Complexity

As I opened the chart on the computer screen, my eyes glazed over. It was the third case of shortness of breath in a row. I combed through the records of yet another octogenarian: stress test (check), xray (check), echo (check), pulmonary function tests(check).

It wasn't even lunch time yet. I sat down quietly at my desk. The screen blinked reminding me that a patient was ready for assessment. The overhead pager system was calling my name. My cell phone started to ring.

I laid my head down on a stack of papers.

When did life become so complex?

*

I push the mop and bucket out behind the counter and move slowly as not to spill. Inching toward the smaller of the two dining areas, I stop at the entrance and remove the garbage can. As I dip the mop into the bucket of soapy water, I listen to a group of girls giggling at a table a few feet away. They look my age, maybe fifteen.

I glide from one end of the room to the next. Pausing to place the mop back in the bucket, I push a row of tables onto the newly mopped floor, before starting the process over again. My arms relax and contract and my hands grip tightly around the handle.

I enjoy this work. My thoughts are free to wander. I calculate how to complete my task more efficiently as I bounce to the music overhead. I think about my life, school, and work. My mind hums like a machine. It jumps from thought to thought without pause or interruption. The sweat roles down my back and the white ice cream parlor uniform clings to my sides.

My muscles ache from physical labor intermixed with occasional jaunts to the equipment room where the teenage employees do pull ups on an old rusted pipe. I am youthful and proud.

I finish the small dining room, and move a garbage can to block the entrance to the large one. I will sweep and mop. Then the bathroom, break room, and equipment room await me.

*

I leave the exam room with more questions then answers. Maybe it's just a bad case of sleep apnea, anxiety, or deconditioning.

I think back fondly to those days in the ice cream parlor. When, at the end of day, I could look out and see all that I had accomplished. I could peruse, contemplate, and record my inconsistencies.

But as time went on, life changed. With education comes complexity.

And as a physician, I spend most of my day flopping in a sea of the abstruse. There is so rarely a finite beginning and end. My work product is subjective and ephemeral.

But sometimes I dream of dropping it all, leaving my profession, and donning the apron once again.

I'm sure I would enjoy myself immensely,

for about a few hours!

Empathy

As Sylvia swept through the door into the waiting room, the receptionist called out from behind the counter.

Dr. Kris, Dr. Kris, Mrs. Beckwith is on the phone. She's having back pain again!

Sylvia paused, the bag carrying her laptop propelled forward and then snapped back on the shoulder straps. Her laboratory jacket was folded neatly across one arm and the adjacent hand held a cell phone. She was about to call the Nanny. She pushed the power button on the phone and glanced at the display.

Technically, it's after four. Give it to Dr. Short, he's on call!

The secretary opened her mouth to explain that the covering physician wasn't familiar with Mrs. Beckwith, but then thought better of it.

It wouldn't have mattered anyway, the front door of the office had already slammed shut.

Sylvia was gone.

*

The choice of practices was perfect. Sylvia could work a full schedule and still have time to cart the kids back and forth to their various activities. Hospitalists had taken over the inpatient responsibilities. Call duties were light and spread among a large group of physicians. The clinic closed at four.

Sylvia congratulated herself on finding the perfect post residency job. The work-life balance was exactly what she and her classmates were looking for. At first, she had been worried about being able to handle the more difficult patients. But she quickley realized that there were always specialists to refer to, and she could send the sick ones to the ER. And when the clock struck four, they were someone elses problem.

As Sylvia bent down to place her bag into the passenger seat, she felt a faint twinge of pain radiate down her stomach and into her pelvis.

I wonder what that was?

She quickly walked around the side of the car and got into the driver seat. Her son would be finishing soccer practice soon, and she didn't want to be late.

*

Upon awakening, it took a moment for Sylvia to realize that she was about to vomit. As she jumped out of bed, she felt a sharp stabbing pain emanate from her epigastrium and spread into her chest. At first her mouth watered, and then she heaved violently. Her body spasmed over and over again until she had completely emptied the contents of her intestines.

She crawled back to bed and fumbled with the phone.

Hello...hello...I need to talk to Dr. Phillips immediately.

She silently prayed that her personal physician could give her some guidance. She felt alone in the large bed left absent by her traveling husband.

Dr. Stone is on call for Dr. Phillips. Please call back If you don't hear from him within the next half an hour.

Each minute seemed like an eternity. As Sylvia watched the clock desperately, she wondered if the phone would ever ring. When she walked into the bathroom to rinse her mouth, she was taken aback by her own reflection. The whites of her eyes had turned yellow.

*

Sylvia watched the nurses bustle back and forth in the emergency room. The dose of dilaudid had calmed her abdominal pain, but not her anxiety. She was all alone. Her husband was thousands of miles away. Her parents were sleeping in her guest room next to the children.

She reached over to the table to check her cell phone. Maybe Dr. Phillips had returned her call. Maybe he would walk through the exam room doors like Marcus Welby, and grasp her hand and tell her that everything would be okay.

Unfortunately, the only one who came was the Surgical PA. He explained in an emotionless tone that the ultrasound showed choleycystitis. In a matter of moments the antibiotic would finish running and then it was time for surgery.

Dr. Carson is on the way. The anesthesiologist will explain everything and then we'll put you under.

Sylvia grasped for words as she felt a sense of terror rise from her belly.

But don't I at least get to meet my surgeon.

The PA's back was turned and he was moving quickly toward the door.

Sure. After the procedure.

*

As the anesthesiologist placed the mask on Sylvia's face, her mind raced. First she thought of her husband and children. She wished that they were by her side.

Then she thought of her parents and how they used to comfort her as a child.

But as the intense feeling of fatigue washed over her body and she started to lose consciousness, she conjured up the face of poor Mrs. Beckwith. She imagined her sitting alone in a cold room with her arm retro flexed and her hand grasping her painful flank.

She recognized the fleeting sensation of empathy.

It was something she hadn't felt recently.

Not since the early days of medical school.

Having Your Story Told

Mrs. Fitz clasped her husbands dangling hand as her son and daughter sat in the empty chairs next to the examining table. The children had brilliant black hair with the beginning of gray streaks at the edges. The family waited quietly while I maneuvered the stool into the corner so I could interact with each member without craning my head. The daughter cleared her throat to speak and looked affectionately towards her father's wheel chair.

Since you are going to help my father die, we thought you should know his story.

*

The mustang glided easily under Captain Fitz's steady hand. The World War II era fighter was reserved for only the most advanced fliers. He was finishing a successful mission in enemy territory, when he noticed a flash out of the corner of his right eye. The staccato sound of gunfire was brief but ended in a large thudding sensation that he felt in his fingertips as he struggled to control the flubbing aircraft.

Seconds later he felt a heave of pressure on his chest as the cabin rolled. He fell into a tailspin. His body hurdled violently toward the ground as the unbearable g-forces lead to a loss of consciousness. As his eyes closed for what he believed to be the last time, he pictured the pale face of his fiancee waiting innocently for his return.

Like a bird suffering from a heart attack in midair, he tumbled lifelessly out of the sky. He later calculated that he fell at least forty thousand feet. He awoke expecting to meet his maker at the pearly gates.

Instead, his first recollection was searing pain coming from his right leg. He looked down to see the bottom half of his lower extremity shattered and bent disfiguringly under his thigh.

Three men stood above him speaking in a foreign tongue. One pointed a rifle in his direction and gesticulated wildly. The other two walked calmly over to the captain and lifted him onto a stretcher.

On the thirtieth anniversary of the crash, Captain Fitz would return to the exact site and be reunited with the three men who had had every intention of killing him. But in a strange twist of fate the men decided it would be a bad omen to kill a man who had survived such an incredible fall.

*

Captain Fitz was taken to a POW camp where a fellow prisoner happened to be an orthopaedic surgeon. His leg was meticulously cleaned and splinted. His extremity was spared but his luck was brief.

The Captain refused to speak of what happened in the camp. But he survived years of torture and forced labor. When the war was over he limped back across enemy lines.

He came home to find a fiancee who had already attended his funeral. Within months they were married and soon were expecting their first child. Captain Fitz became a proud father.

He returned to school and earned a PhD. His research would eventually have profound effects on modern medicine and biology. He would educate the next generation of researchers and physicians.

As he entered his eighties, the miracles would run out. Captain Fitz developed a progressive neurological disease that first stole his words and then his thoughts. Relegated to a wheel chair, his body failed in the same manner as his mind.

As Captain Fitz sat silently in front of me on that day, his daughter's eyes brimmed with tears. His son put his arm gently around his mother's shoulder.

I took a moment to enjoy the silence. We were all lost in thought.

Captain Fitz died a few months later. None of my subsequent visits were nearly as profound.

*

Sometimes part of dying is having your story told.

Sometimes being a healer is less about talking and more about listening.

Medicare has no way of measuring such things. There are no ICD-10 or CPT codes for this kind of interaction.

But ask anyone who spends their life taking care of others.

This is where the healing takes place.

If I Die Young

It's funny how a few words, a phrase, or music can bring back buried memories.

If I die young, bury me in satin
Lay me down on a, bed of roses
Sink me in the river, at dawn
Send me away with the words of a love song

The sharp knife of a short life, oh well
I've had just enough time

I heard this song on the radio this morning. A rush of memories flooded my brain in the form of the smiling face of a beautiful little girl.

*

Hola Flaco!

Hola Flaca!

A peel of giggles erupted from the small figure enveloped by the hospital bed. Her frame was lithe and frail but her eyes were large and luminous. Sparkles of light and fire shot forth when she honored me with her melodic laugh.

I was a third year medical student and unaccustomed to the wall building that accompanies most medical education. I had been assigned to the case because I was the only medical student on the team who spoke passable Spanish.

Although we sometimes had trouble communicating, the relationship had attained a certain level of fluidity. The family called me "flaco", the Spanish word for skinny, because I had started to work out during the rotation and lost ten pounds. My clothes were hanging uncomfortably off my body and my pants were barely held up by my overextended belt.

Although the miniature girl in the hospital bed was alive with passion and spirit, her body was dying. In better times, I referred to her as "flaca", the female version of my nickname. But, as the days passed, I became leery as she lost more weight and her illness progressed. Her rampant giggling reprimanded me for my political correctness and reminded me that it was just a small intimacy between inconvenient friends.

*

Flaca was struggling. Her energy was waining and her laboratory values told the story of a fairy tale that was coming to an end. Her body could no longer sustain the repeated insults of medication and dialysis.

One night toward the end of my pediatrics rotation, she spiked a fever. The nurses hurried to administer Tylenol and draw blood cultures but they were unsuccessful. As I walked into the room with a tourniquet and butterfly needle, Flaca's eyes turned cold.

I fumbled with words in both Spanish and English to explain why I needed to draw her blood. My resident stood above me tapping her foot in disapproval because she felt there was no time for explanations.

Flaca pulled her arm away from me and spit in anger. The fear in her parents eyes was overcome by determination. They nodded at the nurse who walked over and pinned Flaca's arm down against her struggling torso. I quickly grabbed the needle and jabbed her arm. As the blood flowed, we all gasped a sigh of relief.

*

Flaca would never speak to me again. When I entered the room she would turn her head in disapproval. The frailty of her body was betrayed by the unending strength of her anger. It was as if my face had become the form of all the hurt and sadness brought on by her terrible illness.

She died a few days later. And along with her a small part of myself.

I will always hold the greatest respect for those who take care of our ill and dying children.

But I could no longer be one of them.

Practice

My son plays his violin. He practices every day. He attends group and private lessons multiple times a week. Occasionally he learns new pieces. Mostly he plays the same music over and over again. There are days when the music seems to glide sweetly from his hands with little effort. There are also days when screeching mangled notes seem more the norm.

It's a tiring process. Day after day and week after week, he struggles. He concentrates on his posture and fingering. He battles to hold the instrument in just the right manner. His fingers bend and contort. His hands cramp. His progress is measured in small increments.

And if he is lucky and persistent, he will improve. His practice will pay off. His notes will be more melodic and pleasing to the ear. He will graduate from one set of pieces and move to the next. The complexity and pace will increase.

Each time he studies a new composition, he will need extra hours of training. His arms will learn the exact twists and turns. He will repeat over and over until his mind no longer thinks of each separate movement, but learns to play as a whole.

But the violin is knowable. While there are some minor differences to each instrument, he will expect roughly the same sound from any violin he picks up. There are a finite number of sounds and notes to learn.

After countless years and thousands of hours of practice, he will approach mastery. Likely this will take decades of both persistence and luck. It is definitely possible. There are no short cuts. Some will reach mastery faster than others. Some will not reach it at all. But every one will have to put in the appropriate time.

*

I don't understand how we think we can short circuit medical education. Under the rubric of reform we are undermining our training programs.

Residents are being told that they must work shorter shifts and take call less often. As they finish their programs, they are entering their profession with less accrued experience. Their knowledge base is lacking and they learn to consult often, order more tests, and refer to the emergency room.

Primary care physicians are being replaced with nurse practitioners and physicians assistants without requiring the same requisite hours of training. While basic care is surviving, the art of the differential diagnosis and the treatment of the complex patient is being punted to specialists.

Yet my son continues to practice. In order to obtain mastery, he will be expected to study more them most residents and medical students, more then nurse practitioners and physician assistants. And he will learn this tiny instrument. With its four strings and single bow. With its countable number of pieces that move in finite and measurable ways.

No one would expect him to reach his goal without putting in the appropriate time.

Why don't we expect the same out of our medical professionals?

Hubris

The clanking of the wheel chair destroyed my memory of Tim's last visit.

He was healthy then. His long torso sat on top of spindly legs. He strode into the exam room confidently. Although he described burning in his chest, his gait and demeanor were unhindered. He seemed reassured that the work up in the hospital was unrevealing.

The cardiologist's report from the outside facility said that he had clean coronaries. He showed me the bandage on his groin to prove it. Eventually he was given the label of gastroesophageal reflux or anxiety.

His chest pain was worse then ever, but he could manage as long as it wasn't life threatening. He grinned at me as I took out my stethoscope. His exam was normal. I thumbed through the hospital records. His cardiac catheterization, chest xray, ekg, and lab reports were normal.

We discussed different treatment options and finally decided on watchful waiting. As I ushered him out of the office, I had no inkling of the torment that would soon befall him.

Hours later, he collapsed in his living room.

*

Ya, I know he has chest pain!

The caller annoyed me. I just saw Tim in the office. Why was he in the ER now?

The last thing I expected to hear was that he suffered a devastating heart attack, and was being resuscitated. I rushed to the hospital to find him in the Intensive Care Unit on a ventilator.

His status wavered from day to day. His wife and I talked about the poor prognosis and the likelihood of death. But as the days passed, Tim got stronger. When sedation was weaned, we removed the ventilator.

Tim's mind was as sharp as ever. But he couldn't talk, and he was having trouble moving his right leg. The lack of oxygen during the initial days in the ICU took its toll. Tim had suffered a stroke.

I wrote his discharge orders with a heavy heart. He was transferring to a rehab facility and then a nursing home. I didn't have privileges at either location, and I would have to surrender his care to another set of physicians.

*

Months later, Tim was leaving the nursing home and returned to my office to reestablish care. His eyes rested on the ground as his wife pushed him into the room. This was one of his bad days. I could sense the depression before I even talked to him.

I felt a great compulsion to apologize. I wanted to say that I deeply regretted not sending him to the emergency room. I wanted to explain that even when all the protocols are followed correctly, the body is a fickle master. Even the bravest of lion tamers occasionally gets bitten.

I couldn't feel the ache of the tooth marks nor the restraint cast upon his soul. It is only with great hubris that the physician pretends to understand the reality of illness.

So I sat silently next to the wheel chair and put my hand in his. A promise to unlock the bodies secrets would neither be offered nor accepted. Instead I looked him in the eyes, and gave the only thing I had left.

I'll be right here.

You're not alone!

Biofeedback

The spasms of pain were gentle at first. The large muscles of the right side of my neck and shoulder would tense and then ease up. The pain radiated up my spine and ended in my right temple. I sat at the nursing station hunched over a desk with twenty charts sitting by my side. The chair was stuck on a low setting and I had to arch my back and shoulder to reach the desk. Apparently the environmental controls for the building had just two settings: hot and cold. Today it was hot.

I rushed to finish charting so I could drive home, feed the kids dinner, and get my son to his violin class. The pain in my head ebbed and flowed. Some moments severe, like when I turned my shoulders the wrong way, others bearable.

As I cleared the dinner plates, I could feel the nausea building. We hurried to the car and arrived just in time for the violin lesson. The squeaking of bow on string compounded the stress as my cell phone was abuzz with new admissions. As I walked outside to take a call, I perched the phone between my right shoulder and head. The jolt of pain lanced through my scalp and landed above my eye. I stepped into the cold air and took a few deep breaths.

By the time I arrived home, I was fidgeting with discomfort. My stomach was raw and bilious. I fumbled with the ibuprofen container and crawled into bed. I could hear my son and daughter screeching a floor below. My wife was vacuuming the floor.

As I laid in bed prostrate, I knew there was only one way to make the pain abate.

*

Without thinking, my mind began the process autonomously. I started with slow deep breaths as I tried to disassociate myself from the searing enemy. I mentally took stock of each muscle group and localized the pain. I concentrated first on neck and shoulders, then the intricate muscles of the face. I imagined the flexed, agitated, spindles as flaming red orbs.

As I had done so many times in the past, I completed the inventory and then started the process of relaxation. I isolated each inflamed muscle group. I systemically tightened and relaxed. All the while, I visualized the muscle fibers. I commanded them to let go of the tension.

My body swayed up and down rhythmically. My torso sunk into the bed below me. I finished the muscle work and moved on to my breathing. I felt as if a tight band had been released from my cranium. The nausea was gone.

As I tried to fight sleep, my mind drifted off to childhood.

*

I could hear my mom yelling frustratedly at my father behind the closed door.

But your the doctor, what is wrong with him.

We had been to some of the best clinics in the city. I had taken test after test. Xrays, cat scans, and blood work all came up negative. The pediatric neurologist was at a loss on how to cure my headaches.

My mom and dad were struggling. I complained daily of head pain. Some days were mild, others were severe. I was missing school on a regular basis. After months of failed attempts, my mother made an appointment for me to see a new type of doctor.

As the years pass, I can no longer remember his face, but his words stick with me. He wouldn't take any more tests or draw more blood. He simply wanted me to relax in his chair and listen.

We met weekly. He called his technique "self hypnosis". He explained that we have great power over our bodies if we know how to access it. This access is granted when we bring ourselves to a state of relaxation and visualize the changes we want to take place.

He gave me homework. Each day I sat in my room alone and practiced. At first I would lie flat in bed. But as I got better, I was able to do my relaxation exercises sitting up and with my eyes open.

Over the next few months my headaches disappeared. But more importantly, I learned a life skill. Although I no longer practice anymore, I return to biofeedback often. It has helped me with both physical and emotional pain. It has improved my performance academically as well as physically.

Biofeedback has centered me as a human being.

*

My voyage into medicine has been littered with positive role models and teachers. I have many people to thank for becoming the physician that I am today.

But the truth is, this amorphous man whose face I can no longer remember, taught me more about the human body then any gross anatomy professor.