on the interview trail

     Even if there is not a good view, the hotel rooms are usually quite nice.  But interviewing is no vacation as my wife thought.  Even limiting my radius to Texas means quite a lot of traveling.  And living out of a suitcase gets old quite quickly.  After I found my top 3 picks and had enough back ups, I decided to cancel the rest.  This phase of residency searching is over.  Now it is wait until March for Match Day to find out where I go.

swamp juice

   
     An endless knot, no beginning, no end, everything intertwined.  As a wave of grief returns, my son's condition deteriorates.  I am so close to finishing medical school.  Why now?  Couldn't these things wait just one more month?  But why should I think that the end of school would be any easier than the rest?  Further more, why do I think that these episodes will end with the beginning of residency?  Foolish whims of an aging man weakened (or strengthened?) by unrelenting pain.  To survive, I must find meaning in it.  I must confront it again and again.  I must integrate it into who I am. 
     During this chaos of emotions, my sister-in-law gave me my brother's old juicer.  One of the many things he tried in his battle against cancer.  He called it "swamp juice" and hated the taste of it.  But still he did it.  The juicer sits gathering dust.  Eventually, an impetus from nowhere arises and I use it.  It doesn't taste that bad to me.  Am I doing it for health reason?  Do I think it will prevent cancer?  No.  I do it in remembrance of him, an intimate communion.

another wave of grief

     “For in grief nothing "stays put." One keeps on emerging from a phase, but it always recurs. Round and round. Everything repeats. Am I going in circles, or dare I hope I am on a spiral?
     But if a spiral, am I going up or down it?
     How often -- will it be for always? -- how often will the vast emptiness astonish me like a complete novelty and make me say, "I never realized my loss till this moment"? The same leg is cut off time after time.”
- A Grief Observed by CS Lewis

nature of God

     The sun rises slowly as my car moves just as slowly through traffic.  The music coming from my phone is interrupted by a telephone ring.  Even though it's interview season, I don't answer it because of the stop and go traffic.  Eventually, I find the location of my next rotation.  Hospice.  It's my first day and mixed feelings swirl together as I turn off the car.  I grab my phone and listen to the voice mail from the earlier call.  It's a tool company offering a demo of some new tool.  But it's not for me.  It's for my brother.  The first day of my hospice rotation and I get a voice mail for my dead brother.

     Why does this passage from A Grief Observed by CS Lewis immediately come to mind?

     “Not that I am (I think) in much danger of ceasing to believe in God. The real danger is of coming to believe such dreadful things about Him. The conclusion I dread is not 'So there's no God after all,' but 'So this is what God's really like. Deceive yourself no longer.” 

il faut d'abord durer

Three years ago to the day, I wrote these words:

il faut d'abord durer

     Hemingway was known to sign personal letters with the French phrase il faut d'abord durer.  Idiomatically, it translates as "first, to endure".  It's been my motto ever since my brother died.  And it's a hard axiom for me.  I always enjoyed excelling.  Being above average was fun for me.  In football, I played to win.  And you don't get into med school by being middle of the road.  So it's a hard pill to swallow to set my sights at this point on merely surviving.  It feels like I'm settling.  But with the trifecta of med school, death, and my dad's condition.....I remind myself that it's a lofty and noble goal at this point.  If I can just get through all of this intact, that's no small victory.  So entering into the next round of exams, woefully unprepared, I remind myself, "first, to endure."  Go easy on myself and let go of the notion of honors and be content to endure.

It seems fitting as I begin my final rotation of medical school.  Wisely, I have chosen Medical Humanities in an attempt to reflect upon everything.  Has anything changed?  No.  The pain is always there, especially with my son.  Besides, that was after only two tragedies, not three.  And yet, something has changed.  The depth of my understanding, perhaps.  I have endured.  At least until today, and I hope for each day after, as well.  In a short time, I will have those two little letters after my name.  But nothing magically changes on that day when I have earned the degree.  I am the same person before and after.  But speak to me of residency.  Forged in the crucible of soul crushing pain, an alchemical element begins to form.  The Greek element Fire.  Kindling.  Passion.  Change.  Destruction and Creation.  The wisdom of the Gods from whom Prometheus stole and gave to mankind.  The tiniest of candles, no bigger than the thin ones that sit atop a birthday cake, a flame burns ever so meekly.   

 

I told you so

looking towards the future, we were begging for the past
well we know we had the good things but those never seemed to last
oh please just last

oh and I know this of myself
I assume as much for other people
we've listened to more of life's end gong than the sound of life's sweet bells
was it ever worth it
was there all that much to gain
- by Isaac Brock

     Two of my last rotations were picked for very personal reasons.  One was chosen to be better able to help my son with his condition.  The other was to better help understand my brother's death and process of dying.  Months ago when I signed up for them, my wife warned me.  One rotation was going to be hard enough.  Two of the rotations would be foolhardy.  But doing them back to back was inviting pain.  My wife was absolutely right.  Scabs and old wounds have been torn asunder that might ought to have been better left alone.  Perhaps with the passage of time, there will be a wisdom gained from following this gut feeling.  But for now, there is nothing but pain.

on the interview trail

family medicine

Family medicine is one of the less glamorous specialties.  So how do programs go about attracting people such as myself?  By providing free hotels with views like this.

silence

Silence on my blog means one of three things.  I am very busy.  I don't have much to write about.  Or, I do have things to write about but they're difficult to write.  Lately, it's been a bit of #1 and but now it's transitioning into #3.

nocturne

Set off on a night-sea journey
Without memory or desire
Drifting through lost latitudes
With no compass and no chart

Flying through hallucination
Distant voices, signal fires
Lighting up my unconscious
And the secret places of the hear

Dream - temporary madness
Dream - a voice in the wilderness
Dream - unconscious revelations
The morning says, the answer is yes
- nocturne by n. peart

      Dreams, at least for me, are the poetic and prose, the prayers and curses, the fears and desires of my deepest self all written in a tongue that refuses to follow the language of the waking world. Imagery and imagination trump fact and historical accuracy. With that said, I view them as signposts and guides on this journey of my life where all too often of late it leads through paths untrodden and seas untraversed.  As such, I tend to dream more vividly when an unformed cogitation is ruminating.  The biggest obstacle to solidifying this wild imagery into a coherent message is that I often do not remember the dreams.  I wake up in a fitful state, my subconscious agitated that its message was not received and my emotional state confused at the cause of the disrupted sleep.
     When disrupted at 3 am by a visit from the dreamworld, I've found that jotting a few notes will help me remember it in the morning.  Those few notes typically relate to the emotion that the dream generated and I can work back from there.  One such night I was awoken by a powerful dream.  I needed my sleep so I quickly spit out the feeling on my iphone.  The next morning I barely remember any of the events.  Did I have a dream?  I did.  I check my phone and it reads, "NOT the way it used to be."  The imagery refuses to form and I'm left with the haunted feeling that my psyche intuits that more is yet to still change in my surreal life.
    

fruits of labor

     In a hurry, I sat down at a nursing station to grab a computer.  I needed to see if the final read of Mr. Smith's chest CT was up and if the immunology blood work up on Mrs. Jones was completed.  Instead I was interrupted by a nurse.  She stated, "Mrs. Evans in Room 2112 says that you're the best doctor she's ever had.  She says that you were the first one that ever sat down and actually listened to her."

a walking meditation

     My last month was spent in the hospital enrolled in the clerkship dubbed "acting intern".  It is essentially supposed to have me perform as an intern, or first year resident, would.  Now I see why so many residents start to become less empathetic towards the patients.  Overworked, too much red tape, sleep deprived, hassles with the EMR, clashes between the rest of the people taking care of the patient, and did I mention overworked?  I began to imagine ways of fighting against this natural pull of the stream.  One method I developed was to check on my patients in the afternoon for just a few minutes (assuming we were not slammed with new admissions).  When prerounding at 0 dark thirty, your time is spent hurriedly trying to figure out how the patient did overnight and whether they responded to the adjustments in treatments implemented the day before.  Then you have to take all that information and type it into a coherent note for the attending before actual rounds.  Then the patient is often overwhelmed by the presence of the entire team when rounding.  Who would want to talk candidly when 5-6 people step into the room looming over you in the hospital bed?  I know I wouldn't.
     But when I stop by in the afternoon, there is no agenda.  I just sit down and briefly talk to them.  That's it.  Mostly I just ask how they're doing?  It doesn't take long but it does take effort, especially if that time could be spent taking a power nap.  But I've been amazed at how that 3-5 minute visit deepens the connection with the patient far beyond what I would have expected.  They trust me more and are far more willing to engage more in their own treatment.  And in return, I am one step further removed from becoming burned out and jaded. 

insight

     If you've read my blog at all, you know that I have a keen interest in psychology and psychiatry, despite going into family medicine. As one psychiatrist attending told me, "family med is just psychiatry with procedures."  So I've been meaning to post this for awhile but have been too busy in the hospital. This month is a bit slower, so better late than never. It's comic Mark Maron's comments on the suicide of Robin Williams. You only need to listen to the first 7 minutes to get one of the best descriptions of the suffering of depression I've heard in awhile. If you listen to the rest, well, it is Robin Williams so expect both the profane and profound.

Press here to listen.

hard work realized

     Normally I do not check my school email often.  It's mostly announcements from the school about various going ons.  But the past two days, I've started checking it more frequently.  The process for applying to residency has started.  It's a centralized process that is nationwide across multiple specialties.  You apply and then sit and wait to hear back from the programs.  Interviewing usually starts in earnest in November.  And I only had one letter of recommendation uploaded out of the three required.  One got lost somehow.  The other is from a busy faculty member so I figured I'd have to wait a bit longer since I was missing those two letters still.  Only I haven't had to wait that long.  I have three interviews offered for October and one more coming.  After all that has happened in my life, it's hard to imagine moving on to the next step.  It is not that I do not wish to move forward.  Far from it.  Still, it is surreal to be honest.  I wasn't sure this day would come despite all reassurances to the contrary.  There have certainly been far too many opportunities for me to collapse or fall apart.  I have walked along that cliff for what seems a lifetime.  Experientially, I have lived several lives in the past several years.  And yet I am still here.  I cannot say how but yet still the next phase of my journey is beginning nonetheless. 

calling

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     ".....well, we can't all be rich doctors," the patient said smugly.
     Timeout.  I've had it with patients thinking that I'm doing this for the money.  They have no idea the hell I've been through, and continue to go through to do this.  It's time for some patient education.
     "This is not my first career.  I was the primary breadwinner with a respectable salary and a comfortable lifestyle.  I quit and chose to do this because it was my calling."
      "Ah, that's what all the doctor's say until they're driving fancy cars,"  the patient still a skeptic.
      "Let me put into numbers, because I've done the math.  I've given up XXX of a million dollars when I add up lost salary and student loans, never mind the personal sacrifices.  If I'm doing this for the money, I need to rethink my math.  Do you still think I'm doing this for the money?  Or, perhaps is it because it really is my calling?" I respond firmly.
     The patient is caught off guard and to their credit says, "a doctor who actually cares?  They still exist?"
     "Yes, in fact, we do still exist."

ain't no grave

the man comes around

proselytize

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     "What is your religious background?" the patient catches me off guard.
     I try to make as banal a reply as I can think of and respond with, "Presbyterian."
     Said with the zeal of southern Baptist, the patient replies, "Well, just as in your religion you are encouraged to proselytize, I am going to do the same.  Do you eat meat?  Because if you do, now you know that it is a sin and that when you stand in front of your maker, all the blood of those animals will be on your head."
     "Soooooo, obviously you're a vegetarian for moral reasons?" I ask redundantly and stupidly.  I'm trying to recover from this question that came out of left field.  Hell, it didn't come from left field.  It didn't even come from the ballpark. 
     "I'll have to keep that in mind.  Thank you........Now can you please tell me a bit more about your back pain?"

i see a darkness

book of job part II

     Read any western religious text or ask any lay pastor about suffering and inevitably, the answer will be found in Job.  The traditional way Job is read is that in the first two chapters, Satan claims Job praises God only because of his vast riches.  God refutes him and says, do what you will, but you cannot kill him.  So Satan has his way with him and Job loses pretty much everything and anything.  In the last book, Job is rewarded for standing up to the test and is given back his riches.  He's also given a new family (the old one must've worn thin).  So the moral of the story, God still rewards those who are suffering.  It also answers the why.  It's Satan.

     There is a historical problem with this, never mind experiential one.  A chaplain (let's call him Dr. H for simplicity) from whom I have been obtaining informal counseling, pointed out the flaw.  The ENTIRE book of Job is poetry.  Except the first two chapters and the last chapter.  Those are prose.  Now I don't pretend to be the best writer in the world but I do understand writing style.  Hemmingway does not go from short, terse prose to long, complex sentences.  It just wouldn't do.  More likely is that the poetry of Job existed for quite sometime before someone decided, "hmmm, this story isn't very nice.  We need to tidy up the loose strings."  Enter the three prose chapters.  In doing so, it completely ruins the point of the poetic Job.  It smacks of "smile, Jesus loves me" theology.

     Dr. H. reinterpreted the Book of Job in a way that opened my eyes to the true hideous beauty of the book.  Job is the human experiential answer to Deuteronomy.  I don't want to delve into too much religious history, but Deuteronomy can be summed up in one word - LAW.  Do this, and thus shall happen.  The take home message is one of karma.  Follow God, get rewarded with riches.  Disobey, and your riches get taken away.  But law and history do not rhyme.  The law is the way we WISH things would work.  Job is the experiential answer to the existential question - why is there such suffering on this world?

     Job is debating his three friends, who happen to be self righteous assholes, about why he is suffering.  The friends look for tidy, short answers (smile, Yahweh rewards the righteous with gold).  Job answers with poetic pain worthy of The Bard himself.

Does not man have hard service on earth?
   Are not his days like those of a hired man?
Like a slave longing for the evening shadows,
   or a hired main waiting eagerly for his wages,
so I have been allotted months of futility
   and nights of misery have been assigned to me.
When I lie down I think, 'how long before I get up?'
   The night drags on, and I toss till dawn.
My body is clothed with worms and scabs,
   my skin is broken and festering.
My days are swifter than a weaver's shuttle,
   and they come to an end without hope.
Remember, O God, that my life is but a breath;
   my eyes will never see happiness again.
the eye that now sees me will see no longer;
   you will look for me, but I will be no more.
As a cloud vanishes and is gone,
   so he who goes down to the grave does not return.
He will never come to his house again;
   his place will know him no more.

     And how does God answer Job?  By extolling the wildness, complexity and beauty of the universe.  He gives Not.  One.  Single.  Word.  About.  SUFFERING.  In fact, God evades the question entirely.  Either there is no answer as to why Job suffers, or it is so far beyond his comprehension, that it is not even worth bringing up.  Both lead to the same conclusion for me.  There is no why.  Why?  Because life and history teaches us that suffering simply is.  It was true for Job roughly 3,000 years ago and it is no different today.

god's gonna cut you down

book of job part I

When faced with loss or tragedy, well intentioned but misguided people remind me of the Book of Job.  Initially, this was my reaction.  Even when my dad was a lay pastor, he would not preach upon the Book of Job because it was such a thorny issue.  Leave it to South Park to sum it up so succinctly.

the man who couldn't cry

family medicine

     My phone buzzes on silent against my waist during rounds.  As it would be rude to whip my phone out while the attending is talking, I wait for a more opportune moment.  It's my dad and his a-fib has been acting up.  It's not bad but it's been persistent and resistant to his usual dose of medication.  I quickly text back what to do and to let me know how it works.
     A bit later he texts, "it has subsided."
     I respond, somewhat tongue in cheek, somewhat seriously, "how is it having concierge medicine?" 
     My dad responds, "Excellent!"

the man in black

A few years ago, I was driving home from the hospital and flipping through what few radio stations are left.  On the one that ostensibly plays "alternative rock", whatever that even means after the 90s, there was a song playing.  That voice.  I know that voice.  Who else could it be but Johnny Cash?  Why in the hell are they playing Johnny Cash on this station?  The song ended before I could even listen to it but what little I heard intrigued me.  I googled it at home and watched the video from beginning to end.  Tears welled up in my eyes.  I never had really liked Cash.  It turns out I didn't understand him.  Not by a long shot.  This song is a cover from Nine Inch Nails which is about as far from country as you can get.  But he took it and turned it into something......he turned it into high art with such simplicity and authenticity.  He recorded it not too soon before he passed away.  And I suddenly understood The Man in Black.  Actually, understand is not the correct word.  Soulful is probably the word that comes closest to hitting the mark.  It's something that has to be felt to be understood. 

 

 

birthday

Today is my mom's birthday. 

2010 - my mom is at MD Anderson while her son has his potentially cancerous tonsils removed. The first thing he whispers as he groggily came to from the surgery is, "happy birthday, mom". 

2011 - her son is now dead. Despite that, she is still at MD Anderson but this time it's for her husband. 

2012 - nothing is changed. STILL at MD Anderson for her husband. 

2013 - no trips to MD Anderson but now her grandson is sick - the grandson whom she saw being delivered and helped raise since day 1. Once again, life hangs in the balance of a capricious world. 

2014 - what do I say? Happy Birthday? There is no "happy" to her birthday. There only is. And what is, is brutally devastating. 

evermore

     My breaths are coming in gulps as I feel my heart racing.  I know what this is but intellectually that doesn't make it any easier.  Fight or flight.  Only there is no tangible beast from which to flee or stand my ground and fight.  These are beasts of the mind.  Three years of dealing with existential blow after blow after blow and not a single panic attack.  Why the hell are they coming now?  Why does the sun rise in the east might be an easier question.
     The basic medical model of treating these is that one is under too much stress.  No shit.  Since my life experiences are not about to fade into the background anytime soon, the medical model pretty much starts and ends right there for me.  Step back into history a bit before we had good medications, and there are relevant theories about psychological disturbances.  Carl Jung focused on the imagery surrounding the experience and sought to learn from the disturbance.

Jung: What was the most distressful feeling during the experience?
Me:  Feeling like I could not breathe.  With each inward breath, the tightness of my chest would not let it in.
Jung:  So you had trouble inspiring?
Me:  Yes.  It took an effort of force to drive the breath in.  The expirations were short and quick.  But the inspirations were long and labored.
Jung:  I can't do it all for you......
Me:  Ah.  Inspiration.  Or, lack thereof.  So I'm back to Hamlet, again, am I?  Slings and arrows, take up arms, cast off these mortal coils.  I thought I'd moved past that.
Jung:  Apparently not.  That, or there are new slings and arrows.  Since you're not listening to your subconscious, consider the panic attack a not so gentle tapping on your door from your psyche.  You would do well to open the door as the next sound of some one gently rapping, rapping at your chamber door may not be so gentle.

what if?

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     "How are you feeling this morning Mrs. Smith?"  It was my first day on the ICU ward and as with any first day of a rotation, I tend to keep things low key until I get a feel for the way the team functions.  In this case that means the respiratory therapists, the nurses, the new interns who just started practicing being a doctor for a week now, upper level residents, a fellow, and an attending.  It's a large milieu to insert a med student into.
     "You tell me doc," she responded as she was currently passing foamy diarrhea while the nurses cleaned her up.  The nurse looked at me and with her eyes and asked, "you ever seen anything like this before?"  I must confess I had not.  But I did my physical exam and when rounds came I presented the history and the pertinent physical findings, especially a distended abdomen which had not been noted in the chart.  In my plan, though, I stopped short of recommending an abdominal CT.  I thought she definitely needed one but I didn't speak up.  I've been so bruised and battered and broken these last years, I didn't feel like rocking a boat on the very first day.
     I came in the next morning at 0:dark 30.  My patient's room was empty.  Maybe she got transferred and so I picked up another patient.  It wasn't until rounds that I learned that  overnight Mrs. Smith had coded multiple times and died, likely of a gastrointestinal infarct.  An autopsy was scheduled.  My heart sank.  After rounds I went up to the attending and asked why she never received an abdominal CT.  No one knew that she had a distended abdomen.  I said it at rounds.  Loud and clear.  My voice projects as I am no wallflower.  But I never said, "she NEEDS a CT."  Tell anyone this story and clearly it is not the fault of a med student.  There was an intern, an upper level resident, a fellow, and an attending.  And even if she had the CT done, it does not mean she would have survived.  The patient was in the ICU for multiple reasons and when multiple things start to head south, there's not a lot we can do.  But the question, "what if?" hangs in my mind, especially given my past experiences.  I do not allow myself to miss things despite rationally knowing that's impossible.  No one can bat a thousand.  But still, what if?  Would Mrs. Smith still be alive?
 

a shift

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     With every physical, there is a 12-point Review of Systems.  In order to get paid, you must include at least 12 systems.  11 and you don't get paid, and with good reason.  One of those systems in Psych.  This particular patient was smiling and answering no to all of the other systems, even the one involving chronic muscle or joint point.  Usually that gets most people over the age of 40.  Everybody has some ache or former injury that causes some discomfort.  But not this one.  It wasn't until the psych questions came that a pregnant pause occurred.  It was not their psyche that was the cause of concern.  It was one of the children.  They had begun to have their first psychotic break.  The parents never saw it coming. 
     My heart began to break and I had a choice.  Do I begin to connect those rooms with corridors?  Do I let my own pain help others?  But how do you do that without making it about you?  Then I heard what the medications were being used.  The prescribing physician was either 80 years old and hadn't read a new journal in over 40 years, or a complete and lazy asshole who just wanted to snow the kid.  In other words, turn them into a stupefied zombie so they're not causing any trouble.  They're also hardly conscious.  My decision flew out the window.  None of that crap seemed to matter anymore.  Without even thinking, I began, "In my personal experience......"
     I encouraged the patient to stick with the child.  They will need someone steady.  I warned them at the first onset of mental illness, it can take upwards of a full year to get the right diagnosis and more importantly, the right combination of medications that works well for them.  I warned them this will NOT be easy.  I warned it may take multiple opinions to get to that right combination of medications.  And then I again reassured them to take heart, to not give up, to love your child.  And before I even realized it, I said this all in front of the attending.  I had never done such a thing before.  They did not correct me or interrupt me.  Instead, after exiting the room, he asked about my son in a heartfelt way.  As I said in my last post, something is shifting.

unfortunately

     It was a blur, this last month.  A feeling of something important moving from inwards to outwards.  A house with multiple rooms, each room appropriated for its own feelings and thoughts.  Depersonalization.  From the moment the alarm goes off until I stepped into the clinic, one part of me was being turned off, compartmentalized, while another turned on.  Then, the reverse would occur at the end of the day.  There must be some way to integrate these rooms, or at least connect them with corridors.  There is only so long one can function as a whole when functioning as separate parts.
     At the end of the month, I am left with a glowing evaluation and it means absolutely nothing to me.  When questioning the attending, I was strongly advised by the assistant to preface it with, "We were taught xyx...." 
     My response, "Bullshit.  I'm too old and have seen too much to play that nonsense.  I'm not some 20 something kid still wet behind their ears."
     With each passing day, I care less and less what others may or may not think of me.  I am not here to impress upon anyone some false notion of what I am or to stroke someone's ego.  What matters most to me of the past month were the words that did not go into the evaluation.  The attending told me, "unfortunately, you have a level of empathy with patients that very few will ever have." 
     With the exception of that first word, I have been told this multiple times by multiple attendings, family members, colleagues, and even therapists.  Others have called it a gift.  I despise that with every fiber of my being.  I want to strike back with physical force at those who dare call such pain a gift.  Without hesitation I would trade all my wounds to be a mediocre doctor and have those I love back.  But this attending added that one word.  Unfortunately.  It allowed for all of the pain and suffering to be honored while allowing something soulful to emerge.  One does not take away the other.  Unfortunately.  All the pain and agony of my brother's death.  Unfortunately.  Those decisions I made at 3 am with no one else to ask.  Unfortunately.  The last year battling with my son's illness.  Unfortunately.  All the continuing struggles with my son.  Unfortunately.  And my dad?  He was in the ER less than a month ago.  Unfortunately.  He'll try to downplay it in his blog but he forgot to mention that he had an elevated white count of 20,000.  Not something you want to see in a stem cell transplant patient.  Unfortunately.

cell phone

Having just upgraded to an iPhone 5 courtesy of my sister-in-law, this comment below is quite amusing, and very disturbing. My iPhone is a combination of a beautiful design and intuitive functionality that makes my life more productive. The EMR I use everyday leaves me cussing. So read this interesting analogy from a comment on KevinMD.com regarding an article about Electronic Medical Records, aka another requirement by the "Affordable" Care Act which is anything but affordable.

The year is 1990. The federal government has made the decision that everyone needs to switch to cell phones. The government claims that landlines are too inefficient and prone to error which may or may not be true. The only thing everyone can agree upon is that it is much easier for the government to monitor cell phones then landlines. In order to coerce people to switch to cell phones the government first provides bribes, but eventually will fine people for not making the switch. However, in order to get the bribe the users have to follow and document certain guidelines and have to do so within a fixed time frame. 
Cell phone carriers rush in provide the phones. With the rush to make the switch, fundamental errors are made such as different carriers working on different frequencies so some phones won't communicate with each other, if you can get a signal at all. Worse still, the market is dictated not by what the users may want or need, but how best to meet the criteria to get the bribe. Phones are made with a 25 digit keyboard so required codes can be entered. Before each call can be made a pop-up question screen appears so that the user can meet the requirements the government has decided are necessary to make the call. 24 years later some users have gone through multiple phones, cursing the day they ever switched from landlines.

knocking the rust off

     I look at my text.  There's a patient in the ER who has Pick's Disease.  Pick's Disease is a form of dementia a bit like Alzheimer's except instead of memory loss being the major first symptom, they tend to have personality changes first.  What used to be a prim and proper little old lady will start cussing like a sailor and then not see that they've changed or done anything improper.  Like any dementia, it tends to be hardest on the family members and caregivers.  The spouse had reached their limits and could no longer protect the patient from their self so came to the ER.
     There was nothing I could for them medically.  But being a doctor is more than just being a drug monkey.  I did what their neurologist should've had the guts to do but didn't.  I started to have "the talk" with them.  What does the patient want from their last moments on this earth?  What does each of the family member want?  How can it be arranged that the patient is safe but their final wishes still be honored?  I didn't intend to complete the conversation then and there.  I just wanted to plant the seed and begin to allow the questions be pondered and pontificated over.  They still had time to do that.  But I told them they don't want to have that conversation when the patient gets admitted for pneumonia and the next thing you know, they're in the ICU and everyone is too stunned to know what to do next. 
     Before this June rotation, it had been a good 10 months before I had seen an adult patient.  There was a lot of rust to knock off.  And even then, there wasn't the rhythm and flow that I used to have for the first 9/10 of the rotation.  This patient was the first time I got back into that groove.  I heard their story beyond just the physical problems and connected with them.  The fact that it was on a terminal patient is not lost on me. 

fail

     "Failed?  What do you mean 'failed'?" my wife asked puzzled.  "You never fail."

     But indeed I had.  A clinical exam, no less.  In my defense, it had been 10 months since I'd seen an adult patient and had more than my share of problems on my mind.  But I've been operating that way for years now.  Why did the cracks start to show now?  That's really not quite true.  The cracks have been there all along.  And quite a few more have been added along the way.  It would be akin to breaking my leg in the backcountry.  How far could I hike on it before the broken bone becomes too much?  How long can willpower and adrenaline alone last?  At some point, healing must begin to take place, even if in the most minute spots.

     I passed it on the second try.

living with pain

 

Can you tell the difference between these?  Unfortunately, I couldn't.  At 5 am, some things are rocket science until caffeine kicks in.  And I didn't put the deodorant on my back.  I put the icy hot on my armpit.  THAT will wake you up quick.  And I mean jump to it.  I couldn't wash it off quick enough.  My armpit felt burned the rest of the day.

how we learn

     The student I'm on with hands me a patient list after a presentation.  "The resident said for us each to pick up one patient."  I grab the list and look at it.  Wait a minute.  These medical record numbers are for a different hospital than the one I'm assigned at.  And the admission date is from 2 months ago.  Something doesn't add up.  I text the resident for some clarification.  He responds, "just read up on their chart.....and good luck finding them."  I look at the schedule and realize we're supposed to be in the morgue in the afternoon.  It slowly dawns on me, these "patients" aren't really patients in any sense of the word anymore.  They are more specimens, really, by this point.

does God have a dark sense of humor?

     The resident texts me to go see a particular patient who is new.  That means reviewing everything and getting the full story.  And since I'm on a "consult service" these two weeks, that means I have to figure out why the primary team wants us to see them.  I begin reviewing the chart.  The ER note reads, "A 42 year old male with a recent diagnosis of stage IV squamous cell carcinoma presented to the ER with blah, blah, blah."  Seriously?  My first adult patient in over 10 months and it has to be a terminal cancer patient?  I don't need re-exposure therapy for PTSD.  I'm getting re-exposed plenty fine on my own.

     New month, new rotation.  Less than 7 months to go until I am can add those two little extra letters after my name.  My last rotations have been more grad school like classes with seminars and writing papers.  No patients.  It was a nice change for awhile but this month, I'm back to seeing patients.

the meaning in suffering

     I'll be a better doctor.  I'll be more empathetic.  I can feel things on a deeper level.  I'm not afraid of death.  These are all things that could be said about what the suffering gave birth to.  But these are active choices of mine.  They are not the meaning of suffering for me.  Read any book on suffering - religious, philosophical, memoirs, classic literature - and they all try to address the meaning of suffering.  Most offer empty platitudes.  I'm not sure there is a meaning.  Or, if there is, I have yet to figure it out.  The closest I'll come to agreement is with Victor Frankl's notion that one must create meaning out of the suffering.  At least I will not rule that out at this point as it has an appeal that leaves it up to the individual.  There is no set answer.  It's up to you to figure out.  For now, though, I'll settle with continuing to put one foot in front of the other. All I can hope for is to survive the suffering.

the suffering itself

     My wife and I were out eating in yet another attempt to continue to live life.  One of the specific foods appealed to my wife and she remarked fondly that our son would've enjoyed it, as well.  The statement was one of remembrance and fondness.  A happy memory.  And without so much of a word between either of us, a heavy stillness fell.  We were both thinking the same thing but in a choked voice I said, "it's painful to think about happy memories, isn't it?"  We both started to have tears well up in our eyes and it was time to leave the restaurant.  What kind of personal hell is it that to have good memories cause pain?  How does one continue to live life, much less enjoy it when even happiness causes excruciating pain?  And if a pleasant thought can cause torture, how much more worse is the pain in the bad times? 

the foreshadowing of suffering

     Humans are a superstitious lot, especially when undergoing suffering.  We ask what did we do to deserve this?  What act must be atoned for?  Guilt plays heavily because in the clarity of hindsight, I had direct foreshadowing of my son's coming struggle.  I wrote this over a year before his disease became self evident.  But did I see a hint of it in him?  I had to have or I would not have been able to write this.  And if so, the guilt of missing it weighs even heavier on my heart.

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

 

Spirits turned bitter by the poison of envy

Always angry and dissatisfied

Even the lost ones, the frightened and mean ones

Even the ones with a devil inside

 

Thank your stars you're not that way

Turn your back and walk away

Don't even pause and ask them why

Turn around and say goodbye

 

People who judge without a measure of mercy

All the victims who will never learn

Even the lost ones, you can only give up on

Even the ones who make you burn

 

Even though you're going through hell

Just keep on going

Let the demons dwell

Just wish them well

 

"wish them well" by n. peart

      Admitted on a Monday night while I was on call, she was gone by the end of the week.  She left AMA (against medical advice).  She was fed up with her bipolar nature, with the staff, with the hospital, with her life.  She had tried every medication and every street drug and nothing helped.  Her previous suicide attempt had been halted only by a rather miraculous medical intervention. We spoke with the mother over the phone. Unable to listen, the patient stormed out in a fit of rage after only a few minutes. The mother continued her story for a good half an hour.  She corroborated everything the daughter said, even adding details the daughter didn’t get to. This one was not faking, not exagerating, not just a drug seeker. The mother told us:

Look, I appreciate everything you’ve tried, I really do, but you have to realize that she’s been worked up countless times.  She had an extensive psych and neuro workup – everything – at multiple institutions and they couldn’t do anything to help her.  She’s been to so many doctors and nothing. Everything we've tried....nothing. We’ve given her places to live and she’s destroyed them. I’m still paying off the damages at her last place. She's my daughter and I lover her dearly and I know this sounds cold and heartless, but I’m surprised she’s still alive.

      Many of the staff hated the patient.  Her raging temper was set off by saying the wrong thing, even by a wrong look.  And she herself hated it.  She hated herself for not being able to stop it.  You could see her speech begin to speed up fasterfasterfaster as her lips struggled to keep up with her racing thoughts.  She wanted it to stop.  She said so but then two minutes later she was cussing someone out.  There's a fine line sometimes between distinguishing an asshole from someone with mental illness. There was no doubt in my mind she belonged to the latter.  Nor the doc who sadly but realistically doubted this patient would survive the year. 

    And yet the patient had never raised her voice at me.  She never got angry with me.  She never threatened me. The attending, exasperated, finally relegated the patient to me since she seemed not to be able to talk to anyone else without becoming frankly violent. To be honest, I’m not sure why I was able to talk to her. When it comes down to it, I think I saw my son there. My wife’s family has mental illness running in its past and I thought to myself, “if my son had been born into that situation, this could be him.” It scared me tremendously to know that the genetic possibility was there. So I talked to the patient as if she were my own son. But that wasn't enough.

​      Before the patient left, I went to say goodbye to her. I told her, “I wish you well." It's all that I had left to give.

     And that’s the part that bothers me the most. The patient was cognizant enough to know that she needed help.  She knew that she was headed for a bad ending. Her entire being was unraveling. But she was powerless to stop it. And so were we. We had nothing in our bag of tricks to help. Was she too broken for us to fix? Was there ever even a point in her life that interventions could have changed her path? Had the medical system failed her by not being able to permanently institutionalize him? Was she just a bad person who continued to choose drugs over treatment? Was she just trying to manipulate me?

     She’s the one that got away. The patient that I couldn’t treat. But more than that, she was a broken human being that could not be helped. We are taught never to give up. To never quit on a patient. But that doesn’t work in real life. Tragedies do happen. Horrible things do occur. I learned that first hand from my brother. And we as doctors, as human beings, are all too often unable to do anything about. In that regards, serious mental illness is no different than cancer, than heart disease, than HIV. They all tragically take human life.  Her life was indeed tragic and his story will stick with me always.

revelations in suffering

     As I am graduating mid year, I have to make sure that my scheduling doesn't fall through the cracks and I get enrolled in the things that need to happen so I periodically meet with the Dean to ensure I'm still on track.  The very act of going through those motions should prove to myself that I still very much want to be a doctor and finish.  Hey, nothing can be taken for granted at this stage.
     But lately, I have been reliving the last few weeks of my brother's life and the role I personally played.  It's not as if I'm wanting to relive this as it piles stress and pain on to an already broken psyche.  I tell my wife that I'm held together by duct tape.  And I'm serious.  The only person who truly understood the toll from a first hand view that the last 2 days of my brother's life took on me was my mom (my wife was at home in Houston).  It became a shared bond between us.  And for reasons that are not entirely clear to me, I recently decided to tell my eldest brother.  Now he is a highly bright, highly intense man who has served our country as a Ranger and lived through combat.  He has wounds, though, like most military men, he is modest about his service and ill at ease to talk about it.  I wrote him a long email describing all that happened.  His reply was one word.  PTSD.  That response radically changed my self perception of my struggles.  Hearing it from him carried the heft of authority far more than having a doctor diagnose me.  He of all people would know.
     During my meeting with the Dean, I briefly relayed this story to her to give her an example of how I was doing.  She said, "well, of course," as if I was blind.  She remarked, "how you are even still here is a testament to your will."  I don't know that it changes anything practically for me as I'm doing everything possible to keep putting one leg in front of the other.  But it did grant me no small amount of vindication.  It's possible to feel weak, wounded and destitute yet still be incredibly strong.

ave atque vale

Three years later, I have more thoughts on these words:

Through many countries and over many seas
I have come, Brother, to these melancholy rites,
To show this final honour to the dead,
And speak (to what purpose?) to your silent ashes,
Since now fate takes you, even you, from me.
Oh, Brother, ripped away from me so cruelly,
Now at least take these last offerings, blessed
By the tradition of our parents, gifts to the dead.
Accept, by custom, what a brother’s tears drown,
And, for eternity, Brother, ave atque vale
‘Hail and Farewell.’

     My healing of grief became interrupted.  Medically speaking, it would be called complex grief, at least it was in the old DSM IV.  My dad's illness was and still is a battle as evidenced by a recent trip to the ER.  My son's illness has taken an immense toll on me.  And all three of these are intimately tied to my career choice.  How does one even begin to unwind the different threads?  I'm not sure it's even wise to do that at this point.  Pull on a thread long enough and there may be nothing left.
     I was speaking with a faculty member more interested in the philosophy and humanity of being a physician that was offering me a sympathetic ear.  I gave him the abbreviated version.  He asked me, "how are you still here?  I mean, med school is stressful enough but what you've been through...."  I had no answer.  I still don't.  Though I promised him that if I ever figure it out, I'll let him know.  I do know the words above will always fill the space in my life with tears that my brother occupied.

the repetition of suffering

     Every morning it is the same.  As the light of day begins to replace the dark of night, before I am even awake, a small seed of irritation starts to sprout.  The night is the closest thing to relief despite not sleeping well or having my subconscious shine lights into the darker spots of psyche in the form of nightmares.  The light of day intrudes upon that respite, no matter how small.  The more awake I become, the more the irritation builds into anger.  The anger then gives way to a rage which is all consuming.  It is to become a thing of fury and the absence of light:

What it was could not be seen: it was like a great shadow, in the middle of which was a dark form, of man-shape maybe, yet greater; and a power and terror seemed to be in it and go before it...Its streaming mane kindled and blazed behind it. In its right hand was a blade like a stabbing tongue of fire; in its left it held a whip of many thongs....His enemy halted again, facing him, and the shadows about it reached out like two vast wings. It raised the whip, and the thongs whined and cracked. Fire came from its nostrils.               - JRR Tolkien

      When confronted by such a self destructive force I have few options.  I could all too easily turn to drug or drink.  I could become incredibly self destructive.  Or, I can workout, and that is to say not a workout in the traditional sense of the word.  This is not for fitness or stress relief or health.  This is to fight for my very life.  Daily.  Such a Sisyphean task wears one down.  Each day, the multiple joints in my back hurt a bit more and the will is a bit weaker.  I secretly wonder how long can I last at this?  Despite it all, physically, I grow stronger.  Does that translate into mental resilience?  One might as well ask why the sun?  It keeps me alive one more day.

the giving in to suffering

"Do I hope that if feeling disguises itself as thought I shall feel less?  Aren't all these notes the senseless writhings of a man who won't accept the fact that there is nothing we can do with suffering except to suffer it?  Who still thinks there is some device (if only he could find it) which will make pain not be pain.  It doesn't really matter whether you grip the arms of the dentist's chair or let your hands lie in your lap.  The drill drills on."  CS Lewis from A Grief Observed

the giving up in suffering

     The patient had lost his job and his wife was threatening to leave him.  The suffering became overwhelming.  Deliberately, he assembled a mass of various pills, a bottle of Jack Daniels and his hunting knife used to field dress deer.  The knife performed the same function on deer as it did on its master.  Both wrists had to be stapled close along with a massive slash along his neck.  This man truly intended to give up.  How he lived is beyond any medical explanation.  He admitted so himself.  He downed a bottle of pills with a bottle of Jack Daniels and then cut himself in three places where major bleeding IS going to occur.  But somehow he lived.  I don't know what became of him.  Did he get the help he needed?  Or more importantly, was the help even enough?  Or, like a statistic, did he repeat his grisly task only this time completing the grim task?
     So with this patient in mind, when people try to reassure me that the suffering will pass, I wince inside.  It is not always so.  It takes vast amounts of emotional fortitude to step away from that cliff.  It often requires a deliberate choice requiring more will power than many people have.  So that choice is far from a foregone conclusion.  Suffering can, and does, win.  The bodies taken by suicide or the broken human beings who live in constant tension of that dynamic of choosing life or giving up and embracing death are a bodily testament to that fact.

the resistance in suffering

     Those who are not aware of the Battle of Thermopylae would do well to learn about it not for just its historic significance but also its significance on the Will of the human spirit (and no, that movie 300 doesn't even come close).  In a nutshell, the Persian king Xerxes had assembled a massive army which grew daily as his conquests of Asia, the Mediterranean and northern Africa continued.  His sight was set on Europe next.  Standing in the way was the small country of Greece - the birthplace of western thought which includes our republic, our sense of liberty, our morals, nearly every major philosophical building block of the Western World.  Only, these wonderful ideas of freedom were only just beginning to bud and branch out at the time.  They had not yet sufficient time to grow, much less spread and the Persian army was about to wipe away that potential in one fell stroke.  Sparta sent 300 of its most skilled and noble army who had already given birth to a son to resist the massive army of Persia.  There would be no retreat in order to give time for the rest of Greece to marshal its forces.  The King of Sparta sought to make his stand at the hot springs of Thermopylae as it narrowed and would lessen the great advantage of the Persian's superior numbers. 
     Shortly before the battle began, an envoy from the Persians were sent to the Greeks.  They offered the Spartans wealth and fame beyond their wildest dreams if they would only bend their knee.  In exchange, they must lie down their weapons.  The reply King Leonidas gave was extraordinary in its bravery and brevity.  He merely said, "MOLON LABE" which translates as "come and take them."  He knew pain would come.  He knew suffering would come.  He knew death would come.  He knew everyone of his sword brothers on this mission with him would die with him.  All for the chance to for their offspring to remain free men.  There is a grim determination that would say while suffering in the 9th layer of Hell, "molon labe".  Come and take me. 

 

the stillness in suffering

     "What are you going to do with your time off?" is a common question I overhear other students exchange.  They are young and the world is their oyster.  Me?  What do I do?  Wrestle the demons with full attention that had to be put off in order to finish a rotation.  With free time, their is little else to do but confront those demons.  I write both privately and publicly.  I exercise, not for health benefits but to burn off the anger that builds anew each day.  I do yoga in part to help my back but just as much to yoke my spirit to my body.  I read, mostly books about suffering.  I meditate, or at least try to as my current state of mind makes that difficult.  And I think a great deal.  After all, the other stuff does not encompass an entire day.  In my field where constant movement and work are the norm, my day is contrasted by much stillness.  Laziness would be the term the western world would use to describe it.  I call it trying to reconstruct my world and the way I view it brick by brick by brick.  After all, it does keep getting torn down.  The stillness in suffering is hard work.

physical vs spiritual pain

     The patient was terminal and was well aware of his condition.  He was also in intractable pain.  No matter what pain management strategy was employed, it failed.  At last, a chaplain was called in to speak to the man.  The conversation that ensued was between them and their God yet the pain in the man went from a consistent 9/10 to a 2/10.  Some may conclude that he just needed faith and the power of prayer.  Others would say it was all in his head.  I would consider both unwise conclusions.  The man's pain derived from his existential anxiety.  Medication cannot treat the deepest set fears of the soul and heart.  And who among us would deny another person this pain, this suffering by trivializing.  Only by honoring it was that mystery entered.

the roles we play

     I overheard my wife talking with my son and later remarked to her what a different tone in conversation it was from the one I had with him earlier.  My interaction involved me on the receiving end of his tirade which was filled with anger, rage, despondency.  I was jealous of her conversation.  My wife did not so much apologize but lament the role I played.  "You are his Atlas.  You're the only one he feels safe enough to vent his pure venom upon without crumbling.  And he knows this." 
     We are not passive receptors of suffering.  We are engaged actors with different roles to play upon the stage.  Both my wife and I are parents but the quality and nature of our suffering differs tremendously.  One is neither heavier nor lighter, nor more difficult to bear.  Anything that threatens to rip apart the soul is something that does not vary by degrees.  It is an all or nothing proposition.  But there are different roles to play, for better or worse, and we must play them out or risk becoming untrue to thine own nature.

what is found in suffering

     Ram Dass was an eastern mystic yet his approach to suffering differs little from the late Pope John Paul II who also includes a mystic element as well as the road to grace.

Human suffering evokes compassion; it also evokes respect, and in it own way it intimidates.  For in suffering is contained the greatness of a specific mystery.  This special respect for every form of human suffering must be set at the beginning...we dare to touch what appears in every man so intangible: for man, in his suffering, remains an intangible mystery....suffering seems almost inexpressible and not transferable, perhaps at the same time nothing else requires as much as does suffering....and that therefore basic question must asked about it and the answers sought.  It is evident that it is not a question here merely of giving a description of suffering.

This, to me, seems at least an honest answer, if not one of the most honest answers I've seen from biblical scholars, ministers, or even the Bible itself (I find the story of Job absolutely reprehensible).  John Paul concedes the importance and universality of human suffering in the same breath as acknowledging that it is a mystery.  If there is an absolute understanding of suffering, he is willing to admit that meaning lies shrouded in mystery.  And despite that impenetrable shroud, we must still pry to find what it means to us.

the lonliness of suffering

“Oh God, midnight’s not bad, you wake and go back to sleep, one or two’s not bad, you toss but sleep again. Five or six in the morning, there’s hope, for dawn’s just under the horizon. But three, now, Christ, three A.M.! Doctors say the body’s at low tide then. The soul is out. The blood moves slow. You’re the nearest to dead you’ll ever be save dying. Sleep is a patch of death, but three in the morn, full wide-eyed staring, is living death! You dream with your eyes open. God, if you had strength to rouse up, you’d slaughter your half-dreams with buckshot! But no, you lie pinned to a deep well-bottom that’s burned dry. The moon rolls by to look at you down there, with its idiot face. It’s a long way back to sunset, a far way on to dawn, so you summon all the fool things of your life, the stupid lovely things done with people known so very well who are now so very dead – And wasn’t it true, had he read somewhere, more people in hospitals die at 3 A.M. than at any other time...” - Ray Bradbury from Something Wicked This Way Comes

     I can close my eyes and the memory comes unabated.  I was giving my brother liquid morphine every thirty minutes as the hours passed into that abyss nearing 3 am.  It was time for his next dose and as I got all my tools ready, I noticed in the smallest moment that his breathing slowed and became more regular, less labored.  In that small moment, time stood still and spread to infinity.  I felt in that instant the cold stare of Death's eyes upon my brother.  In truth, my brother as I knew him had left long ago leaving only his fading body, myself and Death in the room.  Naught was left but the profane and profound, the sacred and forbidden, the tangible and intangible forever ordained to play out in my head alone.

fierce grace

The most obvious place to look for insight into suffering is religion.  But even within the same religion, differences abound.  The quote below came from watching a documentary about an American who became a guru of eastern thought.  From a wealthy and supportive family, a highly educated psychologist of Ivy League ilk, his books best sellers, sold out speaking engagements, he thought he had it all figured out.  Until he had a debilitating stroke that left half of him paralyzed.  Even more cruelly ironic was that the words that used to flow so easily, no were a sense of frustration as the part of the brain associated with language was also part of the stroke.  He now knew suffering for the first time in his life.  Where he had found solace before, he found hollow words instead.  Several years after the stroke wrestling with both the physical as well as mental limitations, he was still able to put together a book with help.  And his view deepened now to include true suffering which was so inherent to the human condition.  He termed his new found grace a "fierce grace". 

After any major physical “insult,” as they call it, it’s all too easy to see yourself as a collection of symptoms rather than as a total human being, including your spirit — and thus to become your illness. Fear is powerful and contagious, and at first I allowed myself to catch it, worried that if I didn’t do what the doctors ordered, I’d be sorry. But now I’m learning to take my healing into my own hands. Healing is not the same as curing, after all; healing does not mean going back to the way things were before, but rather allowing what is now to move us closer to God. - Ram Dass

suffering

     Over the last few years of my life, I think it is fair to say that I have become well acquainted with suffering.  Only, I haven't really.  I have felt the emotions, the effects, yes.  But I do not understand it well enough to be acquaintances with it.  And as I ponder endlessly about it, it comes down to two concepts, really.  The first is the nature of suffering.  In other words, what is the suffering like? The second is what to do with the suffering.  Life sucks, now what?  Rather than try to explain them, I'm going to try a different approach.  I'm going to use different anecdotes of my time with patients or literary sources.  All of them are as much right as they are wrong in that these are eternal questions of what it means to be human.  Ultimately, I would guess that if one were to interview 100 people undergoing intense suffering, while there would absolutely be some commonalities, there would be 100 different stories rich with their own shadows of gray and subtleties of truth for that individual.  As always, all stories of patients are complete bull plop with respect to facts but 100% true.

drug testing

     This article asks the question of why don't we drug test doctors. Because we'd fail. Though the examples used in the article are not doctors to be fair. I just took an "anonymous" survey for a research project on the misuse of ADHD drugs while in medical school. It'll be interesting to see the results. I'm guessing the number will be damned high.
     The real reason why doctors will never be drug tested is that too many doctors would be ruined in a witch hunt. What would the public do with the knowledge that Dr Bob is taking an antidepressant and anxiolytic because of a recent messy divorce involving a nasty custody battle? Nothing about his practice has changed. Patients haven't complained, in fact, they like the guy. Nurses have noticed no difference in his patient care. But let that information into the hands of lifetime bureaucrat and Dr Bob's license wouldn't be worth the paper it was printed on. It would result in a legal nightmare because that doctor would turn around and sue every party involved - the testing company, the licensing board, hospital, etc. If you think this information would be "confidential" I have a bridge I'd like to sell you.

the power of expectation

     My mom has recently entered the 20th century of texting and developed a liking to it.  She was texting me during an especially boring seminar this past month.  She was proud of her developing a habit of walking and was relaying it to me.  As it was a cold day, she was looking forward to a warm glass of glögg afterwards.  What the hell is that?  Apparently, it's the Nordic version of mulled spiced wine.  Of course, my wife already knew this.  My mom said she came in rosy cheeked and warmed herself a glass of glögg.  Feeling already invigorated by the walk, she said after drinking half the glass that she began to feel a nice feeling of warmth and relaxation.  By the end of the glass, that sense of relaxation and warmth had become even stronger.  This stuff from her Finnish ancestors packed a powerful punch, she thought.

     Only the next day did she read the label.  It said 0% alcohol.  None.  Zip.  Nada.  It's to be mixed with rum or red wine.  I about died laughing when she told me.  Her simple expectation of the effects of alcohol were enough to induce the relaxation effects of alcohol.  She also swears by that stuff Airborne to fend off colds.  Never mind the stuff has been debunked and the company was successfully sued for false advertising.  It's fought off many a cold for her.  I told my mom, "you've figured out something that western medicine has never been able to figure out - a way to harness the power of the placebo.  Run with it."

the altar upon which we worship

     "What happened to evidence based medicine?  I thought we were supposed to be a school that teaches that, not hocus pocus stuff like acupuncture," I overheard a student say at the end of a workshop dealing with integrative medicine.  I will be the first to admit that there is much woo in alternative therapies.  I approach ALL therapies with a skeptical eye.  But how many doctors are willing to admit, hell are even aware that there is quite a bit of our guidelines that have just as much woo and hand waving?  I told the student, "I've gone to acupuncture.  It helped somewhat but just wasn't cost effective," as I gave him a brief rundown of what life is like with chronic pain. 
      "It sounds like you need a good orthopedist," he replied.  Did he think me stupid?  Of course, that's the first person I went to after my family doc.  Surgery couldn't help me so he wished me luck and ominously told me to come back when I "get worse".
     But what I really wanted to tell the student was to be careful at which altar you worship.  Our precious medicine is not always as hard and fast as we've been taught.  For instance, cardiovascular disease is the number one killer in the western world.  You'd think we'd have a very firm grasp on that with it being the number one killer and all.  And yet, when somebody decided to ask the question, how many of the things we preach to patients about avoiding heart disease are really based on solid evidence, the answer was less than awe inspiring.  About 300 recommendations.  Out of 2,700.  About 1 in 10.  What's worse is that more and more recommendations are being added and, "The proportion of recommendations for which there is no conclusive evidence is also growing."  So when my dad got a lecture from the cardiologist about changing his diet, I told my dad that statistically speaking, 9/10 were based on weak data or worse, "expert opinion."  (Actually, it was all nonsense.)

eternal vigilence

     It did not begin with a phone call but instead a text.  I glanced down at my phone which is never more than a step away from me.  It's been that way for at least four years now.  I read the text from my mom, roll my head and mumble quietly, "Ahhhhhhh, shit!"  I did not need this.  My son had been off one of his medications and was just getting back to some level of stability and now this.  But I remind myself that though I don't like my role, neither does anyone else.  My dad didn't want cancer.  My mom didn't want to always being worrying about his health.  And neither one wanted to "bother" me knowing full well the fury that would be unleashed if they didn't bother me.
     My mom was texting me that my dad had been running a fever.  While not a Luddite, I am skeptical of a lot of gadgets because they just don't work well (the home electronic blood pressure cuffs are absolute crap, especially the wrist ones).  Give me an old mercury thermometer and I'll tell you with both great precision and accuracy the actual temperature.  I told my mom to wait 15 minutes.  Measure it three times on my dad.  Then measure it three times on her for comparison.  Get back to me.  His temperature was consistently about 2.5 to 3 degrees higher than hers.  I call them and start the rapid fire questions that I can now do in my sleep thanks to my training, "nausea, vomiting, diarrhea, muscle aches, congestion, blah, blah, blah."  In the background I hear my dad state loudly only half joking, "I'm not going," meaning the ER.  Well, now this requires a house call.
     I drive over to my parents and perform a quick exam on my dad.  "I don't see any signs of a URI (upper respiratory infection) or anything going on with your lungs.  But you are definitely DEHYDRATED big time."  He had also slept 18 of the last 24 hours which was more than unusual for him.  I show my mom how to tell that he is dehydrated and she proves to be a quick study. 
     Back and forth we go.  It was clear that none of us want to have to go down to MD Anderson's ER.  My dad just celebrated his two year old birthday from the stem cell transplant.  He's still feeling elated about reaching that milestone.  Now that gets destroyed by a little on-again off-again fever?  I'm known for being blunt sometimes and this is one of those times.  I tell my dad, "look, you and I both know that this is probably some virus that will just run its course, you'll sleep it off, and you'll be fine.  But there are a long list of things that are unique to you that can kill you.  I have neither the emotional energy nor the patience to go over that list.  Unless you want me waking you up every hour to check vitals on you, you're going to the ER.  And I ain't taking vitals every hour tonight."
     My dad listened to reason and decided that he did need to go.  He was not being unreasonable.  He was just so disappointed.  He wondered aloud, "is the rest of my life going to be like this?  Everytime I get some bug that causes a fever I have to go to the ER?  No matter how long it's been from the SCT?  You wouldn't go to the ER for the same symptoms."  He knew the answer before I even said it.  It's the price of living with cancer.  And I don't care what kind of cancer you have.  You'll notice that reputable cancer hospitals NEVER use the word "cure".  They use the word survivor.  Because they know that there is always the chance it will come back.  Or, a different cancer altogether as a result of all the mutations that the chemotherapy and/or radiation caused. 
     The price of liberty is eternal vigilance.  Nowhere is that more true than in a cancer survivor.  Every cough, every sneeze, every new backache must be analyzed through the lenses of "is it coming back?"  You and I take these things for granted because they will not kill us.  But not the survivor.  No, they must be eternally vigilant.

match day

     Someone interrupted the leader of our workshop, "can we have 5-10 minutes to check our emails and call family and friends?"
     March was all workshops.  No clinic, no hospital, no call, no nothing.  Match Day also occurred during March.  It's that nerve wracking specific date when a graduating student finds out where they're going for residency.  Not graduating until December, I had no emails to check, no phone calls to make.  I was envious of their station.  I should be in the same place.  Looking back, I know that the wear and tear of emotional tragedy piling up one after another caused me to need a break.  Everyone I trusted said I needed it.  I even agreed.  Logically, it was the sane thing to do.  But it still did not lessen the sting of that day.

horse sense

     "So tell me about your 18 month well child checkup," the attending told me.

     I paused a moment and then said in my best Texas accent, "You'll see why in a minute, but something ain't right with this kid."

     The attending laughed and interrupted me saying that's actually quite an important observation.  To have seen enough of the usual suspects to know when something much more dangerous crosses your path is very important.  And to see it within the first few seconds of walking through the door is critical.  It's horse sense, really.  Yes, we have to know libraries of information, but the application of it is really quite simple.  Use your powers of observation and then feed that into a Sherlockian mode of deduction.  I still remember my brother's oncologist saying, "you'll find that the majority of medicine is just common sense."  And he was right.  My common sense told me something wasn't right.  I then began to rattle all the minor things I noticed that if they were by themselves, wouldn't amount to much.  But when you see the big picture and put them altogether, warning bells should start sounding.  And loudly.  This is when I knew I had earned the attending's trust and was going to get a good evaluation.  While I'm still presenting, he starts ordering tests based solely on my presentation as he hadn't even seen the kid yet.  This kid should've had these tests 6-8 months ago but had somehow managed to pass a couple of physicians who missed the boat royally.  We took a shotgun approach since it had been going on so long - genetic screening, early intervention, surgical consult for testes that had not descended (they are supposed to descend by 12 months and the poor kid had physicals which said they were descended at 9 and 12 months, which they most certainly were not), autism screening, cystic fibrosis confirmatory testing, etc.  On the one hand, I felt very proud of myself.  On the other, I felt very sorry for the family.  They were in shock, and deservedly so as no one had told them this before.  And it was only the beginning for them.  Their life was not going to get easier, only harder.  Such is the way of our training.  We learn on the "interesting" patients.  But you never, ever want to be interesting to a doctor.

things rarely present like they do in the textbook

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     I came home from working at the pediatrics clinic all day and told my wife, "If you get syphilis, this is why.  But don't worry.  It's really easy to treat."

     Needless to say, she was not amused.  A rather precocious teenaged patient had come with a rash that was rather widespread.  And the rash didn't look like anything I'd seen before.  Common sense says to wear gloves, which I fortunately I remembered to do.  I went out and presented to my attending.  When he asked me what I wanted to do, I honestly replied, "I've got nothing."

     We both walked in and he looked at the rash in a similar fashion.  I could tell he was just as perplexed as I was.  We went and got the Nurse Practioner.  The NP came in, shrugged her shoulders in uncertainty and thought it might, maybe, just possibly, I don't know be an atypical case of a staph infection, emphasis on the word 'might'.  So the patient got amoxicillin and sent on their way with a follow up in three days because honestly, we were anything but sure.  In the back of everyone's mind lingered the thought, "is this syphilis?"

     Sir William Osler, the founding father of modern 20th century of medicine said, "He who knows syphilis, knows medicine."  The rationale of that statement is because syphilis can pretty much do whatever it damned well wants to do - rash, fever, muscle aches, joint pain, heart disease, brain disease, psychiatric symptoms, etc.  But we rarely see it anymore because it's highly susceptible to antibiotics.  Most people in the western world have had a dose of penicillin or a z-pack for a respiratory infection or sinusitis.  That antibiotic would've knocked out any syphilis hanging around.  So much like rheumatic fever, it's becoming a thing of the past, which is a good thing.

     The patient returns three days later.  I walk in and it's clear the rash hasn't improved at all.  In fact, it's gotten worse.  Again, I smartly put on gloves but now notice that the rash has spread to the palms of the patient's hands.  In the immortal words of Scooby Doo, "Ruh-roh".  There are only a handful of rashes that go to the palms, syphilis being one of them.  It also means that at that stage of syphilis, the lesions are teaming with the parasites.  Even a simple handshake can spread millions of the little buggers.  I've never washed my hands so thoroughly as after that visit. 

     But the patient was already on antibiotics.  Was this a resistant form of syphilis?  Gonorrhea is making a strong comeback with resistance to our usual armamentarium.  So why not syphilis?  We ran the blood tests of syphilis but in the meantime, tried another approach.  We kept her on the antibiotics but treated her as if it might be scabies.  Or, bed bugs.  Hell, it really didn't matter in the end.  It didn't look like either but hey, this is the art of educated guesses.  Again, another three days pass and the patient returns.  This time the rash is subsiding so it must have been an atypical presentation of scabies rather than an atypical case of syphilis.  Who knows?  My wife was only mildly relieved.  She threatened to have me start stripping in the garage before coming home and heading straight to the shower.

     So the next time you hear some politician talking about how medicine can be just algorithms and essentially a cookbook, please, please, please don't vote for that person if you want to help me.  Sure, the algorithm will help about 80% of the patients but removing any concept of actually thinking and relying on our decade of training is going to hurt the other 20%.  It is MUCH more subtle and complex.  There's a reason our training is so long and education continues lifelong.

redemption

     My pediatrics grade is essentially divided equally between three parts - first month evaluation, second month evaluation, and the exam.  For the first time in my life, I received a "Pass" as an written evaluation for my performance.  Now, I've gotten "pass" on plenty of tests.  I know I'm not the strongest test take.  But in the real world?  Never.  I felt a lot of things but pissed off was probably the strongest one.  I was told to be happy for it given all of the stress I've been under for....I can't even recall anymore.  First my brother, then my dad, and finally my son.  Somewhere in there, I went to medical school but I'm not quite sure I recall it.  So I was supposed to be grateful that I passed given the circumstances.  Pardon my language but $*%^ that.

     So the second month of pediatrics rolled around in February.  Different location, different attending, different everything.  And the stars aligned just right for me to be in the type of situations where I do best in.  Lots of work, an attending willing to let me take on as much responsibility as I wanted (and actually listened to my plans), and it was outpatient.  I was going to be damned if I let another month of "Pass" come across my ego.  I put my head down and plowed on handling things as simple as well baby checks to rather complex patients.  And my performance was not undervalued.  I redeemed myself and got "Honors" with rather good comments on the written part.  Those are actually probably the most important part.  At the end of your med school career when you apply to residency programs, probably one of the biggest thing besides your first licensing exam score, is the Dean's Letter.  On the letter goes ALL of your comments from Every.  Single.  Rotation.  I've known a few students who apparently didn't play up the resident's ego enough and got a bad comment on the review, despite passing the class.  I knew the students.  They were not slackers.  But doctors can be assholes just like any other profession.  And that one comment can tank your application.  No one wants to have to explain in an interview the comment "student was disinterested" or "lackadaisical in their approach" even though the rest of the comments were good.  You want to spend your limited interview time talking about other things because your letter has line after line after line reiterating "hard worker", "will make an excellent clinician", "was able to handle the most complex of patients", or my personal favorite "functioned at the level of a resident."  And then there's that one that matters more in Family Medicine than other specialties, "great at developing relationship with patients."

birthday

A happy belated birthday to my dad.  It was two years ago yesterday that he received his stem cell transplant.  It's a birthday that means much more to him than his classic birthday.

chief complaint

     Whenever one makes an appointment with a doctor, they ask for a reason for the appointment.  Everybody's done it.  The person then booking appointment, enters into the electronic medical record what the patient is being seen for.  This is supposed to help us.  Before we go into the room, we like to know what we're walking into, at least I do.  But on my last rotation - pediatrics - the chief complaints were written as if the person entering them had no medical training whatsoever.  Rather than get irritated, I started keeping a running tally of them so I could laugh at them.  But really it is a sign of driving down the cost of healthcare with foreseeable consequences.  Less trained people are replacing those with more training.  PAs are replacing doctors.  LVNs are replacing RNs.  Psychologists are replacing psychiatrists.  But I'm not going to get into that right now.  I'm just going to use my list to laugh.

1. Thrash in mouth - I think you meant thrush in mouth.  Thrashing in the mouth would be quite a terribly different thing.  And I wouldn't know how to treat it either.
2. Swollen right tisticle - Seriously?  We can't get testicle spelled correctly either?  And it was the left tisticle, by the way, but I figured it out.
3. Lump near head - Do you mean the neck?  That thing that the head is connected to?
4. Rash on bottom - Bottom of what?  Bottom of the hands, feet, etc?  It is appropriate to use buttocks in the medical field.
5. Rash in private area -  Oh, good grief.  Can't you use at least the diaper area?  Or, groin?  Or, God forbid, the anatomically correct term of perianal area?
6. Pain - Help me out here.  Pain where?????  Believe it or not, it makes a BIG difference where the pain is.
7. Fever - Again, help me out here.  Fever in and of itself is not a reason to bring someone in (unless it's a newborn).  Fever and what?  Cough?  Abdominal pain?  Those are very different things.

So if ever your doctor walks in and has no clue why you're there or they are running late, it may not be their fault.  They may have quick tried to see a patient with a run-of-the-mill headache and it turned out that the kid could hardly breathe for the wheezing and obvious new diagnosis of asthma.  We can't exactly just let that go.  We've got to try to get the kid stabilized and then decide whether they need to go to the ER.  So the next time you're making an appointment, do everyone a favor and be as specific as possible.  If you have three separate problems, tell them that.  Don't do the infamous, "oh by the way..." as we're trying to walk out the door having solved one problem.