My dream is always the same.
It’s just another day in hell. I stand on the Bone Marrow Transplant unit. There are no windows. Suddenly the building starts to shake. The ceiling cracks letting in rays of sunlight. The ground rumbles below.
Sadness, grief, and despair spew from the floor. They rise as black lava erupting from the innards of the building and drag me to the street. I am swept forward as black death encompasses the earth and moves to envelop the sun. It carries me to the east, always to the east.
*
I've never thrown a punch. Never been in a fight or carried a gun. So if you ask me what it is like to do battle…I only have a limited set of experiences to draw from.
I did, however, catch a glimpse of the desperation of war during residency when I spent a month in the Bone Marrow Transplant unit. I felt continuously under fire, attacked from all sides, desperate. I experienced death every day.
It wasn't just the elderly. It was also the young. Mothers, fathers, children, no one was spared!
*
The Bone Marrow Transplant program during residency was large. There were fifty patients on the unit and then thirty scattered amongst the oncology floors. We had ten admissions a day, and the same number of discharges. On average one patient died every shift.
The job of taking care of these patients fell on two fellows, two residents, one attending physician, and countless dedicated nurses.
There are many beautiful life affirming stories that occur on a Bone Marrow Transplant floor.
This is not one of those.
*
I remember my last day on the unit. I spent the morning avoiding ambush. There were no codes. All our patients survived the night.
I stepped into Mrs. P’s room gingerly. Mrs. P had been in the hospital for over 6 months. She had a stubborn lymphoma that persisted despite treatment. She knew that she would never return home.
She knitted every morning as she watched the news. As with so many patients, our conversation moved from cordial greetings to a discussion of world events. I went through the motions of my examination as she recounted the most recent atrocities. They were particularly horrible today.
We did this every morning. She telling me who recently died, or was killed, or robbed. And I feigning interest although, in reality, I had lost touch with life outside the unit. The world could fall apart but I was too busy: scurrying after labs, running codes, and talking to family members.
Secretly trying to protect myself from the death and destruction that surrounded me.
If you listened closely to the discussions that we had every morning the essence of what was said would sound something like this:
“Doctor, I watch TV and see that in the world things are happening, and I am still here”. And dutifully I would respond, “Yes, yes, bad things are happening in the world and yet, thankfully, you are still here!”
Mrs. P’s days were limited. And my days on the unit were almost over. I worked twelve hours a day, every day, for a month. My time at home, in-between shifts, was surreal. I would sleep, eat, have conversations. They were mostly exhausted bridges to my next stint on the unit.
I had become a robot, a zombie.
I was withdrawing.
*
It was just another day in hell.
I sat down for rounds that morning. Mrs. P was right, things were happening in the world and strangely I couldn't’t relate. The TV above us was blaring the latest news. My attending was sitting down with his daily Tab and being prepped by the other residents.
The hum of the nursing station had reached a fevered pitch. I glanced at my progress notes and realized that I forgot to add the date and time. I looked at the clock on my pager:
10:45 AM
09/11/01
The world had instantly changed.
And it would take a good deal of time and spiritual healing to realize that it wasn’t just another day...
of death and destruction on the unit
Tuesday, September 10, 2013
Monday, September 9, 2013
Blood On Our Hands
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.
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.
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.
Subscribe to:
Posts (Atom)