It was that time of the month again and Mrs. S hobbled feebly into my office. She was 95 years old and we had been through alot together: three hospitalizations, a heart attack, congestive heart failure, atrial fibrilation, spinal stenosis, and pneumonia. Yet, she looked remarkably good for her 95 years. She lived alone in a three story house and somehow managed. Her husband died over 30 years ago and she had no children or other living family. She was alone.
While Mrs. S fought a brave fight, she now was being challenged by a disease that I knew I couldn’t fix. She was going blind. As her vision worsened, her ability to take care of herself faltered. We had long talks about this. It troubled me, as a physician, because I knew there was no recourse. She had gone to 6 different ophthalmologists in the last 6 months and all said the same thing.
I reviewed my notes on Mrs. S. My assessment and plan looked something like this:
1)cad/chf: stable on current lasix dose, chest pain free
2)atrial fibrillation: INR stable, re check in one month
3)spinal stenosis: stable
4)visual loss: follow up with ophthalmology
I was tortured by how little I could do for her. As I said goodbye, I suggested that she didn't need to return for 3 months, her medical issues were stable. She gave a weak smile.
How about next month?
*
As a new medical student I experienced my first care giver relationship. I volunteered for hospice and was given the name of an elderly gentleman dying of prostate cancer. His condo was close to mine, and I would walk over once a week to spend time with him. I did little things like cleaned around the house or occasionally wound run to the grocery store. Often, we would pass the hours just talking.
I call this my first care giver experience although many would argue that I wasn’t really delivering any medical care. I, in fact believe, that it is the exact opposite. As a first year medical student, I didn’t know much about medicine. It was before my mind was clouded by diagnosis and symptoms, drugs and pathophysiology. My lack of medical knowledge allowed me to get to the core of what this gentleman needed: An attentive listener, someone to say they were sorry for his condition, someone to be there.
As I moved along in my medical education I forgot the art of “just being there”. As a resident and young attending, I was always too busy making diagnosis, prescribing medications, and planning the next step. But every now and then I would get caught in a situation where I no longer had anything left to do. Where all the appropriate actions had been taken and yet the patient still wasn’t getting better. These situations used to bother me. As I get older they do so much less.
As with my hospice patient I knew there was very little I could do for Mrs. S. She would eventually lose her sight completely. But I started to go back to my premedical way of thinking and take a more optimistic look. I could continue to be there for Mrs. S. I could hold her hand and say I'm sorry that she is going through this. I could keep my door open and let her know that no matter what happens, I would support her. I would be in her corner if she needed a hand.
I know, sounds like alot of nothing. But sometimes “doing nothing” is some of the best medical care I give!
Friday, March 30, 2012
Wednesday, March 28, 2012
Moving Violations
For years I have driven the same path every morning. I mastered the twists and turns, ups and downs, long ago. Occasionally, as the sun rises, I hallucinate that the roads have become like a patient. The gravel echos in the harshness of a straining voice. The squealing tires mimic the high pitched wheeze of distant lung sounds. The billowing smoke stacks in my rear view mirror recall the pack of cigarettes carefully placed in the breast pocket of a barrel chest.
This morning as I drove down the lonely expressway, I noticed a blue SUV approaching rapidly. With panic, I realized that less then a mile away was a speed trap where a police car often waited to snare unsuspecting victims at a bend in the road. I quickly pulled into the left lane to cut off the oncoming SUV. I felt a sense of camraderie and wanted to protect this complete stranger. I was hoping I could slow him down just enough to avoid the inevitable.
The SUV charged forward within a car length, and then flashed his turn signal. Anticipating the move, I cautiously veered between both lanes knowing that the bend was coming. Unfortunately the SUV pulled around me and sped away.
Moments later, a flash of lights and sirens confirmed that my attempts had been unsuccessful. I continued down the road and took the next exit to my office.
*
The oncologists voice seemed so far away over the telephone line.
I saw your patient today. The cat scan showed that despite chemotherapy the lung cancer has progressed.
I winced and stared down at the ground. I absentmindedly kicked at the side of the desk as I tried to concentrate on the computer screen and listen to the phone at the same time. I felt powerless. My voice, barely above a whisper, came out unsteadily.
So what can we do for him now?
The oncologist paused.
Hospice. That is, unless you can go back thirty years ago and stop him from smoking in the first place.
*
Sometimes I see a moving violation before it happens. Yet often I am helpless nonetheless.
I recall countless conversations about quitting.
But when you get to a certain point, inevitability sets in.
You can no longer undo whats already been done.
This morning as I drove down the lonely expressway, I noticed a blue SUV approaching rapidly. With panic, I realized that less then a mile away was a speed trap where a police car often waited to snare unsuspecting victims at a bend in the road. I quickly pulled into the left lane to cut off the oncoming SUV. I felt a sense of camraderie and wanted to protect this complete stranger. I was hoping I could slow him down just enough to avoid the inevitable.
The SUV charged forward within a car length, and then flashed his turn signal. Anticipating the move, I cautiously veered between both lanes knowing that the bend was coming. Unfortunately the SUV pulled around me and sped away.
Moments later, a flash of lights and sirens confirmed that my attempts had been unsuccessful. I continued down the road and took the next exit to my office.
*
The oncologists voice seemed so far away over the telephone line.
I saw your patient today. The cat scan showed that despite chemotherapy the lung cancer has progressed.
I winced and stared down at the ground. I absentmindedly kicked at the side of the desk as I tried to concentrate on the computer screen and listen to the phone at the same time. I felt powerless. My voice, barely above a whisper, came out unsteadily.
So what can we do for him now?
The oncologist paused.
Hospice. That is, unless you can go back thirty years ago and stop him from smoking in the first place.
*
Sometimes I see a moving violation before it happens. Yet often I am helpless nonetheless.
I recall countless conversations about quitting.
But when you get to a certain point, inevitability sets in.
You can no longer undo whats already been done.
Monday, March 26, 2012
Society's Debt
When he was a child, Darren once accompanied his father to a patients home. He sat on a rickety chair in the corner and watched as his dad administered to an elderly woman buried in a mound of blankets. His father's stethoscope disappeared into the amorphous pulsating mass, his eyes averted as he squinted to listen. He spoke a few quiet words, and left a bottle of pills on the night stand. Upon entering the foyer, a young woman rushed forward with a loaf of freshly baked bread and a cherry pie wrapped in tin foil. Although they returned home with empty pockets, they ate well that night.
The summer after his second year of high school, Darren volunteered at the local hospital. He delivered newspapers and flowers to each room. Occasionally he stared out the corridor windows and watched his friends playing football on the adjacent field.
In his first year of medical school, Darren stood in a crowded room with hundreds of physicians and students. His white coat was overstartched and slightly to large for his shoulders. The name of his medical school was emblazoned on the chest in neat cursive writing. He recited the Oath Of Geneva with the rest of his colleagues and pledged to consecrate his life to the service of humanity.
During residency, Darren sacrificed sleep as well as his youth to an apprenticeship forged in minimal wages. During electives he accompanied the younger attendings to a clinic for the under served. Payment was considered a smile, handshake, or a pat on the back.
And when Darren opened his new clinic, he refused to turn away those who couldn't afford his care. His schedule usually had space, and his medicine cabinet was continuously stocked. Even when overhead costs skyrocketed and medicaid payments were months late, Darren stood by his principles.
So when the bank called one morning looking for payment, and the landlord could no longer wait for overdue rent, Darren figured he deserved some leniency.
A month later, without office space and mired in bankruptcy, he realized that most people weren't like him.
And most professionals don't bother to take such lofty oaths.
The summer after his second year of high school, Darren volunteered at the local hospital. He delivered newspapers and flowers to each room. Occasionally he stared out the corridor windows and watched his friends playing football on the adjacent field.
In his first year of medical school, Darren stood in a crowded room with hundreds of physicians and students. His white coat was overstartched and slightly to large for his shoulders. The name of his medical school was emblazoned on the chest in neat cursive writing. He recited the Oath Of Geneva with the rest of his colleagues and pledged to consecrate his life to the service of humanity.
During residency, Darren sacrificed sleep as well as his youth to an apprenticeship forged in minimal wages. During electives he accompanied the younger attendings to a clinic for the under served. Payment was considered a smile, handshake, or a pat on the back.
And when Darren opened his new clinic, he refused to turn away those who couldn't afford his care. His schedule usually had space, and his medicine cabinet was continuously stocked. Even when overhead costs skyrocketed and medicaid payments were months late, Darren stood by his principles.
So when the bank called one morning looking for payment, and the landlord could no longer wait for overdue rent, Darren figured he deserved some leniency.
A month later, without office space and mired in bankruptcy, he realized that most people weren't like him.
And most professionals don't bother to take such lofty oaths.
Sunday, March 25, 2012
Jordan Grumet On Fame
In our continuing interview series, I discuss with infamous blogger Jordan Grumet the pitfalls of fame.
Me: Jordan, parking on your street was rough and I noticed a number of people milling about with cameras. What gives? Paparazzi?
JG: The girl next door is having her fourth birthday party. She's quite popular!
Me: all joking aside, you recently were interviewed for MDigitalLife and were mentioned in a Medpage article. How did you feel about that?
JG: I was honored to have my work noticed. Greg (Matthews) and Kristina (Fiore) did a wonderful job and helped get my message to a broader audience.
I sit down to write because I have a burning need to express myself, to get something off my chest. It is only later that I realize that others will read and digest what I have said. Each new comment on the blog surprises me.
Me: Speaking of comments, what affect has the reaction to your blog had on your writing process?
JG: I remember my first comment on IMHO (In My Humble Opinion). At first I was baffled by the text.
Get Viagra Cheap!
Yet post after post, Viagra has been one of my most consistant responders. I hope to meet him/her one day.
Me: I noticed that you have a stat counter. Do you check your numbers regularly?
JG:I used to get carried away and check every few minutes or so. Now I'm much better. I only look at that thing 10-20 times per day! I have to say that it's quite thrilling to see the numbers go up. In fact some guy named Googlebot checks my site at least 3-4 times per day. Where ever you are Googlebot-thanks for reading!
Me: Have you ever been recognized in public?
JG: No!
Me: Get asked for an autograph?
JG: No.
Me: What audiences do you think you need to reach out to?
JG: I have a fairly poor readership among non Internet users, and children to young to read.
Me: What was the last email you got about your blog.
JG: My mom wrote to tell me she liked my last post.
Me: What about the one before that.
JG: The same.
Me: Well, I want to thank you for taking the time to talk to us.
JG: Of course. Would you like a signed photograph.
Me: Um...er...I think I already have one.
Me: Jordan, parking on your street was rough and I noticed a number of people milling about with cameras. What gives? Paparazzi?
JG: The girl next door is having her fourth birthday party. She's quite popular!
Me: all joking aside, you recently were interviewed for MDigitalLife and were mentioned in a Medpage article. How did you feel about that?
JG: I was honored to have my work noticed. Greg (Matthews) and Kristina (Fiore) did a wonderful job and helped get my message to a broader audience.
I sit down to write because I have a burning need to express myself, to get something off my chest. It is only later that I realize that others will read and digest what I have said. Each new comment on the blog surprises me.
Me: Speaking of comments, what affect has the reaction to your blog had on your writing process?
JG: I remember my first comment on IMHO (In My Humble Opinion). At first I was baffled by the text.
Get Viagra Cheap!
Yet post after post, Viagra has been one of my most consistant responders. I hope to meet him/her one day.
Me: I noticed that you have a stat counter. Do you check your numbers regularly?
JG:I used to get carried away and check every few minutes or so. Now I'm much better. I only look at that thing 10-20 times per day! I have to say that it's quite thrilling to see the numbers go up. In fact some guy named Googlebot checks my site at least 3-4 times per day. Where ever you are Googlebot-thanks for reading!
Me: Have you ever been recognized in public?
JG: No!
Me: Get asked for an autograph?
JG: No.
Me: What audiences do you think you need to reach out to?
JG: I have a fairly poor readership among non Internet users, and children to young to read.
Me: What was the last email you got about your blog.
JG: My mom wrote to tell me she liked my last post.
Me: What about the one before that.
JG: The same.
Me: Well, I want to thank you for taking the time to talk to us.
JG: Of course. Would you like a signed photograph.
Me: Um...er...I think I already have one.
Friday, March 23, 2012
Losing Battles
Would I not thrash against the rails of the hospital bed?
An uncovered leg protruding below the disheveled sheets is brazenly exposed by a skimpy gown. Arms are blackened and bruised from losing battles with phlebotomists and IV lines.
Eyes squint as faceless bodies in gray fabric roughly flip on light switches at varying hours of the night. The pressure rises as blood vessels are squeezed tightly and released. A thermometer is momentarily inserted and then removed.
Medicines are delivered in tiny paper cups and thrust forward with minimal explanation and large glasses of water. Family members gather by the door, in the waiting room, and outside the lobby. Doctors hurry in hoping the chairs surrounding the bed will be empty.
Days are measured in seconds. A tireless parade of anonymous drones poking, prodding, reporting, and then disappearing. A patient lies flat waiting for an infusion to finish, a fever to decline, or a laboratory value to normalize.
The tears of a child re frame the question and squelch the quips of futility oozing from the doctors lips.
And every time, I leave your room, the same questions echo through my head.
Would I listen to me?
If I was in your shoes?
An uncovered leg protruding below the disheveled sheets is brazenly exposed by a skimpy gown. Arms are blackened and bruised from losing battles with phlebotomists and IV lines.
Eyes squint as faceless bodies in gray fabric roughly flip on light switches at varying hours of the night. The pressure rises as blood vessels are squeezed tightly and released. A thermometer is momentarily inserted and then removed.
Medicines are delivered in tiny paper cups and thrust forward with minimal explanation and large glasses of water. Family members gather by the door, in the waiting room, and outside the lobby. Doctors hurry in hoping the chairs surrounding the bed will be empty.
Days are measured in seconds. A tireless parade of anonymous drones poking, prodding, reporting, and then disappearing. A patient lies flat waiting for an infusion to finish, a fever to decline, or a laboratory value to normalize.
The tears of a child re frame the question and squelch the quips of futility oozing from the doctors lips.
And every time, I leave your room, the same questions echo through my head.
Would I listen to me?
If I was in your shoes?
Thursday, March 22, 2012
Resistance is Futile?
It's not that I don't like the idea of it. I envision roaming tribes of doctors scattered amongst hospital floors rounding on patients. Everyone is polite, all opinions are counted, and decisions are made by consensus. Medical care is exact and parsimonious. The economy is saved and we all live happily ever after. Why not?
Group think has already solved all our problems. Look at congress! We don't need a conductor to lead the orchestra-we need a bunch of conductors. Why have a commander in chief when you can have a think tank instead? In fact, haven't most of the great inventions and discoveries throughout history come from the collective? Let me think: the light bulb, the telephone, penicillin. And haven't the great artistic and musical accomplishments of the last few centuries been produced by groups and not individuals?
So the next time my pager wakes me up in the middle of the night to report on my chf'er becoming hypotensive, I'll conference in the cardiologist, intensivist, and nephrologist and we'll make a decision. Although, most likely I will be the only one on the phone who actually knows the patient. I'll probably get some hodge podge of call coverage with bleary eyed specialists.
No. In reality, the road to expertism is a lonely one. Each individuals pathway to mastery is unique. We all develop our own off centered approach to that which we are good at. This is what separates the brilliant from mediocre. Attempts to sublimate such instincts to the group can only lead to bland homogenization.
The policy wonks have lost themselves in an orgy of false hope. Joining the Borg is not the answer. Collaboration is important, but won't solve all our problems.
Sometimes, the orchestra just needs a conductor.
Group think has already solved all our problems. Look at congress! We don't need a conductor to lead the orchestra-we need a bunch of conductors. Why have a commander in chief when you can have a think tank instead? In fact, haven't most of the great inventions and discoveries throughout history come from the collective? Let me think: the light bulb, the telephone, penicillin. And haven't the great artistic and musical accomplishments of the last few centuries been produced by groups and not individuals?
So the next time my pager wakes me up in the middle of the night to report on my chf'er becoming hypotensive, I'll conference in the cardiologist, intensivist, and nephrologist and we'll make a decision. Although, most likely I will be the only one on the phone who actually knows the patient. I'll probably get some hodge podge of call coverage with bleary eyed specialists.
No. In reality, the road to expertism is a lonely one. Each individuals pathway to mastery is unique. We all develop our own off centered approach to that which we are good at. This is what separates the brilliant from mediocre. Attempts to sublimate such instincts to the group can only lead to bland homogenization.
The policy wonks have lost themselves in an orgy of false hope. Joining the Borg is not the answer. Collaboration is important, but won't solve all our problems.
Sometimes, the orchestra just needs a conductor.
Wednesday, March 21, 2012
The Doctor-Patient Relationship Can Be Difficult
I walked down the hospital corridor listlessly. My feet dragged as they fought each attempt to lift off the ground. My body was tired and achy. The phone calls the night before had been relentless. Each stolen moment of sleep was interrupted before a deep, restful state was reached. It was Monday morning.
I sat at the nursing station flipping through charts. A colleague across the table was staring intently at his computer screen. He previously had been a private practitioner like myself, but he shuttered his practice to become a hospitalist. He glanced over at me appraisingly, taking in my disheveled hair and unshaven face.
Hard night?
I nodded in his direction, and looked up from the progress note I was struggling to complete. I wasn't making much headway.
So why did you leave your practice anyway?
A look of pity came over his face as he stared down at a coffee stain on my wrinkled gray lab coat.
I was tired!
He went on to explain that it was not physical but rather emotional fatigue that spurred his decision. He was tired of fighting with his patients.
*
As I exited the hospital and walked a few hundred feet to my building, I pondered my patient interactions over the the last week.
A healthy thirty five year old woman called my office daily for a benign upper respiratory tract infection. During each conversation she demanded an antibiotic, and each time I explained how it was inappropriate. I cited studies, explained the possible harm to herself as well as society, and gave a number of recommendations for alleviating symptoms. She responded by saying that all her friends doctors gave them antibiotics. Eventually she decided to leave my practice and find care elsewhere.
A hundred year old demented woman was placed in a nursing home after a devastating stroke which left her completely unconscious. Her previous doctor had dutifully ordered a feeding tube and transferred her to the nursing home for further care. Last week her kidneys began to fail, and her son demanded that we initiate hemodialysis. I invited the family to the nursing home and spent an hour discussing futile care and it's consequences. We talked about how hundred year olds don't tolerate dialysis well, and that her quality of life was already low. After becoming very emotional, the son stormed out of the room and accused me of trying to kill his mother.
A 60 year old woman with chronic back pain came to my office for a refill of a narcotic prescribed by her orthopaedist. I talked to her about the pain ad nauseum, and described how narcotics are not affective for long term control of musculoskeletal pain. I looked her up on the Illinois prescription monitor, and my eyes popped as I calculated that she received over 250 hydrocodone pills from three different doctors over the last week. When I refused to write another, she stormed out of the office and threatened to call the local medical board.
*
The doctor-patient relationship can be difficult. At it's best, it is a mutual, symbiotic connection between client and consultant. Sometimes, however, being a physician is like trying to parent two thousand teenagers. Although there is great affection on both sides of the examining table, the perspective is markedly different.
I admit that I can never know exactly what my patients are feeling, I haven't walked a day in their shoes. On the other hand, I have years of experience treating just the sort of complaints they come to my door seeking help with.
There are days when I fervently wish they would let me use this experience to help them.
And there are days when I wonder if I should have ever decided become a parent in the first place.
I sat at the nursing station flipping through charts. A colleague across the table was staring intently at his computer screen. He previously had been a private practitioner like myself, but he shuttered his practice to become a hospitalist. He glanced over at me appraisingly, taking in my disheveled hair and unshaven face.
Hard night?
I nodded in his direction, and looked up from the progress note I was struggling to complete. I wasn't making much headway.
So why did you leave your practice anyway?
A look of pity came over his face as he stared down at a coffee stain on my wrinkled gray lab coat.
I was tired!
He went on to explain that it was not physical but rather emotional fatigue that spurred his decision. He was tired of fighting with his patients.
*
As I exited the hospital and walked a few hundred feet to my building, I pondered my patient interactions over the the last week.
A healthy thirty five year old woman called my office daily for a benign upper respiratory tract infection. During each conversation she demanded an antibiotic, and each time I explained how it was inappropriate. I cited studies, explained the possible harm to herself as well as society, and gave a number of recommendations for alleviating symptoms. She responded by saying that all her friends doctors gave them antibiotics. Eventually she decided to leave my practice and find care elsewhere.
A hundred year old demented woman was placed in a nursing home after a devastating stroke which left her completely unconscious. Her previous doctor had dutifully ordered a feeding tube and transferred her to the nursing home for further care. Last week her kidneys began to fail, and her son demanded that we initiate hemodialysis. I invited the family to the nursing home and spent an hour discussing futile care and it's consequences. We talked about how hundred year olds don't tolerate dialysis well, and that her quality of life was already low. After becoming very emotional, the son stormed out of the room and accused me of trying to kill his mother.
A 60 year old woman with chronic back pain came to my office for a refill of a narcotic prescribed by her orthopaedist. I talked to her about the pain ad nauseum, and described how narcotics are not affective for long term control of musculoskeletal pain. I looked her up on the Illinois prescription monitor, and my eyes popped as I calculated that she received over 250 hydrocodone pills from three different doctors over the last week. When I refused to write another, she stormed out of the office and threatened to call the local medical board.
*
The doctor-patient relationship can be difficult. At it's best, it is a mutual, symbiotic connection between client and consultant. Sometimes, however, being a physician is like trying to parent two thousand teenagers. Although there is great affection on both sides of the examining table, the perspective is markedly different.
I admit that I can never know exactly what my patients are feeling, I haven't walked a day in their shoes. On the other hand, I have years of experience treating just the sort of complaints they come to my door seeking help with.
There are days when I fervently wish they would let me use this experience to help them.
And there are days when I wonder if I should have ever decided become a parent in the first place.
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