Accepted today to the Annals of Internal Medicine Ad Libitum Section:
Penance
I’ve started
To bleed
Again
It happens
Every winter
With cold
And dry
I wash my hands
20-30 x a day
Before and after
Each
Patient
At first
The dryness
Was bothersome
And I used
Lotion
But eventually
I stopped
And my hands
Became painful
But the pain
Gradually
Dissapeared
Occasionally
Blood
On my knuckle
Where the skin
Would crack
The other day
I was calling
Results
A normal stress test
A high cholesterol
And lastly
I came
To your
Biopsy
Quietly
I told you
Over the phone
You cried
Calmly
I explained
What happens
Next
As I hung up
I noticed
I was wringing
My hands
Together
I looked down
With alarm
To see
I was covered
In blood
The cuffs
Of my white coat
Stained
Red
I ran
To the sink
My tears
Joining the water
Down
The drain
I guess
I have been hurting
For a very
Long
Time
However
Sometimes
I forget
To think
About
It
From the chapbook Primary Care, The Lives You Touch Publications
Thursday, October 16, 2008
Wednesday, October 15, 2008
Obsessed
As lawrence listended to the phone ring he thought back to a time when he wasn't this sick. The clock on the nightstand read 10 pm as usual. Not a second before. Not a second after. The lights in the room were all off sparing the overhead lamp on the bedside table. He was in a pair of flannel pajamas but no shirt. The temperature in the house was set at 78 degrees exactly.
Precision had become Lawrence's life. Not a bad thing for a surgeon. Afterall.....hadn't his patients depended on his precision. Couldn't just one small misstep lead to disaster? No...no Lawrence told himself you have to stop thinking that way. It's not healthy! Ironically the disaster that Lawrence was trying so hard to avoid had already happened. Both his personal and professional life were in ruins.
His wife had left him...over five years ago. He had lost most of his friends. His colleagues look at him as an oddity. And although he was still operating, his patient load had dwindled severely. Who wants a surgeon who is so caught up in their personal issues that they show up to the OR 2 hours late for the first case?
The phone continued to ring. Come on Carole.....come on....answer the damn phone. Just this last time. Lawrence felt ill. He remembered pleading with his ex wife similarly when she left him. And now he was doing it every night. Silently. In his own mind. Waiting for her to answer the phone. So he could turn off the light and go to sleep.
"Hello?" Carole's annoyed voice woke him from his reverie...
"Just...just checking," Lawrence sputtered as he could hear Carole's husband recite explatives in the background.
"Go to bed Lawrence!"
"Ok......ok"
And then Lawrence hung up the phone and as usual drifted into a sound sleep.
Precision had become Lawrence's life. Not a bad thing for a surgeon. Afterall.....hadn't his patients depended on his precision. Couldn't just one small misstep lead to disaster? No...no Lawrence told himself you have to stop thinking that way. It's not healthy! Ironically the disaster that Lawrence was trying so hard to avoid had already happened. Both his personal and professional life were in ruins.
His wife had left him...over five years ago. He had lost most of his friends. His colleagues look at him as an oddity. And although he was still operating, his patient load had dwindled severely. Who wants a surgeon who is so caught up in their personal issues that they show up to the OR 2 hours late for the first case?
The phone continued to ring. Come on Carole.....come on....answer the damn phone. Just this last time. Lawrence felt ill. He remembered pleading with his ex wife similarly when she left him. And now he was doing it every night. Silently. In his own mind. Waiting for her to answer the phone. So he could turn off the light and go to sleep.
"Hello?" Carole's annoyed voice woke him from his reverie...
"Just...just checking," Lawrence sputtered as he could hear Carole's husband recite explatives in the background.
"Go to bed Lawrence!"
"Ok......ok"
And then Lawrence hung up the phone and as usual drifted into a sound sleep.
Tuesday, October 14, 2008
Saying Goodbye
Mrs. Jones.....
I am calling today to give my condolences. I heard this morning of your husbands passing. I am truly sorry.
I will never forget the day you both walked into my office. As often happens we ended up laughing as much as talking seriously about his health problems.
Through all the years I have known your husband, he always had a smile on his face and a bounce in his step. He faced every new medical problem with bravery and courage. Each step forward was welcomed. Each step backwards was tolerated.
Your husband lived with great diginity....I saw this in the way the people around him looked up to him. How when it became apparent that death was forthcoming your children and their families rallied around him. How you now celebrate his life as well as mourn his passing.
His body may have passed but his spirit will never die. It lights up the faces of all those little grandchildren you probably have running amongst your feet right now. He will never be forgotten.
I wanted to take a moment to say thank you. For allowing me to take care of him and bear witness to just a fraction of the beauty he has bestowed on this world. I am humbled by the honor you have afforded me. I will never take light of your decision to entrust me with his health and well being.
I will miss him....
I will never forget....
Please don't hesitate to call if I can be of any assistance.
You will always be welcome in our office.
Goodbye
I am calling today to give my condolences. I heard this morning of your husbands passing. I am truly sorry.
I will never forget the day you both walked into my office. As often happens we ended up laughing as much as talking seriously about his health problems.
Through all the years I have known your husband, he always had a smile on his face and a bounce in his step. He faced every new medical problem with bravery and courage. Each step forward was welcomed. Each step backwards was tolerated.
Your husband lived with great diginity....I saw this in the way the people around him looked up to him. How when it became apparent that death was forthcoming your children and their families rallied around him. How you now celebrate his life as well as mourn his passing.
His body may have passed but his spirit will never die. It lights up the faces of all those little grandchildren you probably have running amongst your feet right now. He will never be forgotten.
I wanted to take a moment to say thank you. For allowing me to take care of him and bear witness to just a fraction of the beauty he has bestowed on this world. I am humbled by the honor you have afforded me. I will never take light of your decision to entrust me with his health and well being.
I will miss him....
I will never forget....
Please don't hesitate to call if I can be of any assistance.
You will always be welcome in our office.
Goodbye
Monday, October 13, 2008
You and Me
I woke up
From a nightmare
A decade ago
About being
Alone
I got up
And looked in the mirror
And saw You
Your beautiful soft face
Wavy hair
And those eyes
I looked inside
And saw myself
Strong
Confident
Happy
So I went
Back to sleep
I awoke again
This morning
From another nightmare
And looked in the mirror
And there you were
Just As I had left you
I peered again
Into your eyes
And this time
I saw you
And the kids
All my happiness
But yet something
Was missing
I tried
To turn over
And scream
"How could you
Have gotten rid
Of me?"
But then
I realized
That the mirror
Was more a reflection
On me
Then you
From a nightmare
A decade ago
About being
Alone
I got up
And looked in the mirror
And saw You
Your beautiful soft face
Wavy hair
And those eyes
I looked inside
And saw myself
Strong
Confident
Happy
So I went
Back to sleep
I awoke again
This morning
From another nightmare
And looked in the mirror
And there you were
Just As I had left you
I peered again
Into your eyes
And this time
I saw you
And the kids
All my happiness
But yet something
Was missing
I tried
To turn over
And scream
"How could you
Have gotten rid
Of me?"
But then
I realized
That the mirror
Was more a reflection
On me
Then you
Sunday, October 12, 2008
By The Way, I'm Also Great at Removing Wax from Ears
Years ago, before I started medical school, I thought it was so simple. I would become a doctor. The answers would role off my tongue. People would come to me and I would fix them. I would rush into the hospital room and singlehandedly save the day. It was so obvious. It was so straightforward. It was so laughable.
Back in those days I didn't undersatnd the complexity of medicine. I didn't understand that often the answers are not so clear. That sometimes there are multiple possibilities and it is difficult to differentiate which is right. That sometimes no matter how hard you try.... you miss the mark. That diseases are more likely to present atypically then in textbook fashion.
My naivete was shattered throughout residency and my first few years of practice. I would continually search for the textbook answers and they would often miss lead me. A clear case of cardiac chest pain would end up being heartburn.....and a clear case of constipation and indigestion would end up being a heart attack. The gods of medicine were laughing at me and I was fodder for their cruel sense of humor.
But as time has passed I have started to understand the patterns of human beings better. I am now more likely to diagnose appendicitis by the look on a person's face and their demeanor then anything I specifically note on physical exam. I am now apt to understand that testicular pain in a young man is just as likely anxiety and depression as it is orchitis or a hernia. I have learned these things. Not by reading them somewhere in a textbook but by experience....by missing something once....by vowing never to forget.
The medicine I practice today is much more nuanced. I watch the way patients walk into my office. I pick more up in their facial expressions.....in the words that aren't said. I understand a little better how people work. How they describe their own pain. What the diffetence is between psychic and physical pain. And how to try to treat each.
I also have learned that as a primary care physician I rarely race into the hospital (or office) to save the day. I will leave that for the surgeons. What I do is a lot more tame, a lot more calculated. Although I have never found myself to be a religious man I still beleive that we as humans have only so much power over our own lives. Sometimes people will either live or die and I as a physician may have very little to do with it.
I see my role as more behind the scenes. In those who are living I try to foster life with less pain and suffering. Less worry and concern. I manage their back pain, and diabetes , and heart disease. Like an insurance policy I am a crutch to help face the unimaginable...the unthinkable.
In those who are dying I try to fashion a softer landing. Ease the pain and desperation of what they are going through. I try to get them home and with their families. To die pain free surrounded by those who love them. Sometimes it works, sometimes it doesn't. But there is beauty and salvation in the attempt.
So I guess you could say as a primary care physician I am a jack of all trades. I help people live. I help people die. I try to manage ilness behind the scenes so people can live their lives. And occasionally...occasionally I rush into to save the day (if I'm lucky).
Oh...and by the way
I'm also great at removing wax from ears
Back in those days I didn't undersatnd the complexity of medicine. I didn't understand that often the answers are not so clear. That sometimes there are multiple possibilities and it is difficult to differentiate which is right. That sometimes no matter how hard you try.... you miss the mark. That diseases are more likely to present atypically then in textbook fashion.
My naivete was shattered throughout residency and my first few years of practice. I would continually search for the textbook answers and they would often miss lead me. A clear case of cardiac chest pain would end up being heartburn.....and a clear case of constipation and indigestion would end up being a heart attack. The gods of medicine were laughing at me and I was fodder for their cruel sense of humor.
But as time has passed I have started to understand the patterns of human beings better. I am now more likely to diagnose appendicitis by the look on a person's face and their demeanor then anything I specifically note on physical exam. I am now apt to understand that testicular pain in a young man is just as likely anxiety and depression as it is orchitis or a hernia. I have learned these things. Not by reading them somewhere in a textbook but by experience....by missing something once....by vowing never to forget.
The medicine I practice today is much more nuanced. I watch the way patients walk into my office. I pick more up in their facial expressions.....in the words that aren't said. I understand a little better how people work. How they describe their own pain. What the diffetence is between psychic and physical pain. And how to try to treat each.
I also have learned that as a primary care physician I rarely race into the hospital (or office) to save the day. I will leave that for the surgeons. What I do is a lot more tame, a lot more calculated. Although I have never found myself to be a religious man I still beleive that we as humans have only so much power over our own lives. Sometimes people will either live or die and I as a physician may have very little to do with it.
I see my role as more behind the scenes. In those who are living I try to foster life with less pain and suffering. Less worry and concern. I manage their back pain, and diabetes , and heart disease. Like an insurance policy I am a crutch to help face the unimaginable...the unthinkable.
In those who are dying I try to fashion a softer landing. Ease the pain and desperation of what they are going through. I try to get them home and with their families. To die pain free surrounded by those who love them. Sometimes it works, sometimes it doesn't. But there is beauty and salvation in the attempt.
So I guess you could say as a primary care physician I am a jack of all trades. I help people live. I help people die. I try to manage ilness behind the scenes so people can live their lives. And occasionally...occasionally I rush into to save the day (if I'm lucky).
Oh...and by the way
I'm also great at removing wax from ears
Thursday, October 9, 2008
A Tale of Two Vertebral Fractures
Mrs. Jones is an eighty year old lady with a history of sudden onset acute severe back pain. She walks into Dr. A's office for evaluation. After a thorough history Mrs. Jones is examined and Dr. A notes point tenderness over the lubar vertebrate. He suspects a vertebral fracture. He sends his patient immediately down to xray for a film of the lumbar spine and asks for a wet read. Thirty minutes later Dr. A recieves a call from the radiologist that indeed there is a lumbar fracture. Dr. A then calls the interventional radiologist at the hospital and arranges for Mrs. Jones to get an MRI and a consultation later that day. The next day she undergoes a vertebroplasty as an outpatient and is sent home with her pain relieved. Here's how it breaks down....
Dr. A saw the patient for a simple office visit and billed a 99213 (mid level visit) and spent 15 minutes with the patient.
Dr. A spent 30 minutes reviewing films, talking with radiologists, and organizing Mrs. Jones' care. This time was not compensated for
Mrs. Jones' cost to our medical system: 1 office visit, 1 xray, 1 MRI, costs associated with vertebroplasty (including outpatient interventional radiology consultation).
Alternatively Mrs. Jones walks in to see Dr. B with the same problem. Dr B is not as well trained, not as well informed, or doesn't have enough time. He takes a history and examines the patient. He diagnosis osteoarthritis of the spine and sends Mrs. Jones home with vicodin. Over the next few days Mrs. Jones' pain becomes excruciating. Furthermore more she is constipated. She calls Dr B for advice. He does not have enough time to see her so he sends her to the ER. Mrs. Jones has an xray in the ER that shows vertebral fracture (hospital day 1). She is admitted to Dr B's service. Dr B orders an MRI and gets the result later the next day Hospital day 2). He calls the interventional radiologist. The radiologist sees the patient the next day (hospital day 3)and sets her up for a vertebroplasty the following day (hospital day 4). Mrs. Jones is discharged after post op observation the next day (hospital day 5) with good pain control. Here's how it breaks down...
Dr. B saw the patient in the office and billed a 99213 but then admitted the patient to the hospital billing a 99223 for admission, 99233 x 3 for follow up days, and then a 99239 for discharge.
Mrs. Jones cost to our medical system: 1 office visit, 5 inpatient visits from Dr. B, 1 ER physician charges, 1 inpatient consultation from interventional radiology, 1 xray, 1 MRI, 5 days worth of hospitalization, costs associated with vertebroplasty.
Who benefits (IE MAKES MORE MONEY) from our current medical system: Dr. B, the interventional radiologist (in either scenario), ER physicians, The hospital
Who gets the short end of the straw: Mrs. Jones, Dr. A (good primary care physicians)
I have seen this soo often. Poor doctoring leads to increased costs across the board and increased revenues for those who deserve it least.
Dr. A saw the patient for a simple office visit and billed a 99213 (mid level visit) and spent 15 minutes with the patient.
Dr. A spent 30 minutes reviewing films, talking with radiologists, and organizing Mrs. Jones' care. This time was not compensated for
Mrs. Jones' cost to our medical system: 1 office visit, 1 xray, 1 MRI, costs associated with vertebroplasty (including outpatient interventional radiology consultation).
Alternatively Mrs. Jones walks in to see Dr. B with the same problem. Dr B is not as well trained, not as well informed, or doesn't have enough time. He takes a history and examines the patient. He diagnosis osteoarthritis of the spine and sends Mrs. Jones home with vicodin. Over the next few days Mrs. Jones' pain becomes excruciating. Furthermore more she is constipated. She calls Dr B for advice. He does not have enough time to see her so he sends her to the ER. Mrs. Jones has an xray in the ER that shows vertebral fracture (hospital day 1). She is admitted to Dr B's service. Dr B orders an MRI and gets the result later the next day Hospital day 2). He calls the interventional radiologist. The radiologist sees the patient the next day (hospital day 3)and sets her up for a vertebroplasty the following day (hospital day 4). Mrs. Jones is discharged after post op observation the next day (hospital day 5) with good pain control. Here's how it breaks down...
Dr. B saw the patient in the office and billed a 99213 but then admitted the patient to the hospital billing a 99223 for admission, 99233 x 3 for follow up days, and then a 99239 for discharge.
Mrs. Jones cost to our medical system: 1 office visit, 5 inpatient visits from Dr. B, 1 ER physician charges, 1 inpatient consultation from interventional radiology, 1 xray, 1 MRI, 5 days worth of hospitalization, costs associated with vertebroplasty.
Who benefits (IE MAKES MORE MONEY) from our current medical system: Dr. B, the interventional radiologist (in either scenario), ER physicians, The hospital
Who gets the short end of the straw: Mrs. Jones, Dr. A (good primary care physicians)
I have seen this soo often. Poor doctoring leads to increased costs across the board and increased revenues for those who deserve it least.
Tuesday, October 7, 2008
Letting Yourself Off The Hook
I was all excited yesterday. I finished work early and was enjoying the drive home when it hit me. What a beautiful day. Maybe I'll go for a jog. This was a rare luxury to have time to do this in the middle of the day. The sun was shining and I was psyched at the idea of running along Lake Michigan.
I have started to excersize again. It's been awhile. The first week was just walking on a treadmill. Yah....I'm in that bad a shape. But I figure if I am going to tell my patient's to excersize...I better do the same. All I have to do, I told myself, is start out slowly. Thirty minutes a day on the treadmill translates into roughly a 2 mile walk. A little sweat. A little increased heart rate. No big deal.
But yesterday was different. I had to take advantage of the beautiful day. So I ran into the house. Put on some shorts and a log sleave T shirt and headed out. It took less then 2 minutes to realize how painful this was going to be. First my chest started to hurt. Then my lungs felt like they were going to fall out of my chest. And last my legs and knees ached.
I could have given up. I could have quite. But I told myself that I was going to jog for 30 minutes regardless. So when my body, after five minutes, warned of near death I ignored it. Instead I psyched myself up for the pain. I vividly imagined other times in my life when I was met with harsh realities. In childhood when I had a learning disability...I didn't give up then did I? In residency when I worked 40 hours in a row without sleep....I didn't give up then did I?
As pathetic as it sounds I do this all the time when confronted with difficult situations both physically and emotionally. I turn a basic challenge into a referrendum of my previous successes and failures....a referendum of my character. It's not just getting a workout, it's an epic battle between good and evil. Between success and failure. What if my whole family was kidnapped and held at gunpoint and the only way I could save them was to run a marathon without stopping? Even in my current poor physical condition? Could I do it?
And as funny as it was these thoughts carried me. My breadthing became less labored. My stride became more secure. Although I was in immense pain I made it to the lake and enjoyed the stunning view. As I looked at my watch I realized that I had been running for only fifteen minutes. So I turned course to head back home. The terrain was more up hill and I began to struggle. But as I reached the twenty five minute mark I knew I would make it. I said that nothing would stop me from running the full thirty minutes and I meant it. I would conquer this challenge and live to fight another day.
And that's when it happened. A little girl rode passed me on the sidewalk on her bike. She must have been about ten. I watched as her figure slowly peddled in front of me. About 100 feet ahead she hit an uneven area in the pavement and fell. I looked down at my watch. A few minutes to go. Then I looked over at the girl....tears streaming down her face. As I came to her figure lying on the ground I stopped. I would not accomplish my task. I helped lift her up. She was not hurt. I bent over and picked up her bike as she wiped a tear from her eye. She let out a small embarrased giggle. I laughed. She took her bike and climbed back on. "Thanks," she said as she rode off.
I looked again at my watch and saw my thirty minutes had expired. Strangely and unexpectedly I had not reached my goal. I had not jogged for thirty minutes. I still had a good workout. I still would ache in the morning. But, by no fault of my own, I had fallen short.
As I walked the rest of the way home I thought again about my actions. Maybe life isn't always as black and white as I make it out to be. Maybe sometimes no matter how hard you try to succeed you fail. Maybe failure is not something to flog oneself over but a choice that we often have to make. And that choice can be beautiful and enrich us as opposed to leaving a stain on our character.
Maybe I haven't been feeling as good lately as I want to admit
Maybe it's time I stopped being so damn hard on myself
I have started to excersize again. It's been awhile. The first week was just walking on a treadmill. Yah....I'm in that bad a shape. But I figure if I am going to tell my patient's to excersize...I better do the same. All I have to do, I told myself, is start out slowly. Thirty minutes a day on the treadmill translates into roughly a 2 mile walk. A little sweat. A little increased heart rate. No big deal.
But yesterday was different. I had to take advantage of the beautiful day. So I ran into the house. Put on some shorts and a log sleave T shirt and headed out. It took less then 2 minutes to realize how painful this was going to be. First my chest started to hurt. Then my lungs felt like they were going to fall out of my chest. And last my legs and knees ached.
I could have given up. I could have quite. But I told myself that I was going to jog for 30 minutes regardless. So when my body, after five minutes, warned of near death I ignored it. Instead I psyched myself up for the pain. I vividly imagined other times in my life when I was met with harsh realities. In childhood when I had a learning disability...I didn't give up then did I? In residency when I worked 40 hours in a row without sleep....I didn't give up then did I?
As pathetic as it sounds I do this all the time when confronted with difficult situations both physically and emotionally. I turn a basic challenge into a referrendum of my previous successes and failures....a referendum of my character. It's not just getting a workout, it's an epic battle between good and evil. Between success and failure. What if my whole family was kidnapped and held at gunpoint and the only way I could save them was to run a marathon without stopping? Even in my current poor physical condition? Could I do it?
And as funny as it was these thoughts carried me. My breadthing became less labored. My stride became more secure. Although I was in immense pain I made it to the lake and enjoyed the stunning view. As I looked at my watch I realized that I had been running for only fifteen minutes. So I turned course to head back home. The terrain was more up hill and I began to struggle. But as I reached the twenty five minute mark I knew I would make it. I said that nothing would stop me from running the full thirty minutes and I meant it. I would conquer this challenge and live to fight another day.
And that's when it happened. A little girl rode passed me on the sidewalk on her bike. She must have been about ten. I watched as her figure slowly peddled in front of me. About 100 feet ahead she hit an uneven area in the pavement and fell. I looked down at my watch. A few minutes to go. Then I looked over at the girl....tears streaming down her face. As I came to her figure lying on the ground I stopped. I would not accomplish my task. I helped lift her up. She was not hurt. I bent over and picked up her bike as she wiped a tear from her eye. She let out a small embarrased giggle. I laughed. She took her bike and climbed back on. "Thanks," she said as she rode off.
I looked again at my watch and saw my thirty minutes had expired. Strangely and unexpectedly I had not reached my goal. I had not jogged for thirty minutes. I still had a good workout. I still would ache in the morning. But, by no fault of my own, I had fallen short.
As I walked the rest of the way home I thought again about my actions. Maybe life isn't always as black and white as I make it out to be. Maybe sometimes no matter how hard you try to succeed you fail. Maybe failure is not something to flog oneself over but a choice that we often have to make. And that choice can be beautiful and enrich us as opposed to leaving a stain on our character.
Maybe I haven't been feeling as good lately as I want to admit
Maybe it's time I stopped being so damn hard on myself
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