When asked about his breathing, George would puff out his chest and release his booming tenor. On good days it would seem to last for minutes; on bad, it would peter out in seconds.
If I noted the soars on his feet, he would reminisce about his infantry days. His eyes would sparkle as he described how the heal of his brand new army boots would develop holes after hours of marching through rough terrain.
And if I questioned him about his blood sugars, he sat quietly with a blank look on his face and held his arms up at his side. George was nearly blind. He couldn't read a glucometer or decipher the tiny markings on an insulin syringe.
*
George was alone. He had no living family or friends nor money to hire a caretaker. He spent his days in a small apartment that he rented after the death of his wife. His physical existence was limited by illness and geographic disability but his world was anything but small. His mind was alive with music and poetry. His heart was overflowing with memories of his beloved wife.
Every two weeks he ventured out of his apartment an hobbled over to my office. Each visit was filled with questions which he often answered obliquely with stories. I learned that his wife once worked in an exclusive club for Hugh Hefner. That to pass the time, in his younger days, he would take a twenty mile walk from city to suburbs and then back again.
As he left my office, I was keenly aware that the doctoring skills that I learned in medical school had no place here. I had metamorphasized from an advisor to a student. I had become a companion, George's last connection to the outside world.
*
When I told him that I was moving my practice, The smile vanished from George's face. He knew that he wouldn't be able to travel the thirty minutes to my new location.
With artificial enthusiasm, I promised that I would find a local doctor to take care of him. He looked more feeble than usual as he described how his next door neighbor had recently died of a heart attack. She was a year younger then George.
As I watched him amble out of the front door that day, I felt a deep pang in the pit of my stomach. I knew I was choosing my own well being over his.
It was at that moment that I decided I would take care of George at home. I could stop by his apartment a few times a month on my way to work.
*
When I called the next morning to break the good news, no one answered. A few hours later, I received a note from the local coroner.
George died the night before. The paramedics found him lying on his kitchen floor. The coroner believed that it was a natural death. When he examined the body, he found and old frayed photo clasped tightly in George's hand. It was a picture of a woman dressed in a playboy bunny uniform.
If there's a heaven, I'm sure that George has found it.
It probably looks like an upscale club with a large picture of Hugh Hefner in the corner.
And George is being served
by the prettiest woman in the room.
Monday, December 5, 2011
Sunday, December 4, 2011
Pedagogy
People often ask how I write so consistently. They wonder how I have so many stories to tell. But for me, that's like asking why I breath. My answer is always the same.
How could I not?
I wouldn't describe writing as fluid. To capture the moment to moment drama played out in the confines of the exam room is anything but straightforward. I grasp at the straws of fluency and try to clarify through garbled grammar and awkward phrasing.
But what choice to do I have? How else can I integrate the hum drum reality of family dinners interrupted by phone calls regarding code status and withdrawing life support? How do I explain why I tear up at the end of a sad movie yet negotiate pain and suffering as if I was a weatherman announcing another sunny day in San Diego.
When I stop writing my soul shrivels behind a protectionist shell. I become a shadow of the husband and father that I used to be. I transform from a healer to a nameless, faceless physician. The kind you look up in the index of some health insurance guide book.
But maybe, just maybe, when you read my words you'll feel a little bit closer to understanding.
Physicians will nod their heads in a shared brotherhood of traumatic experiences.
And patients will know that someone is finally listening.
How could I not?
I wouldn't describe writing as fluid. To capture the moment to moment drama played out in the confines of the exam room is anything but straightforward. I grasp at the straws of fluency and try to clarify through garbled grammar and awkward phrasing.
But what choice to do I have? How else can I integrate the hum drum reality of family dinners interrupted by phone calls regarding code status and withdrawing life support? How do I explain why I tear up at the end of a sad movie yet negotiate pain and suffering as if I was a weatherman announcing another sunny day in San Diego.
When I stop writing my soul shrivels behind a protectionist shell. I become a shadow of the husband and father that I used to be. I transform from a healer to a nameless, faceless physician. The kind you look up in the index of some health insurance guide book.
But maybe, just maybe, when you read my words you'll feel a little bit closer to understanding.
Physicians will nod their heads in a shared brotherhood of traumatic experiences.
And patients will know that someone is finally listening.
Saturday, December 3, 2011
The Cost Of Closure
You know Mr Miller?
I adjusted the phone on my ear as I slipped out of bed and snuck into the bathroom. I tiptoed across the floor and winced as the old hardwood started to creek beneath my feet. I craned my head and listened for signs of stirring children.
Remembering the resident holding on the line, I whispered into the cell.
Yeah. What about him? He had a choleycystectomy this morning.
I waited impatiently. I suspected that Mr. Miller had spiked a fever or needed some changes in his pain medication. It was a naive moment. The moment before I was about to hear something awful.
He coded. We were unable to revive him!
The phone slipped from my shaking hand and crashed onto the floor.
Seconds later, my two year old daughter started to cry.
*
I immediately felt out of place as I entered the church. The suit clung uncomfortably and the tie was strangling. I meandered past the pews in the front, and found a seat in the rear of the room.
As the ceremony began, I marveled at how many people had shown up for Mr. Miller's funeral. I watched as men sat stoned face and women wept silently. I searched through the crowd, but couldn't find a single familiar face.
The preacher was standing at the lectern. I tried to concentrate on his words, but It was impossible. The sweat poured down my forehead and I started to tremble.
I couldn't shake the feeling that I let Mr. Miller down. That the medical community offered cure but delivered heartbreak instead.
How did we allow this healthy fifty year old to die?
I quietly extracted myself from the chair and left mid ceremony. A few heads turned as I walked down the center isle and exited through the ornate swinging doors.
*
Sadly, I've never attended another patients funeral. Mr Miller taught me that I don't have the emotional fortitude.
The covenant between doctor and patient is sacred. My commitment to my patients well being is absolute. I vow to stand by them in sickness and in health. I will support them when they are hurting and I will tend to them when they are broken.
And when they are dying, I will devotedly attempt to ease their pain and suffering. But then the commitment ends.
Sure, it would probably be more healthy to go to the funerals. It would be personally gratifying to mourn appropriately each and every time. But when you have a hundred people die a year, it can be emotionally exhausting.
Sometimes the cost of closure
is too great.
I adjusted the phone on my ear as I slipped out of bed and snuck into the bathroom. I tiptoed across the floor and winced as the old hardwood started to creek beneath my feet. I craned my head and listened for signs of stirring children.
Remembering the resident holding on the line, I whispered into the cell.
Yeah. What about him? He had a choleycystectomy this morning.
I waited impatiently. I suspected that Mr. Miller had spiked a fever or needed some changes in his pain medication. It was a naive moment. The moment before I was about to hear something awful.
He coded. We were unable to revive him!
The phone slipped from my shaking hand and crashed onto the floor.
Seconds later, my two year old daughter started to cry.
*
I immediately felt out of place as I entered the church. The suit clung uncomfortably and the tie was strangling. I meandered past the pews in the front, and found a seat in the rear of the room.
As the ceremony began, I marveled at how many people had shown up for Mr. Miller's funeral. I watched as men sat stoned face and women wept silently. I searched through the crowd, but couldn't find a single familiar face.
The preacher was standing at the lectern. I tried to concentrate on his words, but It was impossible. The sweat poured down my forehead and I started to tremble.
I couldn't shake the feeling that I let Mr. Miller down. That the medical community offered cure but delivered heartbreak instead.
How did we allow this healthy fifty year old to die?
I quietly extracted myself from the chair and left mid ceremony. A few heads turned as I walked down the center isle and exited through the ornate swinging doors.
*
Sadly, I've never attended another patients funeral. Mr Miller taught me that I don't have the emotional fortitude.
The covenant between doctor and patient is sacred. My commitment to my patients well being is absolute. I vow to stand by them in sickness and in health. I will support them when they are hurting and I will tend to them when they are broken.
And when they are dying, I will devotedly attempt to ease their pain and suffering. But then the commitment ends.
Sure, it would probably be more healthy to go to the funerals. It would be personally gratifying to mourn appropriately each and every time. But when you have a hundred people die a year, it can be emotionally exhausting.
Sometimes the cost of closure
is too great.
Thursday, December 1, 2011
The Revolution Will Be Tweeted
The doctor/patient relationship is like a conversation. Physicians have been quiet for so long that patients feel like they are talking to themselves. But there is great import in what the doctor didn't say.
It's time you heard the view from the other side of the stethoscope.
*
I am not the government. I am not a politician. I did not choose your insurance for you.
When I accept an invitation to lunch or covet a plastic writing utensil, I am not suckling on the teet of big pharma. Chances are, I'm either hungry or need something to write with.
If you left my office with a referral for an xray, cat scan, or mri it was not given to pad my wallet. You will not see me standing in the parking lot of the imaging center high fiveing a radiologist. It is more likely that I had a clinical question that I couldn't answer with history and exam alone.
I am not sadistic. I withhold antibiotics because it is the right thing to do. Not because I want your Thanksgiving, or flight, or 20Th high school reunion to be miserable. My life would be much easier if I was less of a stickler.
When my treatment plan is unorthodox and doesn't follow protocol, it's because I saw something that doesn't fit. I am trying to balance the art and science. I do not make such decisions lightly.
And when you enter the office and I seem hurried or distracted, it's not because I don't care. Sometimes I am preoccupied with worry and fear over another one of my patients.
*
You will not hear these words on the TV. You will not see groups of physicians clad in lab coats march on Washington or leave the hospital on strike.
We vote on our feet. Doctors retire early or move to non clinical careers. Primary care becomes extinct and goes the way of the dinosaur. Hours are reduced and lifestyle is chosen over commitment.
But, If you're attuned to social media you'll catch the whispers. The discontent oozes from our keyboards and smart phones.
Because we want things to change. We want to remain physicians. Secretly we hope our words will waft into your ears and be the flint that sparks revolution.
Fundamental change is coming. The question is whether it will be for better or worse.
This revolution will not be televised.
It will be blogged.
It will be tweeted.
It's time you heard the view from the other side of the stethoscope.
*
I am not the government. I am not a politician. I did not choose your insurance for you.
When I accept an invitation to lunch or covet a plastic writing utensil, I am not suckling on the teet of big pharma. Chances are, I'm either hungry or need something to write with.
If you left my office with a referral for an xray, cat scan, or mri it was not given to pad my wallet. You will not see me standing in the parking lot of the imaging center high fiveing a radiologist. It is more likely that I had a clinical question that I couldn't answer with history and exam alone.
I am not sadistic. I withhold antibiotics because it is the right thing to do. Not because I want your Thanksgiving, or flight, or 20Th high school reunion to be miserable. My life would be much easier if I was less of a stickler.
When my treatment plan is unorthodox and doesn't follow protocol, it's because I saw something that doesn't fit. I am trying to balance the art and science. I do not make such decisions lightly.
And when you enter the office and I seem hurried or distracted, it's not because I don't care. Sometimes I am preoccupied with worry and fear over another one of my patients.
*
You will not hear these words on the TV. You will not see groups of physicians clad in lab coats march on Washington or leave the hospital on strike.
We vote on our feet. Doctors retire early or move to non clinical careers. Primary care becomes extinct and goes the way of the dinosaur. Hours are reduced and lifestyle is chosen over commitment.
But, If you're attuned to social media you'll catch the whispers. The discontent oozes from our keyboards and smart phones.
Because we want things to change. We want to remain physicians. Secretly we hope our words will waft into your ears and be the flint that sparks revolution.
Fundamental change is coming. The question is whether it will be for better or worse.
This revolution will not be televised.
It will be blogged.
It will be tweeted.
Wednesday, November 30, 2011
A Cutter's Diary
The neon lights of the hospital corridor boldly contrast the bland gray of the morning mist creeping through over sized windows. My feet shuffle and then stumble as I absentmindedly propel myself toward the ICU. My eyes shudder, deflecting remnants of last nights sleep.
At this early hour, the hallway feels like a forgotten graveyard. My reverie is interrupted by a flurry of activity. Transport personnel wheel their patients in front of the door well that leads to the operating room. Family members scurry to give one last hug, say one last goodbye, before their loved ones are pushed through the swinging doors and into the unknown.
I can't help but stare at each face as they pass by. I recognize the strange mix of terror, hope, and desperation brought on by powerlessness.
*
If Dagny Taggart existed in real life she would have been a surgeon.
Josie is standing in a circle of men who don't usually take direction from a woman. They belong to an era of medicine that has long past. Like in the days of the giants, they stalk through the hospital indifferent to their surroundings. They are cardiothoracic surgeons.
Josie presents patients like a machine gun. Each diagnosis and vital sign sprays forth in rhythmic staccato. The appearance of her torso is lengthened by her unorthodox posture; one leg is a stilt while the other folds into a triangle. Her hair is slightly disheveled from missing a night of sleep.
I watch from the corner of the room with the other medical students. Josie is pretty but not in the classical sense. Her jaw juts forward and her body is sleek and thin. As she finishes her conversation with the attendings, she strides effortlessly in my direction.
Come with me. We're opening Mr. Simpson's chest.
*
Mr. Simpson is dying. His blood pressure is dropping and his anemia is worsening. His emergent coronary artery bypass, the night before, has kept Josie busy till daybreak.
She leans over her patient in the cardiothoracic ICU. He is too sick to take to the OR, so Josie scrubs and steriley drapes him in his room. She is on the front lines of a battlefield and has created MASH unit.
She expertly removes the sternal wires and opens the chest cavity. Her eyes survey the operative site. I watch from the corner mesmerized. Her hands move with ease and fluidity. She performs a complicated dance with the attending who is functioning as her first assist. They communicate through movement without the exchange of words.
The blood pressure stabilizes. The anesthesiologist transfuses another few units. Josie closes up and takes off her gown. Their are other patients to tend to.
*
I can't help but feel a touch of anxiety as I pass by the operating room doors every morning. Sometimes there is a rush of fear as if I am the one kissing my wife and saying goodbye.
But no patient enters this solemn and sterile world alone. They are accompanied by a surgeon like Josie. Someone who has sworn to protect and cure with the precision of a scalpel.
Surgeons have been called butchers and carpenters. They have been mythologized as goons and thugs.
But, if you ask me, It takes guts to willingly put another person's life in your hands. It takes skill and mastery.
I think we owe them a debt of grattitude.
At this early hour, the hallway feels like a forgotten graveyard. My reverie is interrupted by a flurry of activity. Transport personnel wheel their patients in front of the door well that leads to the operating room. Family members scurry to give one last hug, say one last goodbye, before their loved ones are pushed through the swinging doors and into the unknown.
I can't help but stare at each face as they pass by. I recognize the strange mix of terror, hope, and desperation brought on by powerlessness.
*
If Dagny Taggart existed in real life she would have been a surgeon.
Josie is standing in a circle of men who don't usually take direction from a woman. They belong to an era of medicine that has long past. Like in the days of the giants, they stalk through the hospital indifferent to their surroundings. They are cardiothoracic surgeons.
Josie presents patients like a machine gun. Each diagnosis and vital sign sprays forth in rhythmic staccato. The appearance of her torso is lengthened by her unorthodox posture; one leg is a stilt while the other folds into a triangle. Her hair is slightly disheveled from missing a night of sleep.
I watch from the corner of the room with the other medical students. Josie is pretty but not in the classical sense. Her jaw juts forward and her body is sleek and thin. As she finishes her conversation with the attendings, she strides effortlessly in my direction.
Come with me. We're opening Mr. Simpson's chest.
*
Mr. Simpson is dying. His blood pressure is dropping and his anemia is worsening. His emergent coronary artery bypass, the night before, has kept Josie busy till daybreak.
She leans over her patient in the cardiothoracic ICU. He is too sick to take to the OR, so Josie scrubs and steriley drapes him in his room. She is on the front lines of a battlefield and has created MASH unit.
She expertly removes the sternal wires and opens the chest cavity. Her eyes survey the operative site. I watch from the corner mesmerized. Her hands move with ease and fluidity. She performs a complicated dance with the attending who is functioning as her first assist. They communicate through movement without the exchange of words.
The blood pressure stabilizes. The anesthesiologist transfuses another few units. Josie closes up and takes off her gown. Their are other patients to tend to.
*
I can't help but feel a touch of anxiety as I pass by the operating room doors every morning. Sometimes there is a rush of fear as if I am the one kissing my wife and saying goodbye.
But no patient enters this solemn and sterile world alone. They are accompanied by a surgeon like Josie. Someone who has sworn to protect and cure with the precision of a scalpel.
Surgeons have been called butchers and carpenters. They have been mythologized as goons and thugs.
But, if you ask me, It takes guts to willingly put another person's life in your hands. It takes skill and mastery.
I think we owe them a debt of grattitude.
Tuesday, November 29, 2011
Anatomy Of Dying
Two weeks ago I told a man that he was dying. We sat together in the mid afternoon haze. Puffs of snow meandered by the hospital window and wended their way down to the ground. The sun was lost behind winter's never ending clouds.
The tempo of my voice was steady, lacking variation in tenor and pitch. I clung to my lab coat as if I was floating outside the window and being blasted by the inclement conditions.
I waited coldly for a response. At first, he stared at me quizzically. His eyes asked so many questions but his lips remained still. He shook his head and sighed. I glanced above him at the ticking clock.
You're wrong. It's not my time yet!
*
Two days ago I entered the same room. I watched as my patients chest heaved up and down slowly. His laborious breathing like spikes piercing the insides of his family members. They sat somberly around his bed in a circle.
It won't be long now.
As the words slithered out, I realized that I failed to convey the proper warmth. My voice box robotic and stale. The phrase lost in a haze of familiarity.
*
Two minutes ago I pronounced him dead. The room still heavy with doubt and false expectations. The social workers and case managers huddle around the family as funeral plans are made.
And in two days, I will call his wife. I will express my condolences and ask if there is anything I can do.
Then, most likely, I will never speak to her again.
*
Two weeks from now I will tell a man he is going to die. He will sit calmly in my exam room as he shifts his weight from side to side. Although his hair has grayed and his body has weakened, his face will sparkle with youth and vibrance.
He'll stare deeply into my eyes and I'll detect a hint of mirth.
We're all dying my friend.
He will draw in a deep breath and put his hand on my shoulder.
The trick is learning how to live!
The tempo of my voice was steady, lacking variation in tenor and pitch. I clung to my lab coat as if I was floating outside the window and being blasted by the inclement conditions.
I waited coldly for a response. At first, he stared at me quizzically. His eyes asked so many questions but his lips remained still. He shook his head and sighed. I glanced above him at the ticking clock.
You're wrong. It's not my time yet!
*
Two days ago I entered the same room. I watched as my patients chest heaved up and down slowly. His laborious breathing like spikes piercing the insides of his family members. They sat somberly around his bed in a circle.
It won't be long now.
As the words slithered out, I realized that I failed to convey the proper warmth. My voice box robotic and stale. The phrase lost in a haze of familiarity.
*
Two minutes ago I pronounced him dead. The room still heavy with doubt and false expectations. The social workers and case managers huddle around the family as funeral plans are made.
And in two days, I will call his wife. I will express my condolences and ask if there is anything I can do.
Then, most likely, I will never speak to her again.
*
Two weeks from now I will tell a man he is going to die. He will sit calmly in my exam room as he shifts his weight from side to side. Although his hair has grayed and his body has weakened, his face will sparkle with youth and vibrance.
He'll stare deeply into my eyes and I'll detect a hint of mirth.
We're all dying my friend.
He will draw in a deep breath and put his hand on my shoulder.
The trick is learning how to live!
Monday, November 28, 2011
Is It Just Me?
I use the words "death" and "dying" so often that I sometimes forget that the majority of my life's work is focused on avoiding such things. In a geriatric population like mine, end of life issues are a part of everyday practice. Lately, however, there seems to be a rent in the fabric of my reality.
Where previously these conversations were nurturing and beneficial, recently they've turned quite negative. As hospice and palliative care are moving forward at a breakneck pace nationally, on the ground, there's more resistance than ever.
I'm finding that my relationships with patients and colleagues are souring around such issues. No one wants to acknowledge the elephant in the room.
Or is it just me?
*
I really hated you that day!
I see the anger migrate through her face as Agnes looks at her elderly parent. Her eyes soften when she walks over to the bed and gently combs her fingers through her mother's hair.
She is referring to when I told her that the dementia had progressed and that death was near. The evidence was incontrovertible. Her mother hadn't spoken in weeks. She wasn't eating and her weight had dropped significantly. Now her breaths were prolonged and erratic.
But the neurologist said she could live for years!
Tears drop slowly from Agnes's eyes and cling to her cheeks to avoid the perilous pull of gravity. I can see the question in her posture before her lips part to vocalize. I interrupt her softly.
A feeding tube would provide more harm then good.
Agnes stops mid sentence and her head bobs down toward the floor. Could I tell her that I don't agree with her neurologist? Should I explain that his reputation is to flog his patients well past the point of no return?
Maybe we should call the neurologist again. He says we should put in a feeding tube.
The same neurologist crucified me on the phone the week before for signing the DNR order.
*
Eventually Agnes sent her mother to the hospital for a feeding tube against my objections.
A few days later it fell out.
When her mother's heart eventually stopped, an ambulance was called.
CPR was performed to no avail.
Where previously these conversations were nurturing and beneficial, recently they've turned quite negative. As hospice and palliative care are moving forward at a breakneck pace nationally, on the ground, there's more resistance than ever.
I'm finding that my relationships with patients and colleagues are souring around such issues. No one wants to acknowledge the elephant in the room.
Or is it just me?
*
I really hated you that day!
I see the anger migrate through her face as Agnes looks at her elderly parent. Her eyes soften when she walks over to the bed and gently combs her fingers through her mother's hair.
She is referring to when I told her that the dementia had progressed and that death was near. The evidence was incontrovertible. Her mother hadn't spoken in weeks. She wasn't eating and her weight had dropped significantly. Now her breaths were prolonged and erratic.
But the neurologist said she could live for years!
Tears drop slowly from Agnes's eyes and cling to her cheeks to avoid the perilous pull of gravity. I can see the question in her posture before her lips part to vocalize. I interrupt her softly.
A feeding tube would provide more harm then good.
Agnes stops mid sentence and her head bobs down toward the floor. Could I tell her that I don't agree with her neurologist? Should I explain that his reputation is to flog his patients well past the point of no return?
Maybe we should call the neurologist again. He says we should put in a feeding tube.
The same neurologist crucified me on the phone the week before for signing the DNR order.
*
Eventually Agnes sent her mother to the hospital for a feeding tube against my objections.
A few days later it fell out.
When her mother's heart eventually stopped, an ambulance was called.
CPR was performed to no avail.
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