I Was Still The Apprentice

Dr. G was like the Jedi master of our residency program. He was board certified in multiple specialities. But it wasn't the training that set him apart. He was just brilliant. An educator at heart. No nonsense. He told you how it was and he was right most of the time.

The residents actively searched for cases to stump Dr. G. We connived to present to him at case conference, something he had never seen before. But mostly we sat back and enjoyed watching the mind of a master clinician at work.

He taught us lessons about being a physician. He hammered us on deductive reasoning. I can still here his raspy voice scolding me in the exam room when I'm struggling to put the pieces together:

Be the detective.

*

While Dr. G could expound on almost any topic, he was known as an expert in one disease in particular: Hereditary Hemorrhagic Telangectasia (HHT). An autosomal dominant disease, HHT was widely recognized among our residents. Patients came from far and wide to see Dr. G in his clinic. By the time I finished training, I treated at least ten patients with this rare problem.

Although years later my mind is fuzzy on the details, every time I see a person with chronic nose bleeds I think of HHT. Often when I hear hoof beats I think of this zebra.

*

I watched in the ER as my patient rolled back from xray. She was thirty five years old and plagued by anemia. She had been admitted to the hospital five times over the last decade for transfusions. She showed up at our door when fatigue and shortness of breath had become unbearable.

The laboratory values confirmed it. She lost quite a bit of blood. Given her good pressure and pulse rate it was likely that this occurred over several months. I introduced myself and started to question her.

As the details unfolded I became excited. Apparently she had nose bleeds since childhood. There was no other cause of blood loss. I examined her. When she opened her mouth I saw a few small red dots on her tongue. Telangectasias! The hallmark of HHT.

As I explained the diagnosis, I informed her that I knew one of the world's experts on this disease. We would transfuse her blood. Have her see an ENT to help with the nose bleeds. If she was willing to travel the few hours to St. Louis, she could even see Dr. G. himself.

*

As the phone rang I felt like I was in residency again. I was calling Dr. G to tell him about another patient. Could I stump him?

After exchanging pleasantries, I informed him that this was not a social call. I had a patient to discuss. I was about to begin with the details when he interrupted me.

What's the patients name?

I stammered. Epi...Mrs Epi Staxis

He laughed a deep belly laugh. I felt small. Like I was a student again.

Another HHT case!

I was taken by surprise.

How...how did you know?

He paused. Well I take care of at least ten different people from the Staxis family! Didn't she tell you she comes from St. Louis?

I felt a growing sense of embarrassment. Dr. G. made the diagnosis without even hearing a single detail of the patient presentation. He was still the Jedi Master. I was still the apprentice.

Didn't we teach you anything hear in St. Louis?

You gotta take a thorough Family History!

What The Undertaker Said

I bolted upright with the sound of the alarm. The first thing I noticed was intense jaw and head pain. My wife sleepily looked up at me.

You were grinding your teeth again last night.

Thirty minutes later I was in the car half way to the hospital. I rubbed my jaw with one hand as I steered with the other. Damn TMJ. It had come back recently as my stress levels increased. One of the physicians left our practice, and my partner and I had to pick up the slack.

I was on call every other day. Every other weekend. The nursing homes were packed and the phone kept ringing. Not to mention that I had taken on other administrative responsibilities and a few speaking engagements.

And of course my son and daughter were getting older. Each day filled with a new activity for me to supervise. Violin practice, homework, dance class. For the first time I felt truly overloaded.

*

I'm not afraid of death.

The gentleman sat on my exam table with a jovial smile. He was strangely at ease in the doctor's office. I suspect this was due to his fifty years as a funeral director. When you spend so much time among the recently deceased, the specter of illness is less a demon and more an old friend.

He liked to take the last appointment before lunch. Countless times he watched as I raced out of the office to go to the nursing home. He would show up early to give me a little extra time. He was all to aware of my tight schedule.

As I finished my exam, I typed the last few sentences into the emr. I would have just enough time to avoid construction and breeze into my noon lecture. After that, I would visit nursing home patients and then rush home to make dinner, feed the kids, and take my son to violin.

I vaguely listened as he started to tell a story. At the funeral home he had an employee who was always bugging him for a promotion. The employee did a good job but was exceedingly slow. So slow, in fact, that he usually had to stay late into the night to finish his daily responsibilities.

That guy just needs to speed up!

I listened to his exclamation as I tried to nonchalantly look at the clock on the wall behind him. If I left immediately, I could make it in time.

He noticed my glance. Unexpectedly he placed his hand on my shoulder and looked me dead in the eyes.

And you, you kid have to slow down!

I paused. It's not everyday that the undertaker offers unsolicited advice.

But even now, as I quickly put the final flourishes on this blog post before facing the onslaught of patients in my waiting room, I wonder.

Will I listen?

Why I Moved To Private Practice

Chief of Medicine
Evanston Hospital
October 23, 2005


To whom it may concern,

I would like to take a moment to express my deep displeasure with one of the interactions I had with a physician in the Church Street location. I use the term "interaction" loosely since the doctor in question, Dr. Jordan, never actually saw me. Apparently he was too busy.

Last Thursday I was shopping in downtown Evanston when I felt the sudden onset of severe abdominal cramps. I ran into the nearest restaurant and spent the next thirty minutes on the toilet. After finishing I felt much better and packed up to leave. As I exited the restaurant, I noticed your clinic across the street.

Thinking that this was my lucky day, I entered the waiting room and asked for an appointment. Since this was my first time in the office, I was asked to fill out numerous forms. A few minutes later a nurse brought me back to an exam room.

She asked a lot of questions about my diarrhea and abdominal pain and then examined me. She then left the room for a few minutes. When she returned she explained that Dr. Jordan was the only doctor in the office and currently seeing other patients. The nurse made up some excuse about another doctor calling in sick. He could see me but it would have to be at the end of the day.

My jaw dropped. That would be like four hours later. Why couldn't I see him immediately? The nurse explained that she had evaluated me and my vitals signs were stable. She said my abdominal exam was normal. She then tried to shoo me away by saying that most diarrhea is self limited.

By now I was quite angry. I demanded that the nurse at least give me an antibiotic before I left. I could be dead by the the end of the day. The nurse left the room yet again and returned a few minutes later. Apparently Dr. Jordan felt that antibiotics are not usually indicated for most forms of diarrhea and he would prefer to examine me himself before he made that decision.

I stormed out of the clinic with my mind made up never to return to one of your facilities again. When I got home I took some amoxicillin which was left over from my root canal. I felt better within minutes.

I am lucky I had the antibiotic in the cabinet or I could have become very sick. I believe Dr. Jordan is a horrible physician and he brings down the quality of care that you are trying to provide. I hope you work to correct his attitude!

Sincerely,

Disappointed Customer


Written in neat cursive on the side of the letter was a note from an administrator:

Dr. Grumet. Can you please call this patient and apologize. We definitely handled this one wrong.

My First Patient

It didn't really happen in the beginning. The atmosphere of awe and mystery was too great. In fact we barely spoke a word those first few sessions. Half the class was buried behind their books while a few students clutched at their scalpels wildly. I made a point of being the first to place blade against cold leathery skin.

As time passed, however, familiarity cut through the tension much like our scalpels. The air of humility was replaced by the buzz of students busily working through their lessons. The quietness was interrupted by voices: some laughing, some arguing, and others carrying on everyday conversations.

*

The inappropriateness was subtle. One day it would be a classmate holding a dismembered limb up to his own body. Or occasionally a group of students would gather around a tank to stare or snicker at a particular body part.

although, on the outside, we each had come to terms with the gruesome act of dissecting the human body, a process of internal hardening had begun.

I disdained my classmates for their lack of taste. I cowered in the corner with the dissector pretending not to notice. Ever dour, I was building my own walls of protectionism but I chose a slightly less infantile route. I abandoned the scalpel and retreated behind the anatomy primer. I would direct the dissection from afar. My hands would not get dirty.

*

There were days in the anatomy lab that seemed to last forever. The students developed back and shoulder pain as they huddled over their tanks. Their were a number of finger sticks. We all carried our scars.

The physical discomfort paled in comparison to the emotional. We didn't like to talk about it. But sometimes, in the middle of a session, the whole mood of the room would change. We sat helplessly as the whirr of the bone saw cut into our cadavers pelvis. The fetid smell of singed bone filled our nostrils and we wanted to vomit.

We carefully dissected the genitals in pure silence. For some, it was the idea of physical discomfort that made them wince. For others, it was the total obliteration of all semblance of privacy. There is a certain amount of human dignity that we expect, even for the dead.

*

My hardest day in the lab came towards the end. As we entered the room, we were confronted with the most human of body parts...the face. I found myself handing the dissector to my tank mate and grabbing a scalpel. It was my first foray into cutting since early in the semester.

As I started to peal layers of skin, I thought about the lady whose body laid below my fingers. I knew so few details. Just some demographics.

As I came to the cheek muscles I wondered how they contracted to form a smile when her grandchild walk into the room. Or how here eyes, now dead and distant, would shine when she was happy. How her tear ducts would create moisture when she was sad.

As the hours passed my neck grew stiff. My joints grew tired. A tank mate had offered to take over but I resisted. I couldn't bare the idea of someone else doing such a horrific and personal task. Certainly not one of those who had previously made fun of the cadavers.

As I finished the dissection my nose began to run underneath my mask. My eyes were tearing. I excused my self and ran to the bathroom

By the time I returned the tanks were closed and the room was empty.

*

She was my first patient.

I tried to give her in death that which I couldn't provide in life. I attended to her with the sanctity and dignity necessary for such an intimate task. To me she was a person, not just a bundle of bones and tissue.

I left the gross anatomy lab that day with a promise.

I protected my patient in death.

For each person who walked through my exam room doors in the future, I would work equally hard...

to protect them in life.

Are You Listening?

I did what all good interns would do in the same situation. I rolled my eyes in the direction of the ER resident and waited for his response.

You have to be the sieve....the sieve.

We all did it. Stonewalled the ER in hopes that they would send our new admission packing. It rarely happened though. Somehow each admission always made it up to the floor. There was no turning back once the papers were filed and the bed was assigned.

Scottie was no different. His twenty year old body was fit and lean. His chest moved up and down in a rapid rhythm. I took my time examining him. As we talked his respiratory rate slowed. I placed my stethoscope on his chest. Maybe a few wheezing sounds but I had my suspicions that they came from his neck and not his lungs.

The paperwork classified him as an admission for asthma and bronchitis. My resident and I were doubtful. Scottie wanted, not needed, to be in the hospital. We just couldn't figure out why.

*

I spent the next three days trying to convince Scottie to go home. By day I would find him sleeping in bed with the covers pulled over his head. At night he awoke. His cell phone dangling from his tattooed arms. He teased the doctors and nurses. He convinced the dietary staff to bring him extra portions. He was king of the ward.

His charm was his greatest weapon. He smiled. He cajoled. He begged. But as another call day was approaching, my resident and I became more stern. We had to clear our census for the next onslaught of patients.

As I wrote the discharge prescriptions, Scottie tried again.

If I leave today I'll die out there. I just need more time!

By now I was immune to his pleas. His lungs sounded great and he was ready to be discharged. He pulled his hat over his eyes and his pants fell low on his waste. A few of the nurses gathered to wish him well. They whistled and catcalled as he disappeared through the hospital doors.

*

A few days later I was paged to the ER at three in the morning. As I yawned and rubbed the sleep from my eyes, A man dressed in sports coat approached from the door. He wore a cowboy hat and boots and I could see the outline of a gun tucked behind his coat.

He introduced himself as a detective from the St. Louis police department. He reached deep into one of his pockets and produced a tattered piece of paper. He held it up in front of my face. I squinted to read the writing. It was a set of discharge instructions with my signature at the bottom.

We found this in Scottie Pearson's back pocket. He was shot in the head and dumped in a field.

*

Scottie's story quickly spread among the physicians in our program. Everyone had a different idea of why he was hiding out in the hospital. Was it drugs? Gangs? Organized crime? A love triangle?

For many, Scottie became another memorable book mark in a series of odd and difficult experiences that marked our years in training. But as I get older, I think more about what he really had to teach me.

As so often happens in our lives, Scottie was trying to tell me exactly what he needed. Although I heard his words, I kept trying to interpret them based on my own point of view. Clearing my patient census for my next call rotation was more important to me then keeping him in the hospital. Sure I justified my actions by saying that he was healthy. But I never took the time to step outside of my own space to understand his.

Whether professionally or personally we all express our deepest needs to the people around us. Years ago, Scottie was trying to tell me his.

I just wasn't listening.

The Ties That Bind

I saw a familiar face amongst the crowd of children dusting the snow off their boots and replacing them with soccer shoes. My wife and I stood in the corner and watched our daughter run into the middle of the gym and socialize with a group of little girls.

As the woman approached I realized she was a former patient. After a brief exchange of greetings her eyes opened wide and she developed a lump in her throat. She turned to my wife.

Your husband saved my life!

She then excused herself to fetch her parents who were helping her daughter get changed for practice. She wanted them to meet me.

*

I will never forget the early morning during residency when I struggled into the hospital with the stomach flu. Between each patient I had to run to the bathroom to vomit. It was one of the hardest days of my career.

Or the time when one of my fellow residents showed up for a weekend on call yellow. Literally yellow from jaundice. It took several hours to convince him to go to the emergency room. Fortunately it was just a bad case of Mononucleosis.

So when Sheri arrived for her ICU shift with a severe headache, she sucked it up like everybody else. As the night progressed, however, she knew something was wrong. Her vision became blurry. Her speech started to slur.

The nurses put her in a wheel chair and sped her through the maze of passages to the emergency room. Upon arriving she had her first of several seizures. Two weeks later she would leave the hospital for a rehab facility with a diagnosis of terminal brain cancer and a fresh scar on her head to prove it.

Sheri struggled over the next few months. She measured life's ups and downs with little triumphs. By the time she walked down the isle with her long time boyfriend, she used only a cane.

A year later she was rounding with the rheumatology consult service. She was no longer a resident but she didn't want to abandon her life's work. She missed every other day for chemotherapy, or radiation, or doctors appointments.

Her life had been extended but her clock was still ticking.

Each resident regarded Sheri in a different manner. Some ignored her. Others acted like nothing had happened. And some of us struggled to treat her as if she was anyone else going through something horrible. We walked the tightrope between caring and melodrama.

After leaving residency I would never hear of Sheri again. A decade later I assume she is dead.

*

As the soccer game began my wife stood by my side smirking. She knew how uncomfortable I was with public recognition.

After all, I didn't really do that much for the woman. She came to me with a mild case of post partum depression. We talked about medications and therapy. But mostly we just talked. I was also a new parent. Like her, I was exhausted and overwhelmed. I was tired all the time.

For brief moments, during our visits, we felt like fellow soldiers in a an arduous battle. Apparently, for her, the personal connection did more then medications or therapy could.

And I thought of my residency program. I thought of my years as an attending. As physicians we spurn our own personal illness as if it does not exist. We stand above it as if we are superhuman. Our patients may get sick but not us. We try to lift ourselves out of the fray.

But what if our own mortality serves a purpose?

What if our frailty is neither embarrassing nor an Achilles heal?

Maybe. Just maybe.

It is the tie that binds.

The Place Between Grief and Guilt

When Donna spoke of the "old bag" it took a moment to realize that she was not being self referencing. Although her left arm laid limply at her side, her right hand clutched a small purse. It was old but sturdy. I imagined it was from the 1920's. One of the handles was slightly eschew and had recently been repaired. Her fingers moved across the fabric rhythmically, absentmindedly.

She explained that the purse belonged to her mother. It was stowed away until Jessica, her granddaughter, came upon it while foraging through the closet. Since that time the two were inseparable.

Jessica would race around the house with the bag tucked under her arm. She refused to carry it properly because the handle was dangling by a thread and she didn't want it to break.

The bag followed her everywhere. When Jessica and her brother would sleep in the guest room, Donna would see the bag standing proudly on the side table basking in the glow of the moonlight.

*

As I examined Donna, I thought about how similar she was to the adornment that sat next to her on the examining table. She was well into her seventies. Fine stitching and excellent craftsmanship. A repair here and there, but generally in good shape.

I took a look at her left arm. The surgical site was clean. Her strength and range of motion were perfect. Her stitches had long been removed but her scars remained. Although functionally proper, the arm fell back lifeless by her side. Donna looked the other way as if it didn't exist.

Memories from the accident were starting to return.

*

Donna remembered waking up confused. She was grasping the small purse that was last in Jessica's hand. The strap was broken and it was speckled with blood. Her grandson was screaming in the back seat.

She remembers the orthopaedist leaving the room after placing her cast. The emergency room doctor returning with eyes shining with empathy. He held her hand and told her that Jessica was gone.

Donna remmebered how the room suddenly became still. How instead of screaming or crying out in anger, she felt she had to concentrate very carefully. She heard the words but she couldn't understand the meaning.

But her brother sitting next to her...not a scratch.

The doctor's eyes became cold and distant. He turned his head away as he continued.

When the back of the car was crushed.....

Donna was no longer on my examining table. Her eyes were blank and looked up towards the ceiling.

She was lost in the place between grief and guilt.

Her words were monotone and spoken into the air as if to no one in particular.

Unlike that old purse and I, Jessica's sins were shockingly innocent.

As most girls of a certain age, she was just a little bit

too tall.