That Which I Miss Most

Empathy

My eyes glare across the table.  I can feel his shoulders hunch forward as he subconsciously recoils in preparation for my response.  The room becomes thick.  Nurses, social workers, a chaplain.  Everyone waiting for the doctor.

Not just the doctor, but me.  Sixteen years out of residency.  Battle scarred and warn by PTSD.  The images from residency still so clear.  A gasp, a gurgle, flat line.  Wailing family members, angry nurses, and an uncompromising chief.  

They died so much more easily back then.  The young, the old, the unwanted, and the uncared for.  The academic medical center with it's social mission.  The Veterans Administration with it's untethered and unloved.  

Practice.  We practiced for lack of a better word.  We  stumbled into situations too big and too great for our burgeoning grip on competence.  We learned as we taught.  We taught as we mastered.  We mastered in the single digits. 

Battle Worn

Emerging from training was like a breath of air.  But not clean air.  Smog.  The same thickness.  Life's murkiness banished to that protected oasis long hidden in the recesses.  Just out of reach.  

Schedules fill.  Patients to squeeze in.  The morass of physical and emotional trauma.  Ducking from the base insults hurled at our backs, and delivering the same into the next examining room when patience grows thin.  

Dragging such toxicity home on the belabored backs of our families.  Of our children.  The raspy voice declares death over the phone with cold and surgical certainty while the kids watch cartoons on a Sunday morning.  Clear eyed retribution turns to tears when the story line on the big screen goes awry.  

That Which I Miss Most.  

In this beloved room full of colleagues battling to make the last gasps of life bearable.  Is the softness.  The weakness of heart and the quietness of spirit.  The empathy that lifted those around me instead of made them cower.  

The absence of fear, and anger, and helplessness.

Not of battling life or death.  Not of winning or losing.  But of learning to feel unhindered.  To feel again.

I defang my claws.  Drop my shoulders and consciously restrain the edge in my voice.

And I do my best to fake it.

     

Something Different

And the dam breaks  

Because it always does.  As the rebellious seas churn and the indelible cracks breach at the base, a web of infirmity spreads it's lacey tendrils unloosening the mooring of a once sturdy structure.  The cackling of unhinged cement, the prepubescent rejoinder to the whoosh as the frothy waters churn past what once was solid, absolving the absurdity of insincere firmness.  That which was an obstacle, now a conduit.  

The mark of the trainee.  The years of suffering, and sweating, and staring down disaster with a stiff upper lip and trembling twenty-four hour knees.  The abuse.  Rampant abuse.  From patients.  From colleagues. From the dumb luck of being on the opposite side of death.  A familiar foe with unbearable strength and agility.

The self effacement.  The drowning of ones own needs.  The rumpled collar, greasy hair, and lazy eyes of a night on call.  Sleep abandoned.  Needs betrayed.  Humanity unraveled into a dream laden schedule.  Every few days.

A calling.  A calling to duty.  A call to sacrifice.

And the dam breaks

Because it had to.  Patients replaced by computers.  Insurance forms and boxes to check, and minutia upon minutia.  Upon minutia.  Until the little becomes so big that you become little too.  With tiny pitiable goals and aspirations.

Far from a healer.  You are a generator of paper.  A signer of forms.  A whipping boy for an ungodly mechanical voice heard disjointedly from somewhere up above.

That drug is not formulary!
That admission is an observation!
That is not a C3, it's a C2!  Run to the fax machine.

Suggestions become commands.  Commands become dictates.  Dictates become laws.

Laws we abide while sneering.  Pitiful sneers that make us hide from the reflection in the mirror.  The reflection in the eyes of those we had sworn to serve.

I'm sorry you're having the most shitty day of your life.  But I can't seem to remember how to order that  coffin in my electronic medical record.  What's the ICD-10 for death?

And the dam breaks

Because the words stop coming.  There is simply nothing more to be said.  There are only so many eloquent ways to talk about something that is broken.  Smashed to pieces.  The whole no longer exists.  



 

Swindled

You've been swindled.  At least that's the conclusion I've come to.  It wasn't the hucksters or the snake oil salesman.  It wasn't big business, big medicine, or some greedy hospital administrator.  It was most likely pharma with a large dose of helping from your doctor.  Plain and simple.

I've learned quite a bit being a hospice medical director.  Covering dozens of new admissions a week has given me much insight into doctor prescribing habits.  Often it is my job to decide with meds are necessary and covered by hospice, which are necessary but not covered by hospice, and which are useless.

Do you have any idea how many useless and often harmful meds our patients are on? I'm not just talking about end of life, but healthy patients to.

Can we talk multivitamins?  Almost every patient I encounter is prescribed a multivitamin.  Healthy, unhealthy, living, dying.  When your in the grasps of stage five thousand and one lung cancer and your brain is riddled with mets, you have no business being on a multi.  It's not going to help you.  It's not going to provide that last bit of energy to overcome the calamitous collapse that is approaching rapidly.  In fact, there is plenty of data to suggest multivitamins are harmful if not neutral at best.  Even in healthy people.

How about Vitamin D?  I swear to g-d, every patient I encounter is on some sort of D supplement.  Never mind that the vast majority of medical evidence implies that supplementation is unhelpful in most disease processes.  Yes, there is osteoporosis, but otherwise, it is a non starter.

Aricept in patients who don't walk, don't talk, and barely interact with the world around them?  Again, started often because there is no other treatment, profound dementia patients are submitted to a host of side effects including diarrhea and syncope without the faintest glimpse of medical benefit.

Vitamin C, Vitamin E, Calcium?

How about statins in patients without a history of coronary disease with end stage-opathies  and malignant cancers.  Do we really think we are going to cut down on cardiac events in the fleeting few months that these patients have to live?  Is there any data to support this?  You better believe that these patients get myalgia and other side effects.

Antibiotics for foul smelling urine, screening urine cultures without symptoms, or agitation in an already agitated patient.  It seems that treating non-utis has become the national past time of our healthcare system.

I could go on and on.  Don't even get me started on antibacterials for non bacterial infections.

The point is, we are not being careful with our prescribing habits.  We are not taking into consideration the wealth of evidence and data regarding some of these treatments.

And we are not being good advocates.

We are not shielding our patients from harm.

 

If you want to hear more stories about medicine and personal finance, check out The Earn & Invest Podcast.

And We Must Breathe

Ask any parent.  Having children is a supreme act of faith.  This revelation does not come easy to one who is particularly uncomfortable kneeling at unfamiliar alters.  It hurts my knees.  Yet there is no more durable truism.

It starts with birth.  The awareness of our own unique helplessness is overwhelming.  We are a slave to our children's genetics, environment, and wholly uncontrollable luck.  We skitter to command a million details to defray the constant anxiety of that which can't be governed.  We worry, lose sleep, and panic till the day we feebly shrug our shoulders and accept.  Then we defer to faith.  Because faith is air, and we must breathe.

As my daughter has grown, that faith has transferred from the intangible nebulous, to the burgeoning humanoid sprouting at my feet.  A far more comfortable leap, a sense of control sets in.  As parents, we can lead by example, teach, shape, and mold.  Destiny has temporarily released her grasp.  My daughter can learn not to climb on the hot stove, to look both ways before crossing, to stop, drop, and roll.

So you would think it is the consequential stuff that I struggle with, but often the ephemera nips just as gratingly at my heels.

A few weeks ago, my daughter informed us that she wanted to perform in the annual school talent show.  Each year, we battle to convince her to play the violin, something she actually holds a sprinkling of talent for.  Sometimes we win, others we lose.

This year she decided that she would perform a solo dance routine, and no matter how much I tried, she could not be dissuaded. My anxiety rose as I pondered our weekend dance performances in the family room.  Rhythm, it turns out, may not be at the top of my daughter's otherwise many talents.

Much discussion was had, videos were You Tubed, lists were made.  And two days before the performance, it was clear that her best option was to free style the whole routine.  My heart raced as I pondered her up on that stage in front of hundreds of people, awkward, and embarrassed.  This has been a hard year for her at school, and the last thing I wanted was for it to end in shame.

My daughter, however, was implacable.  She repeated over and over again:

I got this!

The day of the event, she pushed us out of the way and applied her own makeup.  I marveled at the mix of eye liner and lipstick (something we otherwise would never let our daughter wear).  She looked fierce.

When she took the stage at the tail end of the show after fifty other acts, I stood nervously with camera in hand.  She awaited patiently through three attempts to queue her music correctly.  I could no longer control the fluttering in my chest.

I keenly felt at that moment something, in retrospect, I have always known.  

That I will follow this girl with all my heart down whichever path she leads.  And I will have faith even though the journey will often be awkward and painful and sometimes...

Sometimes joyful and wondrous.

Changing Lanes

I drive a fast car.  Which if you know me, is quite uncharacteristic.  I would say that it is one the few possessions that generally doesn't reflect upon who I am.  How I chose this car, the make, and model, are a long story not to be discussed here.  But let's just say that it has quite a kick.

These thoughts jostled through my mind this morning as I pulled into the hospital parking lot.   A recent momentous decision, I surrendered my privileges at this hospital and started using the hospitalists.  It had all become too hard.  The inane compliance issues with the new EMR.  The ER attendings admitting my patients without calling me.  The slew of protocols, documents, and attestations at this institution recently became particularly onerous. The administration was pushing out the primary physicians with the indignation of a million not so subtle pinpricks.

I was making a courtesy visit.  I had asked the Emergency Room physician to have the hospitalist call me the night before.  I knew this patient exceedingly well over the years, and had a good impression of what had happened.  I was unable to relay this information, however, because I never got a phone call.

I didn't agree with the diagnosis or treatment plan.  The admitting hospitalist was no longer available and the nursing staff had no idea who to call.  I carefully documented my knowledge of the patients past medical history, exam, and my thoughts in a progress note.  I also left my mobile number and begged the rounding physician to call me.  I am not hopeful.  Eventually, after much searching and paging, I will likely reach the physician by the end of the day.  Que sera, sera.

This hospital is in the midst of a major rebuild, and part of the process is a new entrance to the expressway adjacent to the parking lot.  The beauty of this new pathway is that following a few careening turns, the entrance ramp is a straight shot for a few hundred feet.

This morning, I came to a full stop after those turns, and waited for the cars on the expressway to pass at 60 mph.  I put all four windows down.  Then I put the pedal to the metal.

10, 30, 50, 70mph,  I sped past all the cars ahead of me.  The wind blowing into the car and smacking me in the face.  Power, speed, freedom, joy!

Eventually I merged left and began the process of applying the brakes.  I was coming up quickly on a series of cars driving at more conventional speeds.

The fun is over.  It couldn't last forever.

It seems it's no longer our patients that we answer to.

Because I've been told, in no uncertain terms, it's time to stop bucking the system.

And get back into my appointed lane.

Letting Go

You can let go now!

As Hannah's granddaughter clutched at her skeletal fingers, the blanket fell to the side revealing the faded serial numbers on her forearm.  The family gathered, yet again, to say goodbye.  This time her acrid breath had lost humidity, her respirations dry and raspy, the extremities mottled with a bluish tinge.

Death had visited the neighborhood before.  Lounged in the parlor.  Nibbled on crackers and tea.  But letting go was not so easy. Sure the signs were there.  There were the bouts of unconsciousness lasting days.  The hours of irregular breathing with long gaps.  The clutching of chest and recitation of prayer.  All followed by merciless, unrelenting recovery.

Hannah wanted to die.  At least that is what she told the doctors.  She sang it in her sleep and whispered to the hallucinations that pranced on her pillow.  She refused medications.  She spurned nourishment.  She pulled at the tube thoughtlessly plunged into her abdomen a few hospitalizations prior.  She hissed at the Rabbi as he entered her room.

Why won't you take me?

They said she was a survivor.  A code they used in order to avoid talking about dark things. Guilty things.  She was forever marked by the fact that she didn't succumb.  She didn't die.  She was scarred somewhere deeper, more profound, than the ugly thing on her forearm.  She was marred by persistence.

Most of her family died decades ago during the war.  A whole lineage erased. And yet she persisted.  Her colon removed, her brain stroked, her heart fibrosed.  And yet she persisted.  The years passed, friends and lovers gone, a child or two perished.  And yet she persisted.

Persistence had entwined her DNA, calcified her bones, and cascaded past blood cells forever traveling in circles.

Her body was failing, but her spirit couldn't let go.

No matter how much she begged and pleaded.

It didn't know how.


Five Moments, now available on Amazon.


Also available, I Am Your Doctor: and This is My Humble Opinion.

If  you want to hear more stories about medicine and personal finance, check out the Earn & Invest Podcast. 

Drip Drip

Get out.


It was not so much the words as the overall tone of the interaction.  The doctor-patient relationship had been generally affable.  There was the usual exchange of pleasantries over the years.  Questions about family, children and grandchildren.  It was a good relationship.  Until Harvey got sick, that is.


Originally there was weight loss and fatigue.  The initial physical exam and slew of testing showed nothing but a frail, cachectic, middle aged man.  A few cat scans later and he was in the oncologist's office discussing chemotherapy.  A regimen was decided on, and therapy began the next day. 


Therapy was hard.  Nausea. Retching.  More weight loss.  Far from feeling better or cured, Harvey could feel the clothes slipping from his emaciated body.  It was as if life itself was drip dripping away as the chemo bulldozed into his broken veins.  And this pissed Harvey off. 


He lashed his family.  He cursed his friends. He spun into a whirlwind of the most resistant depression. A depression, his therapist would later tell me, whose only salve was anger.  While the anger allowed him to carry on, often he left those around him scorched.


His doctors were no exception.  We often spent half of each visit withstanding abuse before getting down to the business of the appointment.  He blamed us for the cancer.  He blamed us for the lousy response.  He blamed us for the side effects of his abysmal treatment.


So when I walked into the hospital room to tell him the scans showed his latest chemotherapy had failed to stem the red tide of death, I have to admit that I had already somewhat detached.  How could I not?  Although he was fairly lathered by the results, it was the mentioning of hospice that finally led to my expulsion.  His wife ran after me with tears in her eyes.  I'm quite certain that she paid dearly for her kind act of decorum.


Harvey died shortly thereafter.


I am prone to remember the pleasantries Harvey and I enjoyed before his health deteriorated.  I am neither disturbed nor saddened by the anger.  I cannot even say that I would not have been the same way if I  had been lying in his hospital bed.


What surprises me, in retrospect, is how little he affected me.  How his anger didn't penetrate the hardened shell. 


Over my career I have been yelled at, cursed, blamed, hugged, and even loved by my patients.


And like the poor life force oozing out of Harvey's beleaguered body, it drip drips down my back.


 And into a forgotten puddle on the ground.


My new book:  Five Moments, now available on Amazon. 

If you want to hear more stories about medicine and personal finance, check out The Earn & Invest Podcast,