A Calling

Would it surprise you to know that I often contemplate leaving medicine? That I awake some mornings with eyes drooping and jaw clenching. And I begin the day with the promise that it will be my last.

I have sworn off this profession more times than a bad habit. I have stormed out of the office with belly churning and head swimming in a migrainous ocean.

Each time, I feel more resolute then the last. Yet somehow I remain. I sit in my little office typing away on my lap top. The phone is ringing, my pager is buzzing, and the paperwork is piling up.

Yet, I'm still here.

*

Howie was like a tank. His thick muscular arms were covered in tattoos. His belly usually protruded proudly over his Harley as he drove into our parking lot. Needless to say, he wasn't the kind of guy who complained.

So it was with great surprise, that I watched him hobble into my office. His cherubic face was flaming red. Sweat soaked the front of his t-shirt. His left arm wrapped around his son, and they walked in unison as if they were participants in a three legged race.

I paused for a moment as Howie got settled on the examining table.

Doc. I think I'm dying

I was amazed at how this giant of a man had been transformed into a cowering mouse. I waited patiently as he explained the agony of the last few weeks. His knees were aching. His feet were swollen. He couldn't bare to walk or move. His pain was only tolerable if he remained perfectly still.

His trip to the ER had been fruitless. He was told that he didn't have blood clots in his legs, but was otherwise given no explanations. I surveyed the situation. His knees were warm and swollen with small circles of color radiating downward. He jumped with any attempt at manipulation. His ankles were also sensitive and edematous.

I diagnosed him with gout. I faxed a prescription for prednisone to his pharmacy and requested he come back the next day. He limped out of the office unconvinced.

Twenty four hours later, he strode through the hallway towards me a changed man. He walked confidently into the room. He smiled broadly showing his stained front teeth.

Doc. You saved my life!

I was about to disagree when he unexpectedly grabbed me around the shoulders and gave me a bear hug.

I didn't say a word. I was speechless.

*

Sometimes I feel that being a doctor is like fighting a pit bull. You scratch and claw against the vicious opponent in an attempt to survive. And when you finally pick yourself up off the ground in victory, the dogs owner walks over and kicks you in the groin.

Yet there are few professions that give back so much. Physicians are allowed a unique window into the lives of their fellow men. We help people live; we help them die. We bear witness to all that is laid at our doorstep.

We are treated as both kings and peasants. Our rewards are fleeting but much appreciated: a handshake, a pat on the back, a hug.

Years ago my parents asked me what I want to be when I grow up. I didn't know then what I know now. This profession is a calling. A loud, disruptive, unswerving calling.

And with every breath, of every moment, of every day,

I humbly answer it.

The Hand Holder

When the residents referred to Dr. Foster as a "hand holder" it wasn't meant as a term of endearment. In fact, we universally dreaded taking care of his patients. It wasn't just his wishy washy decision making, but also his syrupy bedside manner. Although the patients loved him, we often wanted to run out of the room and vomit.

I remember my last interaction with Dr. Foster. I was a third year resident and we were rounding together on a patient in the ICU. We examined the unfortunate gentleman. He was on a ventilator and his kidneys and heart were failing.

After methodically writing his note, Dr. Foster and I walked over to the waiting room to talk to the wife. Her eyes were stained with tears as she broke the news. The family had decided to withdraw life support.

Dr. Foster held her hand tightly as he looked deeply into her eyes. He begged her.

Don't give up yet. I feel like I could have done so much more!

The wife placed her hand on Dr. Foster's cheek and then embraced him.

Doctor. Don't blame yourself. You did all you could. It's time for him to go now.

I was disgusted. How had Dr. Foster become the center of attention. He should have been comforting the wife and not vice versa.

I would never see Dr. Foster again. But years later his memory would come clearly into focus at a most unexpected time.

*

Walter and Sarah were my favorite patients. Although their bodies had withered seventy years of abuse, their spirits were far younger. They bounced into my office with energy and kindness. They greeted the staff and physicians with equal measures of respect.

A year ago, Walter developed a persistent cough. After various remedies failed, a chest xray revealed a nodule in the lung. A cat scan was highly suspicious for cancer, and Walter's diagnosis was confirmed by lung resection.

He tolerated surgery well and was plugging along when a surveillance cat scan showed multiple new nodules. Months of chemotherapy and radiation followed. We met in the office frequently to discuss each new development. Sarah worried that her husband was dying. She agreed to the various treatments, but wondered if they were doing more harm then good.

Walter, for his part, put on a brave face and took his "medicine" as directed. He also knew that he was dying, but didn't want to leave Sarah behind.

As time passed, Walter's disease progressed. He was so weak that the oncologist cancelled all remaining appointments for chemotherapy. When he woke up one morning and couldn't get out of bed, Sarah took him to the hospital.

It was with great heaviness that I walked into Walter's room. Sarah was seated at his side. She held his hand as they talked. Sarah stood when she noticed me. I leaned over the bed. A faint smile came over Walter's face.

Doc. I think it's time to call it quits.

I felt the air leaving my lungs. I doubled over. As I opened my mouth to speak, I couldn't believe what I found myself saying.

I'm not ready for you to go!

Sarah was now standing next to me, her arm around my shoulder. The iconic image of Dr. Foster in the ICU waiting room came rushing back to me. Maybe I had been to harsh.

Sometimes when the cards are on the table, it's okay to let your guard down and allow this gentle act of submission. There is a time to transcend the doctor-patient relationship and to no longer be physician, patient, and family member.

We were just three human beings with deep emotional attachments.

And we were grieving.

Together.

Why I Blog Part 2

There's an ongoing struggle for the hearts and minds of the American people. The battle rages on quietly, but occasionally bubbles over into the public consciousness. One side is loud, veracious, and spits its tyrannical philosophy far and wide. The other is sheepish, and docile.

We all know that I'm talking about health care. There are those who feel that our system is undeniably broken. They think that we have journeyed so far off course that our moral fiber has eroded. They say our values languish under a system driven more by personal profit than public good. The detractors are a motley crew of journalists, politicians, policy wonks, and health care consultants.

They point their criticism at health care providers and coin new terms to describe the so called depravity. They talk about "accountability" as if they are the ones in the ICU having the family meetings. They pray at the alter of "quality" yet fail to define the specifics of such a term. They resent "over treatment" but never have suffered the consequences of not doing enough.

The veracity of one group of combatants is only equaled by the meekness of the other. Practicioners, actually providing the care in America, find themselves too busy to respond. They watch as the public's confidence erodes but feel overwhelmed by the complexity of patient care. Wasteful exercises in futility steel away their time: billing, coding, preauthorizations, meaningful use, electronic medical records.

It is a learned helplessness. The quiet rebellion continues. Doctors become businessman. Nurses become managers. We cling to new models like concierge and cash practices.

The public, inundated by the power and volume of our detractors message, has noticed our silence. Without a dissenting voice they are left to believe that what they are hearing is true. They are losing faith.

We as physicians and nurses, therapists and social workers, have but one choice left. We must recast the characters and rewrite the plot. We must repaint the fresco to be more airy and accurate.

We must tell our stories.

Agents of Torture

I don't know when I became the angel of death. It was never my plan to be the patron saint of hospice. In fact, I started my career dealing with much less terminal illness. But as I spend more and more time in nursing homes, end of life discussions are a large portion of what I do.

*

I had multiple admissions to the facility this weekend. Of course, there were the occasional rehab patients recovering from hip and knee replacements. I was shocked, however, to see how many people rolled through our doors with end stage illnesses. The expectation was that they were coming for rehab.

There were metastatic cancers, devastating cerebrovascular accidents, and centenarians newly started on dialysis. As I sorted through the admissions paperwork, I started to see familiar patterns.

Peg tube placed for malnutrition. Dialysis initiated for failing kidneys. Chemotherapy scheduled for lung cancer with diffuse metastases.

Since there was no documentation of detailed end of life discussions, I made a point of asking each patient and family member a few questions:

How do you think treatment is going?
Has anyone told you about prognosis?
What are your goals?

Surprisingly, many of these questions had never been asked or answered. I found my patients and families to be largely oblivious. Many of their responses were shockingly uninformed.

*

I don't know how we got to this place. I understand that we as a profession need to make money. That gastroenterologists need to place peg tubes, that oncologists need to give chemo, that internists need to rack up visits.

I accept these facts. But when did it become okay to practice futile medicine and batter our patients?

How did we become agents of torture?

Breaking Up

As I walk out of the building, I wonder if I will ever step through these doors again. I feel a faint ache in my chest and my eyes tear up. We had a few good years-the building and I.

How many mornings had I rushed in at 6AM to evaluate and ailing patient? How many afternoons had I sat at the nursing station writing in charts and chatting with residents and staff?

My letter of resignation was an abrupt and unexpected end to an emotional connection.

I could no longer come to the facility.

*

There was a time, in my career, where I pictured myself a superhero. I swooped into patients rooms in the nick of time. It was a one sided arrangement.

As I matured as a physician, I realized that the doctor-patient relationship is much more complicated. It's more like a dance. Sometimes our steps are in unison. Other times it is as if we are listening to completely different music. But it's two sided. Like most relationships it is messy and complex. Each party has both needs and gifts that require nurturing.

How could I not be changed by my years at the nursing home? I think of the resident who would accost me while I was charting at the desk. How often we talked about baseball and the Cubs. I never had the courage to tell him that I knew nothing of such things. But with time, I came to expect this camaraderie. I learn to look forward to these encounters.

*

It's hard for a physician, nay a person, to admit that we can no longer meet other people's needs. Or better yet, that meeting these needs will encroach on our own.

As we grow and change, we take on these transitions with little thought. We leave practices and hospitals. We move to different cities or change careers. And for the most part, we are oblivious to all that we have left behind.

But today I will be cognizant. I will say goodbye to years of hard work and countless relationships built on blood, sweat, and even tears. I will not be ashamed of my sadness, nor deny that I am leaving behind some who truly need me.

I will also admit that my absence will not be a contradiction to the fact that I need them too. I will not pretend that this is just another day. I will not pretend.

That breaking up isn't hard to do.

Humanity

I'm not sure when I lost my humanity-at least for the most part. Maybe it was the hazing in medical school or the unending nights of residency. I prefer to speculate it was the dull thud of yet another pile of papers dropped on my desk.

Whatever the excuse, it happened. The soft, compassionate, eager student who started this journey is morphing. My skin withers and thickens into sheets of heavy chain mail. My eyes turn a colder shade of grey. My hands become dry and leathery in the midst of the frosty Chicago weather.

My body and soul adapt to form a protective shell. My heart battered and bruised beats in it's restless cage.

But sometimes, for just a moment, I remember the former strength of my innards. How my heart stood front and center. Occasionally knocked by the harshest of realities but never backing down.

Those days seem so far away now.

*

I gently rock back and forth as I stand at the nursing station. Three racks of charts rest beside me. Every few minutes I close one chart, place it back in it's holder, and pull another. I am acutely aware of the ticking clock on the adjacent wall.

My billing sheets collect dust in a pile next to me. I'm tired. For two hours I roamed the hall of the nursing home, interviewing its inhabitants. I put out fires. I calmed angry family members. And I am about to finish documenting, when a young woman walks up to the desk and waits quietly for my attention.

Are you Doctor G? I was wondering if you could come talk to my father.

I glance at the chart the nurse placed on the counter next me and feel an odd sense of relief.

Your father is not my patient. You should call his doctor.

She taps her feet impatiently and looks slightly annoyed.

Well the nurses told me you're covering for Dr. K who is out of town.

I vaguely remember that I offered to manage Dr. K's patients while he is gone. My heart falls. I'm already late and the last thing I want to do is walk into the care of a train wreck.

The woman watches my response closely. She senses hesitation. She's angry

Look! If you don't want to help...

She turns away and stalks down the hallway.

*

I walk into the room with my tail tucked between my legs. A kind elderly man lies in the bed in the center of the room. He is surrounded by his wife and daughters who fawn over him to adjust his bedding. None of the fangs that I witnessed earlier are now apparent.

Their needs are minimal. A simple explanation. Some interpretation of tests. Mostly they are looking for attention. They search for a sign that someone is commanding the ship through the relentless tempest of illness that they bravely face.

And I remember back to a time before my mind was clouded by all this "education". When I would give myself freely to sit with an ailing patient and provide the sort of "doctoring" that now has been squeezed out of me.

I started on this path to provide service to my fellow man.

How have I wandered so far off course?

Actively Dying

The group of students walking behind me move uneasily through the bustling hospital halls. Their crisp clean coats stand in stark contrast to the faded linoleum and stained wallpaper. Doctors and nurses dart quickly to avoid slowing down behind the ambling herd.

I pause for a moment at the end of the hall, think better of it, and walk on. I turn quickly toward the group as my legs propel me forward mechanically. Our next stop is just three doors away. I check to make sure the hallway is empty before addressing the group.

I think we'll skip room 214. She's "actively dying."

A few steps later, it dawns on me that such a term is likely confusing to a third year student. I stop abruptly in front of our next patients room.

So who can tell me the definition of "actively dying"?

The row of faces look up quizzically, but I am already lost in thought.

*

My mom's voice sounded shaky over the phone. I could hear my grandmother breathing heavily in the background. Her silence spoke volumes. I adjusted the receiver and took a deep breath.

How's she doing?

My mom's answer was almost imperceptible. I felt, for a moment, like I was talking to a child.

Okay.

I strained to interpret her uneasiness as I calculated the distance between St. Louis and Chicago. If I left immediately, I could reach the assisted living in six hours.

Is she still talking to you?

Instead of answering, my mother lifted the phone to my grandma's ear and coaxed her to speak. I listened to each struggling gasp. The prolonged breaths were punctuated by pauses.

My mind clicked. As a second year resident, I'd dealt with this before. I slammed down the phone and rushed to my bedroom to pack a few things before leaving the house.

The roads were dark as I sped down the highway.

Time was running out.

*

Six hours later, I walked into my grandmother's room. I was oblivious to the grime and sweat caked on my body. I had driven all night. I knelt next to the bed and placed her hand in mine. My mother and father sat quietly in the corner.

Her breathing had slowed since the night before. The pauses were more apparent. I leaned over and kissed her forehead. I whispered into her ear.

It's OK. You can go now!

I placed the radio on the nightstand and put on the My Fair Lady CD.

Grandma's chest moved up and down slowly with the rhythm. Each rise and fall more gentle till the energy in the room palpably changed.

Her body was still.

Her soul had left us.

*

After a reflective moment, I answer my own question.

"Actively dying" is the final phase of life. The short interlude in which the dying process takes place. It often lasts between twelve and twenty four hours. Patients are usually unconscious and exhibit cheyne stokes breathing.

I can see the puzzlement wash over the student's faces. A few raise their hands as if we are in a classroom. One speaks up.

So what do we do when this happens?

The first thing that comes to mind is my mom's face. She still can't talk about that day without breaking into tears.

We comfort the family.

They are the ones who will carry the scars.