The orders came indirectly from the government.
Reduce hospital re admissions. Cut costs.
So the hospital contacted the local hospice/palliative care center and asked for help. Of course, overwhelmed with work and understaffed, the project was handed off to me.
My task sounded simple. Create a palliative care program at the nursing home. But as I gathered for the first meeting with the administrator, social worker, and clinical staff, I knew there would be resistance.
And, in fact, I had my own feelings of reticence. Although I had learned much over the years, I was not trained in palliative medicine. As I gazed around the room, I realized that neither were any of my colleagues.
*
I looked Nancy squarely in the eye as I explained my vision. Our beginnings would be simple and humble. Admissions would flag appropriate patients based on predefined criteria. Then social work would approach each patient and family within seventy hours and have "the talk".
When Nancy heard her profession mentioned her ears perked up and her face twisted in confusion.
What do you mean, "the talk"?
Ready for her question, I pulled out a POLST (physician orders for life sustaining treatment)form and passed it around the room. The two page document was a series of basic questions.
Do you want to be resuscitated if your heart stops?
Do you want to be hospitalized if your condition worsens?
If you are unable to eat on your own, would you want a feeding tube?
Can IV fluids or antibiotics be given?
Attached, on the back, was a series of questions I had created myself.
Do you have a religious affiliation?
Would you like to be visited by clergy or a therapist?
If you knew you were dying, would you rather pass at home, in a hospital, or in the nursing home?
What are your health care wishes for the next six months?
What is more important to you: quality or quantity of life?
*
I looked around the room as the participants read the form. Nancy was becoming more anxious.
Isn't this the doctor's responsibility?
I answered her with a tinge of melancholy.
Yes, it is the doctor's job. But it's also the nurse's, social worker's, and therapist's job also. It's all of our jobs.
*
We met each week. Nancy presented new patients, and then the nurses and I would discuss clinical issues and pain control. The difficult cases were referred to the associated palliative care doctor from the local center.
During the first few sessions, I continuously hammered Nancy on the POLST form. For each patient, I wanted to know the answer to all of the questions. At first she rolled her eyes, but as time went on she got the hang of it.
A transformation occured during our fourth meeting. We had ten people in the program. As Nancy presented each patient, I could sense a diference in the tone of her voice. She was now approaching the project with a new sense of zest and zeal.
At the end of the meeting, I asked her what was going on.
Well, you know Mr. Smith? He passed yesterday.
Mr Smith had end stage dementia. He was in the process of dying for months, but his physician had not bothered to talk to the family about end of life care.
His daughters and I completed the POLST form a few weeks ago. So when he started to die, we were all on the same page. He passed quietly in bed without ambulances, IVs, or CPR.
I could see the change in her posture. She got it. She now saw how powerful these conversations could be. I smiled and congratulated her on how well she was doing such an important job. She looked down embarrassed.
It's not like I saved his life.
Our eyes met.
No, you did something most doctors have forgotten how to do.
You saved his death!
Saturday, December 10, 2011
Thursday, December 8, 2011
Turning Tables
Dr. Borak's voice was uncharacteristically timid. The authoritative lull and crisp enunciation had receded into a awkward bucket of uncertain phrases. For a moment, I felt as if I was back in grade school discussing the object of his affection.
Did you talk to her? What did she say?
I could feel the intensity through the phone as if the mouth piece had arched upward and was staring me dead in the eye. I felt bad for poor Borak. He suffered greatly the last few months. Although he was dropped from the malpractice suit, the scars brought on by years of finger pointing remained.
Then, there was the dispute with hospital administration. When they formed their own oncology group, Borak's referrals dropped significantly. His years of experience and relationship building couldn't stem the tide of inevitable change.
It was not an opportune time to be part of the old guard.
*
It wasn't particularly notable when Borak's patient asked for a new oncologist. She had visited him once and felt like there was no connection. Hell, people left me all the time! So I offered up a few names and thought nothing of it.
When Borak called to discuss the situation, I was caught completely off guard. I stammered as I tried to explain why I had given her other names. It wasn't the accusatory nature of his questioning that rocked me off balance, it was the hurt and uncertainty in his voice.
Borak was fighting for his professional life, and apparently he was losing ground quickly.
My discussion with the wayward patient was unfruitful.
We just didn't click.
When I reported back to Borak, his anger had receded. With sad recognition he accepted the fact that he lost another patient. He always considered the grim reaper to be his greatest opponent, not his fellow colleagues.
*
Most people become physicians because they feel a calling to help their fellow human beings. For better or worse, doctors are also driven by their own primal wish to be needed.
Our perfectionism, our selflessness, and our ability to waltz in the room and save the day are all self created concepts. They justify our actions.
Rejection, to someone who has spent their whole life learning how to be needed, is a bitter pill to swallow.
In all fairness, I am very aware of how the actions and words of a physician can evoke pain and hurt in his client.
But I wonder if patients realize that they haven't cornered the market on suffering. Do they know that behind the emotionless facade, doctors are soft and pliant on the inside?
Sadness, fear, and rejection are another part of our daily existence.
And it hurts us just the same.
Did you talk to her? What did she say?
I could feel the intensity through the phone as if the mouth piece had arched upward and was staring me dead in the eye. I felt bad for poor Borak. He suffered greatly the last few months. Although he was dropped from the malpractice suit, the scars brought on by years of finger pointing remained.
Then, there was the dispute with hospital administration. When they formed their own oncology group, Borak's referrals dropped significantly. His years of experience and relationship building couldn't stem the tide of inevitable change.
It was not an opportune time to be part of the old guard.
*
It wasn't particularly notable when Borak's patient asked for a new oncologist. She had visited him once and felt like there was no connection. Hell, people left me all the time! So I offered up a few names and thought nothing of it.
When Borak called to discuss the situation, I was caught completely off guard. I stammered as I tried to explain why I had given her other names. It wasn't the accusatory nature of his questioning that rocked me off balance, it was the hurt and uncertainty in his voice.
Borak was fighting for his professional life, and apparently he was losing ground quickly.
My discussion with the wayward patient was unfruitful.
We just didn't click.
When I reported back to Borak, his anger had receded. With sad recognition he accepted the fact that he lost another patient. He always considered the grim reaper to be his greatest opponent, not his fellow colleagues.
*
Most people become physicians because they feel a calling to help their fellow human beings. For better or worse, doctors are also driven by their own primal wish to be needed.
Our perfectionism, our selflessness, and our ability to waltz in the room and save the day are all self created concepts. They justify our actions.
Rejection, to someone who has spent their whole life learning how to be needed, is a bitter pill to swallow.
In all fairness, I am very aware of how the actions and words of a physician can evoke pain and hurt in his client.
But I wonder if patients realize that they haven't cornered the market on suffering. Do they know that behind the emotionless facade, doctors are soft and pliant on the inside?
Sadness, fear, and rejection are another part of our daily existence.
And it hurts us just the same.
Wednesday, December 7, 2011
Of Apes And Men
There is a time for sitting in classrooms. When such heady topics as congestive heart failure are abstract and intangible. Discussion veers from myocytes to cardiac output and stroke volume.
The world, through the student's eyes, is inflamed with passion and opportunity. The reality of doctoring is a distant dream. Hope peals back layers of fear and loss of confidence. Reward is imagined as a handshake, a return to health, and gentle guidance and counseling.
And there is no better place to be.
*
There is a time for rounding in the hospital. Groups of students and pharmacists trail the blue coat tails of residency. Voices tinged with false authority scoff at the regurgitated nursery rhymes of biochemistry and pathophysiology.
Clinical reasoning becomes her majesty's bejeweled throne. The vagaries of the heart are enumerated in clean categories: systolic and diastolic, valvular and ischemic.
The world, through the resident's eyes, is a masterfully structured algorithm guided by skill and knowledge. An apprenticeship forged in sleepless nights and the cold, hard steel of the analytic process.
*
There is a time for taking phone calls at home. Your table is set for thanksgiving dinner.
Congestive heart failure, through the attending's eyes, is neither about biochemistry nor algorithms. It's about missing a night of sleep. It's about another admission for Mr. Miller who forgot to fill his lasix prescription and then ate three servings of salt coated mashed potatoes.
And as you lay down on the stiff couch in the living room, you think about your family. They will sleep quietly in their own beds and not be bothered by the pager and cell phone tethered loosely to your pajamas.
You smile as you remember those student days with a mix of fondness and melancholy.
As your mind drifts lightly off to sleep you wonder:
where has the magic gone?
The world, through the student's eyes, is inflamed with passion and opportunity. The reality of doctoring is a distant dream. Hope peals back layers of fear and loss of confidence. Reward is imagined as a handshake, a return to health, and gentle guidance and counseling.
And there is no better place to be.
*
There is a time for rounding in the hospital. Groups of students and pharmacists trail the blue coat tails of residency. Voices tinged with false authority scoff at the regurgitated nursery rhymes of biochemistry and pathophysiology.
Clinical reasoning becomes her majesty's bejeweled throne. The vagaries of the heart are enumerated in clean categories: systolic and diastolic, valvular and ischemic.
The world, through the resident's eyes, is a masterfully structured algorithm guided by skill and knowledge. An apprenticeship forged in sleepless nights and the cold, hard steel of the analytic process.
*
There is a time for taking phone calls at home. Your table is set for thanksgiving dinner.
Congestive heart failure, through the attending's eyes, is neither about biochemistry nor algorithms. It's about missing a night of sleep. It's about another admission for Mr. Miller who forgot to fill his lasix prescription and then ate three servings of salt coated mashed potatoes.
And as you lay down on the stiff couch in the living room, you think about your family. They will sleep quietly in their own beds and not be bothered by the pager and cell phone tethered loosely to your pajamas.
You smile as you remember those student days with a mix of fondness and melancholy.
As your mind drifts lightly off to sleep you wonder:
where has the magic gone?
Monday, December 5, 2011
Spoils of War
When asked about his breathing, George would puff out his chest and release his booming tenor. On good days it would seem to last for minutes; on bad, it would peter out in seconds.
If I noted the soars on his feet, he would reminisce about his infantry days. His eyes would sparkle as he described how the heal of his brand new army boots would develop holes after hours of marching through rough terrain.
And if I questioned him about his blood sugars, he sat quietly with a blank look on his face and held his arms up at his side. George was nearly blind. He couldn't read a glucometer or decipher the tiny markings on an insulin syringe.
*
George was alone. He had no living family or friends nor money to hire a caretaker. He spent his days in a small apartment that he rented after the death of his wife. His physical existence was limited by illness and geographic disability but his world was anything but small. His mind was alive with music and poetry. His heart was overflowing with memories of his beloved wife.
Every two weeks he ventured out of his apartment an hobbled over to my office. Each visit was filled with questions which he often answered obliquely with stories. I learned that his wife once worked in an exclusive club for Hugh Hefner. That to pass the time, in his younger days, he would take a twenty mile walk from city to suburbs and then back again.
As he left my office, I was keenly aware that the doctoring skills that I learned in medical school had no place here. I had metamorphasized from an advisor to a student. I had become a companion, George's last connection to the outside world.
*
When I told him that I was moving my practice, The smile vanished from George's face. He knew that he wouldn't be able to travel the thirty minutes to my new location.
With artificial enthusiasm, I promised that I would find a local doctor to take care of him. He looked more feeble than usual as he described how his next door neighbor had recently died of a heart attack. She was a year younger then George.
As I watched him amble out of the front door that day, I felt a deep pang in the pit of my stomach. I knew I was choosing my own well being over his.
It was at that moment that I decided I would take care of George at home. I could stop by his apartment a few times a month on my way to work.
*
When I called the next morning to break the good news, no one answered. A few hours later, I received a note from the local coroner.
George died the night before. The paramedics found him lying on his kitchen floor. The coroner believed that it was a natural death. When he examined the body, he found and old frayed photo clasped tightly in George's hand. It was a picture of a woman dressed in a playboy bunny uniform.
If there's a heaven, I'm sure that George has found it.
It probably looks like an upscale club with a large picture of Hugh Hefner in the corner.
And George is being served
by the prettiest woman in the room.
If I noted the soars on his feet, he would reminisce about his infantry days. His eyes would sparkle as he described how the heal of his brand new army boots would develop holes after hours of marching through rough terrain.
And if I questioned him about his blood sugars, he sat quietly with a blank look on his face and held his arms up at his side. George was nearly blind. He couldn't read a glucometer or decipher the tiny markings on an insulin syringe.
*
George was alone. He had no living family or friends nor money to hire a caretaker. He spent his days in a small apartment that he rented after the death of his wife. His physical existence was limited by illness and geographic disability but his world was anything but small. His mind was alive with music and poetry. His heart was overflowing with memories of his beloved wife.
Every two weeks he ventured out of his apartment an hobbled over to my office. Each visit was filled with questions which he often answered obliquely with stories. I learned that his wife once worked in an exclusive club for Hugh Hefner. That to pass the time, in his younger days, he would take a twenty mile walk from city to suburbs and then back again.
As he left my office, I was keenly aware that the doctoring skills that I learned in medical school had no place here. I had metamorphasized from an advisor to a student. I had become a companion, George's last connection to the outside world.
*
When I told him that I was moving my practice, The smile vanished from George's face. He knew that he wouldn't be able to travel the thirty minutes to my new location.
With artificial enthusiasm, I promised that I would find a local doctor to take care of him. He looked more feeble than usual as he described how his next door neighbor had recently died of a heart attack. She was a year younger then George.
As I watched him amble out of the front door that day, I felt a deep pang in the pit of my stomach. I knew I was choosing my own well being over his.
It was at that moment that I decided I would take care of George at home. I could stop by his apartment a few times a month on my way to work.
*
When I called the next morning to break the good news, no one answered. A few hours later, I received a note from the local coroner.
George died the night before. The paramedics found him lying on his kitchen floor. The coroner believed that it was a natural death. When he examined the body, he found and old frayed photo clasped tightly in George's hand. It was a picture of a woman dressed in a playboy bunny uniform.
If there's a heaven, I'm sure that George has found it.
It probably looks like an upscale club with a large picture of Hugh Hefner in the corner.
And George is being served
by the prettiest woman in the room.
Sunday, December 4, 2011
Pedagogy
People often ask how I write so consistently. They wonder how I have so many stories to tell. But for me, that's like asking why I breath. My answer is always the same.
How could I not?
I wouldn't describe writing as fluid. To capture the moment to moment drama played out in the confines of the exam room is anything but straightforward. I grasp at the straws of fluency and try to clarify through garbled grammar and awkward phrasing.
But what choice to do I have? How else can I integrate the hum drum reality of family dinners interrupted by phone calls regarding code status and withdrawing life support? How do I explain why I tear up at the end of a sad movie yet negotiate pain and suffering as if I was a weatherman announcing another sunny day in San Diego.
When I stop writing my soul shrivels behind a protectionist shell. I become a shadow of the husband and father that I used to be. I transform from a healer to a nameless, faceless physician. The kind you look up in the index of some health insurance guide book.
But maybe, just maybe, when you read my words you'll feel a little bit closer to understanding.
Physicians will nod their heads in a shared brotherhood of traumatic experiences.
And patients will know that someone is finally listening.
How could I not?
I wouldn't describe writing as fluid. To capture the moment to moment drama played out in the confines of the exam room is anything but straightforward. I grasp at the straws of fluency and try to clarify through garbled grammar and awkward phrasing.
But what choice to do I have? How else can I integrate the hum drum reality of family dinners interrupted by phone calls regarding code status and withdrawing life support? How do I explain why I tear up at the end of a sad movie yet negotiate pain and suffering as if I was a weatherman announcing another sunny day in San Diego.
When I stop writing my soul shrivels behind a protectionist shell. I become a shadow of the husband and father that I used to be. I transform from a healer to a nameless, faceless physician. The kind you look up in the index of some health insurance guide book.
But maybe, just maybe, when you read my words you'll feel a little bit closer to understanding.
Physicians will nod their heads in a shared brotherhood of traumatic experiences.
And patients will know that someone is finally listening.
Saturday, December 3, 2011
The Cost Of Closure
You know Mr Miller?
I adjusted the phone on my ear as I slipped out of bed and snuck into the bathroom. I tiptoed across the floor and winced as the old hardwood started to creek beneath my feet. I craned my head and listened for signs of stirring children.
Remembering the resident holding on the line, I whispered into the cell.
Yeah. What about him? He had a choleycystectomy this morning.
I waited impatiently. I suspected that Mr. Miller had spiked a fever or needed some changes in his pain medication. It was a naive moment. The moment before I was about to hear something awful.
He coded. We were unable to revive him!
The phone slipped from my shaking hand and crashed onto the floor.
Seconds later, my two year old daughter started to cry.
*
I immediately felt out of place as I entered the church. The suit clung uncomfortably and the tie was strangling. I meandered past the pews in the front, and found a seat in the rear of the room.
As the ceremony began, I marveled at how many people had shown up for Mr. Miller's funeral. I watched as men sat stoned face and women wept silently. I searched through the crowd, but couldn't find a single familiar face.
The preacher was standing at the lectern. I tried to concentrate on his words, but It was impossible. The sweat poured down my forehead and I started to tremble.
I couldn't shake the feeling that I let Mr. Miller down. That the medical community offered cure but delivered heartbreak instead.
How did we allow this healthy fifty year old to die?
I quietly extracted myself from the chair and left mid ceremony. A few heads turned as I walked down the center isle and exited through the ornate swinging doors.
*
Sadly, I've never attended another patients funeral. Mr Miller taught me that I don't have the emotional fortitude.
The covenant between doctor and patient is sacred. My commitment to my patients well being is absolute. I vow to stand by them in sickness and in health. I will support them when they are hurting and I will tend to them when they are broken.
And when they are dying, I will devotedly attempt to ease their pain and suffering. But then the commitment ends.
Sure, it would probably be more healthy to go to the funerals. It would be personally gratifying to mourn appropriately each and every time. But when you have a hundred people die a year, it can be emotionally exhausting.
Sometimes the cost of closure
is too great.
I adjusted the phone on my ear as I slipped out of bed and snuck into the bathroom. I tiptoed across the floor and winced as the old hardwood started to creek beneath my feet. I craned my head and listened for signs of stirring children.
Remembering the resident holding on the line, I whispered into the cell.
Yeah. What about him? He had a choleycystectomy this morning.
I waited impatiently. I suspected that Mr. Miller had spiked a fever or needed some changes in his pain medication. It was a naive moment. The moment before I was about to hear something awful.
He coded. We were unable to revive him!
The phone slipped from my shaking hand and crashed onto the floor.
Seconds later, my two year old daughter started to cry.
*
I immediately felt out of place as I entered the church. The suit clung uncomfortably and the tie was strangling. I meandered past the pews in the front, and found a seat in the rear of the room.
As the ceremony began, I marveled at how many people had shown up for Mr. Miller's funeral. I watched as men sat stoned face and women wept silently. I searched through the crowd, but couldn't find a single familiar face.
The preacher was standing at the lectern. I tried to concentrate on his words, but It was impossible. The sweat poured down my forehead and I started to tremble.
I couldn't shake the feeling that I let Mr. Miller down. That the medical community offered cure but delivered heartbreak instead.
How did we allow this healthy fifty year old to die?
I quietly extracted myself from the chair and left mid ceremony. A few heads turned as I walked down the center isle and exited through the ornate swinging doors.
*
Sadly, I've never attended another patients funeral. Mr Miller taught me that I don't have the emotional fortitude.
The covenant between doctor and patient is sacred. My commitment to my patients well being is absolute. I vow to stand by them in sickness and in health. I will support them when they are hurting and I will tend to them when they are broken.
And when they are dying, I will devotedly attempt to ease their pain and suffering. But then the commitment ends.
Sure, it would probably be more healthy to go to the funerals. It would be personally gratifying to mourn appropriately each and every time. But when you have a hundred people die a year, it can be emotionally exhausting.
Sometimes the cost of closure
is too great.
Thursday, December 1, 2011
The Revolution Will Be Tweeted
The doctor/patient relationship is like a conversation. Physicians have been quiet for so long that patients feel like they are talking to themselves. But there is great import in what the doctor didn't say.
It's time you heard the view from the other side of the stethoscope.
*
I am not the government. I am not a politician. I did not choose your insurance for you.
When I accept an invitation to lunch or covet a plastic writing utensil, I am not suckling on the teet of big pharma. Chances are, I'm either hungry or need something to write with.
If you left my office with a referral for an xray, cat scan, or mri it was not given to pad my wallet. You will not see me standing in the parking lot of the imaging center high fiveing a radiologist. It is more likely that I had a clinical question that I couldn't answer with history and exam alone.
I am not sadistic. I withhold antibiotics because it is the right thing to do. Not because I want your Thanksgiving, or flight, or 20Th high school reunion to be miserable. My life would be much easier if I was less of a stickler.
When my treatment plan is unorthodox and doesn't follow protocol, it's because I saw something that doesn't fit. I am trying to balance the art and science. I do not make such decisions lightly.
And when you enter the office and I seem hurried or distracted, it's not because I don't care. Sometimes I am preoccupied with worry and fear over another one of my patients.
*
You will not hear these words on the TV. You will not see groups of physicians clad in lab coats march on Washington or leave the hospital on strike.
We vote on our feet. Doctors retire early or move to non clinical careers. Primary care becomes extinct and goes the way of the dinosaur. Hours are reduced and lifestyle is chosen over commitment.
But, If you're attuned to social media you'll catch the whispers. The discontent oozes from our keyboards and smart phones.
Because we want things to change. We want to remain physicians. Secretly we hope our words will waft into your ears and be the flint that sparks revolution.
Fundamental change is coming. The question is whether it will be for better or worse.
This revolution will not be televised.
It will be blogged.
It will be tweeted.
It's time you heard the view from the other side of the stethoscope.
*
I am not the government. I am not a politician. I did not choose your insurance for you.
When I accept an invitation to lunch or covet a plastic writing utensil, I am not suckling on the teet of big pharma. Chances are, I'm either hungry or need something to write with.
If you left my office with a referral for an xray, cat scan, or mri it was not given to pad my wallet. You will not see me standing in the parking lot of the imaging center high fiveing a radiologist. It is more likely that I had a clinical question that I couldn't answer with history and exam alone.
I am not sadistic. I withhold antibiotics because it is the right thing to do. Not because I want your Thanksgiving, or flight, or 20Th high school reunion to be miserable. My life would be much easier if I was less of a stickler.
When my treatment plan is unorthodox and doesn't follow protocol, it's because I saw something that doesn't fit. I am trying to balance the art and science. I do not make such decisions lightly.
And when you enter the office and I seem hurried or distracted, it's not because I don't care. Sometimes I am preoccupied with worry and fear over another one of my patients.
*
You will not hear these words on the TV. You will not see groups of physicians clad in lab coats march on Washington or leave the hospital on strike.
We vote on our feet. Doctors retire early or move to non clinical careers. Primary care becomes extinct and goes the way of the dinosaur. Hours are reduced and lifestyle is chosen over commitment.
But, If you're attuned to social media you'll catch the whispers. The discontent oozes from our keyboards and smart phones.
Because we want things to change. We want to remain physicians. Secretly we hope our words will waft into your ears and be the flint that sparks revolution.
Fundamental change is coming. The question is whether it will be for better or worse.
This revolution will not be televised.
It will be blogged.
It will be tweeted.
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