Obsessed (2)

Every morning was the same for Lawrence. His alarm went off at four thirty reliably. Although he didn't need to arrive at the OR for hours he had soo much to do. He had his rituals. And his rituals took time. He had to do them correctly. And if he didn't.... they needed to be repeated...or something bad would happen.

Five steps from the bed to the bathroom. Water on. Open and close the toilet seat three times. use the toilet. Flush twice. Two more steps back to the sink.

And so the morning went. A choreographed dance he performed daily often interrupted by repetition and occasionally by the need to start all over again. Lawrence hadn't always been this way. In fact this all started when his world fell apart. Five years ago. The unimaginable had happened. The unthinkable. So Lawrence tried to order the parts of his life he could control. If he just followed the right steps. If he just didn't mess up.....he would be protected.

By the time he showered, got dressed, and ate breakfast Lawrence was already late for his nine oclock OR slot. In fact he never made it on time. The schedulers at the hospital were so aware of the problem that they always scheduled the first case an hour late. And like clock work Lawrence would arrive at 10am. The staff would trade glances as usual. Mainly they felt sorry for him. They had watched him unravel over the years.

As Lawrence finished changing into his scrubs he walked briskly to the back of the locker room and sat awkwardly on the ledge of the window facing the courtyard. He had exactly five minutes. This was his last ritual before going into the operating room. A tear rolled down his eyes as he replayed the horrible day over and over again in his mind. The day his life went from light to grey.

Never...never again he told himself.

And then he left the locker room and went to scrub for the first case.

Penance

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

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.

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

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

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

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.