The Rise Of The Novice

The dreams of the novice are pure.  He sees a world of possibilities lying bare at his fingertips.  Unencumbered by skills and knowledge, he practices the art of healing in it's most elemental form.  Caring for humanity entails a kind heart, an available ear, and a pat on the shoulder.  It is in these times, the seed is sown for an unswerving path.  An ending that far too often has no recognizable remnants of such a noble beginning.

The mind of the medical student is already entrenched in chains.  The subject is no longer humanity but a textbook of pathology.  Facts, diagnoses, and algorithms lead the wanderer to stray from his path.  To do no harm becomes the lifelong mantra that distracts the addled brain from the primary dictum.  What once was the domain of the soul becomes fodder for the intellectual capacities.  We learn the art of caring through a skill set, we subtract it from the core of our being.

The resident believes himself to be inching closer, not farther from the secret.  Competence is the line between survival and failure.  The punt, the turf, and the buff are perfected as if they were indeed the practice of medicine unto themselves.  Fear and the struggle for survival detract from the ultimate goal. The distortion of the carnival fun house is almost complete.

The practicing physician wears a lab coat of many colors.  One part businessman, one part computer technician, his role changes based on the needs of a complex and rigid system.  He is both the keeper of facts as well as the follower of guidelines.  He is the supervisor and the grunt at the end of the line.  His loyalties are so divided between society and patient, that he has become utterly ineffective.

The secret is shockingly simple.

The novice was more adept in the art of healing than the byproduct of this dehumanizing process.

We must start again.

We must return to the beginning.

Whose Burden Is It Anyway?

I mean, we're all kind of dying a little bit.  Certainly we've had our dark moments.  It's one of the hazards of the profession.  What do we expect after seeing so much pain and suffering, pain and longing?  It would be quite audacious to suppose that it doesn't affect us.  That we can waltz into the exam room and leave our personal feelings and scars behind, the idea is laughable.

We are human.  And as human beings we cope the best we can.  Some have more mature mechanisms, others not so much.  So when I enter the office on a bad day, I  may feel a little bit distant, maybe cold.  Occasionally I might be downright mean.  It's not personal.  Fresh scars are often surrounded by fleshy, more sensitive tissue.

Over the years I have been cursed, threatened with malpractice, and left waiting for patients who have never shown.  I have been mistreated in almost every imaginable way by my clients.  Most of the time, I accept this type of behavior.  When faced with fear, illness, or death, it is common to lash out at the bearer of bad news.  Part of my job is to place my patient's behavior in context and react accordingly.  Often the worst actors are the first to apologize when their situation improves.

I try to give each patient the benefit of the doubt.  Yet it pains me to see how the public reacts to physician's poor behavior.  We have been accused of being aloof, distant, and angry.  I suspect that in reality most doctors are none of these things by nature.  Like anyone faced with fear and destruction, we're in pain.

You see doctors and patients aren't that different in reality.  We all hurt on the inside.  Why do you suppose we suffer alone?

I wonder if we could share this burden.

Eating Crow

I mentally rolled my eyes. The twenty something sitting in front of me was trying his best to influence my plan, but the clinical decision making was quite straight forward. He had no fever, no shortness of breath, and looked nontoxic. His lungs were clear and he was healthy. It seemed like a no brainer. I tried to explain.


We don't treat bronchitis with antibiotics. Especially someone as healthy as you.

I could tell he wasn't buying my explanation even though he had little choice. I recommended hydration, rest, and to call me in a few days or sooner if his symptoms worsened. Then I shut the door and moved on to my next patient. I hardly though about him after that.

It was with considerable shock that I answered the phone call from the emergency room a few days later. He was septic and hypotensive. His xray showed a dense pneumonia and he needed to be admitted to the ICU. I rushed over to the hospital, and climbed the steps to the second floor with trepidation. By the time I reached his bed, his blood pressure was coming up and the color was returning to his face. He scowled as I walked in the door.

I carefully chose my words expressing regret that he had gotten so sick, without making reference to my decision making process. I was wrong. He didn't get better with rest and fluids. But I had taken the right coarse of action based on current guidelines and knowledge.

Sometimes, that just isn't enough.

As physicians we find ourselves wrong all the time. With the complexity of human physiology and the inadequacy of current medical knowledge, it's a miracle that we bat greater than five hundred. Complicating this fact, is that our profession must answer to a number of impatient mistresses.

The government and health care reform have now erected a monument to parsimony. So sometimes even when you right, your wrong because you utilized too many resources. The critical eye of malpractice lawyers also effects our decision process. Forget parsimony, rightness is defined by leaving no stone unturned no matter how small or remote.

At the end of the day, we have many hands pulling at us.   Even when every patient is home tucked in bed safely,

we still feel like we're eating crow.

"Let's Waste Medicare's Money"

Narrator: And now folks it's time to play "Let's Waste Medicare's Money", the game show that shines a light on abuse with a complement of perverse incentives.  Today we have three contestants.  Say hello to Ida Mae, The Colonel, and Wild Bill.  In a moment our lovely guests will each recount how, with the help of their doctors and bureaucratic red tape, they have single handedly bankrupted our health care system.  But first, an explanation of how the game is played.  You, the audience members, decide the winner.  At the end of the show you vote based on who you think wasted more of the governments dollar.  The grand prize will be a full months stay at the contestants nursing home of choice, all expenses covered (that is, of course, unless medicare picks up the tab)!

Narrator: Let's start with contestant one, Ida Mae, how are you doing today?

Ida: Oy!  I'm so tired.  My legs hurt.  And my back, my back...do you happen to have any of those vicodin pills?

Narrator: No Ida.  I was just being polite.  I didn't really want to know how you're doing.  Tell us your story.

Ida: Well I was watching Dr. OZ on TV (he's so cute!) and he said that all diabetics should see the foot doctor.  So I asked my friend Sally, and she gave me the name of her specialist.  The podiatrist thought my feet looked fine, but noticed my legs were swollen. 

I hadn't noticed my legs were swollen.  Who knew?

Narrator: Quite a predicament!

Ida: So he says to me.  You better call your cardiologist.  And I call, but he's busy seeing patients.  His nurse answers the phone instead.  She asks if I'm feeling short of breath.  I say of course.  I been short of breath since nineteen sixty three when I gained that fifty pounds after carrying my last child.  The nurse became all excited. She told me I had to go to the emergency room immediately.  So I says there's no one available to drive me.  She says: call an ambulance right away. 

Once I got to the emergency room,  there were all these doctors I didn't know.  They admitted me over night and ordered a stress test and echocardiogram.

The hospital doctor came the next day and discharged me.  He said my heart was fine.  I told him I already knew that, but wanted to know why my legs were swollen.

Narrator: And what did he say?

Ida: He didn't know.  He thought that that was something my outpatient doctors should figure out!

Narrator: Very nice.  Now let's move to contestant two.  Colonel, can you top that.

The Colonel: Yes sir.  On Monday at 0800 hours I started having pain in my chest.  It was severe and pressure like.  I called my doctor and he sent me to the hospital.  In the emergency room it was decided I would stay over night.  On Tuesday, some case coordinator came to see me and said they were changing my admission to observation.  She said something about hospital readmissions and how this wouldn't count.  I was feeling tired and confused already, and so just went along with whatever she suggested.  Later that night, I spiked a fever.  The next day I was diagnosed with pneumonia.  By then, I was as weak as a wet noodle.  I couldn't get out of bed.  By Friday my doctor told me I needed to go to the nursing home, but they couldn't send me because of my observation status, medicare wouldn't cover it. Finally he agrees to change me to a full admission, but I had to stay in the hospital three extra nights so that medicare would pay for my nursing home.  He told me I could leave sooner,  but then I would foot the bill.  I said: heck no!  I would rather stay in the hospital hotel. 

Narrator: Quite nice accommodations they have there!  OK Wild Bill, your up.

Wild Bill: Well I was out riden my hoarsey when my back started to hurt.  I got off the hoarse and crawled into the ranch.  After searchin on the Internet, I decided I need to go see a neurosurgeon.  I called the doctor but his secretary said that Dr. Back Whisperer won't see anyone without having an MRI done first.  So I asked for a referral from my pcp.  Since my whole back was hurting, he ordered three MRI's to cover everything. 

Narrator: sounds logical.

Wild Bill: When I got in that MRI machine, I felt like a pig in too small a pen.  I had to stop after thirty minutes.  So my PCP called in a prescription for valium so I could retake the test.  The Valium worked alright.  I was so dizzy getting off the table I fell and broke my hip.  Six months later I'm finally recovered but I haven't road my hoarsey since.

Narrator: And how's your back?

Wild Bill: My back?  That felt better before I even took the MRI.

Narrator: Well, there you have it folks.  Which contestant gets your vote?  Who is the winner?  Or better yet, are there any winners?

It certainly isn't us,

the American public.

Unrealistic Expectations

I've cowered behind my gray coat as my hands fidgeted and my mouth sputtered an apology.

I've stood above the body of a dying patient and questioned every single decision.

These are the moments that blacken the soul.  These are the bleeding scars of one who attempts perfection and yet is destined to suffer the realities of being mortal.  I have accepted the weight of these burdens as I will carry them to my grave.  But sometimes it is the subtleties that chip away the edifice of confidence and expose the flesh, weak and unprotected.

Albert hobbled into the office six months after the death of his beloved wife.  Within weeks of developing a cough, she succumbed to lung cancer.  His eighty year old body was healthy, but his posture stooped with grief.  His eyes focused on the ground as he answered my questions in monosyllables.  When he did speak in sentences, he talked of his daughter who was paralyzed in a state of  perpetual mourning.

I examined his gaunt frame.  His blood pressure was good and his pulse steady.  His lungs were clear and his heart lub-dubbed methodically.  We reviewed his medications and recent lab tests.  There was nothing to be done.  I paused and closed the chart on my computer screen.

We stared at each other.

Albert cleared his throat and the light in his eyes extinguished.

She died so quickly!

His head shot back toward the ground, but it was too late.  In the brief second of contact, I saw a window into the depths of his heart.  He might not have even known it himself, but he blamed me.  I could hear the words although he wasn't speaking them.

You should have caught the cancer faster.  You should have saved her life.  No one should traverse between life and death with such minuscule warning.

Like a ton of bricks crashing down on my head, I realized that the only reason he was still coming to my office was that his kids were forcing him to.  I can't explain how I knew all this from one sentence, one look, but I was as sure of it as I was the reflection in the mirror.

He left the room.  My spirit drained, I couldn't muster the appropriate sentiments.  I certainly wasn't going to try to defend myself, although I was certain that I had done everything correctly.

Sometimes, I wish patients understood what physicians experiance.  Not only do we bear the overwhelming guilt when we perform below our own expectations, we often suffer the venom of unrealistic expectations.

Yet to point this out to a grieving family member is to belittle the mourning process in the first place.

We must walk this road alone.

And Now A Word From Our Sponsor

I live in a world of words.

The elderly man leans against the locked door of the dementia unit.  His bottom half pushes against the barrier while his upper flails freely toward the nursing station.  His is more passing the time than agitated.  The tenor of his voice rises and falls.  I discern a cadence, a military march.  His eyes are glazed, far away, in another land.

My secretary coos on the phone to the crying patient.  She placates, she soothes, she checks the schedule.  I can hear the lilt in her voice, the one that signals genuine empathy.  She fields such calls with a  certain expertise.  Her tone, the exact mix of warmth and graciousness, begins the healing process miles before the patient actually enters the exam room.

My son chitters away in the direction of my daughter.  Sometimes my children's voices are like songs, others they are squawking ravens pecking at my feet.  Every word is filled with emotion.  Every sentence ends with an exclamation point.

But words fall empty when there is no audience.  Only the keen observer will note that the demented man in the nursing home is a retired army colonel, or that the secretary has just lost her own mother, or that behind the children's nagging is the overwhelming request to be loved.

I have spent countless hours staring at this blank screen as it reflects back a mangled version  of myself.  My pitiful, misspelled words collide into fragmented sentences.  Thoughts come randomly and build, crescendo and decrescendo.  Purpose languishes in the shackles of rudimentary delivery.

Yet you, my reader, come faithfully without beckoning.  You comment, and retweet, and click like on facebook.  You turn the bald, pragmatic glyphs on page, to something more than ephemera.

You give my words context.

And in that, you bestow upon me the greatest kindness.


Thank You.


Jordan

Drawing A Line

I never liked it that much anyway.  My son was the one who came home with the idea in his head. Before I knew it, I was signing a waiver at the information session and writing a check.  After all, it was an extra curricular activity, and I was impressed with his verve.

Months later after attending a few meetings, it was my wife who sounded the alarm.  She had already supported a petition, but the recent public announcement was just too much.  How could I keep my son in Cub Scouts?  How could I look my community and my patients in the face?  What type of a role model was I becoming for my children?

My son is understandably upset, but we're working on him.  At eight years old, he doesn't yet know how often he will be asked to compromise his morals for ease, personal gain, or a myriad of other reasons.

It is our job to teach him.  It is our job to stand up and take a stance when ugliness and bigotry encroach on our lives.

We are just a few small people drawing a line in the sand, facing a Goliath.

And boy, does it feel good.