Oh shoot!
I looked up from the computer and glanced in my wife's direction. She was standing over a pot with the last drops of milk pouring out of the carton.
We're out of milk.
As straightforward as the statement sounded, I knew the alternate meaning. I would be running to the store shortly. I pouted pathetically.
Come on. You know they need to have chocolate milk before they go to bed.
If I left immediately, I could be home in time for dinner. I walked over to the mud room and struggled to get my shoes on quickly. When I looked up, two sets of small feet blocked my way to the door.
Can I come too?
They both spoke in unison as if they belonged to some sort of synchronized cult. In the blink of an eye, both kids were somehow decked out in boots and rain coats. I paused. My eyes moved from the clock to their quizzical faces.
Daddy is just running out for a moment. I will be right back.
Their smiles turned into frowns. My three year old daughter started to cry. I pushed my way out the door while they followed in tow. They stopped on the porch and waved as I opened the garage door. A sheet of rain separated me from their pitiful little figures.
*
While driving to the grocery store, I couldn't help thinking about the office. Today was the "go live" for our new electronic medical record. As expected, the stress in the air was palpable.
My patients stared glassy eyed as I fiddled with the computer. I repeated myself. I interrupted them. I was distracted. My agenda clearly wasn't their well being.
And strangely, it felt similar to what just happened with my kids.
I was going to the store for their benefit. But my children didn't really care about milk. They just wanted a ride with their father. If I listened to their opinion, I probably wouldn't be alone in the car at the moment. And that's how our patients must feel.
We're moving so fast with meaningful use, ACO's, and patient centered medical homes. We're punishing hospitals for re admissions and collecting "quality" data on our doctors.
We say that we are doing this for the "good" of our community. We talk about "patient centeredness" as if we own the term. But is anyone asking their opinion? Or are our patients left standing in the cold in raincoats and boots like little children?
*
When I arrived at the grocery store, I sprinted through the isles. I quickly grabbed two gallons of milk, and tapped my feet impatiently at the check out counter. I reached for the wallet in my back pocket, and was shocked at what I found. Or better yet, what I didn't find.
I left in such a hurry I forgot my wallet. It was the law of unintended consequences.
Has anyone explained to the government that you can't buy milk If you hastily forget your money?
I think we all need to slow down!
*
I left the store and drove back home. I picked up my wallet and kids, and we all went together on an adventure.
Our destination was the grocery store.
Thursday, October 20, 2011
Wednesday, October 19, 2011
A Physician's Prayer
As I sit down to drink coffee tomarrow morning and type away at the computer, I will do something quite uncomfortable for a non religious person.
I will pray.
I will pray that my children make it safely to school
That the weather is good and the sidewalks are not slick.
That their feet will be steady and their minds alert to the dangers that lurk in any suburban neighborhood.
That my wife will have an excellent day.
That she will face the uncertainties of being a mother and a professional with her usual grace and certitude.
I will pray that I am a humble physician.
That I will be a beacon of strength and hope to those who choose to walk through my door.
That I will garner the right mix of compassion and authority to guide those who seek answers. Mourn with those who receive them, and rejoice in the human condition.
I will pray that the EMR upgrade in my office will be flawless.
That the new platform is indeed a major improvement and not just another money maker for some corporation.
That the emotional distance placed by increasingly complex computer systems will melt away as does the physical distance when I reach for my stehoscope.
That the creators of HIPAA will turn their heads as I sneak out of the exam room in order to ask a trainer the correct way to enter "hemorrhoidectomy" .
That the patients hue of crimson, as they walk past the trainers desk and towards the checkout counter, will be short lived.
I will pray that this government has been wise.
That penalizing me for not checking off the "race" box on the EMR will indeed be the one missing ingredient that will help mollify the pain of the patient with chronic pancreatitis.
Or stem the the sadness of the family watching their loved one fade away from Alzheimers.
I will pray because it seems that this space we call healthcare has denigrated from rational debate and scientific method to an orgy of magical thinking.
And I want to make sure the central authority knows not to penalize me.
That I'm on board.
I will pray.
I will pray that my children make it safely to school
That the weather is good and the sidewalks are not slick.
That their feet will be steady and their minds alert to the dangers that lurk in any suburban neighborhood.
That my wife will have an excellent day.
That she will face the uncertainties of being a mother and a professional with her usual grace and certitude.
I will pray that I am a humble physician.
That I will be a beacon of strength and hope to those who choose to walk through my door.
That I will garner the right mix of compassion and authority to guide those who seek answers. Mourn with those who receive them, and rejoice in the human condition.
I will pray that the EMR upgrade in my office will be flawless.
That the new platform is indeed a major improvement and not just another money maker for some corporation.
That the emotional distance placed by increasingly complex computer systems will melt away as does the physical distance when I reach for my stehoscope.
That the creators of HIPAA will turn their heads as I sneak out of the exam room in order to ask a trainer the correct way to enter "hemorrhoidectomy" .
That the patients hue of crimson, as they walk past the trainers desk and towards the checkout counter, will be short lived.
I will pray that this government has been wise.
That penalizing me for not checking off the "race" box on the EMR will indeed be the one missing ingredient that will help mollify the pain of the patient with chronic pancreatitis.
Or stem the the sadness of the family watching their loved one fade away from Alzheimers.
I will pray because it seems that this space we call healthcare has denigrated from rational debate and scientific method to an orgy of magical thinking.
And I want to make sure the central authority knows not to penalize me.
That I'm on board.
Monday, October 17, 2011
My Career As A Hospitalist
George's mind was spinning. The surgeon described how he would make a hole in his wife's skull. The procedure was called a "hemicraniotomy" but to George the words made little sense. All he knew was that his wife had been dancing in his arms two hours before.
At first, when she collapsed, he thought she was pretending. But then she didn't get up. He saw her chest moving up and down. But she wouldn't respond.
The ambulance came quickly. The paramedics gathered up his wife and placed a breathing tube down her throat. They whisked her off to the hospital.
Two hours later, George sat in a conference room with the neurosurgeon. His wife suffered a devastating stroke. The swelling had already caused sgnificant damage to her thirty five year old brain.
*
I shifted uncomfortably in my seat as I listened to the neurosurgeon. He would offer George's wife a procedure. It would release the pressure on her brain. But there was no mincing words. She was unlikely to recover fully.
After the surgeon left the room, George and I talked for a few moments. I gently pushed him to consider what his wife would say if she could speak for herself.
He rocked back and forth in his chair. In the main ER the PA system called a doctor overhead. The monotone voice of the page operator broke the silence.
She would want to be there to see her kids grow up.
There was little certainty in his statement. It was more a question than a declaration.
I reached out to put my hand on George's shoulder but was surprised to see him pull away. I was neither a trusted advisor nor a long time friend. I was a stranger newly assigned to the case.
It was precisely at that moment that my thoughts began to crystallize.
My career as a hospitalist would be short lived.
At first, when she collapsed, he thought she was pretending. But then she didn't get up. He saw her chest moving up and down. But she wouldn't respond.
The ambulance came quickly. The paramedics gathered up his wife and placed a breathing tube down her throat. They whisked her off to the hospital.
Two hours later, George sat in a conference room with the neurosurgeon. His wife suffered a devastating stroke. The swelling had already caused sgnificant damage to her thirty five year old brain.
*
I shifted uncomfortably in my seat as I listened to the neurosurgeon. He would offer George's wife a procedure. It would release the pressure on her brain. But there was no mincing words. She was unlikely to recover fully.
After the surgeon left the room, George and I talked for a few moments. I gently pushed him to consider what his wife would say if she could speak for herself.
He rocked back and forth in his chair. In the main ER the PA system called a doctor overhead. The monotone voice of the page operator broke the silence.
She would want to be there to see her kids grow up.
There was little certainty in his statement. It was more a question than a declaration.
I reached out to put my hand on George's shoulder but was surprised to see him pull away. I was neither a trusted advisor nor a long time friend. I was a stranger newly assigned to the case.
It was precisely at that moment that my thoughts began to crystallize.
My career as a hospitalist would be short lived.
Sunday, October 16, 2011
A Physician's Credo
There was only one point to the Morbidity and Mortality conference. We ordered the xray. We could have looked at the result sooner. But how was I supposed to know? I was in my first week of internship and had no idea why my resident wanted an xray of a cellulitic leg.
The next day it became clear. The film showed pockets of gas. She had necrotizing fascitis. Within minutes the antibiotics were infusing. Within hours she was on her way to the OR. My fellow interns and I lined up at the back of the operating room. It was a particularly slow call day and there weren't any medicine patients to admit.
We watched as the surgeon expertly filleted opened her thigh. First pus and then black necrotic tissue. He took wide margins and then packed the wound. He didn't close up. He knew he would return to the OR multiple times in the next few days.
Miraculously she survived. Even with the delay, we evaluated and treated her infection far faster then the national average. A number of residents gathered at the door the day they wheeled her out of the hospital. Over her three month incarceration, many of us had taken care of her.
*
She bounced in and out of the hospital over the next year. After her original surgery, she developed bouts of intractable nausea and vomiting and would need to be admitted for intravenous fluids. She accepted each visit with serenity and calm. Her children and grandchildren surrounded her in the Emergency Room. It was as if she knew she was operating on borrowed time. Maybe the grim reaper had missed his chance once. But now he was circling in on his pray.
Between hospitalizations she came to see my partner in the residents clinic. She was physically fragile but mentally strong. She beamed as she talked about her family. Her blood sugars were atrocious. She spent most of her time in a wheel chair. But she was happy.
She returned to our clinic one last time. She had just been discharged from an outside hospital. Dangling from her neck was a central IV catheter that someone forgot to remove. The resident cut the sutures free with a scissor. He advised her to bear down as he pulled the length of the catheter out of her neck. She looked up and her eyes went blank. She took a deep breath and then fell over in her chair.
She was dead. Nothing about the next thirty minutes of resuscitation would change that. Father death had found a weakness in the fabric of her life and moved in swiftly. She may have escaped her fate once, but not twice.
*
As the years pass, I often think of her staring up at the resident as she was getting ready to have the catheter removed. An autopsy would later reveal no obvious cause of death.
As physicians, we have much less control of our patients destinies than we would like to admit. Sometimes, we are like a strong wind that blows the hand of fate inches in either direction.
Other times, we are like a gentle breeze bringing momentary relief to the fevered battle front, but rarely making an impact on the outcome.
So we try to be gentle and humble in our dealings with fate.
Often our true power comes not from altering that which we can't control but controlling that which we can.
We offer a kind heart, open arms,
and a devotion to those we serve.
The next day it became clear. The film showed pockets of gas. She had necrotizing fascitis. Within minutes the antibiotics were infusing. Within hours she was on her way to the OR. My fellow interns and I lined up at the back of the operating room. It was a particularly slow call day and there weren't any medicine patients to admit.
We watched as the surgeon expertly filleted opened her thigh. First pus and then black necrotic tissue. He took wide margins and then packed the wound. He didn't close up. He knew he would return to the OR multiple times in the next few days.
Miraculously she survived. Even with the delay, we evaluated and treated her infection far faster then the national average. A number of residents gathered at the door the day they wheeled her out of the hospital. Over her three month incarceration, many of us had taken care of her.
*
She bounced in and out of the hospital over the next year. After her original surgery, she developed bouts of intractable nausea and vomiting and would need to be admitted for intravenous fluids. She accepted each visit with serenity and calm. Her children and grandchildren surrounded her in the Emergency Room. It was as if she knew she was operating on borrowed time. Maybe the grim reaper had missed his chance once. But now he was circling in on his pray.
Between hospitalizations she came to see my partner in the residents clinic. She was physically fragile but mentally strong. She beamed as she talked about her family. Her blood sugars were atrocious. She spent most of her time in a wheel chair. But she was happy.
She returned to our clinic one last time. She had just been discharged from an outside hospital. Dangling from her neck was a central IV catheter that someone forgot to remove. The resident cut the sutures free with a scissor. He advised her to bear down as he pulled the length of the catheter out of her neck. She looked up and her eyes went blank. She took a deep breath and then fell over in her chair.
She was dead. Nothing about the next thirty minutes of resuscitation would change that. Father death had found a weakness in the fabric of her life and moved in swiftly. She may have escaped her fate once, but not twice.
*
As the years pass, I often think of her staring up at the resident as she was getting ready to have the catheter removed. An autopsy would later reveal no obvious cause of death.
As physicians, we have much less control of our patients destinies than we would like to admit. Sometimes, we are like a strong wind that blows the hand of fate inches in either direction.
Other times, we are like a gentle breeze bringing momentary relief to the fevered battle front, but rarely making an impact on the outcome.
So we try to be gentle and humble in our dealings with fate.
Often our true power comes not from altering that which we can't control but controlling that which we can.
We offer a kind heart, open arms,
and a devotion to those we serve.
Friday, October 14, 2011
Sentimentality
I don't know when I lost my sentimentality.
Whaaap
With a thud the fish stops flopping up and down. It lays still on the floor of the boat. My camp counselor, a tanned college student, carefully places the paddle on the seat and cuts the fishing line. The hook remains dangling from the lifeless mouth.
He grabs the fish with his bare hand and throws it back into the water. He talks slightly above a whisper. I don't know if his words are directed at me or into the air.
Couldn't get the hook out of that one. He would have never survived!
*
My son and daughter sit on the curb in front of our house, stunned. The car pulls over as the dog's owner sprints around the corner. She stops a few paces away and screams.
The animal's chest heaves up and down slowly, but he is otherwise incapacitated. My daughter looks up at me quizzically?
Can we call an ambulance? Can we take him to the hospital?
I don't respond at first. The owner is now leaning over her beloved pet. She strokes his head and whispers softly into his ear. She is crying.
No honey. The dog is dying. There's nothing we can do
My son instinctively grabs my daughter's hand. They sit silently and watch as the dog's respirations slow.
I feel a strong urge to cover their eyes and walk them into the house. But I don't. I put my arms around my children and wait.
We all just wait.
*
So you're putting 421 on hospice?
The nurse leans over my shoulder as I write orders. It's been a long day and I don't feel like talking. I'm starting to drift.
Whaaaap
Sometimes I dream that all those fish are swimming after me. The hooks wag back and forth in their mouths as they pull IV poles behind them.
Her primary sent her here to get therapy. She's due for another round of chemo next week.
The nurse persists even though my mind is clearly elsewhere. She's starting to get on my nerves.
You know, most docs let the oncologist take care of this stuff.
Now I'm angry. I growl as I look up at her, but then think better of it. I turn my head back to the chart.
I mutter under my breath...
just loud enough to make sure she understands.
I wouldn't treat a dog that way!
Whaaap
With a thud the fish stops flopping up and down. It lays still on the floor of the boat. My camp counselor, a tanned college student, carefully places the paddle on the seat and cuts the fishing line. The hook remains dangling from the lifeless mouth.
He grabs the fish with his bare hand and throws it back into the water. He talks slightly above a whisper. I don't know if his words are directed at me or into the air.
Couldn't get the hook out of that one. He would have never survived!
*
My son and daughter sit on the curb in front of our house, stunned. The car pulls over as the dog's owner sprints around the corner. She stops a few paces away and screams.
The animal's chest heaves up and down slowly, but he is otherwise incapacitated. My daughter looks up at me quizzically?
Can we call an ambulance? Can we take him to the hospital?
I don't respond at first. The owner is now leaning over her beloved pet. She strokes his head and whispers softly into his ear. She is crying.
No honey. The dog is dying. There's nothing we can do
My son instinctively grabs my daughter's hand. They sit silently and watch as the dog's respirations slow.
I feel a strong urge to cover their eyes and walk them into the house. But I don't. I put my arms around my children and wait.
We all just wait.
*
So you're putting 421 on hospice?
The nurse leans over my shoulder as I write orders. It's been a long day and I don't feel like talking. I'm starting to drift.
Whaaaap
Sometimes I dream that all those fish are swimming after me. The hooks wag back and forth in their mouths as they pull IV poles behind them.
Her primary sent her here to get therapy. She's due for another round of chemo next week.
The nurse persists even though my mind is clearly elsewhere. She's starting to get on my nerves.
You know, most docs let the oncologist take care of this stuff.
Now I'm angry. I growl as I look up at her, but then think better of it. I turn my head back to the chart.
I mutter under my breath...
just loud enough to make sure she understands.
I wouldn't treat a dog that way!
Thursday, October 13, 2011
Departures and Arrivals
The woman sitting across from me is sniffling. Her chin is tucked into her neck, and a small tear barely leaves her eye before she wipes it away with a tissue. She balances her cell phone under her ear. She talks quietly. Her face contorts as she struggles to control her expression. As I watch, I listen to another flight begin to board.
We are in an airport. I can't help but wonder who this poor woman is talking to. I am a voyeur. I turn my head with embarrassment in the opposite direction, but against my will I glance back.
How often does human drama unravel in places like this? Is she breaking up with a boyfriend? Has she just been to a funeral? Did she say her last goodbye to a favorite aunt or uncle who is dying?
*
Sometimes my office also feels like an airport. There are many arrivals and departures. Each person comes on a different schedule. Occasionally many at once. Other times just a few stragglers.
And they bring their baggage. Usually I am more a helper and less a voyeur. I may procure a larger bag or help them rearrange their contents. Often a few things get discarded.
Before long they are running back to the gate to catch their plane. Waving goodbye until our next visit.
Where we will do the same thing all over again.
*
The woman is boarding her flight. By the time she leaves, the tears are gone. Maybe it was simply a bad day. She smiles as she hands her pass to the man at the counter.
And I remain in my chair, waiting. An elderly gentleman is talking on the phone a few seats away. I catch the last few sentences of his conversation.
Shingles....shingles you say.
We are in an airport. I can't help but wonder who this poor woman is talking to. I am a voyeur. I turn my head with embarrassment in the opposite direction, but against my will I glance back.
How often does human drama unravel in places like this? Is she breaking up with a boyfriend? Has she just been to a funeral? Did she say her last goodbye to a favorite aunt or uncle who is dying?
*
Sometimes my office also feels like an airport. There are many arrivals and departures. Each person comes on a different schedule. Occasionally many at once. Other times just a few stragglers.
And they bring their baggage. Usually I am more a helper and less a voyeur. I may procure a larger bag or help them rearrange their contents. Often a few things get discarded.
Before long they are running back to the gate to catch their plane. Waving goodbye until our next visit.
Where we will do the same thing all over again.
*
The woman is boarding her flight. By the time she leaves, the tears are gone. Maybe it was simply a bad day. She smiles as she hands her pass to the man at the counter.
And I remain in my chair, waiting. An elderly gentleman is talking on the phone a few seats away. I catch the last few sentences of his conversation.
Shingles....shingles you say.
Tuesday, October 11, 2011
My Keynote Address
My son's hand shoots skyward. The teacher appraises the group of students and then motions him to the front of the room. He smiles as he skips forward. All sense of trepidation is lacking. He is aware of the other students, the parents, and the teacher. But he seems unconcerned.
He gently lifts his bow to the strings. The piano starts with an introduction. And he plays. The bow screeches awkwardly at first. A few notes in, he catches his stride. His eyes close slightly.
Seconds later he is finished. He puts his violin in rest position and bows deeply. The crowd claps. He skips back to his seat with a smile on his face. He knows his performance is imperfect.
He doesn't care.
*
Tomorrow I will wake up early and leave my family. I will take a taxi to the airport where I will board a plane to Louisville, Kentucky.
I will attend the Amedysis Strategy Summit. On the second day I will step on stage in front of hundreds of people. My voice will be my bow. My knowledge, my instrument.
And I will play. With a little more trepidation than my son and likely a greater measure of imperfection.
But my joy,
my joy will be the same.
He gently lifts his bow to the strings. The piano starts with an introduction. And he plays. The bow screeches awkwardly at first. A few notes in, he catches his stride. His eyes close slightly.
Seconds later he is finished. He puts his violin in rest position and bows deeply. The crowd claps. He skips back to his seat with a smile on his face. He knows his performance is imperfect.
He doesn't care.
*
Tomorrow I will wake up early and leave my family. I will take a taxi to the airport where I will board a plane to Louisville, Kentucky.
I will attend the Amedysis Strategy Summit. On the second day I will step on stage in front of hundreds of people. My voice will be my bow. My knowledge, my instrument.
And I will play. With a little more trepidation than my son and likely a greater measure of imperfection.
But my joy,
my joy will be the same.
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