were to meet in the outside world. I learned of abuse and infidelity, pain and yearning, secret joys and countless regrets.  I bore witness to the inner pain and struggles that often were hidden from one's closest friends and family.

People undressed.  They replaced their clothes with unflattering gowns.  They demonstrated their body parts unabashedly.  Pointing to that which looked out of place.  Wincing from pain induced by my clumsy touch.

The exam room became a safe zone.  A place where judgement was replaced by support and understanding.  A place where one's darkest secrets could be revealed but not allowed to consume them.

When I abandoned my traditional practice for home visits, I feared that something important would be lost.  I often wondered if there was a certain element of depersonalization that came with such sterile environs.  Maybe my patients revealed their inner needs and fears because the institutional setting of the exam room was a sufficient departure from normal life.

Then there was the question of my lab coat.  The wizard's frock symbolized a certain otherness that separated me from the rest of society.  Again I conjured up visions of a magnificent veil that allowed me special access of a most personal nature.

It's been almost two years now, and I have visited countless homes without the comfort of the exam room nor the lab coat to hide behind.  My fears, of course, were completely unfounded.

My patients still tell me their triumphs and tragedies.  They still pull their shirts up unashamedly to show me a rash or lump or bump.

And I have come to realize that it was never the sanctity of the exam room nor the long gray coat that droops from my shoulders.

With both great awe and humility,

I have come to the conclusion that it is me.

I am the safe zone.