Legislated Out

I have a breathtakingly difficult confession to make.  A confession, that on its face, seems rather innocuous, but in many ways shakes the foundations of who I always thought I was.  How I identify myself.

I no longer love being a physician.

There, I said it.  I winced even as I strung the words together to write the sentence.  You see, to admit this is almost inconceivable.  So much of who I was and who I have become is enmeshed in this intricate quilt of a profession. I view most every aspect of my life through this lens.

How could I not?  Wanting to be a doctor is the first cognition I can recall from childhood.  A childhood marked by a learning disability which brought into contention the idea of being a professional at all.  A childhood in which a father's death became a precursor.  A foreshadowing of who I was fated to become.  I would follow in my father's footsteps.  I would finish the work that was prematurely wrenched from his clutches.  There was never a question whether I would succeed.  The calling was too great.  The pull too strong.

To deny my profession is to deny my father's legacy.  To deny my own reflection.

Yet here I stand.  It didn't happen all at once.  Medical school was difficult and time consuming, but it didn't happen there.  Residency was strenuous and terrifying, but it didn't happen there.  My first days as an attending were grueling, and sometimes awful, but also energizing.

I suppose the change happened sometime after we started using electronic medical records.  It happened with meaningful use.  And MACRA.  And Medicare audits.  And ICD-10.  And face to face encounters.  And attestations.  And PQRS.  And QAPI.  And the ACA.  And MOC. And on and on.

What I do today is no longer practicing medicine.  Instead its like dancing the waltz, tango, and salsa simultaneously to a double timed techno beat.  It's sloppy, rushed, unpleasant to look at, and often leaves my partner more confused and anxious then when we started.

I have become ineffective.  Not by the weight of ever expanding medical knowledge or even the complexity of the human body.  Instead, my hard drive is being spammed by thousands of outside servers.

But make no mistake, I'll never leave.  My love for taking care of people is unwavering.

As for the joy and utter exhilaration of what used to be...

Frankly, it's all been legislated out.

In Memoriam

The text was innocent enough.  Eddie died.  Unlike most human beings, there was no dagger of pain or even pang of grief.  Those types of feelings had long been subdued.  Instead there was just a subtle disturbance, a prick.  I found the normal platitudes bouncing through my skull and down the spinal cord, out through the arms into my hands.

He was old.
He lived a good life.
It was his time.
He didn't suffer.

Words I have said aloud so many times that now I forget to halfheartedly mumble them at all. And of course, the last is a lie.  We all suffer.  Maybe not during death, but in life.  Patients and doctors alike.  Pain is neither a blessing nor a menace, it's more like a life long companion.  A fellow traveler.

A traveler that I, overtime, have begun to ignore, to minimize along the way.  I take care of old people.  My patients die.  All the time.   Over and over again.  I have learned to take the phone call, comfort the family, and say goodbye during interrupted dinners and in-between performances at my children's school.

It's a fallacy to think that these are just professional relationships.  Medicine can only be transactional in it's most basic form.  To really care for people, you have to give of yourself.  You need to be present.  Occasionally offering your own struggles, and always your hand, your shoulder, and even your heart.

Healing is destructive, and painful.  It's taking on another's struggles to lessen their burden.  It's removing your own armor and accepting the glancing blow that rips your own skin.

I'm tired of ignoring the wounds.

Eddie was old when I met him ten years ago. He was crass and chewed tobacco.  He was rough and tough and often swore in Yiddish that I rarely understood.  His hands were thick.  They clapped me on the back every time we saw each other.

And he was so proud of me.  Last week I went to see him, he smiled broadly and proclaimed to the nursing aid that was adjusting him in bed.

That's my doktor.  Hey, where ya been?

I'm here Eddie.  I'm still here.

Now get some rest.

Barren Walls; My Thoughts On Selling Artwork

I bought my first house a few days before starting my second year of residency in St Louis.  It was a townhome actually.  Two bedrooms, one and a half baths, hardwood floors, and lots of wall space.  In fact so much wall space, that I immediately began to look for ways to adorn all those barren surfaces.

After visiting a number of local art galleries, I came to two conclusions.  I knew exactly what I liked, and art work was exceedingly expensive.  Expensive enough to not only prohibit me from decorating my house, but also from buying a single piece for my bedroom.

The easy path would have been to obtain a bunch of prints, frame them, and call it a day.

Instead, I scoured the Internet and eBay. Within days, I was able to find similar paintings, by similar artists, for half the price.  After making my first purchase, I took a few extra minutes to chat with the seller.  Over the next few weeks I spent countless hours researching, calling, and interviewing any art dealer I could find.  Some took my phone calls, others hung up.  I even spoke to a few artists themselves.

I quickly learned that there was a secondary art market with a fairly low cost of entrance.  By making a few friends, I could piggy back my purchases on those of much more wealthy buyers and obtain quite a discount.  A discount, in fact, that was much better than the art galleries I had most recently frequented.

Fast forward a few years, and I was running a business buying and selling artwork.  Originally my purchases were driven by passion for the artist, but eventually I learned to buy whatever I could sell at the best margin.  Hundreds of thousands of dollars worth of product came and went through my business any given year.

But that was the rub.  No longer was the canvas an object of my fascination.  It was now fancy paper that I could move along, and be paid in even fancier paper.   Once I bought ten thousand dollars of artwork that I would have previously coveted.  I inspected it, packed it back up, and sent it on it's way to a buyer who offered me double.

I felt nothing.  Well not exactly nothing, but the thrill had dulled.  A spark was still there, but it was deadened.  Smoothed over by years of experience dealing with beauty that came to and slipped through my fingertips with relative ease.

When I began to run my own medical practice, the extra time for such frivolity evaporated.  There was simply no way to take care of my patients, hire and fire, monitor the books, and tend to an extra business.

The memory of the precious paper never quite left me though.

Often people ask what it's like to be a doctor, to save a life, or watch a patient die.  To know that your mistakes carry such weight.

Usually my mind goes blank, and instead, I think fondly of looking at those barren walls for the first time.

Then I sit them down.  I clear my throat.

And I tell them stories about selling artwork.

Connecting Lines

I both look forward to and despise Sunday mornings.  I awake just before the sun and am on the road by 5:15am.  Although I dread being upright so early on the weekend, I rejoice because it is the only trip to work, all week, at a leisurely pace.  I see the new admits at the nursing home, run by the hospital if necessary, and return just as my family is leaving their beds.

The thirty-minute car ride gives me ample time to reflect.  I often think of my father.  A physician, he died well before I was old enough to understand who he was as a doctor, or a man for that matter.  I often wonder about the parallels.

Did he arise early on the weekend so as to come back before his kids noticed he was gone?  Did he have my bedside manner?  Or I his? Was he the kind of husband and father that I am?

Bringing up my own children has made me ponder the equal parts that go into building a young personality.  My father died when I was eight.  Was that old enough to imprint on me this drive to become a physician?  This will to work insane hours? To be relentless?  Maybe it was all genetics and his behavior had very little effect.

These thoughts make me worry about my kids.  I would give them everything they need to be happy successful adults if I just knew how.  Or maybe in the giving, I am causing harm.  Maybe I need to let them run free without direction and let will be the guide.  The possibilities are dizzying and the options endless.

So I plot and plunder as best as I can.  I sometimes dole advice and others hold my tongue. I try to be an example of honesty, and hard work, and integrity.  I fail from time to time. Or maybe often.

I woke up this Sunday morning.  Like every Sunday morning.  Before everyone else.  In order to be a good physician and father.  Driving the same roads, I had the same thoughts.  I returned home to find that my son had crawled out of bed an hour early, slipped his clothes on, and was shoveling the neighbors snow.  Apparently he also had work to do.

And time passes, memories of dad fade, and my children grow forming their own pathways.

They connect the lines between father and child.

Child and father.

Spoiled Milk

There is no use in crying over spoiled milk!

I have been thinking a lot lately about focus.  As a young physician my ability to multitask was breathtaking.  I could answer an emergency phone call from the hospital, change a diaper, and mow the lawn while stopping at the store to buy my wife flowers.  I was able to navigate the roadblocks of each day without losing stride.  Sure I sometimes stumbled, but I was up and running again without cutting precious seconds off my daily wind sprints.

Age has changed me.  Through the years my career has grown, and the number of pressing professional interruptions has exploded. But more importantly, my mental agility has slowed.  My brain is no longer as nimble at managing multiple concurrent situations.  So choices have to be made.  When I am discussing end of life options with the family of an imminently dying patient, I tend to ignore the pulling on my sleeve as my son tries to convince me to buy the latest trinket in the department store.

Choosing becomes a mode of survival.

This weekend was no different.  The holiday season ushers in a  long slog of patient care crises that usually last well into March.  Between phone calls, I tried my best to navigate family activities, errands, and nursing home rounds.

And of course, it was imperfect. I missed the end of my children's violin concert because I was being berated by another physician for the care of her family friend in one of my nursing homes.  Later that night, as my kids frolicked in the newly fallen snow, I sulked at the edges of the park consumed by a patient care issue that didn't go exactly as planned.

My wife awoke to me sitting on the bed Sunday morning charting on a hospice patient instead of chatting affably and yawning away the last remnants of sleep.  We eventually rounded up the kids for a full day of errands, capped off by a trip to the grocery store, before going to my parents for dinner.  Katie had been looking for a special brand of milk that she explained, between phone call interruptions, would somehow be well suited for our children (I was too distracted to put it all together).

When we arrived at my parents, I dutifully put the milk in the refrigerator so as not to spoil.  After dinner, I retrieved the carton and packed it away with the other groceries stuffed into a bag with a bunch of binders for my son to take to school.

That night, during more phone calls, we unpacked the groceries, got the kids settled, and relaxed a few minutes before going to bed.

I woke up this morning at 4am in a panic wondering if I had remembered to unpack the milk and put it in the refrigerator.  After a quick shower, I got dressed and squeaked down the stairs to find that my fears had been realized.  There the milk was, sitting in the doorway, next to the binders, stuffed in a bag, spoiled.

On the way to work, I looked around at the deserted streets as my car whisked through the snow.  It was a little after five and the rest of the world had not yet wiped the sleep from their eyes.  And I began to cry.

Because the wisdom I have gained from years of dealing with sickness and death has taught me that I can't go back and start the weekend over again.

And be a better dad, a better husband, a better doctor.

What's done is done.

The milk has already spoiled.

I'm Sorry

Dear Mrs J,

I would like to express my deepest condolences in the passing of your mother.  A magnificent woman, I had the pleasure of being her doctor for almost a decade.  And it was a pleasure.  During our short visits she regaled me with stories of childhood and often gently sprinkled in advice gleaned from years of experience.  Even as she began to decline, we would sit together in the nursing home and she would reach out to hold my hand.  She was a gift, your mother.  A gift that I in no way deserved.

I'm sorry she got cancer.  As a physician, there is no word worse than the word metastases.  It not only creates fear in the hearts of our patients but cleaves a chunk out of our souls.  We are never as hapless in our calling as when we admit that we are mere unarmed foot soldiers in the face of this raving beast.  We are not helpless.  We can comfort and palliate.  Cure, however, becomes an ever increasing implausibility.

I'm sorry that your mom experienced pain at the end.  Lying in bed in the nursing home, she somehow mustered a smile through the groans as the nurses and I passed through the room. She told  me that she didn't see the point anymore.  We discussed the risks and benefits of morphine, and I dutifully wrote all the orders.

And I'm sorry, most of all, that you stormed into the room that morning and ordered the nurse to stop.  That you somehow convinced your mother, in the last hours of life, that she would get addicted to morphine. That you screamed at her for not participating in physical therapy the day before because she was far too exhausted.  And that she saw you and I arguing in those last precious moments when you should have been sitting at her bedside, holding her hands, and sobbing.

Your mom is now at peace.  She will suffer no longer.

I know that you meant well.  I am all to aware that the next few years will be excruciatingly hard as you try to work through loss and maybe even come to terms with the fact that you willfully denied your mom a peaceful death.  There was probably much sadness, denial, and guilt that led you to make such decisions.

I am no longer angry.

But I'm sorry that I will not be able to be by your side during this arduous journey.  Because above being a doctor, I am an imperfect human being.  And far from above it all, I am right there in the muck with you

I cannot help you at this time.

Frankly, I'm still too disgusted.

Writing and Imperfection

For the first decade of life, I had headaches. Daily.  Every day.  Occasionally they were mild, but often severe.  I saw various doctors.  Suffered through multiple scans.  At the end of the workup, the answers were no more forthcoming than the day we began.  There was never a clear antidote.  Never a divine potion.
  
Then something magical happened.  Exasperated, my parents took me to a biofeedback specialist who taught self meditation. And my life was transformed.

I won't say that my headaches went away completely.  They didn't.  But practicing regular meditation instilled in me a confidence and a calm that revolutionized my life.  At the age of ten, I learned to manage stress, physical discomfort, and visualize the place I wanted to inhabit in the world.  It helped center me.

Although the habit of daily meditation has fallen off over the years, I still return from time to time.  Whether physical illness or mental, there is a safe harbor in times of need.  There are few practices that have been so impactful on my life. 

The last year, for many reasons, has been hard. I have found myself pulled in too many directions.  And my centeredness has skewed.  My balance faltered.

I have been thinking a lot about this balance.  As a child, it was built on meditation and thoughtfulness.  As an adult, I now realize what has been missing in the last year.

Writing.

My daily routine of putting thoughts into words had recently become too overwhelming.  My days were so disjointed that I had neither the emotional energy nor the physical time to place fingers to keyboard.

Because writing, as life, is excruciating.  Filled with psychic pitfalls, it is awkward at best and messy often.  The words come out disjointed and backwards, and rarely reflect the intangible emotion that circulates amongst the fussy neurons in my brain.

I am rarely satisfied with a piece, even after all the edits have been made.  Imperfection pervades my writing, my soul.

Yet somehow this imperfection provides that thing.  That thing which is missing most.