It will start as a minor curiosity. Maybe a student will seem slightly too close to the resident on your team. When the grades are posted you'll wonder why you didn't get honors but he did. You might wallow for a few days. Make an off-handed comment to your fellow students. Then you'll let it go, and move on. Or so you think. Until during surgery when the scrub nurse rips into you to make a point to the rest of your peers. And then the surgeon does the same to her in the operating room.
There will be other times. During residency you will roll your eyes when you realize your co-intern is sick again, and you're up for all the admissions. You will curse the medical student who created the cockeyed explanation and scared the heck out of the frightened social admit in room 5. You might not yell. You might not lose your cool. But rage will boil over from time to time. You may let it loose on the radiology tech who is refusing to get up in the middle of the night and do your stat study.
Your path will continue even after you are done with training. There will always be plenty of culprits. The secretary who double booked your over packed schedule. The prior authorization phone tree that will waste the precious moments you could be spending with your children. The paranoid anxious patient who will put it off all day, and show up to the emergency room at midnight and awake you from a deep sleep. You will argue incessantly with the emergency room attending who will refuse to send him home and insists on observing for cardiac ischemia.
And you will find yourself yelling uncontrollably at the cowering patient who pulled you out of the examining room with the young guy with melanoma who was finally willing to talk about hospice, because she forgot to ask a question thirty minutes ago during her appointment.
When you look into her tear soaked eyes, a hard reality will come upon you. You are angry. You have been for years. Rage is constantly simmering below the surface scalding you and those you interact with.
You have truly become a doctor.
My advice is simple. Forgive yourself. Remember that that medical student who undercut you was wallowing in much the same way as you. The surgical scrub nurse had felt a hundred times the abuse from the surgeon who was still scarred from his own training. Your fellow resident was actually sick and spent all night puking in the bathroom. The radiology tech hadn't slept well for weeks. The secretary had been cursed out by the patient for not making room in your schedule. The anxious patient was suffering, and the ER attending was trying to be compassionate.
And yes, the young melanoma guy is dying and no one is dealing with it.
Then shrug your shoulders, exhale, and decide to turn the anger into love and understanding.
Life is much better that way.
Wednesday, January 11, 2017
Monday, January 9, 2017
The Guidelineification of American Medicine
His voice was gruff and his expression surly.
I don't want any more medications.
His face was indented by deep clefts, remnants of eight decades of life hard lived. His tone was commanding and certain. I knew that he was fond of me, but I could feel his patience slipping. He neither asked about nor accepted his diagnosis of heart failure. I could tell him till I was blue (or he was for that matter) in the face that his low ejection fraction portended a poor prognosis, and national guidelines suggested both a beta blocker and defibrillator placement.
He wouldn't budge. And before the age of electronic medical records, evidence based medicine, and quality scores, no one really cared. Before we would have taken the patient's wishes into account. Noted that he couldn't afford the new med, nor was particularly compliant with his other medications. Considered that his wife had died a few years back, and he had no interest in extending his life. Weighed the positives and negatives from the patients perspective, and come to a tailored decision for this particular human being.
But now the guidelineification of American medicine has turned this proud and aged skill into a humdrum maze of algorithms.
Algorithms that are more expert opinion and less evidence based. Algorithms that rely on evidence collected from typical white male patients with isolated disease processes and may not be generalizable. Algorithms that will change often and probably contradict themselves in the decades to come.
The true art of medicine, expertly meshing the known with the unknown. Factoring in human variability and preference to develop a unique plan. Has been lost. Ridiculed. Chewed and spit into the trash.
We pray to the ever eroding alter of longevity. Even as our patients have abandoned such false deities.
They want quality of life. They want control over their own decisions. They want to go with their gut sometimes.
And I think we should support them.
I don't want any more medications.
His face was indented by deep clefts, remnants of eight decades of life hard lived. His tone was commanding and certain. I knew that he was fond of me, but I could feel his patience slipping. He neither asked about nor accepted his diagnosis of heart failure. I could tell him till I was blue (or he was for that matter) in the face that his low ejection fraction portended a poor prognosis, and national guidelines suggested both a beta blocker and defibrillator placement.
He wouldn't budge. And before the age of electronic medical records, evidence based medicine, and quality scores, no one really cared. Before we would have taken the patient's wishes into account. Noted that he couldn't afford the new med, nor was particularly compliant with his other medications. Considered that his wife had died a few years back, and he had no interest in extending his life. Weighed the positives and negatives from the patients perspective, and come to a tailored decision for this particular human being.
But now the guidelineification of American medicine has turned this proud and aged skill into a humdrum maze of algorithms.
Algorithms that are more expert opinion and less evidence based. Algorithms that rely on evidence collected from typical white male patients with isolated disease processes and may not be generalizable. Algorithms that will change often and probably contradict themselves in the decades to come.
The true art of medicine, expertly meshing the known with the unknown. Factoring in human variability and preference to develop a unique plan. Has been lost. Ridiculed. Chewed and spit into the trash.
We pray to the ever eroding alter of longevity. Even as our patients have abandoned such false deities.
They want quality of life. They want control over their own decisions. They want to go with their gut sometimes.
And I think we should support them.
Saturday, January 7, 2017
A Doctors Story
Many years ago, three doctors formed an internal medicine practice and were proud of the thousands of patients they accumulated. They were fine physicians and very dedicated to the masses who walked through their clinic doors. They saw patients in the office, rounded at two hospitals, and visited a number of nursing homes. This was truly a full service practice.
Around 2005, Dr. A was starting to fatigue. He was well into his sixties and did not like the direction medicine was going. The hours were too strenuous, the documentation requirements were getting increasingly complicated, and he saw the writing on the wall. Regulation was coming and the results would be devastating. So he decided to retire.
Luckily, Dr. A's patients (around 5000 at the time) could be seen by the two younger physicians in the practice (Dr. B and Dr. C) after he left. They both, by now, had thousands of patients of their own, but were happy for the extra work. A final retirement date was set, and Dr. A officially left the practice in 2006.
Unfortunately, without Dr. A's influence, Dr. B and Dr. C had a series of disagreements and decided to break off the relationship. Half the practices ten thousand patients stayed with Dr. B, while the other half moved locations to join with Dr. C.
Dr. B needed extra help handling all those patients and hired Dr. D. Dr. C needed extra help handling all those patients and in 2007 hired Dr. E. Both practices thrived. Their client rosters swelled even as they faced the continuing assault of governmental regulation. Thousands of dollars were spent acquiring and utilizing electronic medical records. Countless hours were wasted filling out forms and on administrative phone calls.
Around 2013 Dr. E realized that he was spending more and more time on paperwork, and less and less time on patient care. His patients were upset, his personal life was suffering, and most importantly, he was no longer proud of the quality of medicine he was practicing.
So in 2013 Dr. E made a momentous decision. He left his 2500 patient practice and started a home based concierge model consisting of only 100 of his former patients. The rest stayed with Dr. C. Dr. E also continued to do nursing home work taking care of other physicians patients, as well as started an administrative role with a local hospice. And he thrived.
Dr. C continued to manage his own patients as well as all those extra that were no longer under Dr. E. But by 2015 he was having trouble maintaining a reasonable lifestyle, and his economic fortunes had worsened. Feeling forced, Dr. C also converted his practice to a concierge model and his patient panel shrunk from over 5000 to less than 500. And he thrived.
Now we must not forget Dr. B and D. They made a successful run at private practice and hired various other physicians and nurse practitioners over the years. The ranks of their patient population swelled. By 2015, however, they began to feel the futility of the current medical system. Thus Dr. B and Dr. D also eventually went concierge, and limited their practices to 500 patients each. And they thrived.
So if we do the math:
Dr. A had 5000 patients and retired. He no longer is involved with patient care.
Dr. B moved to a concierge practice and narrowed his patient population from 5000 to 500.
Dr. C moved to a concierge practice and narrowed his patient population from 5000 to 500.
Dr. D moved to a concierge practice and narrowed his patient population from 2500 to 500.
Dr. E moved to a home based concierge practice and narrowed his patient population from 2500 to 100.
Now before you get in a huff, of course there is some overlap here.
Most of the abandoned patients joined the prominent medical group in the area and still have doctors, though often have to wait months for simple appointments. Many of them barely know their physicians and are seen by nurse practitioners. None of them have the benefit of having their own doctors in the hospital or nursing home.
You might think I am being hyperbolic.
You might think this story is an exaggeration or fairy tale.
But I'm here to tell you it's not. I know.
Because I am Dr. E.
Around 2005, Dr. A was starting to fatigue. He was well into his sixties and did not like the direction medicine was going. The hours were too strenuous, the documentation requirements were getting increasingly complicated, and he saw the writing on the wall. Regulation was coming and the results would be devastating. So he decided to retire.
Luckily, Dr. A's patients (around 5000 at the time) could be seen by the two younger physicians in the practice (Dr. B and Dr. C) after he left. They both, by now, had thousands of patients of their own, but were happy for the extra work. A final retirement date was set, and Dr. A officially left the practice in 2006.
Unfortunately, without Dr. A's influence, Dr. B and Dr. C had a series of disagreements and decided to break off the relationship. Half the practices ten thousand patients stayed with Dr. B, while the other half moved locations to join with Dr. C.
Dr. B needed extra help handling all those patients and hired Dr. D. Dr. C needed extra help handling all those patients and in 2007 hired Dr. E. Both practices thrived. Their client rosters swelled even as they faced the continuing assault of governmental regulation. Thousands of dollars were spent acquiring and utilizing electronic medical records. Countless hours were wasted filling out forms and on administrative phone calls.
Around 2013 Dr. E realized that he was spending more and more time on paperwork, and less and less time on patient care. His patients were upset, his personal life was suffering, and most importantly, he was no longer proud of the quality of medicine he was practicing.
So in 2013 Dr. E made a momentous decision. He left his 2500 patient practice and started a home based concierge model consisting of only 100 of his former patients. The rest stayed with Dr. C. Dr. E also continued to do nursing home work taking care of other physicians patients, as well as started an administrative role with a local hospice. And he thrived.
Dr. C continued to manage his own patients as well as all those extra that were no longer under Dr. E. But by 2015 he was having trouble maintaining a reasonable lifestyle, and his economic fortunes had worsened. Feeling forced, Dr. C also converted his practice to a concierge model and his patient panel shrunk from over 5000 to less than 500. And he thrived.
Now we must not forget Dr. B and D. They made a successful run at private practice and hired various other physicians and nurse practitioners over the years. The ranks of their patient population swelled. By 2015, however, they began to feel the futility of the current medical system. Thus Dr. B and Dr. D also eventually went concierge, and limited their practices to 500 patients each. And they thrived.
So if we do the math:
Dr. A had 5000 patients and retired. He no longer is involved with patient care.
Dr. B moved to a concierge practice and narrowed his patient population from 5000 to 500.
Dr. C moved to a concierge practice and narrowed his patient population from 5000 to 500.
Dr. D moved to a concierge practice and narrowed his patient population from 2500 to 500.
Dr. E moved to a home based concierge practice and narrowed his patient population from 2500 to 100.
Now before you get in a huff, of course there is some overlap here.
Most of the abandoned patients joined the prominent medical group in the area and still have doctors, though often have to wait months for simple appointments. Many of them barely know their physicians and are seen by nurse practitioners. None of them have the benefit of having their own doctors in the hospital or nursing home.
You might think I am being hyperbolic.
You might think this story is an exaggeration or fairy tale.
But I'm here to tell you it's not. I know.
Because I am Dr. E.
Thursday, January 5, 2017
Just Like She Said
If Bob had realized that these were his mother's last words, he might have stopped what he was doing and stood by her side. But her foley catheter was leaking again and the sheets were a mess. Besides, he didn't want to wake Rhonda in the adjacent bedroom. She had just gotten off third shift and needed to rest before taking over in a few hours.
Bob felt guilty about losing his job, but given his mother's current state, he couldn't justify taking another gig out of town. Because the Medicare days at the nursing facility had finally run out, his aging mom was forced back home. At first she was able to smile and even talk occasionally, but that was mostly gone. She mumbled from time to time. Nonsensical mumbo-jumbo. Or stared blankly.
Bob listened to his mother's distorted vocalizations as he undid her flimsy coverings He had debated whether to change the diaper or remove the bed sheets first, and settled on the diaper. The morning news blared on a TV which had been optimistically moved into the room before her arrival. She no longer could focus on the screen, but at least there was background noise.
Bob's hands moved quick and efficiently. He sometimes wondered during these long days if he should have become a nursing assistant. He was strong and able. He had the right constitution and didn't get queasy when dealing with the indelicacies of the human body.
His mom exhaled and then did something she hadn't done in months. She spoke.
Bob, Bob quit messing with those sheets. I'm dying.
Of course Bob didn't think. She has been talking out of her mind ever since leaving the hospital. He secured the diaper and pulled up the sheets. It was then he noticed that she wasn't breathing. Her chest was completely still. He called out for Rhonda and she rushed into the room blurry-eyed. They stared at each other for a moment, not knowing what to do. Then he called 911.
Bob new the chest compressions were futile, but allowed them for a short time before asking the paramedics to stop.
His mother was gone.
Just like she said.
Bob felt guilty about losing his job, but given his mother's current state, he couldn't justify taking another gig out of town. Because the Medicare days at the nursing facility had finally run out, his aging mom was forced back home. At first she was able to smile and even talk occasionally, but that was mostly gone. She mumbled from time to time. Nonsensical mumbo-jumbo. Or stared blankly.
Bob listened to his mother's distorted vocalizations as he undid her flimsy coverings He had debated whether to change the diaper or remove the bed sheets first, and settled on the diaper. The morning news blared on a TV which had been optimistically moved into the room before her arrival. She no longer could focus on the screen, but at least there was background noise.
Bob's hands moved quick and efficiently. He sometimes wondered during these long days if he should have become a nursing assistant. He was strong and able. He had the right constitution and didn't get queasy when dealing with the indelicacies of the human body.
His mom exhaled and then did something she hadn't done in months. She spoke.
Bob, Bob quit messing with those sheets. I'm dying.
Of course Bob didn't think. She has been talking out of her mind ever since leaving the hospital. He secured the diaper and pulled up the sheets. It was then he noticed that she wasn't breathing. Her chest was completely still. He called out for Rhonda and she rushed into the room blurry-eyed. They stared at each other for a moment, not knowing what to do. Then he called 911.
Bob new the chest compressions were futile, but allowed them for a short time before asking the paramedics to stop.
His mother was gone.
Just like she said.
Tuesday, January 3, 2017
Evolution
You won't at first. But then you will.
It will start innocently. Probably even before medical school. You will have a morbid curiosity about passing ambulances and motor vehicle accidents. Your original empathy for the victim will disappear when you begin to think of them as patients. Test cases.
The commodification accelerates during the early years of medical school. Anatomy, pathology, and physiology provide you a vocabulary to replace human pain and suffering. In gross anatomy you violate the viscera even as you hear your fellow students snigger in the background. You may not take part in their school-boy antics, but it loosens in you a certain callousness that you were previously cautious to recognize.
During the clinical years you will learn to build walls with the most rudimentary artifacts. Your first death. A mistake. Your resident standing over blaming you for the post op infection and eventual demise of a beloved patient. Your hands will scramble as you crouch amongst the linoleum of some hidden dark corner of the hospital ward, collecting dust and discarded gum. Your eyes no longer seeing, your heart trying desperately not to feel.
Residency is when you will become the master builder. Unslept nights. Missed meals. Standing on the front line wading through the intolerable excrement and blood of actual healthcare. You will learn not to cry, not to contemplate. To traipse from life to death wearing the same distracted grimace. And you will yell at that poor medical school student about the post op infection for which you secretly wonder if you caused. You now work with brick and mortar, clay and stone. Your tower rises above and beyond, up to the sky, encircling you. You are alone.
Your expertise will be so great by the time you are an attending physician, nothing will penetrate your ironclad barriers. Unlike those walls, however, your heart will be porous and ooze sadness, anger, and despair. Trapped inside that small space. Devouring you. And love, and family, and friends, and light, and oxygen will all be awaiting on the other side.
A breath away, a mile apart.
If you're lucky, you'll fall to your knees to the grit and grime and start clawing with bloodied knuckles.
Brick by brick you must undo that which you have built.
That which has been built for you.
It will start innocently. Probably even before medical school. You will have a morbid curiosity about passing ambulances and motor vehicle accidents. Your original empathy for the victim will disappear when you begin to think of them as patients. Test cases.
The commodification accelerates during the early years of medical school. Anatomy, pathology, and physiology provide you a vocabulary to replace human pain and suffering. In gross anatomy you violate the viscera even as you hear your fellow students snigger in the background. You may not take part in their school-boy antics, but it loosens in you a certain callousness that you were previously cautious to recognize.
During the clinical years you will learn to build walls with the most rudimentary artifacts. Your first death. A mistake. Your resident standing over blaming you for the post op infection and eventual demise of a beloved patient. Your hands will scramble as you crouch amongst the linoleum of some hidden dark corner of the hospital ward, collecting dust and discarded gum. Your eyes no longer seeing, your heart trying desperately not to feel.
Residency is when you will become the master builder. Unslept nights. Missed meals. Standing on the front line wading through the intolerable excrement and blood of actual healthcare. You will learn not to cry, not to contemplate. To traipse from life to death wearing the same distracted grimace. And you will yell at that poor medical school student about the post op infection for which you secretly wonder if you caused. You now work with brick and mortar, clay and stone. Your tower rises above and beyond, up to the sky, encircling you. You are alone.
Your expertise will be so great by the time you are an attending physician, nothing will penetrate your ironclad barriers. Unlike those walls, however, your heart will be porous and ooze sadness, anger, and despair. Trapped inside that small space. Devouring you. And love, and family, and friends, and light, and oxygen will all be awaiting on the other side.
A breath away, a mile apart.
If you're lucky, you'll fall to your knees to the grit and grime and start clawing with bloodied knuckles.
Brick by brick you must undo that which you have built.
That which has been built for you.
Sunday, January 1, 2017
And You Will Answer
There is a basic communication gap between you and I. How could there not be? It's not what you expect. I say you have cancer, or heart failure, or emphysema. Full stop. A conversation ensues. This is not what I'm talking about.
It's more like when I report to you a series of normal lab results, and at the end flippantly mention a slight elevation of the white blood cell count. In my mind, it is a minor issue and likely do to that viral infection that you are recovering from. As the days pass, my words simmer and eventually come to a boil, consuming you. The elevation could be leukemia after all. You could be dying. You could be like your uncle Stew who went to the office for routine blood tests and was gone a week later. You search the Internet and are confused by what you see. You wait anxiously to repeat the blood tests four weeks later.
The white blood cell count comes back normal. You are relieved and tired. It has been a long and scary four weeks.
And I had no idea that you even suffered through this. I apologize. The problem with familiarity is that it is easy to forget perspective. I have spent the last few decades becoming intimately familiar with the ebb and flow of wayward lab results. And you have not. Frankly, I sometimes forget to look at my words, my utterances, through your eyes. The big stuff, sure. But it's the minor less tangible that escapes careful scrutiny.
God knows, there are also many other barriers. I am rushing off the phone to get back to the call from the emergency room. We are separated by an electronic elephant in the room that stubbornly inserts itself between us, and blocks my view. There are boxes and checks to be marked, and I am stuck trying to figure out whether you are a Pacific Islander while you just want to talk about your chest pain.
Per usual, I don't have adequate answers to this conundrum. Sometimes the gulf is overwhelmingly vast. Although I take full responsibility, I doubt that I will always be attuned to which of my words affect you so. Unfortunately, my experience will still color me blind from time to time.
But going forward there is one minor adjustment I will pledge to make. One way we can work together as a team.
At the end of every visit, every phone conversation, I will train myself to ask:
Tell me what questions you have? What haven't I made clear?
Then I will pause.
And you will answer.
It's more like when I report to you a series of normal lab results, and at the end flippantly mention a slight elevation of the white blood cell count. In my mind, it is a minor issue and likely do to that viral infection that you are recovering from. As the days pass, my words simmer and eventually come to a boil, consuming you. The elevation could be leukemia after all. You could be dying. You could be like your uncle Stew who went to the office for routine blood tests and was gone a week later. You search the Internet and are confused by what you see. You wait anxiously to repeat the blood tests four weeks later.
The white blood cell count comes back normal. You are relieved and tired. It has been a long and scary four weeks.
And I had no idea that you even suffered through this. I apologize. The problem with familiarity is that it is easy to forget perspective. I have spent the last few decades becoming intimately familiar with the ebb and flow of wayward lab results. And you have not. Frankly, I sometimes forget to look at my words, my utterances, through your eyes. The big stuff, sure. But it's the minor less tangible that escapes careful scrutiny.
God knows, there are also many other barriers. I am rushing off the phone to get back to the call from the emergency room. We are separated by an electronic elephant in the room that stubbornly inserts itself between us, and blocks my view. There are boxes and checks to be marked, and I am stuck trying to figure out whether you are a Pacific Islander while you just want to talk about your chest pain.
Per usual, I don't have adequate answers to this conundrum. Sometimes the gulf is overwhelmingly vast. Although I take full responsibility, I doubt that I will always be attuned to which of my words affect you so. Unfortunately, my experience will still color me blind from time to time.
But going forward there is one minor adjustment I will pledge to make. One way we can work together as a team.
At the end of every visit, every phone conversation, I will train myself to ask:
Tell me what questions you have? What haven't I made clear?
Then I will pause.
And you will answer.
Friday, December 30, 2016
A Reconstructer Of Disassembled Parts
To say that William hardly thought about hospice would be an inaccuracy. He contemplated it, from time to time, during his thirty year tenure as a trauma surgeon. Usually for fleeting moments before dodging the conversation or deferring to one of his more junior colleagues. Surgeons didn't give up so easily, he reasoned. He fancied himself a fixer, a reconstructer of disassembled parts.
Mostly, that is what was expected of him. His patients didn't come because of cancer or chronic illness. They came after tragedy. Unwillingly. Bodies sprawled on metal tables with insides amiss. And he put them back together. There was no time for a prolonged conversation of whether the parts should remain disjointed.
It was easier to look at his patients as parts and pieces. Easier to round in the ICU and figure out how the puzzle fit together again, or even how the motif in the far right corner connected to the shadow in the lower left. Complex systems no doubt. But admittedly there was a refusal, subconscious or not, to discern the forest from the trees.
Thus, the irony was not lost on William, when his oncologist shrugged and suggested hospice care. This was only after all options had been exhausted. His body could only withstand so much surgery, radiation, and chemotherapy. Upon hearing the words, William flopped onto the examining room table and thought of the many conversations he had excused himself from over the years.
His oncologist was not much better. After dropping the H word, he handed him a card with a name and phone number, and left the room. William held onto card for a few days stuck in the pre-contemplation stage. He then made the call.
Hospice was tolerable. William's body began to erode under the enormous burden of cancer. His eyes sunk, and the skin hung from his atrophied skeleton. The nurses and CNA's were pleasant and tended to his ever increasing physical needs. The morphine controlled his pain.
William had already made peace with leaving this world. There was only one problem. He had expected to die months ago. Yet, he was still here.
He prayed to a God that he only partially believed in. He begged and pleaded. Take me. Take me.
Yet he woke up every morning, opened his eyes, and loathed that he was still here.
He had long ago stopped living, and now was solely waiting to die. Death taunted him at times, holding the prize within reach. A storm of lethargy would be followed by a an ocean of dyspnea. With nightfall came peace and quiet. The next morning all would be tranquil once again.
Sometimes William dreamt that death was seeking revenge for all those lives he had snatched back from the abyss during his surgical career. All those souls whose path and destiny were interrupted by his mechanical hands.
He fantasized that after a horrible car accident he was rushed to the emergency room with his aorta transected and the pompous surgeon stood over his body, and licked his lips at the chance of letting the scalpel have free range. As William begged and pleaded, the surgeon removed his mask and revealed his true identity. And he recognized his own facade and knew that he would be taken to the operating room.
It was then that William came to terms with a reality that had escaped him his whole clinical career.
Like birth, death is just a natural life event.
A natural event, that somehow kept alluding him.
Mostly, that is what was expected of him. His patients didn't come because of cancer or chronic illness. They came after tragedy. Unwillingly. Bodies sprawled on metal tables with insides amiss. And he put them back together. There was no time for a prolonged conversation of whether the parts should remain disjointed.
It was easier to look at his patients as parts and pieces. Easier to round in the ICU and figure out how the puzzle fit together again, or even how the motif in the far right corner connected to the shadow in the lower left. Complex systems no doubt. But admittedly there was a refusal, subconscious or not, to discern the forest from the trees.
Thus, the irony was not lost on William, when his oncologist shrugged and suggested hospice care. This was only after all options had been exhausted. His body could only withstand so much surgery, radiation, and chemotherapy. Upon hearing the words, William flopped onto the examining room table and thought of the many conversations he had excused himself from over the years.
His oncologist was not much better. After dropping the H word, he handed him a card with a name and phone number, and left the room. William held onto card for a few days stuck in the pre-contemplation stage. He then made the call.
Hospice was tolerable. William's body began to erode under the enormous burden of cancer. His eyes sunk, and the skin hung from his atrophied skeleton. The nurses and CNA's were pleasant and tended to his ever increasing physical needs. The morphine controlled his pain.
William had already made peace with leaving this world. There was only one problem. He had expected to die months ago. Yet, he was still here.
He prayed to a God that he only partially believed in. He begged and pleaded. Take me. Take me.
Yet he woke up every morning, opened his eyes, and loathed that he was still here.
He had long ago stopped living, and now was solely waiting to die. Death taunted him at times, holding the prize within reach. A storm of lethargy would be followed by a an ocean of dyspnea. With nightfall came peace and quiet. The next morning all would be tranquil once again.
Sometimes William dreamt that death was seeking revenge for all those lives he had snatched back from the abyss during his surgical career. All those souls whose path and destiny were interrupted by his mechanical hands.
He fantasized that after a horrible car accident he was rushed to the emergency room with his aorta transected and the pompous surgeon stood over his body, and licked his lips at the chance of letting the scalpel have free range. As William begged and pleaded, the surgeon removed his mask and revealed his true identity. And he recognized his own facade and knew that he would be taken to the operating room.
It was then that William came to terms with a reality that had escaped him his whole clinical career.
Like birth, death is just a natural life event.
A natural event, that somehow kept alluding him.
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