We all know what happens when you make assumptions.
And the truth is, labels are no better. Yet as physicians we make them all the time. The label is less about the person and more the feeling they invoke inside of you. When you like a patient they become "friendly" or "easy". When the relationship is more strained, they are "complicated" or just plain "crazy".
Labels not only color the interaction between doctor and patient, they also are intimately tied to clinical decision making. We live and die by our own sword. But occasionally we draw a faulty cover for the book we pick up to read. The result is chaos, and poor medical care.
*
Allison was a difficult patient. A striking middle aged woman, she strode into the exam room with the same confidence that she entered board meetings. Her control over her appearance and profession, however, were in stark contrast to her personal life.
Allison was a mess. Full of anxiety and inner loathing, she bounced from one tumultuous relationship to another. Men and women passed in and out of her life quickly. She was unable to maintain even the simplest bond whether platonic or otherwise. Because of this, she spent an extraordinary amount of time in her therapist's office.
The stress and loneliness manifested itself in the form of somatic complaints. Years ago, when we first met, it was headaches. She later progressed to myalgias. Her most recent issue was chronic abdominal pain. Her labs, cat scans, and scopes were all normal. Yet her pain was unrelieved.
My relationship with Allison had it's ups and downs. Although she was nice enough, I couldn't help getting that sinking feeling when she showed up on my schedule. After countless attempts to solve her problems, I often came up with the big zero. Undoubtedly patients like Allison make physicians question their professional relevance. There is nothing worse then striking out every time at bat.
*
When Allison entered my office this morning, I figured I was in store for yet another fruitless workup. But today was different. She walked into the room with her head held low, and a slouching posture that I had never seen before. The confidence was gone. As she sat down on the examining table, she lifted her head to speak. The left side of her upper lip was swollen and her left eye was black and blue.
I stood quietly and touched her face, palpating the cheek bones and orbits for signs of fracture. Then I sat back down on my stool, and decided not to ask any questions. We stared at each other, and I waited for her to talk. A few moments later she began to speak.
In a fit of anger, her latest boyfriend punched her in the face. Allison picked herself off the floor and left his house immediately. She then called the police. I was saddened by her story, but glad that she had the presence of mind to protect herself in this horrible situation. I told her that I was proud of her while being careful not to be condescending. Allison looked up more defiantly this time.
I would never go through that shit again!
My mind caught on the word "again" as I waited for her to explain. Apparently Allison had been removed from her home by social services as a child. She had been a victim of abuse and neglect. She moved from home to home as a child. Some times her caretakers were good, other times not so much. She was raped by the teenage son of one of her foster parents.
My mind was spinning as she continued to tell her story. I clicked over to the social history section of the electronic medical record and read in horror. One lazy sentence.
Adopted, family history unknown.
*
Things have changed between Allison and I. I look forward to her visits, even though I still often can't fix the emotional and physical problems that plague her. I now recognize that the "difficult" moniker is more appropriate for her experiences and less so for her intentions or personality.
In fact, I've found an altogether different label for Allison now:
Courageous.
Monday, April 30, 2012
Saturday, April 28, 2012
A Movie Without A Soundtrack
I wouldn't call myself a music snob. Sure there were years in high school where I bought tapes and Cd's. I pictured myself a suburban outcast. The titles lining my bookshelf represented a smattering of rap, R + B, and soul. I can still hear the haunting rhymes of Chuck D and KRS-1 run through my mind at random times.
As the years passed, I listened to music regularly although I was no longer a consumer. I spun the dial on the car radio and settled on syrupy, upbeat top 40. And that's where I stayed. To this day, the younger members of my office staff are surprised when I recognize the stylings of the newest radio stars. I catch their pop culture references and shoot a few back at them. What else is a guy going to do while driving a few hours a day?
A few months ago, I felt my self inundated with noxious stimuli and searched for something a little more calming on my daily commute. Like an answer to my prayers, I happened upon National Public Radio. Each morning, I listened to the smooth calming diction of NPR's announcers. The programming was informative and stimulating. The afternoon doldrums were interrupted by the latest news and interviews. For the first time in my life, I felt well informed.
But something else subtle was beginning to happen after this seismic shift. I began to struggle with my writing. The blog posts became slower and more labored. The depth and breath of my emotion began to fade. I sat down many mornings and started to write, but ended up staring at a blank screen. My mood began to sour and my enjoyment in work was fading. It was like I had lost my internal rhythm.
This morning while running errands, my kids convinced me to turn off the "boring" talk radio and play some music. As I cruised down the highway, I started to feel myself shift. My body unconsciously bounced to the melodic drumbeats coming from the speakers.
A flood of memories returned to me. Memories of driving quiet mornings before the sun came up. It was during these lonely moments where the impetus to write welled up in my chest. Inspiration was not the monotonous chatter nor the informative stories of talk radio, but rather the booming of base, the riff of the guitar, and the soul of lyrics.
Without music, I was lost. I had become a movie without a soundtrack.
As the years passed, I listened to music regularly although I was no longer a consumer. I spun the dial on the car radio and settled on syrupy, upbeat top 40. And that's where I stayed. To this day, the younger members of my office staff are surprised when I recognize the stylings of the newest radio stars. I catch their pop culture references and shoot a few back at them. What else is a guy going to do while driving a few hours a day?
A few months ago, I felt my self inundated with noxious stimuli and searched for something a little more calming on my daily commute. Like an answer to my prayers, I happened upon National Public Radio. Each morning, I listened to the smooth calming diction of NPR's announcers. The programming was informative and stimulating. The afternoon doldrums were interrupted by the latest news and interviews. For the first time in my life, I felt well informed.
But something else subtle was beginning to happen after this seismic shift. I began to struggle with my writing. The blog posts became slower and more labored. The depth and breath of my emotion began to fade. I sat down many mornings and started to write, but ended up staring at a blank screen. My mood began to sour and my enjoyment in work was fading. It was like I had lost my internal rhythm.
This morning while running errands, my kids convinced me to turn off the "boring" talk radio and play some music. As I cruised down the highway, I started to feel myself shift. My body unconsciously bounced to the melodic drumbeats coming from the speakers.
A flood of memories returned to me. Memories of driving quiet mornings before the sun came up. It was during these lonely moments where the impetus to write welled up in my chest. Inspiration was not the monotonous chatter nor the informative stories of talk radio, but rather the booming of base, the riff of the guitar, and the soul of lyrics.
Without music, I was lost. I had become a movie without a soundtrack.
Thursday, April 26, 2012
Whose Team Are You On?
It couldn't have been worse. The complaints in the office were unsolvable. The regulars came late to their appointments. The "oh, by the way doctor" questions required more then cursory explanations offered from the doorway. I sat down during a stolen moment for lunch only to be harassed by a call from the emergency department that needed urgent attention.
It was the kind of day where office visits were interrupted by mobile phone calls that were interrupted by a beeping pager. By the end of clinic, I was ready to hang up my stethoscope. I was physically and emotionally exhausted. These were the times that tested one's will to be a physician.
As I crawled into my car for the drive home, my phone started to ring. I read the display before picking up. It was another call from the nursing home. Mr. G was being admitted after a prolonged hospitalization. I remembered Mr. G well.
I took care of him a few years ago after a hip replacement. He had been assigned to my case load because his primary care doctor didn't come to the facility. He was a large, gruff, strapping sixty year old at the time. After a few weeks, he fired me because I refused to give him an antibiotic for a mild respiratory infection.
One moment I was in charge of his care, the next I wasn't allowed into his room. I have forgotten many of the hundreds of patients I have taken care of in nursing homes over the years, but I'll always remember the faces of those who have fired me. I still take it personally.
Although I was itching to get home, I pulled into the parking lot a few minutes later. I suspected Mr. G would take one look at me and remember our colored history. I braced for a confrontation.
When I walked into his room, I couldn't have been more surprised. Mr. G was a shadow of the man he used to be. His face was drawn, and his frail body rested listlessly on the hospital bed. His dialysis catheter was taped neatly on his chest wall.
He didn't even remember me.
When I finished questioning, I silently examined Mr. G. How much had changed over the last few years. Although I entered the room like a lion, I left like a lamb. After seeing him, I couldn't help but wonder when the doctor-patient relationship became a confrontational one. We have so much in common.
We both agonize over the limitations of the human body. We suffer with life's unexpected turns. And we face our own limitations every day while gazing in the mirror.
Maybe it's time to allow humility to remind us,
we're playing for the same team.
It was the kind of day where office visits were interrupted by mobile phone calls that were interrupted by a beeping pager. By the end of clinic, I was ready to hang up my stethoscope. I was physically and emotionally exhausted. These were the times that tested one's will to be a physician.
As I crawled into my car for the drive home, my phone started to ring. I read the display before picking up. It was another call from the nursing home. Mr. G was being admitted after a prolonged hospitalization. I remembered Mr. G well.
I took care of him a few years ago after a hip replacement. He had been assigned to my case load because his primary care doctor didn't come to the facility. He was a large, gruff, strapping sixty year old at the time. After a few weeks, he fired me because I refused to give him an antibiotic for a mild respiratory infection.
One moment I was in charge of his care, the next I wasn't allowed into his room. I have forgotten many of the hundreds of patients I have taken care of in nursing homes over the years, but I'll always remember the faces of those who have fired me. I still take it personally.
Although I was itching to get home, I pulled into the parking lot a few minutes later. I suspected Mr. G would take one look at me and remember our colored history. I braced for a confrontation.
When I walked into his room, I couldn't have been more surprised. Mr. G was a shadow of the man he used to be. His face was drawn, and his frail body rested listlessly on the hospital bed. His dialysis catheter was taped neatly on his chest wall.
He didn't even remember me.
When I finished questioning, I silently examined Mr. G. How much had changed over the last few years. Although I entered the room like a lion, I left like a lamb. After seeing him, I couldn't help but wonder when the doctor-patient relationship became a confrontational one. We have so much in common.
We both agonize over the limitations of the human body. We suffer with life's unexpected turns. And we face our own limitations every day while gazing in the mirror.
Maybe it's time to allow humility to remind us,
we're playing for the same team.
Tuesday, April 24, 2012
Dropping The Ball?
I love Juggling. I started when I was a little kid. Originally my brother learned from reading a book. But I had to be better than him. I taught myself. I started with one ball and tossed it back and forth from hand to hand. I did this for weeks till I had mastered the skill. I could do it with my eyes closed.
Next I added a second ball. Two balls are a little more tricky. The juggler's concentration is split. The chief process is still similar. Throw the ball up with one hand and catch with the other; except now two hands are both engaged at the same time.
Months later, I was ready to try three, and then four. The trick to juggling is to be able to give the appropriate amount of attention to each ball at the right time, while being generally aware of all the rest. It is a dance performed by the hands, but mastered by the eyes. The more balls one has in the air, the quicker and more intense one must focus on each ball, and then move on. Once concentration is lost, everything tumbles to the ground.
*
Medicine is a lot like juggling. The doctor must have razor sharp focus on each patient at times, but also be aware of thousands of others in the background. It's a balancing act. One in which we struggle to keep all balls up in the air at one time. This is becoming more difficult. Even in the last year, the number of distractions facing the lowly generalist are increasing.
Five years ago, the paperwork and hassles were less. There was no such thing as face to face encounter forms to fill out, or med reconciliation forms. Pre authorization was slightly less rampant. Electronical medical records are dutifully adding to time spent on charting. While all of these may have some beneficial impacts (emphasis on "may"), there are consequences also.
The struggling primary care doctor can no longer keep up with all the balls in the air. Attention and focus are being nudged away by paperwork. One would argue that maybe the physician should start to focus on fewer balls. But with decreasing reimbursements and increasing need in the community, that's just not likely to happen.
So the question is no longer whether physicians are dropping the ball,
it's why?
Next I added a second ball. Two balls are a little more tricky. The juggler's concentration is split. The chief process is still similar. Throw the ball up with one hand and catch with the other; except now two hands are both engaged at the same time.
Months later, I was ready to try three, and then four. The trick to juggling is to be able to give the appropriate amount of attention to each ball at the right time, while being generally aware of all the rest. It is a dance performed by the hands, but mastered by the eyes. The more balls one has in the air, the quicker and more intense one must focus on each ball, and then move on. Once concentration is lost, everything tumbles to the ground.
*
Medicine is a lot like juggling. The doctor must have razor sharp focus on each patient at times, but also be aware of thousands of others in the background. It's a balancing act. One in which we struggle to keep all balls up in the air at one time. This is becoming more difficult. Even in the last year, the number of distractions facing the lowly generalist are increasing.
Five years ago, the paperwork and hassles were less. There was no such thing as face to face encounter forms to fill out, or med reconciliation forms. Pre authorization was slightly less rampant. Electronical medical records are dutifully adding to time spent on charting. While all of these may have some beneficial impacts (emphasis on "may"), there are consequences also.
The struggling primary care doctor can no longer keep up with all the balls in the air. Attention and focus are being nudged away by paperwork. One would argue that maybe the physician should start to focus on fewer balls. But with decreasing reimbursements and increasing need in the community, that's just not likely to happen.
So the question is no longer whether physicians are dropping the ball,
it's why?
Sunday, April 22, 2012
For The First Time
My son sits quietly as the train clanks from track to track. The morning sun streams into the the mostly empty car. We both squint and stare as the cityscape passes by. The suburban scenery is quickly replaced by advancing urban sprawl.
With each stop, more passengers pile into the sliding metal doors. Apartment buildings and unlucky homes rush by. A hurd of satellite dishes lopes past at the blink of an eye. Signage marks the borders of each neighborhood. First comes Arabic, which quickly gives rise to Vietnamese glyphs. A mix of Spanish and English signals yet another enclave. The stores are more authentic here. Glaringly absent are the cartoonish donkeys or the boasting burritos.
The air grows thick as seats fill. A businessman dressed in an Armani suite sits uncomfortably next to a disheveled homeless man. The clean tailored jacket clings to its owner as if aware of its unkempt neighbor. A Student sits across from us with her head buried in a series of photocopied pages stapled together at the corner. Her eyes dart back and forth between occasional page turns.
Young and old intermix and intertwine. Porcelain skin confronts wrinkles. The athletic youth in workout clothes stands and offers his seat to the elderly woman limping through the aisle as the train begins to lurch forward.
Hands are weighted down by shopping bags, back packs, and electronic paraphernalia. Eyes stare at mobile phones, or Ipads. Heads bob up and down and side to side revealing small white cords leaving the ears and wending their way down into jackets and disappearing out of site.
Over decades the details have changed but the feelings are the same. How long has it been since I took the train? My son doesn't notice that my attention has turned to him. He's too busy inebriated by the sites and sounds of a lazy weekend. My thoughts return to the window, and the world awaiting on the other side.
It's like, for just a moment I can experience the world through his eyes,
and see everything for the first time.
With each stop, more passengers pile into the sliding metal doors. Apartment buildings and unlucky homes rush by. A hurd of satellite dishes lopes past at the blink of an eye. Signage marks the borders of each neighborhood. First comes Arabic, which quickly gives rise to Vietnamese glyphs. A mix of Spanish and English signals yet another enclave. The stores are more authentic here. Glaringly absent are the cartoonish donkeys or the boasting burritos.
The air grows thick as seats fill. A businessman dressed in an Armani suite sits uncomfortably next to a disheveled homeless man. The clean tailored jacket clings to its owner as if aware of its unkempt neighbor. A Student sits across from us with her head buried in a series of photocopied pages stapled together at the corner. Her eyes dart back and forth between occasional page turns.
Young and old intermix and intertwine. Porcelain skin confronts wrinkles. The athletic youth in workout clothes stands and offers his seat to the elderly woman limping through the aisle as the train begins to lurch forward.
Hands are weighted down by shopping bags, back packs, and electronic paraphernalia. Eyes stare at mobile phones, or Ipads. Heads bob up and down and side to side revealing small white cords leaving the ears and wending their way down into jackets and disappearing out of site.
Over decades the details have changed but the feelings are the same. How long has it been since I took the train? My son doesn't notice that my attention has turned to him. He's too busy inebriated by the sites and sounds of a lazy weekend. My thoughts return to the window, and the world awaiting on the other side.
It's like, for just a moment I can experience the world through his eyes,
and see everything for the first time.
Friday, April 20, 2012
Swan Song
He rushed out of the elevator bank and made a b-line to the first patient room at the edge of the nursing station. His smart clothing and athletic build did little to portray his age. He looked about sixty, at least one or two decades younger then reality. We had discussed, plotted, and strategized in the past. But this morning he didn't even notice me buried under the weight of a computer screen. He was a thousand miles away.
I continued with the clean, unemotional tone of the note that I was writing. I thought I would give him a few moments alone.
I was called by the nursing staff at approximately 6am to evaluate for obtundation. Patient was unresponsive to voice or stimulation. Breath and heart tones were absent.
I marveled at how plain the words could be. How the last markings on the chart could be so similar for each patient who passed. We all live such varied lives. Yet we all die the same. Every chart is buffed and polished with the same cold, objective wording. I pulled away from the computer screen and ambled over to the door. I waited before entering.
His movements were jerky and unnatural. He bounced around the room picking through her belongings and stuffing occasional articles in a shopping bag. He had planned for this moment. He watched the months slip by as her condition worsened. Death hovered at her bedside in continuous battle. She finally waved the white flag.
I entered and put my hand on his shoulder. There was no place for words. I slipped the bag out of his hand and walked him over to a chair adjacent the hospital bed. He sat for a time by his wife's body. But both of us new that her essence was gone. Only inanimate limbs and tissue remained.
After a few minutes he got up and left the room. He would make funeral arrangements and call family.
His companion of sixty years was gone. Everything in his life had changed. But in the end he had no choice.
He would reenter the world of the living.
I continued with the clean, unemotional tone of the note that I was writing. I thought I would give him a few moments alone.
I was called by the nursing staff at approximately 6am to evaluate for obtundation. Patient was unresponsive to voice or stimulation. Breath and heart tones were absent.
I marveled at how plain the words could be. How the last markings on the chart could be so similar for each patient who passed. We all live such varied lives. Yet we all die the same. Every chart is buffed and polished with the same cold, objective wording. I pulled away from the computer screen and ambled over to the door. I waited before entering.
His movements were jerky and unnatural. He bounced around the room picking through her belongings and stuffing occasional articles in a shopping bag. He had planned for this moment. He watched the months slip by as her condition worsened. Death hovered at her bedside in continuous battle. She finally waved the white flag.
I entered and put my hand on his shoulder. There was no place for words. I slipped the bag out of his hand and walked him over to a chair adjacent the hospital bed. He sat for a time by his wife's body. But both of us new that her essence was gone. Only inanimate limbs and tissue remained.
After a few minutes he got up and left the room. He would make funeral arrangements and call family.
His companion of sixty years was gone. Everything in his life had changed. But in the end he had no choice.
He would reenter the world of the living.
Wednesday, April 18, 2012
Minor Trauma
My daughter is crying uncontrollably. One hand is pressing her head as the other gestures wildly. Through angry sobs she attempts to articulate her pain.
My head...my head!
I try to hold her close, but she pushes away. I settle for clinging to her hand. Nothing irks a parent more then listening to his child shriek in pain. I can feel the bile rise in my chest as I split in half. The emotional parent wants to rush to the phone and call an ambulance. The objective clinician sees a child who is upset, but shows no signs of real distress.
*
I've seen children die. I have watched the stillness that accompanies mortality. I will never forget the cat scan with the big sphere of blood entombed by such a small skull. I remember taking slow steps down the long hallway to meet the family in the crisis room.
I am not the same person I was before I started medical school. My eyes have been torn open and forced to watch the cruelty of human existence. The marks have left stains on my soul in much the same way the spatter has marked my lab coats.
I am broken.
I am empty.
I am less than when I started.
Yet I have been placed on this earth to protect these children. My love and knowledge must be enough to shield them from the abyss.
*
Thirty minutes later my daughter is calm. After wiping away her tears, we begin the real work of talking about what upset her. She doesn't have a brain bleed, or meningitis, or an aneurysm. She is simply a victim of minor bullying at school.
After she falls soundly asleep, I tip toe out of the room. She will recover from these minor traumas.
The better question, I guess, is will I?
My head...my head!
I try to hold her close, but she pushes away. I settle for clinging to her hand. Nothing irks a parent more then listening to his child shriek in pain. I can feel the bile rise in my chest as I split in half. The emotional parent wants to rush to the phone and call an ambulance. The objective clinician sees a child who is upset, but shows no signs of real distress.
*
I've seen children die. I have watched the stillness that accompanies mortality. I will never forget the cat scan with the big sphere of blood entombed by such a small skull. I remember taking slow steps down the long hallway to meet the family in the crisis room.
I am not the same person I was before I started medical school. My eyes have been torn open and forced to watch the cruelty of human existence. The marks have left stains on my soul in much the same way the spatter has marked my lab coats.
I am broken.
I am empty.
I am less than when I started.
Yet I have been placed on this earth to protect these children. My love and knowledge must be enough to shield them from the abyss.
*
Thirty minutes later my daughter is calm. After wiping away her tears, we begin the real work of talking about what upset her. She doesn't have a brain bleed, or meningitis, or an aneurysm. She is simply a victim of minor bullying at school.
After she falls soundly asleep, I tip toe out of the room. She will recover from these minor traumas.
The better question, I guess, is will I?
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