And You Will Answer

There is a basic communication gap between you and I.  How could there not be?  It's not what you expect.  I say you have cancer, or heart failure, or emphysema.  Full stop.  A conversation ensues.  This is not what I'm talking about.

It's more like when I report to you a series of normal lab results, and at the end flippantly mention a slight elevation of the white blood cell count.  In my mind, it is a minor issue and likely do to that viral infection that you are recovering from.  As the days pass, my words simmer and eventually come to a boil, consuming you.  The elevation could be leukemia after all.  You could be dying.  You could be like your uncle Stew who went to the office for routine blood tests and was gone a week later.  You search the Internet and are confused by what you see.  You wait anxiously to repeat the blood tests four weeks later.

The white blood cell count comes back normal.  You are relieved and tired.  It has been a long and scary four weeks.

And I had no idea that you even suffered through this.  I apologize.  The problem with familiarity is that it is easy to forget perspective.  I have spent the last few decades becoming intimately familiar with the ebb and flow of wayward lab results.  And you have not.  Frankly, I sometimes forget to look at my words, my utterances, through your eyes.  The big stuff, sure.  But it's the minor less tangible that escapes careful scrutiny.

God knows, there are also many other barriers.  I am rushing off the phone to get back to the call from the emergency room.  We are separated by an electronic elephant in the room that stubbornly inserts itself between us, and blocks my view.  There are boxes and checks to be marked, and I am stuck trying to figure out whether you are a Pacific Islander while you just want to talk about your chest pain.

Per usual, I don't have adequate answers to this conundrum.  Sometimes the gulf is overwhelmingly vast.  Although I take full responsibility, I doubt that I will always be attuned to which of my words affect you so.  Unfortunately, my experience will still color me blind from time to time.

But going forward there is one minor adjustment I will pledge to make.  One way we can work together as a team.

At the end of every visit, every phone conversation, I will train myself to ask:

Tell me what questions you have?  What haven't I made clear?

Then I will pause.

And you will answer.  

A Reconstructer Of Disassembled Parts

To say that William hardly thought about hospice would be an inaccuracy. He contemplated it, from time to time, during his thirty year tenure as a trauma surgeon.  Usually for fleeting moments before dodging the conversation or deferring to one of his more junior colleagues.  Surgeons didn't give up so easily, he reasoned.  He fancied himself a fixer, a reconstructer of disassembled parts.

Mostly, that is what was expected of him.  His patients didn't come because of cancer or chronic illness.  They came after tragedy.  Unwillingly.   Bodies sprawled on metal tables with insides amiss.  And he put them back together.  There was no time for a prolonged conversation of whether the parts should remain disjointed.

It was easier to look at his patients as parts and pieces.  Easier to round in the ICU and figure out how the puzzle fit together again, or even how the motif in the far right corner connected to the shadow in the lower left.  Complex systems no doubt.  But admittedly there was a refusal, subconscious or not, to discern the forest from the trees.

Thus, the irony was not lost on William, when his oncologist shrugged and suggested hospice care.  This was only after all options had been exhausted.  His body could only withstand so much surgery, radiation, and chemotherapy.  Upon hearing the words, William flopped onto the examining room table and thought of the many conversations he had excused himself from over the years.

His oncologist was not much better. After dropping the H word, he handed him a card with a name and phone number, and left the room.  William held onto card for a few days stuck in the pre-contemplation stage.   He then made the call.

Hospice was tolerable.  William's body began to erode under the enormous burden of cancer.  His eyes sunk, and the skin hung from his atrophied skeleton.  The nurses and CNA's were pleasant and tended to his ever increasing physical needs.  The morphine controlled his pain.

William had already made peace with leaving this world.  There was only one problem.   He had expected to die months ago.  Yet, he was still here.

He prayed to a God that he only partially believed in.  He begged and pleaded.  Take me.  Take me.

Yet he woke up every morning, opened his eyes, and loathed that he was still here.

He had long ago stopped living, and now was solely waiting to die.  Death taunted him at times, holding the prize within reach.  A storm of lethargy would be followed by a an ocean of dyspnea.  With nightfall came peace and quiet.  The next morning all would be tranquil once again.

Sometimes William dreamt that death was seeking revenge for all those lives he had snatched back from the abyss during his surgical career.  All those souls whose path and destiny were interrupted by his mechanical hands.  

He fantasized that after a horrible car accident he was rushed to the emergency room with his aorta transected and the pompous surgeon stood over his body, and licked his lips at the chance of letting the scalpel have free range.  As William begged and pleaded, the surgeon removed his mask and revealed his true identity.  And he recognized his own facade and knew that he would be taken to the operating room.

It was then that William came to terms with a reality that had escaped him his whole clinical career.

Like birth, death is just a natural life event.

A natural event, that somehow kept alluding him.

The Ear Game

If I could, I would spend all day cleaning ears.  Seriously,  There is almost nothing I do that makes patients happier.  Not diagnosing a rare disease,  not treating diabetes or heart failure.  Of course, those patients are thankful too.  But very little lights up a face more than the instantaneous relief and the rush of sound that comes when knocking loose a particularly egregious glob of cerumen.

I figure I could set up four or five rooms in tandem.  Each with a its own sink, syringe, and various plastic scooping tools.  I would spend all day excavating.  Sifting through the mud to expose tympanic membranes long buried.  I would deliver every doctors dream-sudden, immediate, uncomplicated relief.

I would spurn insurance.  Each patient would come in with ears full and leave with pockets empty.  There would no longer be any electronic medical record or meaningful use.  MACRA would be a thing of the past.  Instead, I would spend my time doing that which I was most trained to do.

Clean ears.

I would become an expert and be known far and wide.  I would be listed as one of America's Top Doctors.  I could be interviewed on the Today Show and Good Morning America about the sinister danger lurking in those funny protruding orifice (who knew orifice was the plural of orifice?)

And life would be good.

Sure, you might argue that I will miss the struggle and humanity of treating real human disease.  The rush of delving into the bowels of human suffering and trying to lift my fellow man.  I can't argue with you there.

But when you clean ears for a living, you don't get those angry calls.  The family members who are convinced that you harmed their loved ones or the drug abuser who finally met a physician who won't just fill the meds.

You don't have to worry about malpractice.  No one is going to bring a million dollar suit against you because you forgot an ear.  Or left equipment in the canal.  In fact, you most likely can stop paying those crazy twenty thousand dollar a year premiums.

When you clean ears for a living no one cares if you use an electronic medical record.  There are no books for medicare to audit.  No ICD 10 codes or CPTs when you take cash.  There are no late nights combing over documentation to make sure that you remembered to mark off smoking status or that your PQRS data are crystal clear.

You can stop wearing your pager and turn off your cell phone at night.  No more interruptions while your sitting on the toilet, or taking a shower, or god knows what other personal things you are doing when all of the sudden a nurse must immediately report a skin tear.

And when you clean ears for a living you can stop building those damn walls.  You know, the ones you make in those dark times when something hurts really bad.  The ones your fortify day after day, week after week, and year after year.  Because before you got into the ear game, there was a lot of pain and suffering.  There were late nights and honest questions of culpability.  There were those patients you couldn't save.  And those that you could save but somehow didn't.  And those mistakes you made, or didn't make, or maybe are not sure about.

You wouldn't wake up in the middle of the night in a cold sweat.  Or jump every time your daughter texted you because you thought it was the hospital.

And maybe,  just maybe,  you would stop getting up every morning before the alarm went off.

First, Dispense of False Uncertainty

First, dispense of false uncertainty.

Your father is dying.  I'm sorry.  I know this sucks.  It is horrible, and unfair, and heartbreaking.  I have been there with my own loved ones and counseled many patients through similar situations.  Your brain will try to convince you that it isn't so.  That cure is around the corner, or that if you just make the right decision everything will be OK.

Everything will not be OK.  Your father has cancer laced through his bones and inner organs.  He is bound to his bed and can no longer feed or bath himself.  He has lost interest in eating.  Although I wholeheartedly regret this,  I must not mince my words here.  My bluntness is not meant to be unkind or crude.  It is crucial that you understand where we are in order to move forward.

Death is coming no matter how much you or I wish to deny.

So let's not.

Indecision is decisive.

There will be a strong inclination to pause.  These are horrid decisions that no family member should have to make.  Yet doing nothing creates its own set of consequences.  Without actionable breakers, our medical systems can become a runaway train of horrors.  CPR will break your fathers ribs but will not remove the invaders overtaking his internal organs.  Feeding tubes and IVs will deliver nutrients, but those nutrients will more likely feed the raving beast, and less likely provide meaningful benefit to his ailing body.

Ventilators are magical and awe inspiring when they support the respiratory system of someone who will eventually recover, and conversely barbaric when they provide buoyancy to an otherwise porous ship.

You should sign your father's DNR form.  Life support will not save him, it will prolong his death.

Dignity turns process into an event.

In my interactions with your father, he has seemed a dignified and kind man.   My wish is to provide as much dignity in death as he has enjoyed in life.   To do this, we must move away from futility.  Futile medical treatment brings pain and discomfort.  Pain and discomfort turn death into a process.  A prolonged, agonizing, distressing process.

I would like, instead, to think of his life as the process and death as an event.  By treating him with dignity, managing his symptoms, avoiding unnecessary medical treatments, and providing joy in whatever ever mode possible-we can truly help him feel like he is living until the unfortunate moment he dies.

Bring it home.

I want you to know that I not only worry about your father's wellbeing, but also your own.  After his death, despite your best intentions, you will spend much time thinking about his last days.  Let's create a safe and peaceful landing place for him.

I hope to leave you with the memory that at this most difficult and important time of your father's life, you provided him selfless dignity and comfort.

You gave him one last gift.

You will sleep better during those future restless nights knowing this.

We Were There

Jordan?

She peered up at me, her face alighted by the morning haze streaming through an adjacent window.  A soft kind face, she had aged over the years.  A pair of reading glasses sat perched on her nose ready to be squinted through as she turned her attention to the ever shrinking font on the glowing computer screen in front of her.

We had been colleagues once, lifetimes ago.  My first job after residency.  She, being a few years older than I, was less of an amateur back then.  We stumbled and bumbled though those early days of hospitalism.  I remember the practice of medicine felt so raw and new.   I spent many hours traversing those winding hallways.  And it became my home.

It's hard to explain what the concept of hospital means to a physician.  It is the place where we start as novice, move to apprentice, and exist ever after striving towards mastery.  Many of our significant moments have occurred under those sterile lights.  We have seen lives saved and lost, tears shed in both joy and despair.  It is the place where we have been broken down and if lucky, built back up.

So when you happen upon a colleague on Christmas morning after over a decade, it gives you a moment to contemplate.  A funny thing happens over time.  Doctors show all the telltale signs of aging.  Our hair thins, our backs bend ever so gently forward, maybe the waistline expands a touch.  We wear our battle scars unabashedly.

Yet the hospital, our home, our outer shell, no longer reflects these changes,  Floors are remodeled, wings are expanded, computers are upgraded.  Everything new and young.  And the medical students and residents scurry through the newly updated units.  It is their hospital now.

My colleague and I.  Banished from our childhood home.  Visitors in a foreign country. Strangers in a familiar land.  We will be accepted again one day.  Not as healers anymore, but as patients.  

We may die in the place we once lived.  But the signs of our existence will have been long washed away by progress and expansion.

There will be little left of us.  Except the lives of the those we touched.  And their families and children.  And children's children.

On forgetful Sunday mornings and even on Christmas.

We were there.

Streaming From The Mental Netflix

The memory came unexpectedly.  Buried somewhere deeply in the stacks of significant but not often recalled life experiences.  My conversation with my son had dragged it up, pushed it forward, and blasted it out into my embarrassingly small space of wakeful consciousness.   And I remembered.

My son is in sixth grade and goes to the same middle school that I went to as a child.  On the few occasions I have visited, a wave of familiarity washes over me.  Feelings submersed for decades return with smoothness and clarity.  For a few moments, I remember what it feels like to be twelve years old again.

My son's interests are mainly confined to science and electronics.  I, of course, try to talk to him about subjects like politics, art, and the opposite sex.  Recently I asked him if boys are talking to girls? Dating? Holding hands?

While he immediately demurred and squirmed in discomfort,  an uninvited apparition suddenly streamed out of my mental Netflix. And her name was Christina.

Christina was in my sixth grade homeroom class.  Everyday we chatted, joked, and passed the time until the bell rang and we moved on to more serious academic endeavors.  I liked her.  She was kind, and pretty, and funny.  By the middle of the year, boys were beginning to ask girls to form more formal relationships.  They called it "going with".  It was basically equivalent to a childish version of dating.

I finally built up the courage to write Christina a note, and passed it to her during homeroom.  She opened it, read for a moment, and then put it down.  I glanced backed at her inquisitively, hoping to glean some indication of her feelings.  She folded it cleanly, and put it in her backpack.  At the end of the period she took me aside.  She explained that while she liked me, she wasn't ready to "go with" me, and that she preferred to remain friends.  She smiled affably, she laughed, and that was it.

Nothing changed.  She continued to chat with me before class.  We joked.  There was no awkwardness or unkindness.  And she never told another soul about the whole incident.

I can't remember when Christina and I parted ways.  Maybe it was the next year when we changed homerooms.  Or after middle school.  Who knows?

But I will always remember her kindness and maturity. She could have mocked me.  She could have avoided me.  She could have reacted in a thousand other possible hurtful ways which most likely would have marred my own self image as well as my future interactions with the opposite sex.

Instead she was gracious and sincere.

A sincerity that I cherish.

A sincerity that I now often contemplate as I continue the herculean effort of trying to form my daughter and son into compassionate, loving human beings.  

The Data Was Suffering

The notion began early in computer science class during Jason's freshman year.  The professor had noticed a certain elegance and zeal in his work and suggested medicine.  That was in the days of the giants when clinicians were tied to such clunky programs as Meaningful Use and PQRS.  In this antiquated milieu, Jason cut his teeth on basic healthcare architecture.

In those prehistoric years, there still remained a bias toward eye contact and empathic expression.  Thankfully, over time, the technocrats pushed the boundaries.  Jason couldn't be happier.  His hands hovered over the keyboard and his eyes took in each field with accuracy.  Diagnostic algorithms, demographic screens, drug to drug interactions.  By the end of the first year of medical school, he mastered every simulation.

Years two and three couldn't have been easier.  The newly approved glass separators made clinical encounters almost identical to the simulations. Jason was a pro from day one.  He rarely felt the need to look up from the monitor.

By residency, Jason had mastered the new duplex screen modalities.  Instant messaging allowed for multiple simultaneous visits.  Each patient's biometrics were scanned during registration and appeared  on the client visualization window.

The truth was, Jason ignored the biometrics.  He hated to connect a face to the data.  He avoided names also.  Too personal.  Too close.   He preferred raw data.  Each numeric morsel placed in exactly the right box, on the right screen, in the right folder.  Clean as can be, no mess.

Jason spent the next decade honing his skills in practice.  He rose to the top quickly.  His data was entered faster, more cleanly, and with less errors than his peers.  Such accuracy was profitable.  He qualified for almost every governmental bonus, and his year end stipend was among the highest.

Change came subtly at first.  Jason felt mild anxiety when the glass separators were removed.  Then there was the thing about shaking hands.   A new quality indicator, a governmental big wig had suddenly decided that human touch was somehow related to well being.

A few years passed before the new physical exam mandate was rolled out.  Some yahoo decided that stethoscopes were required for each exam.  Jason figured that a crooked politician had a friend who sold the old time relics and needed a new revenue stream.

The changes began coming faster.  First the state sponsored communication classes.  Then the new gowns and privacy policies.  The  yearly clinical exam.

Each mandate cleaved at Jason's soul.  He was a master, and his mastery was slowly being eroded by non technical politicians who barely understood the beauty nor complexity of a clean data input screen.   He was slipping.  He almost submitted an incomplete claim the other day because he was futzing around with a defective sphygmomanometer.

The data was suffering.  The consequences were momentous.  Doctors were working untoward hours to feed a ravenous monster that was no longer connected to any real version of healthcare.  

And Jason was on the internet every spare hour, looking for a posh consulting job.

Screw the government!