I have blood on my hands.
No matter how hard I scrub, the fingers retain their burnt hue.
Many cannot see what I see; They cannot feel what I feel. They look at me with my crisp white coat, picturesque family, and all the trappings of middle class success. I am a doctor. I am to be envied. How dare I suggest that the profession that has buoyed me through this tumultuous economy is flawed? I should be thankful.
And indeed, I am, on those days when I see past the red. For there is a dark secret bouncing in an out of the minds of those who took this oath. None of us escape. Not even the ones who no longer "touch" patients. The pathologist has the image seared on his brain of the slide with neglected cells. The radiologist spies a lesion in every chest to make up for the one that was missed.
Those of us with our fingers deeply enmeshed in the bowels of human suffering have more tangible remindings of our shortcomings. How many decisions were made with the best intentions but faulty logic? How many lives were taken? I'm not talking about malpractice here. That's too easy. I'm referring to climbing out on the branches of thousands of small decision trees with simple yes or no answers but dyer consequences.
How many of the rest of you live with the fallout of these type of decisions?
How many of you can track the fatherless child, the husbandless wife, or mourning sibling to a choice that you were in charge of making?
I can.
No one told me that no matter how many lives I saved, there would be scars, wounds that would never heal. No one told me that like the most base of murderers, I too would have blood on my hands.
This is my privilege. This is my envy.
I grew up without a father. I understand the pain of premature death. I am fully aware of the consequences of my decisions.
I would not choose this profession for my children.
The pure act of doctoring is enough to give merit to the sacrifice. But today we practice a bastardized art. The power of touch has been overtaken by expensive machines. A knowing glance and kind smile have been reserved for the computer screen.
And true love and empathy have been replaced by fear of a tort system that accuses and a government.
A government bent on destroying a profession we hold most sacred.
Monday, September 9, 2013
Thursday, September 5, 2013
Worrier In Chief
Saul couldn't have been a nicer guy. The story behind his arrival to the nursing home was long and sorted. But now we had a black gangrenous foot to deal with. The culprit, not the toe ulcer that brought him in to the hospital in the first place, but small thrombosed blood vessels from heparin induced thrombosis and thrombocytopenia, a reaction to a medication given as a precaution.
The vascular surgeon was equivocal, amputation versus watchful waiting. Toes can autonecrose (self amputate), but when the black tide of dead tissue spread towards the ankle our options became limited. As the white count began to rise, I had the wound care nurse unwrap the limb. Fluffs of inflammatory transudate soaked the dressing but no signs of active infection.
The leukocytosis (high infection count) was bothersome. Although the course of vancomycin had been long finished, the specter of clostridium difficile remained. And of course there was the polycythemia to deal with. A bone marrow disorder, the white count could shoot up for almost any reason, especially since he had been taken of the hydrea (treatment for polycythemia) as a precaution while treating the bowel infection.
So there were multiple possibilities: inflammatory reaction to necrotic tissue, C Diff, polycythemia, other infection? When the diarrhea began it was almost a relief. Cultures were resent, vancomycin and flagyl started, and daily INR's to track the interaction between coumadin (started to allay the risk of clotting with untreated polycythemia-hydrea on hold because of C Diff) and antibiotics.
Saul, though, had no fever, no abdominal pain, and the diarrhea slowed within days of starting antibiotics. But the white count (infection) was now heading towards thirty and the platelets were over a million. I tracked down the infectious disease specialist while in the hospital and briefly discussed oral antibiotics vs intravenous Tygacil. I paged the hematologist and we debated restarting hydrea in case this was just a noninfectious leukamoid reaction.
When cases are starting to get out of control, I like to sit and talk to the patient. Saul, bless his heart, was probably too demented to understand the complexities. His daughter, however, was involved and interested. We discussed the upcoming surgery. We talked of my clinical impasse between infection and inflammation. She was more concerned with her dad's comfort than prolonging his life.
And Saul was as happy as a lark. His functional abilities were declining, but his biggest complaint was being stuck in the room due to isolation from his infection.
Ultimately I decided to give the antibiotics a little more time. I held off on hydrea, and gambled that the high white count was more a reaction to the foot necrosis and less so infection. I watched tentatively at his bedside, visiting the nursing home daily.
Saul's dilemma bubbled up in my mind, even at home. Occasionally waking in the middle of the night with a startle, I wondered if I was missing something.
With time the white and platelet count started to abate. The diarrhea disappeared. A surgical date was set and another flurry of calls was made to figure out the anticoagulation. Coumadin needed to be stopped, lovenox was risky given the HITT syndrome, and no one wanted to put him in the hospital for agatroban. The hematologist thought that Arixtra would do, and be a nice middle ground.
Saul is by no means out of the woods, but there are signs of improvement.
***
When people ask what an Internist does, I sometimes have to pause. Unlike common perception, our job is much more complex then treating colds. We are not just followers of our specialists directions. What always surprises medical students is that when the lab results come back, or the phone rings in the middle of the night, the specialists are long gone. Often I have to take all the information I have gleaned over time, and make the call.
Hydrea or no hydrea.
Infection or inflammation.
Aggressive treatment or palliative care.
I guess I would say that my job is to think deeply, build consensus, and help families plan. I do this for a few in the hospital, seventy in the nursing home, and two thousand outpatients.
Everyday.
Call me an Internist, a primary care doctor, or a flea. The sign on my office door will tell you how I feel about it.
Worrier In Chief
The vascular surgeon was equivocal, amputation versus watchful waiting. Toes can autonecrose (self amputate), but when the black tide of dead tissue spread towards the ankle our options became limited. As the white count began to rise, I had the wound care nurse unwrap the limb. Fluffs of inflammatory transudate soaked the dressing but no signs of active infection.
The leukocytosis (high infection count) was bothersome. Although the course of vancomycin had been long finished, the specter of clostridium difficile remained. And of course there was the polycythemia to deal with. A bone marrow disorder, the white count could shoot up for almost any reason, especially since he had been taken of the hydrea (treatment for polycythemia) as a precaution while treating the bowel infection.
So there were multiple possibilities: inflammatory reaction to necrotic tissue, C Diff, polycythemia, other infection? When the diarrhea began it was almost a relief. Cultures were resent, vancomycin and flagyl started, and daily INR's to track the interaction between coumadin (started to allay the risk of clotting with untreated polycythemia-hydrea on hold because of C Diff) and antibiotics.
Saul, though, had no fever, no abdominal pain, and the diarrhea slowed within days of starting antibiotics. But the white count (infection) was now heading towards thirty and the platelets were over a million. I tracked down the infectious disease specialist while in the hospital and briefly discussed oral antibiotics vs intravenous Tygacil. I paged the hematologist and we debated restarting hydrea in case this was just a noninfectious leukamoid reaction.
When cases are starting to get out of control, I like to sit and talk to the patient. Saul, bless his heart, was probably too demented to understand the complexities. His daughter, however, was involved and interested. We discussed the upcoming surgery. We talked of my clinical impasse between infection and inflammation. She was more concerned with her dad's comfort than prolonging his life.
And Saul was as happy as a lark. His functional abilities were declining, but his biggest complaint was being stuck in the room due to isolation from his infection.
Ultimately I decided to give the antibiotics a little more time. I held off on hydrea, and gambled that the high white count was more a reaction to the foot necrosis and less so infection. I watched tentatively at his bedside, visiting the nursing home daily.
Saul's dilemma bubbled up in my mind, even at home. Occasionally waking in the middle of the night with a startle, I wondered if I was missing something.
With time the white and platelet count started to abate. The diarrhea disappeared. A surgical date was set and another flurry of calls was made to figure out the anticoagulation. Coumadin needed to be stopped, lovenox was risky given the HITT syndrome, and no one wanted to put him in the hospital for agatroban. The hematologist thought that Arixtra would do, and be a nice middle ground.
Saul is by no means out of the woods, but there are signs of improvement.
***
When people ask what an Internist does, I sometimes have to pause. Unlike common perception, our job is much more complex then treating colds. We are not just followers of our specialists directions. What always surprises medical students is that when the lab results come back, or the phone rings in the middle of the night, the specialists are long gone. Often I have to take all the information I have gleaned over time, and make the call.
Hydrea or no hydrea.
Infection or inflammation.
Aggressive treatment or palliative care.
I guess I would say that my job is to think deeply, build consensus, and help families plan. I do this for a few in the hospital, seventy in the nursing home, and two thousand outpatients.
Everyday.
Call me an Internist, a primary care doctor, or a flea. The sign on my office door will tell you how I feel about it.
Worrier In Chief
Monday, September 2, 2013
The Anatomy Of A Hospital Admission
If Hattie had but one flaw, it was that she held her doctors in too high esteem. It was not unusual for an eighty year old woman of her culture to want to please her cardiologist. So when her blood pressure came up a little high, she was too embarrassed to admit that she had forgotten to pick up the toprol and hadn't taken it in over a week. The cardiologist hemmed and hawed, he buried his head in the computer, and eventually wrote for norvasc, a new blood pressure medication. What he didn't do was ask about whether she had regularly taken her pills. He also forgot to tell her that leg swelling is a side effect of the medication
But Hattie wanted to be a good patient. She squinted her eyes tightly and bowed her torso respectfully.
So you want me to take both the toprol and norvasc?
The cardiologist shook his head vigorously in affirmation as he reached for the door knob. He looked back, half his body already out of the room, and asked if there was anything else. By the time Hattie tried to lift her voice to answer, he was long gone. The waiting room was full and surely he didn't have time to stay around for her.
The next week, Hattie arrived at her primary care doctor's office for a diabetes check. After arriving thirty minutes late, he reviewed her chart. Although he read the cardiologist's note, the eleven page novel was so dense that he missed the part about the new prescription. He spent the majority of the visit clicking away at his computer, and making sure Hattie was up to date with her Hgb a1c and lipid monitoring. When he was about to zoom on to his next patient, she leaped up to catch his attention.
But the swelling in my feet, what is causing the swelling in my feet?
Befuddled by his computer, rushing to get to the next patient, and thoroughly annoyed by trying to address an issue other than diabetes, he sat back down and scrathced his forehead. The blood pressure was low and the legs were indeed swollen. Under intense pressure, he quickly reasoned that this must be an exacerbation of her congestive heart failure. He looked up at the clock and then down at the patient. He didn't re review the patient's medications. He didn't get on the phone and call Hattie's cardiologist. These precautions would have taken too much time. Instead he wrote her for a prescription of lasix ( a diuretic which would lower her blood pressure further) and ordered an echocardiogram.
Two days later, Hattie showed up to the emergency room dizzy and short of breath after lifting heavy boxes in ninety degree weather. She was dehydrated and had low blood pressure. This is exactly what would be expected to happen to an elderly woman who:
1.Inappropriately was put on an extra blood pressure pill because her cardiologist was too busy to ask about whether she was compliant with her medications.
2.Inappropriately was diagnosed with congestive heart failure instead of norvasc induced lower extremity edema because her primary care physician failed to illicit the history of a new medication or call her cardiologist.
3. Was exposed to high ambient temperatures.
And what happened in the emergency room? The ER doc read the history in the electronic medical record of congestive heart failure, examined the patient and saw the lower extremity edema, and incorrectly gave Hattie IV diuretic.
It was only hours later, when the hospitalist sat down at Hattie's bedside, that the tale of her woes came clearly to light. He ordered IV hydration, stopped the lasix and norvasc, and restarted the toprol the next day when the blood pressure came back up. Then he sent her home.
Now you may read this diatribe and think that my point is to trump the benefits of hospitalists or talk about the terrible diagnostic abilities of outpatient physicians.
But what I really want to say is that good doctoring takes time and concentration.
Both are commodities that most well intentioned clinicians caught in the dictates of our flawed healthcare system,
no longer have the luxury of.
But Hattie wanted to be a good patient. She squinted her eyes tightly and bowed her torso respectfully.
So you want me to take both the toprol and norvasc?
The cardiologist shook his head vigorously in affirmation as he reached for the door knob. He looked back, half his body already out of the room, and asked if there was anything else. By the time Hattie tried to lift her voice to answer, he was long gone. The waiting room was full and surely he didn't have time to stay around for her.
The next week, Hattie arrived at her primary care doctor's office for a diabetes check. After arriving thirty minutes late, he reviewed her chart. Although he read the cardiologist's note, the eleven page novel was so dense that he missed the part about the new prescription. He spent the majority of the visit clicking away at his computer, and making sure Hattie was up to date with her Hgb a1c and lipid monitoring. When he was about to zoom on to his next patient, she leaped up to catch his attention.
But the swelling in my feet, what is causing the swelling in my feet?
Befuddled by his computer, rushing to get to the next patient, and thoroughly annoyed by trying to address an issue other than diabetes, he sat back down and scrathced his forehead. The blood pressure was low and the legs were indeed swollen. Under intense pressure, he quickly reasoned that this must be an exacerbation of her congestive heart failure. He looked up at the clock and then down at the patient. He didn't re review the patient's medications. He didn't get on the phone and call Hattie's cardiologist. These precautions would have taken too much time. Instead he wrote her for a prescription of lasix ( a diuretic which would lower her blood pressure further) and ordered an echocardiogram.
Two days later, Hattie showed up to the emergency room dizzy and short of breath after lifting heavy boxes in ninety degree weather. She was dehydrated and had low blood pressure. This is exactly what would be expected to happen to an elderly woman who:
1.Inappropriately was put on an extra blood pressure pill because her cardiologist was too busy to ask about whether she was compliant with her medications.
2.Inappropriately was diagnosed with congestive heart failure instead of norvasc induced lower extremity edema because her primary care physician failed to illicit the history of a new medication or call her cardiologist.
3. Was exposed to high ambient temperatures.
And what happened in the emergency room? The ER doc read the history in the electronic medical record of congestive heart failure, examined the patient and saw the lower extremity edema, and incorrectly gave Hattie IV diuretic.
It was only hours later, when the hospitalist sat down at Hattie's bedside, that the tale of her woes came clearly to light. He ordered IV hydration, stopped the lasix and norvasc, and restarted the toprol the next day when the blood pressure came back up. Then he sent her home.
Now you may read this diatribe and think that my point is to trump the benefits of hospitalists or talk about the terrible diagnostic abilities of outpatient physicians.
But what I really want to say is that good doctoring takes time and concentration.
Both are commodities that most well intentioned clinicians caught in the dictates of our flawed healthcare system,
no longer have the luxury of.
Wednesday, August 28, 2013
The Impatient Mistress
Leave him alone, he's talking about dying again!
My son gently pulls at one of my daughter's arms as she thrusts the other towards my face. Her delicate fingers are wrapped around a small tattered paperback book. She wants me to read to her. I squint and struggle to concentrate on the words coming from the mobile phone glued to my forehead. I make menacing looks hoping they will scare easily and run off. They stand their ground emboldened by experience. My children are all to familiar with these histrionic antics.
My son is right. I am talking about dying again. Five thirty in the evening is as good a time as any. My family is accustomed to me discussing such things: at dinner, on weekends, at their cousins birthday party.
Death is an impatient mistress.
And my patients are old and frail. They wallow in the tempest of disease and antiquity. Their bodies fail at the most inopportune moments, and I refuse to learn the venerable deception of unavailability. Which means that death infuses even my most private occasions.
Yet the fault lines of our lives can also shift in sudden and cataclysmic ways. Once the growth plate fuses, the child's bones will expand no further. Missed opportunities become memories of inconsequence.
Father, husband, physician...physician, husband, father.
Moments lost.
My son gently pulls at one of my daughter's arms as she thrusts the other towards my face. Her delicate fingers are wrapped around a small tattered paperback book. She wants me to read to her. I squint and struggle to concentrate on the words coming from the mobile phone glued to my forehead. I make menacing looks hoping they will scare easily and run off. They stand their ground emboldened by experience. My children are all to familiar with these histrionic antics.
My son is right. I am talking about dying again. Five thirty in the evening is as good a time as any. My family is accustomed to me discussing such things: at dinner, on weekends, at their cousins birthday party.
Death is an impatient mistress.
And my patients are old and frail. They wallow in the tempest of disease and antiquity. Their bodies fail at the most inopportune moments, and I refuse to learn the venerable deception of unavailability. Which means that death infuses even my most private occasions.
Yet the fault lines of our lives can also shift in sudden and cataclysmic ways. Once the growth plate fuses, the child's bones will expand no further. Missed opportunities become memories of inconsequence.
Father, husband, physician...physician, husband, father.
Moments lost.
Sunday, August 25, 2013
Pedestrian
I've experienced much loss in my life, both personal and professional. It's no secret that as a physician people come and go often without warning. And I worry about my patients. Not just about diseases and diagnoses, but I think about their well being. Are they happy? Do they have enough support? Are they in pain?
The doctor-patient relationship is a bidirectional investment. Over years of visits, I have become intimately familiar with the people who inhabit my exam room. I ask about their families and hobbies, not to be a more avid physician, but to be a better human being. I am not just pedestrian. Making the right diagnosis is a joy but doesn't sustain, becoming part of the intricate stitching of the quilt of another's life is ultimately what pulls me out of bed every morning. When a patient dies, or moves, or leaves to see another physician, the effect can be devastating.
I accept the inevitability of my career choice. I hear the sound of the door closing most every time a new patient enters my office. I will journey with them, maybe for days, maybe years. I will give of myself freely and try to take sparingly. It is a familiar cycle. Seasons change.
People come and go.
When I decided to convert to a concierge practice, I hoped to retain ten percent of my patients. I fully realized that, in a sense, I was closing the door on the other ninety percent. I planned carefully. I sent my letters six months early to help people land on their feet. As the months have passed, jubilation has given way to harsh reality.
I now have to help plan for the mass exodus of many people I have spent the last ten years worrying about. I stressed over their heart attacks and strokes as well as their colds and gout attacks. I have held hands, mourned losses, and celebrated triumphant victories.
I knew intellectually what I was in for when I made this decision.
But right here, right now, in the midst of it I can't help but pause.
This humongous, cataclysmic, overwhelming loss
is nothing less then suffocating.
The doctor-patient relationship is a bidirectional investment. Over years of visits, I have become intimately familiar with the people who inhabit my exam room. I ask about their families and hobbies, not to be a more avid physician, but to be a better human being. I am not just pedestrian. Making the right diagnosis is a joy but doesn't sustain, becoming part of the intricate stitching of the quilt of another's life is ultimately what pulls me out of bed every morning. When a patient dies, or moves, or leaves to see another physician, the effect can be devastating.
I accept the inevitability of my career choice. I hear the sound of the door closing most every time a new patient enters my office. I will journey with them, maybe for days, maybe years. I will give of myself freely and try to take sparingly. It is a familiar cycle. Seasons change.
People come and go.
When I decided to convert to a concierge practice, I hoped to retain ten percent of my patients. I fully realized that, in a sense, I was closing the door on the other ninety percent. I planned carefully. I sent my letters six months early to help people land on their feet. As the months have passed, jubilation has given way to harsh reality.
I now have to help plan for the mass exodus of many people I have spent the last ten years worrying about. I stressed over their heart attacks and strokes as well as their colds and gout attacks. I have held hands, mourned losses, and celebrated triumphant victories.
I knew intellectually what I was in for when I made this decision.
But right here, right now, in the midst of it I can't help but pause.
This humongous, cataclysmic, overwhelming loss
is nothing less then suffocating.
Monday, August 19, 2013
Girls, Fast Cars, And Healthcare
It wasn't that I was so enamored with the girl herself. But as an awkward teenager, when a member of the opposite sex takes an interest, you tend to notice. We had gone on a couple of dates; spent some time together. So it took milliseconds to accept the invitation to join her and a friend for a ride in her new white Volkswagen Jetta. I slid into the back, and tried to nonchalantly fasten the seat belt. She hopped into the drivers seat with her best friend by her side.
Moments later, we were off.
The radio blared and the windows were open. My hair flew spastically in a multitude of directions. I patted the wayward tendrils and keened forward to listen. The conversation in front was lost in the rhythmic trance of radio waves. Expecting the joy ride to be over soon, I held tightly to my seat cushion as the car swerved onto Lake Shore Drive.
The rush of air was just enough to totally ablate the wild and carefree screams of the young girls in the front. Picturing them now with animated but mute faces would surely give the pair heartburn to know that this was my lasting, silly impression. I watched with slight horror as the odometer began to climb.
40, 50, 75, 100mph
We weaved back and forth through traffic. I closed my eyes tightly as the near misses became more near and less misses. I braced myself for the imagined impact. With relief the car began to slow and pull over to the right. The music was abruptly stopped, and the sound of approaching sirens filled the air. The policeman sauntered out of the squad car, and rested his elbow on the open driver's seat window. He looked at the two crimson faces in the front, then smirked at my pale white facade.
Her license was suspended for a year.
As I grew older and more confident, I developed the ability to speak up and not get myself into such situations. But as a hormonal teenager, there was definite gain in remaining silent: being cool in front of the object of my affection.
Unfortunately, as adults, we are confronted with many similarly confusing and difficult situations. Being a doctor, my patients often ask for tests or treatments that I don't feel comfortable dispensing. Every day I am approached for antibiotics, narcotics, and cat scans, usually in the absence of medically reasonable indications.
And like the teenager, there are many gains to being silent and acquiescing. Happier patients refer their friends. Happy patients rarely sue their doctor. Happy patients score their physicians better on quality surveys.
Yet studies are beginning to show that contented patients cost our healthcare system more, and suffer greater morbidity and mortality.
I'm all for shared decision making. When reasonable options exist (including declining care), I believe our patients should be fully informed. But some in the ranks of healthcare reform opine that patients should always be the driver of care. They say that a well informed patient can make the right decision even if it is deemed by the physician as unnecessary or even harmful.
To me, that sounds alot like getting in the passenger seat of a car with a sixteen year old girl for a 100mph joy ride down Lake Shore Drive. It may sound appealing at first.
But in the end it's downright dangerous.
Moments later, we were off.
The radio blared and the windows were open. My hair flew spastically in a multitude of directions. I patted the wayward tendrils and keened forward to listen. The conversation in front was lost in the rhythmic trance of radio waves. Expecting the joy ride to be over soon, I held tightly to my seat cushion as the car swerved onto Lake Shore Drive.
The rush of air was just enough to totally ablate the wild and carefree screams of the young girls in the front. Picturing them now with animated but mute faces would surely give the pair heartburn to know that this was my lasting, silly impression. I watched with slight horror as the odometer began to climb.
40, 50, 75, 100mph
We weaved back and forth through traffic. I closed my eyes tightly as the near misses became more near and less misses. I braced myself for the imagined impact. With relief the car began to slow and pull over to the right. The music was abruptly stopped, and the sound of approaching sirens filled the air. The policeman sauntered out of the squad car, and rested his elbow on the open driver's seat window. He looked at the two crimson faces in the front, then smirked at my pale white facade.
Her license was suspended for a year.
As I grew older and more confident, I developed the ability to speak up and not get myself into such situations. But as a hormonal teenager, there was definite gain in remaining silent: being cool in front of the object of my affection.
Unfortunately, as adults, we are confronted with many similarly confusing and difficult situations. Being a doctor, my patients often ask for tests or treatments that I don't feel comfortable dispensing. Every day I am approached for antibiotics, narcotics, and cat scans, usually in the absence of medically reasonable indications.
And like the teenager, there are many gains to being silent and acquiescing. Happier patients refer their friends. Happy patients rarely sue their doctor. Happy patients score their physicians better on quality surveys.
Yet studies are beginning to show that contented patients cost our healthcare system more, and suffer greater morbidity and mortality.
I'm all for shared decision making. When reasonable options exist (including declining care), I believe our patients should be fully informed. But some in the ranks of healthcare reform opine that patients should always be the driver of care. They say that a well informed patient can make the right decision even if it is deemed by the physician as unnecessary or even harmful.
To me, that sounds alot like getting in the passenger seat of a car with a sixteen year old girl for a 100mph joy ride down Lake Shore Drive. It may sound appealing at first.
But in the end it's downright dangerous.
Friday, August 16, 2013
A Review of @danielleofri What Doctors Feel
When I started residency in July of 1999, I felt confident that I was doing my life’s work. I came to the hospital early the first morning. The chief physician brought me to the third-year resident who was covering the patients who would become mine. This was the resident’s last day of training. I will never forget the phrase my chief used when introducing him.
He said, “This is John. You’re taking his patients. Today is his last day of residency. He can’t be hurt anymore!”
My thoughts raced. What did he mean “can’t be hurt”? Who was hurting him? And why couldn’t he be hurt anymore? Unfortunately, I would eventually learn.
*
In What Doctors Feel:How Emotions Affect The Practice of Medicine Danielle Ofri plays us like a celebrated cello concerto.
Piano
In the beginning she caresses the strings softly, piano. Her fingers dance around the definition of empathy . Her stories (the rape victim and the cockroach, the patient with ulcers incompatible with life)are the vibrato giving color and nuance. The pace is still humble, andante, as she asks if we can build a better doctor. This is Danielle the scientist. She delves into notable clinicians and teachers, and touches on studies of how empathy affects patient care.
Mezzoforte
The volume grows as we enter the chapter "Scared Witless". Here we encounter the complexities of physicians as fallible human beings. She struggles with her first chance to run a code, stumbles over a forgotten psyche consult, and trembles at a missed life threatening diagnosis of a pulmonary embolism. She describes the fallout of medical errors:
There's no easy answer about how to proceed onward in daily medical life with the ongoing churn of anxiety and fear, and certainly no research to guide us. Each doctor has to come to terms with it and negotiate an individual emotional armistice.
Forte Fortissimo
The thrum becomes loudest and most persistent In a "Daily Dose of Death". Here we meet Eva and learn of her heartbreaking experiences as a pediatric resident. Ofri transitions from the calm cool scientist to the impassioned story teller. Although the narrative is always controlled, the reader is punched in the belly by the raw staccato jabs. She follows with "Drowning" where we see the poor coping mechanisms Joanne (and so many other physicians) use to deal with burnout.
Finale
In "Under The Microscope" we come full circle with a discussion of malpractice and the physician psyche. Both the scientist and story teller intertwine. Piano, fortissimo, vibrato. We at last learn of the ultimate outcome for Julia, the heart failure patient, whose story meandered through the chapters and set the overall tonality.
We end where we began, not doctor and patient, but two human beings traveling the same lonely road.
*
I only have a minor criticism for this wonderful book. My quip is that Ofri refuses (and this may be her true brilliance) to name the emotion that kept coming to mind as I read. She answers the question posed by the title with such words as fear, shame, grief and anger. Yet I can only imagine she purposefully uses pain sparingly.
Why?
As a physician, pain is the apparition that hides behind the closet door of my nightmares. Pain is what I felt when I told the three unsuspecting women that their father died knowing that I had fumbled in the ICU with the intubation. Pain is what drove my chief resident on my obstetrics rotation to break down after standing by helplessly as a mother stabbed in the neck, and her unborn baby, died. Pain is realizing that you are not the hero you hoped you would become, and that medicine is opaque, murky, and just plain messy at best.
The chief physician from my residency program had it all wrong.
I too felt at the end of my training that I couldn't be hurt anymore. I was drowning in the steely leather of self protectionism. But then in October of 2004 my world radically changed with the birth of my son. When I looked into his eyes looking back at me with complete trust, the barriers that I had erected since those horrible days of residency came down. I could cry again. I didn’t have to shield myself anymore. And I began to understand the meaning of empathy.
It is only when we allow the pain to flow through us unhindered and mix with the joy and awe, that we are truly free. Danielle realized this much earlier in her career then I did. Not only friendship and caring, but pain is the tie that bound her to her beloved patient with heart failure, Julia. In hurting she transcended the physical barrier and truly walked a mile in Julia's shoes. This may be the greatest gift that any doctor can give a patient. This is empathy, the jump that allows us to pass over "doctor" and become "healer"
*
You want to know what doctors feel?
You have kindly read my feeble opinions.
You want a more nuanced and articulate view?
Read the book!
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