Our relationship was difficult. I dare say strained at times.
I internally gasped as I listened to my own words as if they had come out of someone else's mouth. The walls closed in on the little office as the three men lingered by the door. They each appraised me differently. The oldest nodded his head in agreement while the middle stared at me blankly. The youngest twisted his mouth in a scornful grin.
There was no doubt about the elephant in the room. They wanted to know why their mother suffered six months before dying. Why the pain and weight loss could only be attributed to cancer in the last moments of life.
I had no clear explanations for why I, the oncologist, and the pulmonologist couldn't make a proper diagnosis. It mattered little that her emphysema was severe or that her heart was already failing. It calmed few nerves to assure that even if the cancer had been diagnosed she wouldn't have tolerated surgery or chemotherapy.
I can see the youngest squirm
But she said you were always rushing out of the room. That you never had time for her.
And she was right. She was the kind of patient who needed everything done in triplicate. She would pick apart each sentence. Forty five minutes later she would look up and accuse you of not explaining and want to start over again.
Most of her doctors had thrown their arms up in the air and given up. They abandoned her when the appointments began to prolapse into their other commitments.
Yes. At times your mother's needs were overwhelming and I'm sure she felt like I was rushing.
I wasn't going to hide the truth. I wasn't going sugar coat.
I handed over a copy of the medical records without being prompted. I urged them to take a close look. Talk it over with family and call me back with questions.
They slowly filed out of my office, the youngest clinging to the stack of papers.
I never saw or heard from them again.
I would love to end this blog post with something pithy or profound like my others. I would love to say that some greater truth evolved that brought peace to the family or made me a better physician.
But I would be telling a lie. The doctor patient relationship can be difficult and complicated. Each side comes to the table with inherent biases and personality disorders.
Sometimes it works and sometimes it doesn't.
It ain't always a bed of roses.
Friday, September 23, 2011
Thursday, September 22, 2011
A Love Letter To My Patients
If I can explain it will you understand?
Will you understand the wave and roll of the belly upon waking every morning of residency. The overwhelming nausea not caused by anxiety or fear (both of which are present)but by lack of sleep accumulated over months.
Or the shear panic of getting up after an hour of rest to an incomprehensible day chocked full of lectures, rounding, and an overwhelming amount of patient care to deliver. And realizing that returning home will only occur in twelve hours after each task is completed.
Will you understand a training that stresses pushiness, impatience, and bullying to such an extent that softness and empathy turn from a golden star to an Achilles heal. How one learns to yell, scream, and shake fists as a matter of course. As if these are things that normal people do in normal professions.
Until the outer skin becomes so tough and protective that not only can't sadness and pain get in but love and joy can't escape out. And a spouse sitting across the table watching as words sputter and a head bobs forward in mid sentence, wonders if it is worth it.
Would you understand the distant look as you describe the pain from your fracture, your migraine, or your gout. The mind cluttered and reeling from the last patient who was told that she was dying as her husband groaned and sobbed by her side. The brain numb from a torrent of paper, and forms, and phone calls accumulating on the desk in the adjacent office.
Has anyone ever told you that physicians are skilled at building barriers? On bad days we carry a mortar and trawl.
Can you see that I am trying to carry a sledge hammer here?
Will you understand the wave and roll of the belly upon waking every morning of residency. The overwhelming nausea not caused by anxiety or fear (both of which are present)but by lack of sleep accumulated over months.
Or the shear panic of getting up after an hour of rest to an incomprehensible day chocked full of lectures, rounding, and an overwhelming amount of patient care to deliver. And realizing that returning home will only occur in twelve hours after each task is completed.
Will you understand a training that stresses pushiness, impatience, and bullying to such an extent that softness and empathy turn from a golden star to an Achilles heal. How one learns to yell, scream, and shake fists as a matter of course. As if these are things that normal people do in normal professions.
Until the outer skin becomes so tough and protective that not only can't sadness and pain get in but love and joy can't escape out. And a spouse sitting across the table watching as words sputter and a head bobs forward in mid sentence, wonders if it is worth it.
Would you understand the distant look as you describe the pain from your fracture, your migraine, or your gout. The mind cluttered and reeling from the last patient who was told that she was dying as her husband groaned and sobbed by her side. The brain numb from a torrent of paper, and forms, and phone calls accumulating on the desk in the adjacent office.
Has anyone ever told you that physicians are skilled at building barriers? On bad days we carry a mortar and trawl.
Can you see that I am trying to carry a sledge hammer here?
Wednesday, September 21, 2011
Landscaping
I sat dejectedly at the nurses station with my head buried in a chart to hide my tears. I felt a hand on my shoulder but didn't look up.
If you practice long enough, Jordan, there will be a small graveyard with your name on it.
I recognized the voice as that of a veteran cardiologist I often worked with.
We never spoke of this again.
*
It took a moment to integrate the melancholy of the words coming from the pretty young woman who sat on my examining table. Her face was bright and expressive. She neither smiled nor grinned. She spoke evenly without hesitation or stutter.
She recounted the events that changed her life. The morning she, a careless twenty year old, got into her car to drive to school. She would return home a drastically different person.
Of course she hadn't meant any harm. She would never hurt another human being...at least on purpose. Her parents had warned her about drinking and driving. No one ever told her, however, of the dangers of cell phones. After all, she could text with her eyes closed.
She never forgot the feeling of the body as it bounced against her car. The blood that soaked her shoes as she jumped out to investigate. Or the look of the poor child's parents in court.
These are the kind of things that stay with you.
*
I was fascinated as she continued with her story. I felt not only great sympathy but a strange sense of camaraderie.
After the accident she took stock of her life. She neither granted forgiveness nor wallowed in self pity. But she did change just about everything.
A few years later she was a national spokesperson. She lectured around the country. The loss of one life ignited the courage to save countless others. A young self absorbed child had now become a world citizen.
She transformed her graveyard with its single inhabitant into a lively garden.
*
As she left I paused momentarily in the examining room. I could hear the phone ringing. The secretary chatted amiably as new patients checked in. The medical assistants scurried back and forth between hallways.
I contemplated that little place carefully buried in the deepest recesses of my soul. How many headstones had accumulated with names that long ago had become unreadable.
Maybe it's time to face my demons.
Maybe it's time for me to do a little landscaping.
If you practice long enough, Jordan, there will be a small graveyard with your name on it.
I recognized the voice as that of a veteran cardiologist I often worked with.
We never spoke of this again.
*
It took a moment to integrate the melancholy of the words coming from the pretty young woman who sat on my examining table. Her face was bright and expressive. She neither smiled nor grinned. She spoke evenly without hesitation or stutter.
She recounted the events that changed her life. The morning she, a careless twenty year old, got into her car to drive to school. She would return home a drastically different person.
Of course she hadn't meant any harm. She would never hurt another human being...at least on purpose. Her parents had warned her about drinking and driving. No one ever told her, however, of the dangers of cell phones. After all, she could text with her eyes closed.
She never forgot the feeling of the body as it bounced against her car. The blood that soaked her shoes as she jumped out to investigate. Or the look of the poor child's parents in court.
These are the kind of things that stay with you.
*
I was fascinated as she continued with her story. I felt not only great sympathy but a strange sense of camaraderie.
After the accident she took stock of her life. She neither granted forgiveness nor wallowed in self pity. But she did change just about everything.
A few years later she was a national spokesperson. She lectured around the country. The loss of one life ignited the courage to save countless others. A young self absorbed child had now become a world citizen.
She transformed her graveyard with its single inhabitant into a lively garden.
*
As she left I paused momentarily in the examining room. I could hear the phone ringing. The secretary chatted amiably as new patients checked in. The medical assistants scurried back and forth between hallways.
I contemplated that little place carefully buried in the deepest recesses of my soul. How many headstones had accumulated with names that long ago had become unreadable.
Maybe it's time to face my demons.
Maybe it's time for me to do a little landscaping.
Tuesday, September 20, 2011
Why Social Media?
The voice on other other end of the phone shook with volume and power. I could envision her fists shaking, her brow sweating, and her eyes bulging as if I was watching a bad reality show on TV. She was not just insinuating. She was outright accusing me of doctoring her medical record for my own personal gain.
I calmly listened to her fowl mouthed diatribe and waited for a moment to interrupt as she caught her breath. Should I tell her it was a hard day in the office? Explain that a patient was dying in the hospital? Would she have understood that I was just trying to follow government mandates and had been distracted by my first attempt at eprescribe?
So Yes...I did miss that my front desk employee had placed the wrong chart on my schedule. The names were so close. And I asked about her insurance status not to profile her but to decide whether to use eprescrbe or not.
In my heart I realized that she didn't want explanations. She was convinced that I was trying to harm her and I wasn't going to change her mind. It didn't matter that I correctly diagnosed her with pneumonia. She, in fact, got her antibiotic a few hours late but was feeling perfectly well now. But none of that mattered.
The truth is as physicians we are suffering from poor PR. Between the loss o faith from To Err is Human and the political wrangling of the PPACA we have gone from knights to knaves.
In the public eye the empathic physician has been replaced by the miserly clod who clumsily dances through doctoring in order to drive home in his BMW and trade stocks online.
We are looked at as greedy. We spend to much. We order too many tests. We make to many errors.
If those darn doctors would just do what they were trained to do!
Many physicians who struggle on the front lines see a very different picture. We are consumed by our career. We fight for our patent's well being as if they were family members. And we get burned over and over again by the oversimplification purveyed by catchy headlines and enthusiastic politicians.
In order to reverse the egregious harm done to our profession we have but one choice. We have to take our fight to the people.
Why do I use social media? I see it as a profound and effective way to communicate to our patients who we are. To re brand us back to the knights we strive to be.
Only then will they know our commitment. Only then will they have a window into our souls. Only then will they know that although we may not be lying with them on the operating table.....
we still bleed.
I calmly listened to her fowl mouthed diatribe and waited for a moment to interrupt as she caught her breath. Should I tell her it was a hard day in the office? Explain that a patient was dying in the hospital? Would she have understood that I was just trying to follow government mandates and had been distracted by my first attempt at eprescribe?
So Yes...I did miss that my front desk employee had placed the wrong chart on my schedule. The names were so close. And I asked about her insurance status not to profile her but to decide whether to use eprescrbe or not.
In my heart I realized that she didn't want explanations. She was convinced that I was trying to harm her and I wasn't going to change her mind. It didn't matter that I correctly diagnosed her with pneumonia. She, in fact, got her antibiotic a few hours late but was feeling perfectly well now. But none of that mattered.
The truth is as physicians we are suffering from poor PR. Between the loss o faith from To Err is Human and the political wrangling of the PPACA we have gone from knights to knaves.
In the public eye the empathic physician has been replaced by the miserly clod who clumsily dances through doctoring in order to drive home in his BMW and trade stocks online.
We are looked at as greedy. We spend to much. We order too many tests. We make to many errors.
If those darn doctors would just do what they were trained to do!
Many physicians who struggle on the front lines see a very different picture. We are consumed by our career. We fight for our patent's well being as if they were family members. And we get burned over and over again by the oversimplification purveyed by catchy headlines and enthusiastic politicians.
In order to reverse the egregious harm done to our profession we have but one choice. We have to take our fight to the people.
Why do I use social media? I see it as a profound and effective way to communicate to our patients who we are. To re brand us back to the knights we strive to be.
Only then will they know our commitment. Only then will they have a window into our souls. Only then will they know that although we may not be lying with them on the operating table.....
we still bleed.
Sunday, September 18, 2011
What Do You Want?
I sat uneasily staring at the young man sitting across from me. He winced and painstakingly adjusted in his seat to find a comfortable position. His face gray and withered had taken on the look of the nursing home surrounding us. Drabness pervaded.
At thirty eight he was much too young to be incarcerated in such a manner. He was a victim of biology's cruel misfortune. He had usurped the privileges of age prematurely. He was dying of cancer.
His legs were paralyzed since undergoing surgery to remove tumor from his spine. His lungs, stifled by nodules, gurgled and sputtered with every breath. His hands clenched with each movement. The pain was debilitating.
His doctor discharged him from the hospital with instructions to get stronger. A few weeks of therapy and you'll be ready for your next round of chemo...your next back surgery.
I listened to his explanations and begrudgingly hid the doubt and disgust that percolated through my brain. What kind of physician encourages his dying patient to waste his last hours of life doing physical therapy?
I focused my thoughts for a moment. If I impose my will on him am I any better then the doctor who exhorted physical therapy? Could I recommend hospice with a clear conscience?
So what do you think of all this?
As I waited I searched him for direction. He paused. He closed his eyes and took a deep breath. A tear formed and rolled down his cheek.
I think I'm dying!
I reached over to the desk and handed him a tissue. I thought of my wife and children. How would I handle his situation? Would I except the harshness of reality or would I fight impossible odds?
What do you want?
His eyes, which had been focusing on the floor, shot up to meet mine.
I want this to be over. I want to be out of pain.
His face brightened. The grayness disappeared and he smiled and started to laugh. I asked what was so amusing.
What I want?
No one has ever asked me that before!
At thirty eight he was much too young to be incarcerated in such a manner. He was a victim of biology's cruel misfortune. He had usurped the privileges of age prematurely. He was dying of cancer.
His legs were paralyzed since undergoing surgery to remove tumor from his spine. His lungs, stifled by nodules, gurgled and sputtered with every breath. His hands clenched with each movement. The pain was debilitating.
His doctor discharged him from the hospital with instructions to get stronger. A few weeks of therapy and you'll be ready for your next round of chemo...your next back surgery.
I listened to his explanations and begrudgingly hid the doubt and disgust that percolated through my brain. What kind of physician encourages his dying patient to waste his last hours of life doing physical therapy?
I focused my thoughts for a moment. If I impose my will on him am I any better then the doctor who exhorted physical therapy? Could I recommend hospice with a clear conscience?
So what do you think of all this?
As I waited I searched him for direction. He paused. He closed his eyes and took a deep breath. A tear formed and rolled down his cheek.
I think I'm dying!
I reached over to the desk and handed him a tissue. I thought of my wife and children. How would I handle his situation? Would I except the harshness of reality or would I fight impossible odds?
What do you want?
His eyes, which had been focusing on the floor, shot up to meet mine.
I want this to be over. I want to be out of pain.
His face brightened. The grayness disappeared and he smiled and started to laugh. I asked what was so amusing.
What I want?
No one has ever asked me that before!
Saturday, September 17, 2011
The Kind Of Doctor Who Takes Care Of Colds
It was my favorite kind of gathering. The room was filled with young attractive non medical people. Most carried a cocktail effortlessly as they stood in their best Friday night apparel. The tempo of the conversations rose and fell.
I caught a glimpse of my wife standing across the room with a small group of friends. I watched her hand gestures and the shift in her posture. I had just enough alcohol to amuse myself by conjuring up mock details of their conversation. Boy Sally I love that purse but those shoes are just dreadful!
I cradled a Corona in my right hand as a distant acquaintance wandered forward in my direction. He was well dressed. A business type if I remembered correctly. He was a friend of a friend.
We chatted amiably for a few moments. Quickly running through our list of polite conversational topics before a look of excitement flashed across his face. Hey...your a doctor right? What do you practice?
I felt a twinge of disappointment and embarrassment. I really didn't like talking about my profession in public. I paused for a moment and then explained that I am an Internist.
An Internist? Like a primary care doctor? The kind of doctor who takes care of colds right?
I probably would have taken offense to his comment if his words hadn't transported me back to the struggles of the last week. My eyes glazed over.
I signed four death certificates last week. Each patient was in hospice. One in the hospital. One at home, and two in a hospice unit. Three I had known for years. The fourth was a young man who I just met. I spent hours counseling each one of them.
I admitted ten people to the hospital. Some got better. Some got worse. A few ended up in the ICU.
I was on call half the week and hadn't slept most of those nights. I returned each morning dutifully to see patients in clinic. I struggled as always to sort out the bio-psycho-social causes of illness. I diagnosed a case or two of gout. Saw a patient with erythema chronica migrans whose Lyme titers were markedly positive. I told a young woman she has cancer.
I worried. I paced. I stressed. I ignored my children nagging at my feet as I returned the deluge of phone calls from the nursing home.
I held hands. I teared up several times. And I laughed...in the hospital, in the exam room, at home. I laughed even when sometimes I felt like I wanted to cry.
I woke up from my haze to see that my companion was now waving his hand in front of my face. For a moment I focused on him before I purposefully walked in the direction of my wife.
Yes. The kind of doctor who takes care of colds.
I caught a glimpse of my wife standing across the room with a small group of friends. I watched her hand gestures and the shift in her posture. I had just enough alcohol to amuse myself by conjuring up mock details of their conversation. Boy Sally I love that purse but those shoes are just dreadful!
I cradled a Corona in my right hand as a distant acquaintance wandered forward in my direction. He was well dressed. A business type if I remembered correctly. He was a friend of a friend.
We chatted amiably for a few moments. Quickly running through our list of polite conversational topics before a look of excitement flashed across his face. Hey...your a doctor right? What do you practice?
I felt a twinge of disappointment and embarrassment. I really didn't like talking about my profession in public. I paused for a moment and then explained that I am an Internist.
An Internist? Like a primary care doctor? The kind of doctor who takes care of colds right?
I probably would have taken offense to his comment if his words hadn't transported me back to the struggles of the last week. My eyes glazed over.
I signed four death certificates last week. Each patient was in hospice. One in the hospital. One at home, and two in a hospice unit. Three I had known for years. The fourth was a young man who I just met. I spent hours counseling each one of them.
I admitted ten people to the hospital. Some got better. Some got worse. A few ended up in the ICU.
I was on call half the week and hadn't slept most of those nights. I returned each morning dutifully to see patients in clinic. I struggled as always to sort out the bio-psycho-social causes of illness. I diagnosed a case or two of gout. Saw a patient with erythema chronica migrans whose Lyme titers were markedly positive. I told a young woman she has cancer.
I worried. I paced. I stressed. I ignored my children nagging at my feet as I returned the deluge of phone calls from the nursing home.
I held hands. I teared up several times. And I laughed...in the hospital, in the exam room, at home. I laughed even when sometimes I felt like I wanted to cry.
I woke up from my haze to see that my companion was now waving his hand in front of my face. For a moment I focused on him before I purposefully walked in the direction of my wife.
Yes. The kind of doctor who takes care of colds.
Friday, September 16, 2011
For Safe Keeping
He skated into my room with his hair disheveled and his hands waving wildly. For a moment I thought he was Kramer from an old a Seinfeld episode. His lips moved erratically as he gasped for breath.
Doc...doc you got a help me!
I motioned him into a chair. As his backside was about to touch the seat he bolted upright. He stood with one arm resting on his hip and the other holding him steady against the desk. His eyes squinted in pain. A drop of sweat formed at his hairline.
What happened to you?
As I asked his face turned from pain to humiliation. His voice lowered and he strained to lean closer. He looked up at the door cautiously to make sure that it was closed.
Doc I got a chicken bone!
He must of recognized the confusion in my facial expression because his eyebrows furrowed in frustration. He looked like a poor school teacher forced to explain yet again to his substandard students the difference between a noun and a verb.
Jeeeeeez, I got a chicken bone stuck up my ass.
I almost fell off my chair. I turned my head and bit my lip. Anything to avoid breaking into peels of laughter.
Upon regaining composure I turned back toward him again.
Surely your wrong! A hemorrhoid? An abscess? Some left over toilet paper?
He was losing patience quickly. He gritted his teeth in a last effort to control his emotions.
I know what I know. Last night I ate chicken and this morning I got a chicken bone stuck up my ass. Are you going to take it out or what?
With that he dropped his pants, turned around, and leaned forward against the exam table. I cleared my throat and took a step backwards.
Um...Um....I better get some gloves for this one.
I adjusted the exam light over his behind and pulled my stool closer to take a peak. Apparently he enjoyed the warmth because he moved his torso from side to side in mock pleasure.
And there it was. A minuscule shaft of pearly bone with a forking arm wedged perfectly in his rectum. With forceps in hand I gently coaxed the obstruction free. I could hear the sigh of relief escape form the other side of of my precariously perched patient.
I laid the product of my excavation indignantly on the tray and turned to leave the exam room.
No more chicken for you I called over my shoulder as I gathered my computer and raced toward the door. Out of the corner of my eye I could see him grab a tissue and grasp the bone between two fingers.
He then put it into his pocket...
for safe keeping.
Doc...doc you got a help me!
I motioned him into a chair. As his backside was about to touch the seat he bolted upright. He stood with one arm resting on his hip and the other holding him steady against the desk. His eyes squinted in pain. A drop of sweat formed at his hairline.
What happened to you?
As I asked his face turned from pain to humiliation. His voice lowered and he strained to lean closer. He looked up at the door cautiously to make sure that it was closed.
Doc I got a chicken bone!
He must of recognized the confusion in my facial expression because his eyebrows furrowed in frustration. He looked like a poor school teacher forced to explain yet again to his substandard students the difference between a noun and a verb.
Jeeeeeez, I got a chicken bone stuck up my ass.
I almost fell off my chair. I turned my head and bit my lip. Anything to avoid breaking into peels of laughter.
Upon regaining composure I turned back toward him again.
Surely your wrong! A hemorrhoid? An abscess? Some left over toilet paper?
He was losing patience quickly. He gritted his teeth in a last effort to control his emotions.
I know what I know. Last night I ate chicken and this morning I got a chicken bone stuck up my ass. Are you going to take it out or what?
With that he dropped his pants, turned around, and leaned forward against the exam table. I cleared my throat and took a step backwards.
Um...Um....I better get some gloves for this one.
I adjusted the exam light over his behind and pulled my stool closer to take a peak. Apparently he enjoyed the warmth because he moved his torso from side to side in mock pleasure.
And there it was. A minuscule shaft of pearly bone with a forking arm wedged perfectly in his rectum. With forceps in hand I gently coaxed the obstruction free. I could hear the sigh of relief escape form the other side of of my precariously perched patient.
I laid the product of my excavation indignantly on the tray and turned to leave the exam room.
No more chicken for you I called over my shoulder as I gathered my computer and raced toward the door. Out of the corner of my eye I could see him grab a tissue and grasp the bone between two fingers.
He then put it into his pocket...
for safe keeping.
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