Sitting in a trendy bar in LA I find myself out of my element. My eyes wander to the tables adjacent. The room sways with the music as the beautiful people inhabit their space. And then out of the corner of my eye I catch a glimpse of two men embracing. Young. One then reaches his arm around the other putting him in a mock headlock. And instantaneously the image transports me back to a week earlier...
I'm rushing to the emergency room from my office. I have a thirty minute break between patients. The buildings are connected. I try to sort out what I am gong to say to the family I'm running to meet. Their mother has just died unexpectedly in the nursing home. She was deathly ill but that won't make it any easier. I feel a twinge of guilt as if I could have done anything differently.
I enter the hospital from a side door and start down the long passage that eventually leads to the main entrance and the ER. My eyes forward I almost crash right into the women in the white coat. She is standing at the intersection between hallways. Holding a hand up towards me she is speaking in harsh loud sentences. Her head is turned towards the bisecting hallway. "Okay...okay...they have a bed for us move him forward..." a bead of sweat falls from her forehead.
Next five large security guards stumble forward into view. They are struggling to carry a thrashing figure. They each have a limb wrapped squarely between large arms. The fifth has the patient's head in his hands and is holding it for dear life in a headlock. They are all obviously fatigued already. The man in front responds, "okay...we have to hurry...we can't take it much longer".
And just as quickly as it has come the commotion disappears. Later as I walk through ER I see the attending and nurses scurrying to the exam room with syringes. Ready to sedate on command. The security guards are loitering at the nursing station. Each grasping a cup of water. And I, distracted by the scene, still am not sure what I am going to say to the family as I pass through the main area and head towards the crisis room.
The men in the bar are now sitting. They toast eachother with their newly delivered drinks. And I let go of that day in the ER. It all seems so far away now....
sitting in a trendy bar in LA.
Sunday, January 11, 2009
Friday, January 9, 2009
Another Holiday
As the snow gently drops onto my windshield it is quickly whisked away by the wipers. It's another holiday. 5:30 AM. And I'm in the car on the way to the hospital. I've worked them all. Holidays, birthdays, anniversaries. I've missed countless family events. I generally leave the house before the children awake. Occasionally I return after they are sleeping. And when I'm not working...I'm constantly thinking. Mulling over a patient....a disease. Agonizingly trying to grasp the ephemeral. The missed diagnosis..the hidden clue. My wife rolls her eyes when she asks a question and I fail to respond. My head in a cloud I'm lost in the ether, desperately clinging to fleeting thoughts. So why do I do it. Why be a physician?
I am not a religious man. I have never read the bible. When times get tough I do not pray. But I have a sense of what must make it so gratifying. The husbands gentleness as he helps his wife onto the examining table. The ward secretary who sneaks into the hospital room to hold the patient's hand because there is no one to sit with him while he dies. The countless acts of beauty and kindness that occur behind closed doors when we are all at our worst. This....this is as close as I get to feeling God's presence.
This is the mistress that whispers in my ear early in the morning and forces me to get up. To leave my family on a holiday. To drive a half an hour in the snow to the hospital. To practice the craft that I have been taught. A craft which invites me into the most intimate moments of others lives. And gives me the unique possibility to help.
No matter how bad it gets there will always be doctors.....
There will always be doctors!
I am not a religious man. I have never read the bible. When times get tough I do not pray. But I have a sense of what must make it so gratifying. The husbands gentleness as he helps his wife onto the examining table. The ward secretary who sneaks into the hospital room to hold the patient's hand because there is no one to sit with him while he dies. The countless acts of beauty and kindness that occur behind closed doors when we are all at our worst. This....this is as close as I get to feeling God's presence.
This is the mistress that whispers in my ear early in the morning and forces me to get up. To leave my family on a holiday. To drive a half an hour in the snow to the hospital. To practice the craft that I have been taught. A craft which invites me into the most intimate moments of others lives. And gives me the unique possibility to help.
No matter how bad it gets there will always be doctors.....
There will always be doctors!
Saturday, December 20, 2008
The Day I Lost My Confidence
I brace as the sheets of white assault my car. My foot on the clutch sways with each loss of traction. The clock reads 5:30 or some ungodly hour. The roads are empty except f0r the occasional companion that passes in the early morning darkness. My mind is distracted. The forecast is bleak. Snow all day. The department of streets and sanitation has released a travel warning and suggests staying off the roads.
Why not work from home? Call into the office? Not exactly an option for a physician. The patients in the hospital can't be cancelled. I can't just wait to see them the next day. And then there's the expectation. That I will be available. Even on the worst of days. I'll be there...Just call. I'm not sure if the unreasonableness is theirs or mine.
And my brain races back. To a year ago. On a morning like this. Before the snow plows. Hurrying to make it to the hospital for who knows what. Just a few blocks from the office. On the expressway. When I lost control I thought I was going to crash into the barrier. But then to my complete horror the car skidded in the opposite direction. I had just moments to contemplate before I hit the semi. Luckily in the back. And then I swayed to safety to the side of the road.
Unscathed...physically at least. But a year later I 'm still a little skittish. Moment by moment trying to recover.....from the day I lost my confidence.
Why not work from home? Call into the office? Not exactly an option for a physician. The patients in the hospital can't be cancelled. I can't just wait to see them the next day. And then there's the expectation. That I will be available. Even on the worst of days. I'll be there...Just call. I'm not sure if the unreasonableness is theirs or mine.
And my brain races back. To a year ago. On a morning like this. Before the snow plows. Hurrying to make it to the hospital for who knows what. Just a few blocks from the office. On the expressway. When I lost control I thought I was going to crash into the barrier. But then to my complete horror the car skidded in the opposite direction. I had just moments to contemplate before I hit the semi. Luckily in the back. And then I swayed to safety to the side of the road.
Unscathed...physically at least. But a year later I 'm still a little skittish. Moment by moment trying to recover.....from the day I lost my confidence.
Wednesday, December 17, 2008
The Caregiver Phenomena
A thought gelled in my mind today which has been subconsciously stirring for years. I was seeing a 90 year old women who came to the office accompanied by her daughter and caregiver. She had not been feeling well for the last few weeks. She was coughing, having chest pain, and generally feeling under the weather.
The patient didn't look sick. In fact she looked pretty good. She even voiced that she felt OK. The daughter agreed that her mother was looking fine. The only one in the room who seemed in disagreement was the caregiver. The caregiver described how her charge was getting worse and failing to turn the corner. In fact I could almost predict the care giver's responses to my questions before I gave them. Basically for any open ended question there was almost always a negative response suggesting that the patient wasn't doing well.
I have known this caregiver for years. And she does a great job. Very attentive, loving, and hard working. She is present for every cough, and sneeze, and complaint. She works tirelessly long hours. So what gives? Am I and the daughter missing something significant or is the story from the caregiver not exactly accurate? And if it's not accurate then why?
While pondering this question I quickly realized that I encounter this type of behavior regularly. In fact I often find myself going to great lengths to corroborate information given from caregivers. My experience has shown that they often overstate or occasionally exaggerate their charges complaints. In the beginning of my career I took these reports literally and found myself over treating: ordering too many tests and giving too many antibiotics.
I have coined the term the caregiver phenomena to describe this type of behavior. I suspect it stems from two different causes. First, the caregiver who is not medically trained, is often present for every complaint and is afraid that something bad will happen during their watch. They are terrified of missing something significant. Second, I believe the caregiver is often the one who blows the whistle by alerting the family and thus initiates the actions that eventually lead to the doctors visit. Many caregivers feel pressure to justify the visit by making sure the doctor knows the levity of the situation.
Whatever the cause of this effect I feel that most caregivers are genuinely interested and preoccupied with performing their job well. But I now consider the caregiver phenomena when ever I interview an elderly patient.
......................................................................................................................................................................
By the way thanks to Tracy for this. Even if all my ten readers vote for me it still wouldn't be enough!
The patient didn't look sick. In fact she looked pretty good. She even voiced that she felt OK. The daughter agreed that her mother was looking fine. The only one in the room who seemed in disagreement was the caregiver. The caregiver described how her charge was getting worse and failing to turn the corner. In fact I could almost predict the care giver's responses to my questions before I gave them. Basically for any open ended question there was almost always a negative response suggesting that the patient wasn't doing well.
I have known this caregiver for years. And she does a great job. Very attentive, loving, and hard working. She is present for every cough, and sneeze, and complaint. She works tirelessly long hours. So what gives? Am I and the daughter missing something significant or is the story from the caregiver not exactly accurate? And if it's not accurate then why?
While pondering this question I quickly realized that I encounter this type of behavior regularly. In fact I often find myself going to great lengths to corroborate information given from caregivers. My experience has shown that they often overstate or occasionally exaggerate their charges complaints. In the beginning of my career I took these reports literally and found myself over treating: ordering too many tests and giving too many antibiotics.
I have coined the term the caregiver phenomena to describe this type of behavior. I suspect it stems from two different causes. First, the caregiver who is not medically trained, is often present for every complaint and is afraid that something bad will happen during their watch. They are terrified of missing something significant. Second, I believe the caregiver is often the one who blows the whistle by alerting the family and thus initiates the actions that eventually lead to the doctors visit. Many caregivers feel pressure to justify the visit by making sure the doctor knows the levity of the situation.
Whatever the cause of this effect I feel that most caregivers are genuinely interested and preoccupied with performing their job well. But I now consider the caregiver phenomena when ever I interview an elderly patient.
......................................................................................................................................................................
By the way thanks to Tracy for this. Even if all my ten readers vote for me it still wouldn't be enough!
Sunday, December 14, 2008
Inside The Examining Room
The elderly gentleman limps into the examining room. His 89 years etched into his gait as if each day delivered a small but crippling blow. His callused hand grips mine briefly but with the confidence of experience.
He didn't trust me. At least not in the beginning. I could have spoken his first words before they left his lips....I generally don't like doctors. But pain is a strongly coercive force. He spent the first few visits feeling things out. But over time he learned to confide in me. And as the protective layer of fear and angst were discarded...the humanity came through.
He was having surgery. The orthopaedist had convinced him he needed a new hip. My litany of questions were usual. I left short pauses for him to answer. No chest pain. No shortness of breath. Good exercise tolerance. No tobacco. And alcohol.....I quit years ago!
His answer was unexpected. I pictured him the kind of guy who lived hard...and drank hard. A generalization.....but generalizations got your far in the doctor business. I knew I shouldn't have asked but I couldn't help myself...so why did you quite?
He took a moment to collect his thoughts.
It was the forties. I and a bunch of buddies worked for a company that put up television antennas across southern Illinois. It was the early days. A new technology. I left my wife for months at a time.
We worked all day in the sun during the summer and in the cold in the winter. They were long days. After work there wasn't much to do. We usually left early and went directly to the bar. Often not taking time to eat dinner. And we would drink. Well into the morning. Then get up a few hours later and go back to work.
It was the same thing six days a week. The same fellas. The same bar. The same drinks. I was wasting my life away but I can't say I minded. We didn't know any better. It was just what we did.
So one day I walk into the tavern in a bad mood. It was something insignificant; I can't remember why now. The owner, Charlie, was standing behind the bar in a full hunting suite. He had a brand new expensive rifle. And he was holding up a picture of a ranch. He bought it for his wife and kids.
And there I was eking out this existence. Sharing bunk bends in a dirty motel. My wife and I barley able to afford our apartment. And I was pissing away my money getting drunk. That son of a bitch... I was paying for his four star ranch and his shiny rifle.
So that was it.
That was it?.... I repeated
That was it....never took another god damn drink again!
He didn't trust me. At least not in the beginning. I could have spoken his first words before they left his lips....I generally don't like doctors. But pain is a strongly coercive force. He spent the first few visits feeling things out. But over time he learned to confide in me. And as the protective layer of fear and angst were discarded...the humanity came through.
He was having surgery. The orthopaedist had convinced him he needed a new hip. My litany of questions were usual. I left short pauses for him to answer. No chest pain. No shortness of breath. Good exercise tolerance. No tobacco. And alcohol.....I quit years ago!
His answer was unexpected. I pictured him the kind of guy who lived hard...and drank hard. A generalization.....but generalizations got your far in the doctor business. I knew I shouldn't have asked but I couldn't help myself...so why did you quite?
He took a moment to collect his thoughts.
It was the forties. I and a bunch of buddies worked for a company that put up television antennas across southern Illinois. It was the early days. A new technology. I left my wife for months at a time.
We worked all day in the sun during the summer and in the cold in the winter. They were long days. After work there wasn't much to do. We usually left early and went directly to the bar. Often not taking time to eat dinner. And we would drink. Well into the morning. Then get up a few hours later and go back to work.
It was the same thing six days a week. The same fellas. The same bar. The same drinks. I was wasting my life away but I can't say I minded. We didn't know any better. It was just what we did.
So one day I walk into the tavern in a bad mood. It was something insignificant; I can't remember why now. The owner, Charlie, was standing behind the bar in a full hunting suite. He had a brand new expensive rifle. And he was holding up a picture of a ranch. He bought it for his wife and kids.
And there I was eking out this existence. Sharing bunk bends in a dirty motel. My wife and I barley able to afford our apartment. And I was pissing away my money getting drunk. That son of a bitch... I was paying for his four star ranch and his shiny rifle.
So that was it.
That was it?.... I repeated
That was it....never took another god damn drink again!
Friday, December 12, 2008
In Memorium
My whole life I have been immersed in a world of words. Not just meaning but sounds. The cadence of a sentence. The emotion behind the basic structure. I have surrounded myself with diversity. Often associated with people who don't look like me. I grew up sitting at tables where the language spoken often wasn't my own.
It never bothered me. I would get lost in the rhythm of a foreign tongue. Picking up on the nuances and facial expressions. Missing the exact definitions but understanding the meanings. The better I knew a person the more I could piece together. There was always more in common then not. One had to look for it.
Recently I accompanied my wife and children to a relative's house to mourn the loss one who had recently departed. As we entered the women and children were directed to one location and I was shuffled off with the men to another. The room was solemn. Twenty men gathered dressed in black. Many bearded. I immediately felt a stranger in a strange land. My hand absentmindedly pawed the top of my head were the ritualistic covering was glaringly absent.
I socialized with many of these men a dozen times over the years. Separated by foreign birth and a religious orthodoxy I had never felt much kinship. American born and uninterested in religion I was more like the foreigner.
The conversation started with a deep philosophical discussion of Jewish law and culture. The Rabbi in the center of the room paused between points. Intermixing Hebrew and English. The gentleman sitting next to me noticing my discomfort whispered softly in my ear, "It is only after years of studying Jewish law that you can have such conversations!"
The words took form and shape in front of my eyes. They were no longer English and Hebrew but musical notes dancing through the air. The rise and fall with each pause as the Rabbi spoke. The room moved in unity. Chests filled with air and then exhaled. Release and expand. Release and expand.
Yit'gadal v'yit'kadash sh'mei raba....
The men of the room had now stood and were reciting the Mourner's Kaddish or Jewish Prayer For the Dead. And suddenly I was transported back to childhood. My mother, brothers, and I are in temple. It is my father's yahrtzeit (anniversary of his death). I must be about ten years old. Every year we made the trip to temple on this particular week.
Most days we lived our lives as if nothing happened. But on this day. We came to temple. We remembered. The service always felt unending. Standing up and sitting down. Standing up and sitting down. My brother's and I distracted ourselves the best we could. Making funny faces....playing silly games. Anything to pass the time.
But then the Rabbi would clear his throat and boom from the lectern, "And now let us remember those loved ones who have passed this week...". He then recited the mourners kaddish followed by a list of congregation members who had died. Our ears perk up and we wait to hear my father's name. And then we leave the synagogue shortly thereafter.
I awake from my reverie. the group of men have now finished praying and are chatting comfortably amongst themselves. I long to join my wife and children in the other room. I scan the faces around me. We are so different. For them, religion is their life. For me, my life is my religion. Yet it dawns on me that we share common bonds. Our words may be different but we all experience happiness and pain. We all mourn...
And when wounded we all bleed the same.
It never bothered me. I would get lost in the rhythm of a foreign tongue. Picking up on the nuances and facial expressions. Missing the exact definitions but understanding the meanings. The better I knew a person the more I could piece together. There was always more in common then not. One had to look for it.
Recently I accompanied my wife and children to a relative's house to mourn the loss one who had recently departed. As we entered the women and children were directed to one location and I was shuffled off with the men to another. The room was solemn. Twenty men gathered dressed in black. Many bearded. I immediately felt a stranger in a strange land. My hand absentmindedly pawed the top of my head were the ritualistic covering was glaringly absent.
I socialized with many of these men a dozen times over the years. Separated by foreign birth and a religious orthodoxy I had never felt much kinship. American born and uninterested in religion I was more like the foreigner.
The conversation started with a deep philosophical discussion of Jewish law and culture. The Rabbi in the center of the room paused between points. Intermixing Hebrew and English. The gentleman sitting next to me noticing my discomfort whispered softly in my ear, "It is only after years of studying Jewish law that you can have such conversations!"
The words took form and shape in front of my eyes. They were no longer English and Hebrew but musical notes dancing through the air. The rise and fall with each pause as the Rabbi spoke. The room moved in unity. Chests filled with air and then exhaled. Release and expand. Release and expand.
Yit'gadal v'yit'kadash sh'mei raba....
The men of the room had now stood and were reciting the Mourner's Kaddish or Jewish Prayer For the Dead. And suddenly I was transported back to childhood. My mother, brothers, and I are in temple. It is my father's yahrtzeit (anniversary of his death). I must be about ten years old. Every year we made the trip to temple on this particular week.
Most days we lived our lives as if nothing happened. But on this day. We came to temple. We remembered. The service always felt unending. Standing up and sitting down. Standing up and sitting down. My brother's and I distracted ourselves the best we could. Making funny faces....playing silly games. Anything to pass the time.
But then the Rabbi would clear his throat and boom from the lectern, "And now let us remember those loved ones who have passed this week...". He then recited the mourners kaddish followed by a list of congregation members who had died. Our ears perk up and we wait to hear my father's name. And then we leave the synagogue shortly thereafter.
I awake from my reverie. the group of men have now finished praying and are chatting comfortably amongst themselves. I long to join my wife and children in the other room. I scan the faces around me. We are so different. For them, religion is their life. For me, my life is my religion. Yet it dawns on me that we share common bonds. Our words may be different but we all experience happiness and pain. We all mourn...
And when wounded we all bleed the same.
Tuesday, December 9, 2008
Some Thoughts on Quality
Recently in response to a post (somewhat tongue in cheek) about renaming primary care physicians "prehospitalists" Mathew Mintz commented:
Don't like it. Pre-hospitalist implies that everyone will eventually go to the hospital. Though we certainly do our best to prevent patients from needing hospitalization, this doesn't capture the bulk of what we do: screening, prevention, counselling, chronic disease management,etc.
Mathew's comment really made me think. While he is right....keeping people out of the hospital does not describe the bulk of what we do. He misses the point. Our ability as primary care physicians to cut down on admissions may be the single best indicator of physician quality.
The physician who keeps his patients out of the hospital probably:
Is an excellent diagnostician
Manages chronic disease states well
Is timely
Calls his patients back promptly
Likely is highly active in screening and prevention
Sees urgent appointments on the same day
The list goes on and on. Sure there has to be an adjustment for patient age, socioeconomic status, and overall health of the patient population (a clinician who treats esrd, end stage copd, end stage cad...will have a higher hospitalization rate then others).
But I like hospitalization rate as an overall indicator. It certainly is hard to game this one...unlike the other quality indicators that have been used (a1c, colonoscopies, etc.).
So what do you think?
Don't like it. Pre-hospitalist implies that everyone will eventually go to the hospital. Though we certainly do our best to prevent patients from needing hospitalization, this doesn't capture the bulk of what we do: screening, prevention, counselling, chronic disease management,etc.
Mathew's comment really made me think. While he is right....keeping people out of the hospital does not describe the bulk of what we do. He misses the point. Our ability as primary care physicians to cut down on admissions may be the single best indicator of physician quality.
The physician who keeps his patients out of the hospital probably:
Is an excellent diagnostician
Manages chronic disease states well
Is timely
Calls his patients back promptly
Likely is highly active in screening and prevention
Sees urgent appointments on the same day
The list goes on and on. Sure there has to be an adjustment for patient age, socioeconomic status, and overall health of the patient population (a clinician who treats esrd, end stage copd, end stage cad...will have a higher hospitalization rate then others).
But I like hospitalization rate as an overall indicator. It certainly is hard to game this one...unlike the other quality indicators that have been used (a1c, colonoscopies, etc.).
So what do you think?
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