Thursday, September 11, 2014

Intimacy

We were intimate.

As intimate as a doctor and patient can become.  He had long outlived his wife and there were no children, no family, just friends.  When he first came to me he was lively and active, but the years took their toll.  Our visits became more regular.  Every six months.  Then every three.

His memory started to slip.  Occasionally he would look at me suspiciously when something went wrong.  His mind no longer able to wrap around the intricacies of medical care, he grasped at what was left.  If he forgot to pick up his prescription from the pharmacy it somehow became my fault for not calling it in.  Like family members do, we had our ups and downs.

But every time I walked into his hospital room after one mishap or another, he always looked relieved  and his lips would curve into a giant grin.  The last such occasion, he had had a stroke.  Although his limbs were working well, the muscles of his throat had been afflicted.  Each time he tried to eat he would choke and sputter.

His stay in the nursing home was disastrous.  His weight plummeted and he lost interest in living. We had long conversations about what could be done.  Although I hated the idea of a feeding tube, this simple surgery would bypass the problem and allow him to live comfortably.  It all made such great sense except that he wanted nothing to do with it.  He was ninety years old and didn't want a tube sticking out of his body.  He was ready.

I consulted hospice and we arranged his discharge.  A week before leaving he presented me with a neatly wrapped box.  I opened it to find his favorite bolo tie.  He wore it often with a short sleeve button down shirt and a cowboy hat.  He wanted me to have it.  I accepted it reluctantly, full of pride and yet mortified at the idea of actually wearing it.

I saw him a few more times in the nursing home before he left.  Each time his disappointment was clear.  He wondered why I wasn't wearing his tie.  And the truth is, I have no rational explanation for my actions.  It clearly would have looked ridiculous on me, but I could have put it on before entering the room and taken it off after leaving.

Decisions don't always make sense.  It's like that when your intimate with people.  You periodically disappoint them.  You can't always explain why.

He returned home, and died a week later.  From time to time I come across his bolo tie when rummaging through my drawers.  When this happens, I feel such longing and also a bit of shame.

Its not that he died, or that my medical care was sub par.  We were both quite comfortable with his decision.  It's the fact that I could have done something so simple, so straightforward, to make him happy.  And inexplicably, I didn't.

I have become fairly comfortable with the premise that occasionally being a human being exposes my shortcomings as a doctor.

It devastates me, however,  that sometimes doctoring reveals my failings as a human being.

Monday, September 8, 2014

Are We Emasculating Our Physicians?

On the face of it, the phone call was relatively innocent.  A family member was confused about the test I scheduled.  Apparently the lab refused to draw the blood.  When I inquired why, I was informed that the patient hadn't been fasting.  I calmly explained to the daughter that fasting was not necessary.  Recent studies had shown little effect on lipid panel results and I was using the glycosylated hemoglobin to asses diabetes.  The daughter, however, said the lab technician was steadfast.  They wouldn't draw the blood unless my order specifically stated: no fasting necessary.  Furthermore, the lab refused to call me directly, I had to hear this all secondhand from the family.

Not a moment later, a fax was returned to my office,  Although I had filled out the durable medical equipment form correctly, medicare wouldn't accept it.  Apparently I had typed instead of hand written the date.

My hospice patient wasn't doing so great either.  Actively dying in the nursing home, I had written a prescription for morphine hours ago.  Unfortunately the pharmacy wouldn't fill my order.  Although I had specified the numeric version of the quantity on the script, I hadn't also spelled it out.  The pharmacist on the phone was less than apologetic.  Government regulation!

There is no question that physicians should not be above the regular pains and hassles of any professional workforce.  I accept that governments regulate industry and sometimes one has to deal with nonsensical rules from time to time.  But the recent systemic demoralization of this highly skilled and trained group of individuals is having untoward effects.

Facing arduous and difficult decisions while being distracted by an ever-growing mound of minutia molded by technocrats and enforced by unskilled labor is nothing less than emasculating.  It is no wonder why the modern day physician is becoming ever more distant and emotionally as well as physically unavailable.

If we truly want to build a high value, high quality version of our healthcare system, we need our physician workforce to feel a strong sense of internal motivation and pride in their work product.

We can't do this if we keep cutting them off at the legs.

Wednesday, September 3, 2014

All Of These

You want to know what it feels like to be a doctor?

I want to know what it feels like not to be.

There has never been a time that I wasn't a doctor.  There are things that one strives towards and things that reside in ones bosom before the act of becoming has yet occurred.  This has been my birthright.  I could no more have chosen a profession than I could my gender, my parents.

That is not to say that my future was carved in stone.  I suffered as did my brethren through self imposed asceticism, my head buried in text, my eyes watering, my intellect at times crying for mercy.  I did this not out of want or love, but more of unconscious habit.  Buried in the perverse coding of my DNA was a migration pattern, a way forward.

Graduating medical school, finishing residency was less about reaching the tip or peak of the mountain and more growing comfortably into the shoes that I had worn since childhood.  I had matured.

And being a doctor, being a doctor is neither a hobby nor a profession.  It is who I am.  It is complicated.    On occasion filled with terror and regret, fatigue and fear.  Triumphant at times, and downright disappointing others.  Like so much of life, emotions mix and homogenize.  Rough edges become smooth.

A blessing and a curse.

A privilege.

All of these.

Sunday, August 31, 2014

The Last Thing On Our Mind

She was having excruciating pain in her pelvic area.  I pulled the sheets down cautiously and noted the bruising encircling the waist and inching towards the thighs.  I finished my exam and retreated to the nursing station of the skilled nursing facility to comb through the chart.  ER records, floor notes, consultations, but no X-ray of the pelvis. There was no mention of pelvic pain.

The emergency room physician had dutifully ordered a cat scan of the head and neck to rule out injury.  The hospitalist had noted a fourteen point review of symptoms.  The social worker had informed the patient that she was admitted as an observation.  He made sure a discharge plan was in place before two midnights which effectively meant that the patient would foot the bill for her whole rehab stay.  Notes upon notes documenting that the patient was not able to return home.  But no mention why.   She couldn't walk.  She couldn't walk because she was having excruciating pelvic pain.

The next day the X-ray confirmed my suspicions.  She had a pelvic fracture.  I called the nurse and ordered an orthopedic consultation.  Although I knew that she would not need surgery, I felt that they should examine her and comment on weight bearing status, etc.

Of course, it was only hours before the director of the nursing home was calling me on my mobile.  No orthopedist in the area could fit the patient it.  Furthermore, the nursing home was doing an investigation and had to prove that the fracture was a result of the fall that brought the patient into the hospital and not an an on site injury.  The wrath of the state weighed heavily on their minds.

So they wanted to transport the patient back to the emergency room.  Document the injury, get an orthopedic consultation, dot the i's and cross the t's.  Don't worry, they will send her right back!  There was no consideration of the cost of such deliberations.  No concern for the discomfort or pain that the patient would have to suffer.

So this is what we have come to in medicine:

Shoddy, rushed hospital care.
Offloading costs from Medicare to the patient.
Bending backwards to meet the requirements of the state.

And the comfort and suffering of the poor patient lying in the bed in front of us,

the absolute last thing on our minds.

Wednesday, August 20, 2014

The End Of Days

Sometimes my day is like a book.  The first chapter may begin in the darkness of a self imposed corner as a phone call is made.  A voice, full with the thickness of slumber, answers unexpectedly.

I think today is the day.

No matter how many years I have been discussing death I still find myself using poor euphemisms.  The bain of medical school teaching, I often struggle with the directness.  Your mother will die today.  So cold.  So hard to muster the courage and keep one's voice strong and confident.  I used to shy away from such dire predictions.  I no longer do.  Better to tell prematurely than not at all.

I pick up my stethoscope and jacket and move on to the next room, the next hospital, the next home.  And the memory of the fading elderly woman falls into the recesses of my mind.  These days are so full, the plot so complex, that plans are made, thoughts are compartmentalized.  Family called (check), Roxanol and Ativan written for (check), DNR, Do not hospitalize (check).  There is nothing more I can do.

The next stop may be a hospital.  Where a leg is broken, or saliva aspirated, or hearts fail.  The clickety click clack of the computer keyboard is accompanied by the ringing of phones.  Family meetings are carried out in hush tones in corners or conference rooms.  The rise and fall of a chest, a sigh.

I have an octogenarian to visit at home.  He just returned from the hospital after a pneumonia.  He still needed a few more days but was afraid to leave his wife alone.  Her memory is not as good as it used to be.  She had never stayed by herself before.  Fifty years of marriage and she had never slept without him by her side.

Work life quickly intermingles with personal.  I pick up the kids at their grandparents as I absentmindedly squawk into the blue tooth.  Most days there is some activity.  Violin, tennis, or Spanish.  The phone calls pepper my afternoon and evening.  At some point we find time for dinner.  Maybe a short jog with the family or a long walk.  Have you ever seen a jogger talking on his mobile?  That was probably me answering a page.

I might take a quick shower before  bed or watch some TV.   My phone almost always goes off when I am in the shower.  Almost always.

Around ten, I climb the stairs to the bedroom.  After brushing my teeth and hobbling into bed the phone buzzes one last time.  It's the nursing home.  The prophecy from the beginning of my day has come true.  I give my condolences to the daughter and turn off the lights.  I can't sleep.

It's like a book, you see?  There is a beginning.  Then a muddled and twisted middle that almost makes you forget.  But everything comes full circle eventually.  I put my head down and jerkily fade into sleep.

The end of one's day.

The end of one's days.

Tuesday, August 12, 2014

Why Come To The Doctor In The First Place?

William was doing great.  His C Diff  was finally gone after a month taper of vancomycin.  He was stronger.  The nursing home staff reveled in how much progress was being made over such little time.  It seemed every one was ecstatic, except for, of course his family.  Every step this octogenarian took forward was accompanied by a litany of concerns and complaints from his daughter.

If he was not gaining weight, she wanted to know why.  If he then put on a few pounds, she wanted his diet restricted.  Through each "emergency" I calmly talked her down.  I often spent thirty minutes a day defending each minute order that was placed. And through all the commotion, I was able to withstand the barrage because I knew that William was getting better and would go home soon where his daughter could torture him instead of me.

A few days before discharge, I received yet another panicked phone call.  William had cloudy urine and his daughter wanted me to put him on an antibiotic for a urinary tract infection.  I dutifully hurried to the bedside and asked a series of questions.  He had no burning, no pain, no frequency, no hesitancy and no fevers or back pain.  I called his daughter and explained that cloudy urine, and even bacteria in the urine, are not indications of infection, and given the history I believed an antibiotic would do more harm than good.  This answer while appeasing for a moment, quickly became unsatisfactory the next day.  So there were more phone calls, and more discussions reiterating how it was inappropriate to treat with antibiotics when there were no active signs of infection in this elderly high risk patient.

But William's daughter was smarter than I.  She waited till the night before discharge and called the doctor covering for me.  He, faced with little information and an agitated family member, was easily convinced to call in a antibiotic prescription for discharge.  I never even found out about it.

Until, that is, when I ran into his primary care physician while rounding at the hospital.  William was back in the ICU.  He suffered severe dehydration and sepsis do to (you guessed it) C. Diff.  A complication of his recent and unnecessary antibiotic use.

These type of situations happen all the time.  And while I am a big proponent of empowered patients and families, lately it seems that many really want to be managing their own care without the benefit of our experience and years of training.  In other word, they just don't want to listen to us.  This is fine.

But why come to the doctor in the first place?

Friday, August 1, 2014

Diaspora

I fully reject this notion of wholeness.

I have never been whole.  More like an incomplete conglomeration of parts,  friends, lovers, and family have all received a bit of me.  As I have given myself freely.

And I worry, as a physician especially, what will be left.  As I tend to the sick and dying I wonder if that which is transferred will be lost forever with the frailty of the heart beat, the rattle of the lungs.  Much better to be an obstetrician, I reason, who bestows each piece upon a burgeoning miracle.  There is great longevity in such things.

But as I rest at the bedside in those last moments of illness, I wonder if what I am giving is even mine to bestow. Is it me sitting there or my father ( a physician himself who died when I was a little boy)? These thoughts can be dizzying.

The hair on my head grays and grows scarce.  The seasons blur as if someone waited till the middle of the movie and then hit the fast forward button.  It brings comfort to think that although the body becomes feeble, a diaspora of pieces grows and flourishes out in the world.  A human tapestry of parts past far and wide from continent to continent, generation to generation, person to person.  Our bodies die but our souls live on in those we have touched?

The currency of humanity is neither money nor love.  For "love" is an amorphous concept not well defined by us realists.  I have come to believe that it's the best parts of ourselves that we give to others.  These are the ties that bind communities.  This is the bedrock of the generations.

You may ask, my dear reader, how all this rambling concerns the present company.  

As I see it.  Bit by bit, day by day, blog post by blog post.

I am giving a little piece of myself.

To you.