Dystopia

He had been educated at the finest universities.  He had graduated cum laude, or whatever the term is they use nowadays to signify distinction.  His pedigree was squeaky-clean.

But as he haltingly entered the dark building at the end of an otherwise unexceptional suburban street, he felt more like a criminal than a scholar.  His office was drab.  Each room a glow with the artificial light provided by an incandescent bulb.  He often wondered whether the lack of windows was to keep the light from piercing the imperturbable darkness or to trap the terror in.

He knew his place.  He was the last stop on a frightful train line that ended in horror.  There was no solace.  His clients never dreamed of needing his services, and yet they came.  Without fail, they averted their eyes to hide the excruciating pain and loss.  He met them in life's basement.  In a lonesome quagmire, he helped them wade through the morass.

In his younger years. his work clung to his back even outside the office.  He awoke from nightmares of the vilest kind.  Remnants of the day stuck to his clothing.  He tried to scrub and scrub but they refused to fade away.  A sort of blackness pervaded his waking hours.

It was in this acrid garden that a certain soullessness grew and flourished.  He found that he could approach his clients with a coldness that became rather comforting.  Empathy wouldn't pull them through the manure laden pit that they found themselves trapped in.  His voice, certain and clinical, could.

As the years passed, his body bent and his haired thinned.  Years of tumult left scars that were far passed the point of healing.  From time to time he found himself wandering through the office on the weekends, or in the evening when no one in particular was scheduled to visit.

He sometimes felt lost amongst his family and friends.  He occasionally had bouts of agoraphobia at home with all the light and windows.

He left the office cautiously everyday and found the outside world to be a place that was no longer black nor white but filled with incomprehensible shades of gray.

And that terrified him.

Most of all.

If We Fight For It

It occurred to me towards the end of our conversation that there was a large gaping hole.  We had talked about physician burnout, career choices, and his current plans.  He had drawn a map of his future.   It originally shot like a straight arrow towards clinical medicine, but now veered precipitously.  I took a moment to first clear my thoughts, and then my throat.

Medicine, I explained, is still as noble a profession as ever.  Every day I dip my toes tentatively into the current that swirls around me.  Often I am pulled violently into the depths.  My body bumps and sways in the mass of humanity.  Our rhythms join at times and depart at others.  Amongst the tumult my mind strains to unlock riddles, my hands reach forward pawing the Rubix Cube of disjointed anatomy laid bare on my table.

I am imperfect, and it is hard.  Maddening.  I sometimes curse my own feeble abilities.  Yet this profession offers the opportunity to be with our fellow humans.   Regardless of outcome.  It offers the ability to reach an imperfect hand towards a suffering soul.  Over and over again.  On weekends, on holidays, in the middle of the night.  When it's inconvenient.  When it really matters.

You become the beacon of light to someone's darkness.  The epitome of meaning, wrapped in a profession, crafted over years of practice.

There is nothing that I would rather due for a lifetime.  No profession more worthy.  No pastime more challenging.  No calling more sacred.

We suffer today not from a failure of training nor a mighty profession gone astray, but from the greedy, lecherous, and diabolical distortion foisted upon us,

We suffer from a government so mired in special interests that often the most simplified and logical tasks become overly burdensome.  Administrators with little knowledge of actual medical practice add layers of bureaucratic minutia on the backs of hapless workers.  Computer systems are generated with the wrongheaded idea of Big Data collection as they further warp severely strained processes.

We suffer from big business, hospitals, and insurers bent on squeezing every last cent from a system where they produce nothing.  They repackage the knowledge and ability of their clinicians, and slap a brand new inflated price tag.

And we suffer from ourselves. Our medical societies who pat our back with one hand while picking our pockets with the other.  Our physicians who have lost their way, and traded in this holy art for a chance to feast on the leftovers from the carcass of their debilitated brethren.  

The doctors who value bloat, cruelty, over-testing, and over-diagnosis to add to their wealth and not the health of their patients.

Medicine can still be noble and worthy.

If society allows it.

If we fight for it.

Being Your Doctor Is...You Pick

Being your doctor is exhilarating.

Everyday I wake up to a schedule brimmed with purpose.  The door of my office is a portal into the richness of the human experience.  I become a thread in the tapestry of other's lives.  I bear witness to the joy and pain, laughter and heartache,  and mundane daily routine.

I spend my days bouncing between art and science.  Paid to be the wily detective, my brain stumbles on detail.  Some cases are typical, quickly resolved with an adjustment here or there.  Others are more enduring, months are spent contemplating the possibilities until answers present themselves.  The sick become healthy.  The terminal are comforted and allowed a soft place to land.

A familiarity grows out of the wisdom of experience.  An acceptance of the limits of human knowledge.  Self acceptance soon follows.  The connection between me and my fellow man is the bedrock of my professional existence. I help people solve problems.

I make a good living.  My title still carries a certain amount of respect.  Job security is a good bet.  And my days are anything but boring.

Being your doctor is excruciating.

Everyday I stare into the abyss of humanity.  I become a party to every patient's agony and despair.   I have witnessed pain and loss that endure.  My mind is scarred from an invisible emotional battle much like the physical ailments of an infantryman.

I am haunted by countless decisions that profoundly affect other's lives.  The devil hides behind every dichotomy.  Poking out it's steely head, waiting to attack the supple underbelly.  I remember each battle lost, each face.  Until the next horrific calamity erases the last.  Over and over again.

I rarely sleep uninterrupted.  My phone rings while I'm taking a jog, in the shower, or on the toilet.  Occasionally a nursing home thinks my mobile is a fax number, and my phone rings over and over again in the middle of the night, waking my family.

I am constantly told that I am wrong by technicians, administrators, insurers, and the government.  I often have to fill out the same paperwork over and over again.  I sign thousands of papers a month for what appears to be no reason.

I often feel crushed by both the enormous responsibility and stupidity that the American healthcare system has placed on its doctors.

Being your doctor is...

Have We Lost Our Heart?

There was once a little boy who loved to draw.  He would wake up every morning, pull out his box of colored pencils, and let his hands explore the promise of a pristine sheet of blank paper.  For him, the canvas was anything but empty,  images and ideas exploded out of his mind and magically appeared on the pages in front of him.

His parents and teachers recognized his talent early in childhood.  Accordingly, he was afforded the luxury of the finest education.  His ability grew with each class and workshop.  He graduated college among the most gifted, and found work in one of the finest drawing shops in the country.

Here, surrounded by his friends and peers, he found his daily work to be anything but taxing.  Every morning he would role up his sleeves, open the very same box of colored pencils, and draw from the early morning to the late evening.  The time would pass by unnoticed as his mind wandered, and his hands dutifully followed suit.

Others would watch in astonishment as his creations took form.  They came from far and wide to witness the miracle.  Every drawing was lovingly produced for its exact purpose.  He was an expert.  A master whose skill was honed from countless years of repetition, innovation, and experience.

It was in this state that he toiled for many years, happily fulfilling his purpose, until the day the mandates started to roll in.  His shop was bought by another, management changed.  The first directive was annoying, but easy enough to comply with.

Straight lines were no longer acceptable.  Zigzags, however, were allowed.  So he substituted where he could.  He found that if he worked slowly and laboriously, he could make such small lines that from afar his zigzags looked straight.  A pain to say the least, but a fair approximation in the end.

Next came the war on green.  His boss appeared at his desk one day and fingered through his box of pencils, removing anything with a greenish hue.  Again, a work around was fashioned.  Blues and yellows were carefully mixed to create the right effect.  Some shades were easy, others could take hours to get just right.

As usual, the boy who had now become a man, refrained from raising his voice in defiance.

The directives flew out of the C-suite at a maddening pace.  Some were perfectly reasonable, others were odd and senseless.  All required an accelerating amount of time and concentration to be compliant, and yet still create a product that he could be proud of.

He no longer enjoyed his work.  He often left the office past midnight, and refrained from whistling on his walk home.  He even stopped drawing for fun.  He didn't have the energy or interest in reading up on new techniques.

And the sad truth was that his drawings were technically flawless.  They followed each directive expertly, but one couldn't help but notice that they had lost their purpose.

They had lost their heart.

His bosses shook their heads approvingly.

His customers turned their backs and mumbled,

and never returned to his office again.

On The Internet

Of course there are patient archetypes.  We all use them.  I mean, there is the old lady that is super sensitive to even the smallest dose of just about every medicine.  The psychiatric patient whose allergy list runs a mile long.  The drug seeking guy that swears his pills were stolen from his suitcase yet again.

My favorite is the widowed war hero.  His unrequited love for his deceased spouse pervades most visits.  He writes poetry and can carry a note to operatic proportions.  He is kind and humble.  He lives lost in a world of dreams and sweet memories.  He is both jovial and melancholy at the same time.

I have known many of these.  Taken care of them.  Watched them die.  They do so with a grace and determination which is nothing less than dignified.  They take their last breaths with a certainty and peace that I can't help but admire.  Maybe they know that they are one last gasp away from their lover's arms.

And I often contemplate whether they are right.

Perhaps we physicians also have our archetypes.  The arrogant and the too busy to be bothered.  The hand-holder.  The incompetent and the God-complex.  The automaton.

Then there's me.  I have seen myself in almost every archetype, good and bad.   And as with our patients,  these are poor constructs.  Because even though our most glaring attributes fit well into cubby holes, the reality is that human beings are so much more sloppy.

I am.

Maybe a bit introspective.

Over-contemplative.

The kind of guy who writes about being a doctor to no one in particular.

On the Internet.  

The Sh$t You Read In The Newspaper

Jim almost convinced me.  The burning in his chest, after all, could have just been gastroesophageal reflux.  He assured me that the sensation was nothing new; that he got it from time to time after a large meal and took Tums.    I couldn't, however, ignore that it seemed to worsen with activity.  The pain was bothersome enough to drag him into my office, without taking the time to make an appointment.

Jim and I argued over the EKG.  He wanted to take his prescription and go home.  No hospitalization, no blood tests, no diagnostic studies.  I grabbed his shoulder, and did my best to convince him to reconsider.  He slowly turned back toward the exam room.  A few minutes later, I gulped as I looked down at the electrocardiogram.  He was having a heart attack.  Right there in my office.  We called an ambulance and rushed him to the ER.

Jim's story is nothing new.  I can recall countless episodes of personal beliefs contradicting my strongly held suspicions as a clinician.  I have begged, pleaded, and occasionally dragged unwilling patients back to the office or into the emergency room.

And occasionally I have saved their lives, or interrupted a malignant disease process before the effects could become irreversible.

Sometimes we are not so lucky. Many clinicians can recall a case in which they had been lulled into a false sense of security by a patient's own certainty.  There is nothing worse than a call from an emergency room, specialist, or coroner notifying you of a deadly misjudgement.

Conversely, everyday we face patients who are utterly convinced that they know what is wrong.  These beliefs, occasionally correct, but often heretical can be terribly difficult to dispel and lead to over-testing and over-diagnosis.

It's quite a slippery slope.

So when I read in the newspaper about the latest story of the mishap patient who was certain of the correct diagnosis, yet their pleas fell deaf on their doctor's ears, I kind of get it.

The layman's diagnosis is often wrong, but sporadically on target.  It takes great courage and concentration to accurately weigh the data, the patient's beliefs, and empiric science.  We actually get it right far more often than not.

We often listen to our patients, and take their beliefs into account.

But you mostly don't read about that in the newspapers.

Are You Proud Of Your Patients?

It was only afterwords that I wondered if I had been condescending.  The words had come out so naturally.  We were sitting across from each other in the nursing home.  It didn't take a doctor to recognize that his leg was visibly less swollen.  I had seen him walking down the hallway with the physical therapist.  His face a mix of pain, concentration and triumph.

Each day had brought improvements.  The range of motion was returning.  His strength was growing.  His body balanced now with only the most minimal of assistive devices.  What had once been disability had transformed to normal physiologic functioning.  

In medicine we often talk in the most passive of manners.  We say that the knee is improving, or the wound is closing.  We talk as if healing is a mere act of God.  A blessing that is bestowed on the weary from time to time in a somewhat whimsical manner.   

And I am not a denier that randomness pervades our experience in hospitals and medical clinics.  But I have been trying to be more cognizant of the role that human will plays in the rehabilitation of both body and soul.  The force and strength, the sweat and tears, the physical act of becoming healthy.

So I said what was on my mind.

You know, I'm really proud of you!

Funny words coming from a middle aged doctor to his geriatric patient.  But his face lit up, and I could see that he was thankful for the recognition of the difficult road he had travelled and barriers that still lay ahead.  It wasn't condescending.  It was a truthful moment that transcended the artificial barriers between doctor and patient.  I was just an innocent bystander acknowledging the remarkable personal will it took to get better.

I feel both awe and pride, frequently, at the strength and endurance of those patients that fill my moment to moment existence.  

From time to time, when appropriate, I try to let them know that.