Monday, January 26, 2015

Mortally Wounded

Neither of the two most important people in Aaron's life could stand to be in the same room with each other.  There was a long colorful history between his ex-wife and his brother, and as his disease began to accelerate, the feuding became quite intense.  They argued over Aaron's advance directives.  They both tried to coerce and manipulate themselves into commanding positions.  The shouting became louder, the fury more fierce.  Aaron, for his part, was fading under the colossus of his difficult to treat leukemia.  Any bit of energy left after chemotherapy, was quickly snuffed out by his loved one's bickering.

We talked in the office the day before he was to enter the hospital for the bone marrow transplant.  He was afraid.  His brother sat quietly by his side and listened intently.  A truce had momentarily been arranged.  Aaron's ex would drive him to the hospital and keep him company until his brother got off work.  The next week was then cleaved between schedules and availability.  Each visit timed precisely in order to avoid an unexpected crossing of the two offended parties.

Everything went as planned, until it didn't.  Hospital's rarely run on tight schedules, and neither do people.  Before long, Aaron's brother was angry because the chemotherapy schedule had been changed.  And his ex's car broke down and she couldn't come when promised.  The inevitable chance meetings between the two became a poignant explosive metaphor for the turmoil taking place in Aaron's body.

I walked into his room on the morning of the actual transplant.  Aaron was sitting alone in bed trembling.  He was tired and afraid.  His brother and ex had run into each other in the hospital lobby, and both left the premises fuming.  Consumed by their hatred for one another, they abandoned Aaron in his greatest time of need.

Eventually, I raced out of the hospital to drive across town to my first appointment in the office.  By then the nurses and doctors were shuffling in and out of his room.  But Aaron had no confidant; no protector from all that the cancer, chemotherapy, and the hospital had to ensnare him in.

He was alone.

A victim of a disease,

mortally wounded by those purported to love him.

Friday, January 23, 2015

Health Care's Newest Dirty Word

As a child, I loved games of strategy. Whether it was Monopoly, Stratego, or Risk, certain themes pervaded. One had to learn how to think multiple maneuvers into the future and form beneficial partnerships to survive the onslaught. The goal, of course, was total world domination. The game was over when one side was economically or physically manipulated into full capitulation.
I have carried these strategies with me on my long voyage through medical education and doctorhood. Disease, the great evil adversary, is wily and deft.  The ability to foresee her courageous moves, plan and prepare for the future, and meet her on the battlefield is a skill that every physician must obtain.
The political maneuvering and manipulating, however, was something that I was always grateful to be able to avoid in this laudable profession. Unlike my friends in the fields of business, law, and accounting, there were minimal office politics. My relationships were formed out of mutual respect and admiration, rarely out of a strategic need to protect myself. My naiveté, it turns out, was short lived.

Read the rest of my post at The Medical Bag.

Monday, January 19, 2015

Doctor On Doctor Crime

Her heart was failing; her ejection fraction was unmeasurable.  Her hip was broken, and she developed a pulmonary embolism post-operatively.  She was painfully close to death.  Yet at some point, the hospital finished, and spit her out at the nursing home.

She was confused.

I tried to take the best history that I could.  Her answers where usually no more than a single word.  Her physical exam revealed a desperately weak woman, swollen from head to toe.  Fluid seeped out of the wounds and lacerations on her legs.

I hopefully clung to the one positive portion of her assessment, it appeared that her pneumonia had cleared.  I wrote my admitting note and placed a few orders.  Forty-eight hours later, her nurse called to report a low grade fever.  I dragged myself out of a deep sleep on a Sunday morning, and came to her bedside.  Her exam was unchanged,  all catheters were clean, there was no rash. Her lungs were clear and she had no new complaints.  The temperature remained a hair below one-hundred, so I sent for a chest X-ray and urine culture.

The next morning as I reviewed the labs, my mobile rung once again.  She was confused and agitated.  Her blood pressure was unmeasurable and her heart rate was high.  An ambulance was summoned to take her to the hospital.

A few days later, I received a call from her cardiologist.  We had never met before, and he introduced himself quickly before cutting to the chase.  He wanted to know why I let his patient get so sick.  She was doing poorly, and had to be put on hospice.  He commented on how she was fine when he discharged her from the hospital.  Why had we not treated her fever with antibiotics?  His smugness brimmed as he probed further,

How can we make sure this doesn't happen again?

I was completely taken aback by his questioning.  Surely he must have known how sick his patient was.  There is no denying the mortality for an elderly person, in severe heart failure, with a broken hip (and a pulmonary embolism and pneumonia) is incredibly high.   He also likely understood that one generally doesn't treat a low grade fever without identifying a cause.

His diatribe was not a rational discourse on clinical care.  It was a witch hunt.  He was frustrated that his patient was dying, and he was out for blood from the physician he believed delivered sub-par care.

As I felt the pulse explode in my head, I took a deep breath.  Then I thanked him for his phone call and hung up.

I felt horrible for a time.  I wished our patient could have survived.  I painstakingly re-evaluated each decision.  I gave myself credit for some and not so much for others.  Eventually the pain abated because it had to.  Not because the tragedy had become any less, but more in order to continue to provide the best care possible to those who remain.

But I didn't decry the accusations as toxic as they may have been.  I didn't try to protect myself from the venom or shield my skin from the burn.  I didn't jab or parry.

Because the other side of the pendulum is the repugnant physician who lacks insight into his own shortcomings, and believes too heavily in his own righteousness.  He blames his patients.  He blames other physicians.

He often does more harm than good.

And I don't want to ever become like that.

Tuesday, January 13, 2015


My mother-in-law has a theory about our children, and it has to do with their hands.

My son, the eldest, would sleep from his earliest infancy with his fingers balled tightly into tiny little fists.  He was born with a herculean grasping reflex resistant to any sort of outside manipulation.  Over the months, his fingers learned how to curl around a wide variety of colorful and textured devices.  He would fixate on one toy or another, refusing to let go.  Every attempt to remove the object of his affection would be met with squawks of displeasure.  Eventually enthralled in a drunken fit of sleep or fatigued ride in the stroller, his grasp would loosen, and whatever had become his beloved thing would fall to it's peril.

Over the years his love of objects has continued.  Whether it be books or remote controlled cars.  And he has become a merchant: a dealer of things.  He often leaves for school in the morning with a small array of left over Halloween candy and returns with a handful of erasers, pencils, or other electronic doodads.  He has formed a complex bargaining system in which he somehow comes back with handfuls more than he began.

He is a fiddler, an architect, an engineer.  His fingers are antennae reaching out and probing his environment.  He is most at peace when he is manipulating.  Changing one form to another.  Fixing that which is broken.  Breaking that which is pristine.  He is continuous motion.  His hands literally consume the environment around him.

My daughter, on the other hand, sleeps with her palms open and pointing towards the sky.  And her personality, since infancy, has followed my mother-in-law's prophecy.  From her first ability to hold a pencil, she has become a creator of letters.  A giver of gifts, from an early age she would drag her babysitter down the street depositing trinkets in the neighbor's mail boxes.

She is open and emotional.  Her realm is too large and complex to be worshipped in one's hands.  She concerns herself with social graces, and has learned the grown-up habit of complementing those around her.  Incredibly smart and able, she seems much more interested in the ephemeral.  She sometimes takes the money from her piggy bank, and tries to convince us to give it away to her friends.

She is lovely.

Last night my daughter was owed a visit from the tooth fairy.  She lost her front tooth, and knew that upon awaking in the morning, there would be two gold coins under her pillow.  She questions us often about the authenticity of the tooth fairy, but then smiles her serrated grin and tells us that the fairy must be invisible.

This morning there was an added surprise.  Someone had placed an extra one-dollar bill underneath her pillow beside the two coins.  She assured my wife that this was a sign that she has been an extra "good girl" lately.  But we both know that it was my son.  He snuck into her room, gave her a kiss on the cheek, and placed one of his hard earned bills under the pillow.

I used to worry about my son's hands, but do so a little less now.

It seems his grip has loosened a bit,

and now he holds on tightly to people too.

Monday, January 12, 2015

Is Meaningful Use Killing Us?

It took days to unravel what happened.
The patient first presented to her cardiologist a few weeks prior. We figured that she must have doubled her amlodipine dose that morning, because her blood pressure was uncharacteristically low. He dutifully documented the hypotension and discontinued the 5 mg of amlodipine, not realizing that she had accidentally taken too much.
Seven days later, her systolic pressure reached the 200 mark. She, of course, didn’t know that. She only knew that her head started to hurt and that she was slurring her speech. By the time she arrived at the emergency room, she could barely move her right arm and leg.
Please see the rest of my post at The Medical Bag.

Sunday, January 11, 2015

The Final Gift Of The Dying

I assumed many things that morning.  For instance, I thought it was likely that Ronald's fatigue was from lung cancer that had metastasized to the liver.  Or that he decided to stay in his room in the nursing facility because the decision to elect hospice had finally taken it's toll. I was sure that he was both physically and emotionally spent.  I reasoned that I wouldn't want to get out of bed either.

My visit, however, was much more optimistic than anticipated.  Ronald was jovial and inviting.

And he was spent.

The holidays brought an onslaught of family and friends to his little corner of the skilled nursing facility.  Children and grandchildren travelled half the country.  Acquaintances, both intimate and not so, appeared from corners and crevices around the world.  They all came in with smiles on their faces, and flowers in their hands.  They wanted to talk, and drink coffee, and reminisce.  Ronald smiled so many times that his cheeks hurt more than his chest or abdomen.  His voice was hoarse from laughing, and his belly was full of coffee cake and donuts that he truly had no interest in eating.

Who knew that dying could be so tiring?

We both chuckled for a moment, and then became more serious.  I sat down and began to tell him a secret that is many times lost on those in his situation.  The Dying often have a few basic wishes: to be free of pain, to enjoy whatever time is left, and to know that their loved ones will survive and eventually thrive after they are gone.

The process of dealing with physical pain, and trying to improve quality of life, is exactly what hospice providers are adept at.  The emotional suffering of those that remain after a death, unfortunately,  is frequently difficult to manage.

The final gift of the dying is allowing family and friends to be present.  To be patient as they stammer and sputter.  To rejoice when they show up at occasionally inconvenient times.  And to let them play a role no matter how insignificant.

These were things that Ronald could offer.  These were moments that could bring peace to his loved ones long after his own personal suffering ended.

Tuesday, January 6, 2015

Begin Again

It was a rather unlikely place to begin my clinical career.

Shortly after starting medical school, I signed up to volunteer in the hospice unit of my academic medical center.   The first few visits I relegated myself to fairly banal activities.  I shredded old medical records, or I might do a load of laundry for a family member who had been waiting tentatively by their loved one's side and was unable to carry out such basic human necessities.  Over time I became more familiar and would engage families, sit with the dying, and comfort the staff.  I once helped a nurse prepare a newly deceased body, and as we zipped the bag closed she crouched into the corner and started to cry.

The act of caring for people in a medical setting was new to me.  Everything was fresh and pure.  I leaped at the chance to graduate from the hospice unit and tackle my first home patient.  Unfortunately the day before my planned trip, he fell and was brought to the unit.  I visited him briefly before he died.  I even made a trip to the grocery store, and bought a bottle of white wine for his last meal.

A few weeks later, another home patient requested a volunteer.  I walked through the brisk winter day down the city sidewalks, through the congestion, and stopped short of his building.

Ralph was an octagenerian dying of prostate cancer.  His wife had passed years before, and he had no children or close family.   His daily needs fell to a handful of caretakers who took shifts feeding and bathing him, arranging his personal affairs, and keeping him company.  I came on Thursday afternoons.  Usually we would talk for an hour before he became tired.  Then as he settled in for a nap, I would run across the street and buy groceries to stock his pantry.

Sometimes we walked down the hallway towards the elevator.  He was a poet, and we talked above the rattle of his walker and tentative footsteps. My class schedule was brisk and I had begun my clinical responsibilities.  I often imagined that medical education was somehow diminishing my humanity.  The thrash of knowledge and depersonalization of doctoring was smoothing out my rough edges, and making me bland and unpalatable.  But Ralph would trample me with his walker, replacing my rough edges by and by.

I woke up one morning to find that I could no longer hear his footsteps or that creaky old walker.

Ralph died.

I still think of him from time to time, and marvel at how inspiring it felt to be engaged in the humble profession of taking care of each other.

Decades into my career as a physician, after all the hurt and pain I have been a part of, it devastates me that I no longer know how to get back there.


December 1996


Help often comes from those we least expect:
Sometimes your footsteps separate my dreams from reality as the echo of your walker disrupts the silence of an empty hallway. 
I dream the great teachers of the world have taken me as their student. With sand paper they smooth the rough edges but all the while I worry that in becoming soft and supple I will lose my character, my humanity. They give their knowledge freely but fight for it back with a vengeance. Your laughter distracts as you trample me with your walker, replacing my rough edges, and making me forfeit my strength by and by.
Recently, our walks are becoming shorter. You no longer have energy to make it past the elevator and after you want to lie down. As we pass our time together we watch our lives float by. Neither of us drowning but both frustrated by our lack of ability to control the direction in which the current leads. You, trapped in a body that can no longer house your vitality and I sleep walking through a world of lost humanity.
I once dreamt that you were reaching out your hand to me. I was surprised to find that instead of needing help you just wanted to shake hands. But then, I was falling into a pit and you were above me, my life line. But the expression on your face was undeniably saying good-bye. I woke up terrified to find that for the first time in months I can no longer hear your footsteps

I know now that you are free……and so am I.

Saturday, January 3, 2015

Sometimes Medical Care Requires More Than Just A Minute (Clinic)

The truth is, I know it's easy to go to the Minute Clinic.  I know the enticement of not needing an appointment, of being able to shop while you wait, of having the prescription ready to pick up by the end of your appointment.  Who doesn't like convenience and a friendly smile to add?  Who doesn't like the customer service offered at CVS, Target, or your local pharmacy?  I certainly do.  And I know that the doctor's office can be a pain.  I also loathe the annoying phone tree that leads to a tired nurse or secretary, and possibly the hours of waiting to have the physician call you back and tell you to rest and drink fluids anyway.

Realize, though, that these clinics do not have your best interests at hand.  Of course they can manage the typical medical problems that often don't require much intervention in the first place: respiratory infections and minor rashes and such.  They can even treat your strep throat or urinary tract infection.  Until, of course, something goes wrong.  At midnight when your temperature soars and you are unable to swallow because of tonsillar swelling, there will be no one at Target to prescribe you steroids.  Or when your simple bladder infection turns into pyelonephritis, there will be no expertise available to guide your way.

You then will be stuck calling me, the beleaguered primary care physician.  I, however, am a vanishing breed.  Because I saw the writing on the wall years ago and became a hospitalist, or concierge doctor, or departed from clinical medicine.  And those few of us who are left, certainly won't want to clean up the mess of a pharmacy clinic at some ungodly hour when we would rather be sleeping.  You didn't come to me in the first place, why should I now be responsible when taking care of you has suddenly become inconvenient?

Yep, now you're getting it.  These clinics pick off the easy, high margin care and then punt when push comes to shove.  They have less interest in your well being, and more in your wallet.  Low acuity, high volume primary care can be very lucrative.  Don't expect them to be there, however, when you really need them.

And don't expect me either.

Because I'll be long gone.  Forced to abandon my life's work due medicine's lack of convenience.

Looks like someone will be going to the emergency room.

Good Luck!

Thursday, January 1, 2015

In My Humble Opinion; The Most Popular Posts of 2014

These were my most viewed posts of 2014.  Enjoy!

1.Let's Be Real Clear About This...Are doctors being overpaid and causing the catastrophic rise in American Healthcare costs?
2.Doctors Behaving Badly...A dozen set of eyes stared upwards.  The nurses ate their pizza and glanced back and forth between me and the dry erase board that I had recently filled with incomprehensible scrawl.
3.Malcolm Gladwell Is Wrong, Tell Them That You Love Them...Malcolm Gladwell thinks we should tell people whats it's really like to be a doctor.  And by God I have invested the last seven years in doing just that.
4.Creative Destruction Or Internal Combustion...Everyone seems to have a solution for the primary care crisis.  Businessman and venture capitalist Vinod Khosla thinks technology and big data will replace the imperfect physician.
5.We Will Always Have This...As I have said before, when done correctly,  doctoring is an act of love. 

Thanks again for reading and have a great New Year!