The Art of Differential Diagnosis.

I awkwardly unscrewed the top off the dishwasher door. The two young women stood above me approvingly. I acted like I knew what to do.

It was a new machine but I already drove out twice in the last six months. Damn latch. I didn't have the heart to tell the girls that I couldn't fix it. Or to explain how, as a child, I avoided the cabinets full of tools that my father left behind when he died. So much material but no capable hands to teach me how the hell to use it.

So I grew up in a mother centered household. We didn't fix things. We called someone.

As I pulled the cover off the door my mind raced back to the office. To the image of the uncoordinated violinist.

She taught music until the economic downturn. Saddled with impatient debt and screaming debtors she started to perform regularly. Until the day she noticed something wrong.

I glanced blankly at the guts of the washing machine door. Gently I eased the latch out of its compartment and glared. Why was it stuck?

My violinist had lost control of her left index finger. Try as she might...she couldn't play the challenging pieces. The finger was lame...dumb. Slowly responding to the music while the others raced ahead obliviously. But the index could no longer keep pace on the finger board.

The latch was being held back by a catch. A safety mechanism perhaps?

I stared into her eyes. Her pupils were reactive. I weaved and bobbed through the neurological exam noting no abnormalities. At last I came to the hand. I compressed each nerve in the wrist carefully and watched for a response. Her pulses were normal. Then I asked her to place both hands on the exam table face up.

I greased the catch with DW40. It still wouldn't release the latch. Finally I removed the spring from the catch and watched it fall to the side. The latch now moved freely.

After concentrating for a few minutes I noticed it. A lump in her left wrist. It was small but placed perfectly to impinge on the long tendon that races through the hand and ends at the tip of the index finger.

I suspected a ganglion cyst. A quick procedure by the hand surgeon and her finger would dance again.

It took another thirty minutes to remember how to fit the latch back in and then screw the top on. I watched with satisfaction as I closed the door.

Flipped the latch...

and started the dishwasher.

The Plan

He came to the office with an idea.

He came to the office with a plan.

Because his mother told him that a cough could be a sign of cancer. And his wife reminded him of his history of smoking. And his cousin's friend's sister's fiance's grandfather had died and his doctor hadn't bothered to get a cat scan.

He refused to entertain questions. He dodged and darted to avoid my probing stethoscope. He asked for...nay demanded a cat scan.

He was unperturbed when his symptoms magically disappeared with an antacid. He was downright sullen when I warned of the risks of radiation....when I cautioned about incidentalomas.

So in Berwickian fashion I gave in. I ordered the cat scan. I waited.

It was a lung nodule. To big to ignore. Reluctantly I offered biopsy.

He wanted to see a pulmonologist. The pulmonologist offered biopsy. He wanted to see a cardiothoracic surgeon. The surgeon offered the same.

After many phone calls and much discussion and great trepidation he entered the radiology suite for a ct guided biopsy.

He left with a chest tube....a short hospital stay....and the most physically painful experience of his life.

On the day of discharge I entered his room with good news.....It's benign

Benign....great. And then he paused a moment. Maybe we should take it out anyway.

I want to see the cardiothoracic surgeon!

A Covenant

I mean it is kind of lonely....being your doctor. I picture it as sort of a covenant. Between you and I.

On one side you. And your family. And friends. Your house and your dogs. Your communities and lives.

On the other side me. Alone. Of course there is always the hospital...but were really not friends. My partners and specialists. They all make an appearance. But when the going gets tough.

I am like an island. That you inhabit from time to time. Occasionally good times. Often bad. And I pray that there is enough of me to sustain. For there are rarely other visitors. Rarely extra provisions.

My island floats independently in the sea. I face each brutality and hardship with you. But since I am land and you are my inhabitants we often see from very different perspectives.

When you hurt, and suffer, and die. You call. And sometimes from the depths of hibernation I answer. My eyes twitching in the darkness as I try to decide whether to give more lasix or should I try fluids? There is no nephrologist in the bed next to me. No cardiologist. And if there were would they remember the time your shortness of breath was anxiety? Remember the time your anxiety was a heart attack?

You pray that I make the right decision. Did you know that I pray to? Pray that tonight I will be less fallible. Pray that I will remember each piece of imminent minutia. Unlock the bodies tenuous riddles and splay them out in front of you as if they were a healing potion. A soothing balm

Each covenant ends the same. Either you or I will die. Your suffering over and your family mourning.

And I will Remain. Alone. Fighting to provide for the other two thousand inhabitants of my island.

Each one a covenant...

Each one signed with a golden quill...

signed in my own blood.

As I walked Into....

As I walked into the store an old memory rushed into the corners of my consciousness.

Mary had a little lamb....little lamb...little lamb

There I sat. A young boy with a recorder on my lips. My fingers dutifully covering and then uncovering the holes on the long end of the instrument. I was in elementary school. It would be the first and last instrument I ever played.

I started strongly. In the beginning. Far ahead of my classmates. Under my mother's tutelage I practiced each and every day. But eventually something happened.

I became bored. Or tired of the monotony. My heart wasn't really in it. The teacher quickly noted the change. My skills faltered. The class moved forward and the turtles passed the hare...

I skipped my only concert.

But now I entered the store on my own volition. A few months earlier Cameron and I had made the same journey. The store clerk sized him up and handed us a violin and bow to try on for size.

Father and son stood together. Tentative at first. Eyes wide to marvel the beautiful instrument that had been placed in his little unsteady hands.

The next week he started lessons. As I sat in the corner of the small study the teacher first instructed Cameron and then turned her attention to me. She gave tips on how to moniter, how to hold the violin, how to angle the bow.

And we learned...Cameron and I. Over months he began to adjust to the weight of the bow, the tension of the strings. I stood over him. I listened to the plink and pluck, the ebb and flow. At times picking up the miniature violin and instructing on what I perceived to be the right stance. I moved the bow back and forth awkwardly my body curled to meet the requirements of such a small instrument.

I found myself looking forward to every evening session. Whistling the tunes as Cameron learned them. My voice straining to the highest E or groaning to the lowest G. A great peace overcame me.

So it was really not very surprising this afternoon when I pulled over upon passing the store on my way home from work. The clerk greeted me energetically.

Are you picking something up for your son?

No! I answered without hesitation...

I was hoping to rent one for myself.

The Floor Is Yours

A few years ago my post on physician extenders and their role in medicine got quite a few comments. Most of them from angry nurse practitioners and physician assistants who didn't agree and took particular glee in noting my spelling errors.

The truth is my feelings have somewhat changed. I guess it's all about percentages. Both the top and the bottom five percent of primary care practitioners, from a quality perspective, are probably MDs. Most physician extenders, as well as physicians, fall somewhere inbetween.

I guess my problem is that I expect all MDs to be part of that top five percent (and strive myself to reach that goal). But that's not reality.

My expectations in the past were so high that I was very unaccepting of those who tried to practice the same medicine but with less training.

However, as I get older and encounter our medical system as a patient, family member, and even consumer I realize that many MDs don't live up to my (unrealistic?) hopes.

So I give up.

A message to all nurse practitioners and physician assistants....

You want to practice primary care without overview?

You want my job?

Go for it...the floor is yours.

But one question still remains.

Why ever would you want to do something so hard....so all consuming... and so frustrating...with less training and for less money?

Something People Do Every Day

The recycling container was already full. But I had two more bags to stow before lugging the bin through the gate and into the front yard for pick up. My button down shirt untidy and bulging out from the waist. My long khaki pants felt like a fur coat in the ninety plus Chicago humidity. It was 4pm and I had just arrived home from work, dropped my computer in the doorway, gathered up the last bit of recycling, and headed for the door.

As I struggled to force the trash into the container my pager began to vibrate. I pulled the bin to the stairs and sat down on the steps. I fumbled with my phone and awkwardly punched in the numbers on the display. The sweat formed on my forehead and slowly waltzed down my face.

I recognized the number. An eighty year old woman with end stage lung cancer. Her care had been overseen by hospice for the last few weeks. But we still talked from time to time. And when she became too sick to talk her daughter would call.

The end was near. Her family huddled around her bedside and waited for her last breath. The inevitable conclusion to eighty years of constant motion.

Now her daughter was on the phone crying. Her mother had just passed. And we talked. The serenity and calm of my backyard a contrast to the turmoil of the conversation.

I concentrated to distill all that I had learned about death. All that I knew as an internal medicine physician who takes care of the aged and dying. How it always hurts to lose a parent. Even if you are expecting it. How when your second parent dies you feel lost....alone...disconnected. How the terrible pain will eventually abate. How one day the memories will make you smile instead of hurt.

But all that wouldn't help now. So instead I told her that I was sorry. That it was both a pleasure and honor to take care of her mother. And that If there was anything I could do.....she should call.

Then I hung up. Slipped the phone back into my pocket. Stood. Grabbed the trash bin and struggled toward the gate.

And continued on with my day....as if this wasn't out of the ordinary...

as if this was something....

people do every day.

I Would Not Be a Doctor Today

Out of the corner of my eye I glimpsed something familiar. The unmistakable dance of syncope. An effortless falling. A surrender to gravity. Her body arched as her young companion lunged forward. Supporting her from behind he gently walked/carried her to the cabana.

And I watched from my chair at the pool. I reached reflexively for the stethoscope around my neck but then realized it was thousands of miles away. My children played at my feet. My quiet vacation in Mexico interrupted by my identity....my profession. My mind spinning, calculating...should I intercede?

The women was now laying face down in the cabana with her head hanging over the side. A bucket had been propped under her mouth. Her young companion sat next to her and stroked her graying hair. An older gentleman approached. They laughed and chided without worry. They shared a passing resemblance. Father and son?

A man in a life guard uniform approached with walkie talkie flapping in front of his face. He was met by two security guards who hoisted the woman and carried her agilely toward an adjacent building. The companions continued a heated converstaion as if nothing had happened.

I turned to my wife whose head was buried in a book.

"Did you see that?"

"See what?"

My children entered the shallow end of the pool. I lifted the Corona to my mouth and took another swig.

It was 10am on a Monday morning.

I pulled my hat over my eyes and reclined like the rest of the tourists sitting poolside...oblivious.

For the first time in years I felt permission to relax...

I would not be a doctor today.