Saul knew his numbers. He knew his HDL. He knew his LDL. In fact, he kept track of just about every measurable parameter. Daily weights, mean body temperature, blood pressure, blood sugar, nothing was left to chance.
He bounced into my office with spreadsheets in hand. He highlighted the numbers and pointed out peaks and valleys, trends and outliers. He had every lab value graphed to the most detailed minutia. He once called me to discuss a change in percentage of neutrophils from his complete blood count.
Saul wasn't crazy, he was afraid. He was hoping that by tracking his own physiology he could escape the inevitable. Unfortunately, his fears had driven him to obsession. He spent more and more time and energy pouring over measurements. It eventually became unhealthy.
When a message flashed across my EMR to call Saul immediately, I was unperturbed. Likely he found another minor aberrancy needing an explanation. I listened to the dial tone, and waited patiently for him to pick up the phone. Recognizing my number on the caller ID, he began speaking immediately.
Dr. G, I'm having chest pain!
Thirty minutes later, I was walking into the emergency room. His EKG screamed the diagnosis before I physically evaluated him: acute myocardial infarction. I grasped his hand as he was being whisked off to the cardiac catheterization lab.
You're gonna be just fine!
And he was. But it all makes me wonder. This quantified self movement is nothing new. Whether it be blood pressure or blood sugars, there have always been those with an interest in self knowledge through technology and self-tracking.
The better question is what do we do with the data once we obtain it? How do we know what measures are meaningful and which are complete rubbish? And what are the mental and emotional consequences of such vague self knowledge?
I think if your goal is to be healthy, my advice is to concentrate on the unquantifiable.
Eat well.
Exercise.
Don't smoke.
Drink a little alcohol everyday.
Cut down on stress.
Love.
Do something selfless to further mankind.
Saturday, October 13, 2012
Wednesday, October 10, 2012
Mistaken Youth
I could feel the burn arise from my throat. I had been talking for hours. My first day back after a short trip to give grand rounds at the Carolinas Medical Center, I was overwhelmed. Only gone for two days, I was feeling a week behind. My calves ached and my shoulders were heavy.
I knew I was coming down with something. Likely a virus of some sort or another. I packed up the computer, and gathered my papers to rush off to the nursing home. The administrator had a four alarm fire that had been building in my absence. It had to be put out.
My secretary caught me just as I was slipping on my jacket to leave.
Mr Preston's daughter was wondering if you had a moment for her.
I glanced up at the clock and nodded in assent. It was a hard decision to to take Mr. Preston off life support, one steeped in years of conversations and familiarity between father and daughter, patient and doctor. It was anything but easy.
She wanted to thank me for caring for her father. She found great value in the speed I returned phone calls, and the direct manner in which I explained difficult situations. She hoped that time would not erase my sensitive nature.
I almost laughed at the unspoken assumption that I was new to doctoring. She must have thought that I was a recent graduate at great risk for losing my idealism. I decided not to correct her, and basked in the glory of being mistaken for someone more youthful. I thanked her profusely as she left the office.
Moments later, I was bounding down the stairs to my car parked at the far end of the lot. My lungs constricted, my nose clogged, and my ears plugged.
I could feel the last ten years surge through me like pints of blood coursing through thirsty vessels. Not quite forty, I'd become keenly aware of the foibles of the aging human body.
A decade after graduating residency, I felt old.
Physically and emotionally.
I knew I was coming down with something. Likely a virus of some sort or another. I packed up the computer, and gathered my papers to rush off to the nursing home. The administrator had a four alarm fire that had been building in my absence. It had to be put out.
My secretary caught me just as I was slipping on my jacket to leave.
Mr Preston's daughter was wondering if you had a moment for her.
I glanced up at the clock and nodded in assent. It was a hard decision to to take Mr. Preston off life support, one steeped in years of conversations and familiarity between father and daughter, patient and doctor. It was anything but easy.
She wanted to thank me for caring for her father. She found great value in the speed I returned phone calls, and the direct manner in which I explained difficult situations. She hoped that time would not erase my sensitive nature.
I almost laughed at the unspoken assumption that I was new to doctoring. She must have thought that I was a recent graduate at great risk for losing my idealism. I decided not to correct her, and basked in the glory of being mistaken for someone more youthful. I thanked her profusely as she left the office.
Moments later, I was bounding down the stairs to my car parked at the far end of the lot. My lungs constricted, my nose clogged, and my ears plugged.
I could feel the last ten years surge through me like pints of blood coursing through thirsty vessels. Not quite forty, I'd become keenly aware of the foibles of the aging human body.
A decade after graduating residency, I felt old.
Physically and emotionally.
Sunday, October 7, 2012
Who Needs Us Anyway?
What's this?
My four year old daughter was staring quizzically at her right knee. I bent down and squinted to get a better look. Sticking out from her flesh was a small pearly growth. She had a wart.
My wife and I bought a role of duct tape and religiously placed a piece on her knee every night. It seemed to get smaller, but never went away completely. My daughter was indifferent. She neither complained or shied away from showing it. It was a part of her.
Eventually we decided that something had to be done. I contemplated making an appointment with a local dermatologist. But who wanted to spend a hundred dollars (deductible) on such a little thing?
In a strange turn of irony, I did that which I always criticized my patients for. I ignored it. I turned a blind eye to the festering imperfection that seemed to grow a little every day. If I just put it off. if I just ignored it, maybe it would go away.
Time passed. We continued with our busy lives in denial of this small but annoying problem. Until yesterday. Yesterday, my daughter tripped while running on the side walk. As I swooped down to pick her up, I noticed a small flesh wound on her knee. And there on the cement lay her wart. Decapitated.
The lonely parasite stared up at me smugly. It mocked me.
You doctors think your so important!
Who needs you anyway?
My four year old daughter was staring quizzically at her right knee. I bent down and squinted to get a better look. Sticking out from her flesh was a small pearly growth. She had a wart.
My wife and I bought a role of duct tape and religiously placed a piece on her knee every night. It seemed to get smaller, but never went away completely. My daughter was indifferent. She neither complained or shied away from showing it. It was a part of her.
Eventually we decided that something had to be done. I contemplated making an appointment with a local dermatologist. But who wanted to spend a hundred dollars (deductible) on such a little thing?
In a strange turn of irony, I did that which I always criticized my patients for. I ignored it. I turned a blind eye to the festering imperfection that seemed to grow a little every day. If I just put it off. if I just ignored it, maybe it would go away.
Time passed. We continued with our busy lives in denial of this small but annoying problem. Until yesterday. Yesterday, my daughter tripped while running on the side walk. As I swooped down to pick her up, I noticed a small flesh wound on her knee. And there on the cement lay her wart. Decapitated.
The lonely parasite stared up at me smugly. It mocked me.
You doctors think your so important!
Who needs you anyway?
Saturday, October 6, 2012
Wisdom, Action, And Planning
Drip. Drip. Drip.
The drops of chocalate ice cream cascaded down the cone and landed impetously on the ground. They formed a line for about fifty feet tracing the path of the shopping cart with the infant dangling in the front. The mess facing the checkout counter didn't go unnoticed for long. Seconds later, a team of teenage Target employees swarmed with their red shirts and faded khakis. Shoppers unknowingly steered back and forth through the gelatinous puddles.
I expected the whole thing to take seconds. I could see the paper towels dangling from their hands. But strangely, the flurry of action was delayed. The young mouths moved and words were exchanged. I stepped closer to hear what was being said.
Apparently calculations were being made. A young man tried to triangulate where the offending drops had come from. A brief discussion was held about which direction was the correct starting place. All the while, the streaks of chocolate were being disrupted by the wheels of carts and unwitting footsteps. Within moments, the problem multiplied.
Eventually the team split up and attacked from multiple directions. One woman got on her hands and knees and scrubbed while a boy placed his paper towel on the floor and pushed it carelessly forward with his shoe.
The job got done, albeit inefficiently. Sticky sneakers could be heard making the pilgrimage to the front door. And I couldn't help but think of our health care system.
A generation of doers has been replaced with teams of measurers. As communities bleed, the new mangers tabulate and plot, calculate and proportion. But sometimes action is more timely than planning. Sometimes the guy on the floor scrubbing is the only one fast enough to prevent widespread disaster.
Planning and action. Action and planning.
Have we lost the wisdom to discern the difference?
The drops of chocalate ice cream cascaded down the cone and landed impetously on the ground. They formed a line for about fifty feet tracing the path of the shopping cart with the infant dangling in the front. The mess facing the checkout counter didn't go unnoticed for long. Seconds later, a team of teenage Target employees swarmed with their red shirts and faded khakis. Shoppers unknowingly steered back and forth through the gelatinous puddles.
I expected the whole thing to take seconds. I could see the paper towels dangling from their hands. But strangely, the flurry of action was delayed. The young mouths moved and words were exchanged. I stepped closer to hear what was being said.
Apparently calculations were being made. A young man tried to triangulate where the offending drops had come from. A brief discussion was held about which direction was the correct starting place. All the while, the streaks of chocolate were being disrupted by the wheels of carts and unwitting footsteps. Within moments, the problem multiplied.
Eventually the team split up and attacked from multiple directions. One woman got on her hands and knees and scrubbed while a boy placed his paper towel on the floor and pushed it carelessly forward with his shoe.
The job got done, albeit inefficiently. Sticky sneakers could be heard making the pilgrimage to the front door. And I couldn't help but think of our health care system.
A generation of doers has been replaced with teams of measurers. As communities bleed, the new mangers tabulate and plot, calculate and proportion. But sometimes action is more timely than planning. Sometimes the guy on the floor scrubbing is the only one fast enough to prevent widespread disaster.
Planning and action. Action and planning.
Have we lost the wisdom to discern the difference?
Thursday, October 4, 2012
Maybe She Was Right
It's not that I have a problem with big box cancer centers. I just feel like we have some great specialists in our neck of the woods. So I rarely suggest my patients cross state lines for care.
From time to time it happens anyway.
I didn't blame Sarah for going to the far away Mecca for treatment. Her colon cancer, routine as it was, was still a big deal. She could afford to put her life on hold, rent a hotel room, and get the very best her bank account could afford. As she said on the visit before leaving:
I'm not taking any chances!
Sarah was a youngish sixty year old who was in the prime of her career. She entered the office wearing the latest fashions and exited the parking lot in flashy new cars. Her cancer was found on routine screening. The stage and pathology were favorable.
Her treatment plan was carried out flawlessly. She returned to pre cancer life a bit more cautious, but otherwise no worse for wear. Every year she made the pilgrimage back for her annual checkup.
And every year I rolled my eyes as I read through the gracious consult note that arrived on my desk a few weeks later. But this year was different. I skimmed through the first few lines.
Sarah is doing well. She has no signs or symptoms of recurrent cancer. She recently welcomed the birth of her first grandchild (Nora!).
It was the name that caught my attention. I could no longer push this off as some distant big box cancer center staffed by arrogant clinicians. This physician had taken the time to learn about Sarah's life and rejoice in her triumphs. From these few sentences it was abundantly clear that she was not just another case, another number.
She was truly being cared for.
From time to time it happens anyway.
I didn't blame Sarah for going to the far away Mecca for treatment. Her colon cancer, routine as it was, was still a big deal. She could afford to put her life on hold, rent a hotel room, and get the very best her bank account could afford. As she said on the visit before leaving:
I'm not taking any chances!
Sarah was a youngish sixty year old who was in the prime of her career. She entered the office wearing the latest fashions and exited the parking lot in flashy new cars. Her cancer was found on routine screening. The stage and pathology were favorable.
Her treatment plan was carried out flawlessly. She returned to pre cancer life a bit more cautious, but otherwise no worse for wear. Every year she made the pilgrimage back for her annual checkup.
And every year I rolled my eyes as I read through the gracious consult note that arrived on my desk a few weeks later. But this year was different. I skimmed through the first few lines.
Sarah is doing well. She has no signs or symptoms of recurrent cancer. She recently welcomed the birth of her first grandchild (Nora!).
It was the name that caught my attention. I could no longer push this off as some distant big box cancer center staffed by arrogant clinicians. This physician had taken the time to learn about Sarah's life and rejoice in her triumphs. From these few sentences it was abundantly clear that she was not just another case, another number.
She was truly being cared for.
Wednesday, October 3, 2012
Let Sleeping Dogs Lie
I'm sorry!
I really am! No one deserves breast cancer. Especially the kind that spreads to your liver, lungs and brain. The fact that you lived to your eighth decade doesn't detract from the sadness. You deserve to live. I can't blame you for not being ready to go.
I apologize that our meeting was so abrupt. I was consulted to see you in the nursing home to address various issues. I swept in the door, and introduced myself to you and your daughter. I explained what the word "palliative" means, and why I was asked to see you. Although I saw a full hospice consult in the hospital chart, you both stared at me blankly as if this was the first time you heard of such things.
I asked if you were in pain. I asked about your breathing as I watched your chest move back and forth laboriously, and your dreadfully weak body sink into the gigantic hospital bed. Finally, I tried to discuss prognosis.
You mentioned how your oncologist said that "we can get it all". You placed great hope in the upcoming brain radiation. When I pushed further, you had vague ideas about seeing your grandson's wedding that was slated for next fall.
Your skin sallow, your breath heavy, there was absolutely no way you were going to be alive for that wedding. I had doubts about the weekend. When I started to express my concerns that your expectations were unrealistic, the conversation turned. Your daughter shook her head and her glance shot arrows through my chest. You became angry and shooed my out of the room. I was asked not to return.
I thought of a million ways I could have done better. I should have approached the situation differently. I could have brought these subjects up over many visits and allowed you to come to conclusions on your own.
But for some reason, I felt a great sense of urgency. Rounding the next morning in the nursing home, I found your bed empty. You coded an hour after I saw you. The ambulance came, life support was initiated, and now you lie half dead in the local ICU. Your daughter is left to make the horrible decision of when to pull the plug, if ever at all. You will not recover.
Some may think that I write this post to gloat; to say I told you so. The truth is agonizingly more complex. I wish I could do this one over. I wish I could have left you in your mist of denial, and taken a more simple approach. I could have held your hand, said I was sorry, and let sleeping dogs lie. Your weren't going to listen to me anyway.
Now, I am stuck with the great possibility that your daughter will see my visit as the straw that broke the camel's back. And you, your last memory before dying, will be of some young pompous doctor who walked into the room,
and told you he was giving up on you.
I really am! No one deserves breast cancer. Especially the kind that spreads to your liver, lungs and brain. The fact that you lived to your eighth decade doesn't detract from the sadness. You deserve to live. I can't blame you for not being ready to go.
I apologize that our meeting was so abrupt. I was consulted to see you in the nursing home to address various issues. I swept in the door, and introduced myself to you and your daughter. I explained what the word "palliative" means, and why I was asked to see you. Although I saw a full hospice consult in the hospital chart, you both stared at me blankly as if this was the first time you heard of such things.
I asked if you were in pain. I asked about your breathing as I watched your chest move back and forth laboriously, and your dreadfully weak body sink into the gigantic hospital bed. Finally, I tried to discuss prognosis.
You mentioned how your oncologist said that "we can get it all". You placed great hope in the upcoming brain radiation. When I pushed further, you had vague ideas about seeing your grandson's wedding that was slated for next fall.
Your skin sallow, your breath heavy, there was absolutely no way you were going to be alive for that wedding. I had doubts about the weekend. When I started to express my concerns that your expectations were unrealistic, the conversation turned. Your daughter shook her head and her glance shot arrows through my chest. You became angry and shooed my out of the room. I was asked not to return.
I thought of a million ways I could have done better. I should have approached the situation differently. I could have brought these subjects up over many visits and allowed you to come to conclusions on your own.
But for some reason, I felt a great sense of urgency. Rounding the next morning in the nursing home, I found your bed empty. You coded an hour after I saw you. The ambulance came, life support was initiated, and now you lie half dead in the local ICU. Your daughter is left to make the horrible decision of when to pull the plug, if ever at all. You will not recover.
Some may think that I write this post to gloat; to say I told you so. The truth is agonizingly more complex. I wish I could do this one over. I wish I could have left you in your mist of denial, and taken a more simple approach. I could have held your hand, said I was sorry, and let sleeping dogs lie. Your weren't going to listen to me anyway.
Now, I am stuck with the great possibility that your daughter will see my visit as the straw that broke the camel's back. And you, your last memory before dying, will be of some young pompous doctor who walked into the room,
and told you he was giving up on you.
Monday, October 1, 2012
What Happened To Hope?
I scratched my head as I pulled into the parking lot of the hospital clinic. There were quite a number of cars for a Sunday morning. I watched a young woman and man (I presumed husband and wife) making their way towards the front entrance. There was a certain hope in their movements.
Of course! It must have been the fertility clinic weekend. About once a month, dozens of couples come to be artificially inseminated. Or at least that's what I figure. I've never actually asked what goes on in the clinic. I'm just guessing.
This rush of optimistic people seemed strangely peculiar amongst the back drop of the gloomy, voluminous hospital. Enclosed in the concrete walls of this massive building was almost every type of pain and suffering imaginable.
I began to wonder, what happened to hope?
It seems that medical centers should feel like spaces of great opportunity. It's where you go to have your disease cured, your broken arm set, or your life saved. And when the outcomes will be more dire, it's the place to have your pain palliated, your hand held, and where you come to die embraced in the compassionate bosom of those who have dedicated their lives to doing such work.
Sound a little pie in the sky? Maybe it shouldn't! I've been a great component of physicians re branding. I think it's time we started to tell our stories about what happens behind the stethoscope in an attempt to humanize; to inoculate our patients against the growing furor against us.
Hospitals are facing the same crisis. Under Medicare's gun and hounded by malpractice lawyers, the loss of identity is staggering. Once a pillar of the community, today's medical center is under increasing fire.
There are such great opportunities, and so much room for improvement. Let's get back to practicing high quality, patient centered, no strings attached care of our community.
Do we have to wait for some guy in a suit with an MBA to spur us to change?
Of course! It must have been the fertility clinic weekend. About once a month, dozens of couples come to be artificially inseminated. Or at least that's what I figure. I've never actually asked what goes on in the clinic. I'm just guessing.
This rush of optimistic people seemed strangely peculiar amongst the back drop of the gloomy, voluminous hospital. Enclosed in the concrete walls of this massive building was almost every type of pain and suffering imaginable.
I began to wonder, what happened to hope?
It seems that medical centers should feel like spaces of great opportunity. It's where you go to have your disease cured, your broken arm set, or your life saved. And when the outcomes will be more dire, it's the place to have your pain palliated, your hand held, and where you come to die embraced in the compassionate bosom of those who have dedicated their lives to doing such work.
Sound a little pie in the sky? Maybe it shouldn't! I've been a great component of physicians re branding. I think it's time we started to tell our stories about what happens behind the stethoscope in an attempt to humanize; to inoculate our patients against the growing furor against us.
Hospitals are facing the same crisis. Under Medicare's gun and hounded by malpractice lawyers, the loss of identity is staggering. Once a pillar of the community, today's medical center is under increasing fire.
There are such great opportunities, and so much room for improvement. Let's get back to practicing high quality, patient centered, no strings attached care of our community.
Do we have to wait for some guy in a suit with an MBA to spur us to change?
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