Is Doctoring Easier For Men?

She was everything one could ask for in a medical resident. During the few weeks she had been shadowing in my office, I found her fund of knowledge to be exceptional. Her intuition was right more times than not. And she negotiated the fine line between detached clinician and caring advocate. My patients loved her.

Did I forget to mention that she was exceptionally attractive? I hope so. I really feel that such things have little relevance in medical training (or life in general). Sure, I could tell that she was careful about how she presented herself. She dressed over-conservatively in an attempt to deflect attention from her looks. I occasionally noticed a prolonged stare by a young patient or a twinkle in an elderly gentleman’s eye, but for the most part everything ran smoothly.

Read the rest of my post at The Medical Bag.

The Spoils Of War

There was once a kind and merciful General.  His joy of the study of war could only be matched by his love for the soldiers who trained dutifully beneath him.  Day in and day out, he could be seen in the barracks beside his men.  He was both dogged and forgiving, relentless but affable.  His mind was laser sharp, and his physical agility could match that of any of his much younger recruits.

He was a nationalist.  More willing to devote his life to the calling of country than to risk those of the young people who gathered around him.  So his attention to detail was incessant, his expectations for his pupils absolute.  His men both feared and adored him.  Their greatest dread was disappointing the man who placed so much energy into their training.

And this General gained the reputation of having the tightest, most well trained crew. Their physical abilities only outmatched by their mental toughness and strategic planning.  Other troops vied to join this proud gathering of young men.  Many found that they were not tough enough, their skills too weak.

Because of his great ability and courage, the General was often asked to lead his men into battle.  He studied each engagement with great concentration, and spent many a night locked away in his office trying to divine the infinite possibilities of war.  He did not take such responsibilities lightly, and felt the acute sting of placing his troops in harms way.

There was one painful truth to being the General.  While he studied maps and battle formations, it was his men who put their lives on the line.  He encouraged, threatened, and persuaded such young hearts to risk all for him.  For country.  

He had once done so.  He had watched his brothers fall in battle beside him, and yet carried on.  He had tasted both blood and sweat stream from his own brow.  He had seen many victories and quite a few losses over the years.  He survived long enough that eventually he was promoted out of the line of fire.  His knowledge and abilities were now thought too precious.

Year after year he toiled in the name of war.  Engagements were won and lost.  At the end of the day it was often hard to tell the difference. Each battle zone was littered with the bodies of men whom he loved dearly.

Some lives saved,

others mortally wounded by decisions that only he could have made.  

Mortally Wounded

Neither of the two most important people in Aaron's life could stand to be in the same room with each other.  There was a long colorful history between his ex-wife and his brother, and as his disease began to accelerate, the feuding became quite intense.  They argued over Aaron's advance directives.  They both tried to coerce and manipulate themselves into commanding positions.  The shouting became louder, the fury more fierce.  Aaron, for his part, was fading under the colossus of his difficult to treat leukemia.  Any bit of energy left after chemotherapy, was quickly snuffed out by his loved one's bickering.

We talked in the office the day before he was to enter the hospital for the bone marrow transplant.  He was afraid.  His brother sat quietly by his side and listened intently.  A truce had momentarily been arranged.  Aaron's ex would drive him to the hospital and keep him company until his brother got off work.  The next week was then cleaved between schedules and availability.  Each visit timed precisely in order to avoid an unexpected crossing of the two offended parties.

Everything went as planned, until it didn't.  Hospital's rarely run on tight schedules, and neither do people.  Before long, Aaron's brother was angry because the chemotherapy schedule had been changed.  And his ex's car broke down and she couldn't come when promised.  The inevitable chance meetings between the two became a poignant explosive metaphor for the turmoil taking place in Aaron's body.

I walked into his room on the morning of the actual transplant.  Aaron was sitting alone in bed trembling.  He was tired and afraid.  His brother and ex had run into each other in the hospital lobby, and both left the premises fuming.  Consumed by their hatred for one another, they abandoned Aaron in his greatest time of need.

Eventually, I raced out of the hospital to drive across town to my first appointment in the office.  By then the nurses and doctors were shuffling in and out of his room.  But Aaron had no confidant; no protector from all that the cancer, chemotherapy, and the hospital had to ensnare him in.

He was alone.

A victim of a disease,

mortally wounded by those purported to love him.

Health Care's Newest Dirty Word

As a child, I loved games of strategy. Whether it was Monopoly, Stratego, or Risk, certain themes pervaded. One had to learn how to think multiple maneuvers into the future and form beneficial partnerships to survive the onslaught. The goal, of course, was total world domination. The game was over when one side was economically or physically manipulated into full capitulation.

I have carried these strategies with me on my long voyage through medical education and doctorhood. Disease, the great evil adversary, is wily and deft.  The ability to foresee her courageous moves, plan and prepare for the future, and meet her on the battlefield is a skill that every physician must obtain.

The political maneuvering and manipulating, however, was something that I was always grateful to be able to avoid in this laudable profession. Unlike my friends in the fields of business, law, and accounting, there were minimal office politics. My relationships were formed out of mutual respect and admiration, rarely out of a strategic need to protect myself. My naiveté, it turns out, was short lived.

Read the rest of my post at The Medical Bag.

Doctor On Doctor Crime

Her heart was failing; her ejection fraction was unmeasurable.  Her hip was broken, and she developed a pulmonary embolism post-operatively.  She was painfully close to death.  Yet at some point, the hospital finished, and spit her out at the nursing home.

She was confused.

I tried to take the best history that I could.  Her answers where usually no more than a single word.  Her physical exam revealed a desperately weak woman, swollen from head to toe.  Fluid seeped out of the wounds and lacerations on her legs.

I hopefully clung to the one positive portion of her assessment, it appeared that her pneumonia had cleared.  I wrote my admitting note and placed a few orders.  Forty-eight hours later, her nurse called to report a low grade fever.  I dragged myself out of a deep sleep on a Sunday morning, and came to her bedside.  Her exam was unchanged,  all catheters were clean, there was no rash. Her lungs were clear and she had no new complaints.  The temperature remained a hair below one-hundred, so I sent for a chest X-ray and urine culture.

The next morning as I reviewed the labs, my mobile rung once again.  She was confused and agitated.  Her blood pressure was unmeasurable and her heart rate was high.  An ambulance was summoned to take her to the hospital.

A few days later, I received a call from her cardiologist.  We had never met before, and he introduced himself quickly before cutting to the chase.  He wanted to know why I let his patient get so sick.  She was doing poorly, and had to be put on hospice.  He commented on how she was fine when he discharged her from the hospital.  Why had we not treated her fever with antibiotics?  His smugness brimmed as he probed further,

How can we make sure this doesn't happen again?

I was completely taken aback by his questioning.  Surely he must have known how sick his patient was.  There is no denying the mortality for an elderly person, in severe heart failure, with a broken hip (and a pulmonary embolism and pneumonia) is incredibly high.   He also likely understood that one generally doesn't treat a low grade fever without identifying a cause.

His diatribe was not a rational discourse on clinical care.  It was a witch hunt.  He was frustrated that his patient was dying, and he was out for blood from the physician he believed delivered sub-par care.

As I felt the pulse explode in my head, I took a deep breath.  Then I thanked him for his phone call and hung up.

I felt horrible for a time.  I wished our patient could have survived.  I painstakingly re-evaluated each decision.  I gave myself credit for some and not so much for others.  Eventually the pain abated because it had to.  Not because the tragedy had become any less, but more in order to continue to provide the best care possible to those who remain.

But I didn't decry the accusations as toxic as they may have been.  I didn't try to protect myself from the venom or shield my skin from the burn.  I didn't jab or parry.

Because the other side of the pendulum is the repugnant physician who lacks insight into his own shortcomings, and believes too heavily in his own righteousness.  He blames his patients.  He blames other physicians.

He often does more harm than good.

And I don't want to ever become like that.

Hands

My mother-in-law has a theory about our children, and it has to do with their hands.

My son, the eldest, would sleep from his earliest infancy with his fingers balled tightly into tiny little fists.  He was born with a herculean grasping reflex resistant to any sort of outside manipulation.  Over the months, his fingers learned how to curl around a wide variety of colorful and textured devices.  He would fixate on one toy or another, refusing to let go.  Every attempt to remove the object of his affection would be met with squawks of displeasure.  Eventually enthralled in a drunken fit of sleep or fatigued ride in the stroller, his grasp would loosen, and whatever had become his beloved thing would fall to it's peril.

Over the years his love of objects has continued.  Whether it be books or remote controlled cars.  And he has become a merchant: a dealer of things.  He often leaves for school in the morning with a small array of left over Halloween candy and returns with a handful of erasers, pencils, or other electronic doodads.  He has formed a complex bargaining system in which he somehow comes back with handfuls more than he began.

He is a fiddler, an architect, an engineer.  His fingers are antennae reaching out and probing his environment.  He is most at peace when he is manipulating.  Changing one form to another.  Fixing that which is broken.  Breaking that which is pristine.  He is continuous motion.  His hands literally consume the environment around him.

My daughter, on the other hand, sleeps with her palms open and pointing towards the sky.  And her personality, since infancy, has followed my mother-in-law's prophecy.  From her first ability to hold a pencil, she has become a creator of letters.  A giver of gifts, from an early age she would drag her babysitter down the street depositing trinkets in the neighbor's mail boxes.

She is open and emotional.  Her realm is too large and complex to be worshipped in one's hands.  She concerns herself with social graces, and has learned the grown-up habit of complementing those around her.  Incredibly smart and able, she seems much more interested in the ephemeral.  She sometimes takes the money from her piggy bank, and tries to convince us to give it away to her friends.

She is lovely.

Last night my daughter was owed a visit from the tooth fairy.  She lost her front tooth, and knew that upon awaking in the morning, there would be two gold coins under her pillow.  She questions us often about the authenticity of the tooth fairy, but then smiles her serrated grin and tells us that the fairy must be invisible.

This morning there was an added surprise.  Someone had placed an extra one-dollar bill underneath her pillow beside the two coins.  She assured my wife that this was a sign that she has been an extra "good girl" lately.  But we both know that it was my son.  He snuck into her room, gave her a kiss on the cheek, and placed one of his hard earned bills under the pillow.

I used to worry about my son's hands, but do so a little less now.

It seems his grip has loosened a bit,

and now he holds on tightly to people too.

Is Meaningful Use Killing Us?

It took days to unravel what happened.

The patient first presented to her cardiologist a few weeks prior. We figured that she must have doubled her amlodipine dose that morning, because her blood pressure was uncharacteristically low. He dutifully documented the hypotension and discontinued the 5 mg of amlodipine, not realizing that she had accidentally taken too much.

Seven days later, her systolic pressure reached the 200 mark. She, of course, didn’t know that. She only knew that her head started to hurt and that she was slurring her speech. By the time she arrived at the emergency room, she could barely move her right arm and leg.

Please see the rest of my post at The Medical Bag.