Tuesday, October 17, 2017

living in awe


One of the perks of being a physician is that you get to live in a state of perpetual awe. It starts with the first pass of the scalpel on your first day in the anatomy lab. It continues as you tease out every organ, blood vessel, and nerve in the body you’ve been assigned to dissect. A sense of wonder punches you in the gut the first time you hear a beating human heart, and you realize that your own heart has been beating steadily and predictably without any effort on your part since before the day you were born.
“Stay in a state of
gratitude and awe.”
~Wayne Dyer~
You’d have to be a toadstool not to be mystified by the anatomy, physiology, and psychology of your very own body. You’d have no choice but to believe in miracles if you understood the way a broken body heals, what it takes for an open wound to close, how a lifeless heart can pick up the beat again. Don’t even ask what happens during sex.
I studied medicine for seven years and practiced for over three decades so I understand how the body heals. I know what it takes to keep it up and running. Most of the time, I know how to fix it when something goes wrong. Most people don’t. They get out of bed in the morning and expect their bodies to work.
The problem is sometimes they don’t. We take good health for granted until something goes wrong. The cancer comes back. The paralysis turns out to be permanent. The depression won’t lift. Sometimes the afflictions of the body go beyond its ability to heal. Beyond the physician’s ability to help.
“Every patient you see
is a lesson in much more than
the malady from which he suffers.
~Sir William Osler~
For example, Pat’s son has undergone forty operations to correct the disfiguring wounds caused by the explosion that blew the side of his face away. At first, the doctors didn’t think he would live. Now he’s not so sure he wants to. Each time he goes back for the next stage in reconstruction, the incisions heal. Not so his spirit. The hospital scares him. His reflection repulses him. He wants this to be over—the repairs, the rehabilitation, the pain. Life itself. His wounds may heal but he still has a hole in his heart.
Pat would gladly take on his pain, frustration, and despair if she could spare him a lifetime of misery. She would do anything to restore him to the brave, handsome young man he was before his deployment. If his lot in life is physical and mental anguish, hers is paralyzing heartache. He feels abandoned and she feels helpless.
Helpless—the way a doctor feels when a patient under his care gets worse and there is nothing he can do about it. When he has tried everything and nothing has worked. When he feels like a failure—so not God, as is sometimes still expected of physicians.
And that’s a problem. The downside of doctoring is that sometimes the patient gets worse despite your noblest efforts. The cancer spreads. The heart fails. The wound won’t close. There is nothing more you can do. You concede that it would take a miracle for the patient to recover. All you really have left is prayer.
But what if you don’t believe in prayer?
What would it take to change your mind?
Brenda was forty years old when she went in for her first routine mammogram. Yes, she performed regular breast self-examination. No, she hadn’t felt anything unusual, nor had her husband, a breast surgeon who would have known something was wrong had his highly trained fingertips come up against a lump there. Nor did she have a family history of breast cancer that put her at risk. Nothing.
Which is why the X-ray report came as such a shock. A large mass occupied most of her left breast and the calcifications in it looked suspicious. While she explained to her children why she had to go into the hospital, her friends and family stormed the heavens with prayer. You can imagine the collective sigh of gratitude and relief that went up when the surgical reports came back negative. When they failed to turn up a single cancer cell.
“Impossible,” the doctors said. They re-examined the X-rays. They pulled the slides out and went over them again in excruciating detail, searching for even one abnormal cell. They were left to shrug their shoulders in disbelief. She was healed. Her surgeon couldn’t explain it, but her friends and family hailed it as a miracle and they attributed it to prayer.
“Be patient toward all that is
unsolved in your heart
and try to love
the questions themselves.”
~Rainer Maria Rilke~
On the other hand, the doubting Thomases explained it away based on the limits of technology. After all, they insisted, not every X-ray is accurate. It might have been caused by human error. Perhaps the planets were aligned in her favor that day. They would accept any explanation but they would not acknowledge the triumph of a medical miracle. In cases like this, the faithful celebrate while skeptics ramp up arguments to explain it away, and doctors are left to shake their heads in disbelief.
Or in awe, depending on how you see it.
“I think this is how
we’re supposed to be in the world~
present and in awe.
~Anne Lamott~


Monday, October 2, 2017

how stories bring us to wisdom


To really understand a story, you have to know something about the person who is telling it.
“It may take a doctor
to diagnose someone’s disease,
but it takes a friend
to recognize someone’s suffering.”
Picture this: a four-year old is enjoying an ice cream cone on a hot summer day. But the ice cream is melting faster than she can lick it off. Suddenly the whole thing just gives way and ends up a pool of sticky sweetness on the hot sidewalk. She starts to cry. She is unconsolable because her ice cream is gone.
If she could tell her story, she might describe how happy she was when her mother bought her the ice cream cone, and how her heart was broken when it fell to the sidewalk. She might blame herself for being careless and feel guilty about having ruined it.
Depending upon her personality, her mother might see it two ways. It might upset her to see her child’s disappointment and to hear her crying. Or, she might be angry because her daughter was careless with it and her money was wasted. Two different stories.
Her bratty brother might describe his perverse delight in her predicament.
Everyone would tell the story differently.
Likewise, patients tell their stories from different perspectives depending on the situation. This can be misleading for the physician. Some people panic at the slightest ache or pain. Some people ignore a serious problem out of fear. A good example is rectal bleeding. Everyone knows it can be a warning sign of colon cancer…but no one wants to have a colonoscopy.
“Fear of illness
accounts for more deaths
than illness itself.”
Others may be in denial about their symptoms. Chest pain is blamed on indigestion when the patient is actually having a heart attack. Or heartburn is blamed on stress when the problem is an ulcer. They try to convince themselves it isn't serious.
Stoic patients may minimize their symptoms. My mother was a stoic woman. I called her one Sunday evening, like I did every week, and I noticed her speech was slurred. When I asked her about it she said, “Oh, I think I might have had a slight stroke a couple of days ago.” Did she call the doctor? No. She didn’t think it was severe enough to bother him about.
“Listening is often
the only thing needed
to help someone.”
The medical history, then, can be misleading. To get the whole story, the physician has to listen to the patient’s story while also observing his expression and body language. It helps to know what is going on at home and at work. It takes time to explore his beliefs, his fears, and his experience of illness.
It helps to know the patient. It helps us know his disease.
“Facts bring us to knowledge,
but stories bring us to wisdom.”
~Rachel Naomi Remen~

Monday, September 25, 2017

no contest

I’m pretty sure Mother Earth wobbled on her axis last week after three epic hurricanes, raging wild fires, and a catastrophic earthquake disfigured the face of the planet we call home. The urgent and passionate stories that erupted in the aftermath of these disasters held us spellbound…horrified…as tragedy unfolded before our eyes.
We witnessed accounts of terror, helplessness, grief, and pain. We heard stories of courage, strength, compassion, and faith.
I don’t know about you, but those stories silenced me. The worries I harbor, the sadness I feel, the losses I face in my life pale by comparison. Who would want to hear about them?
“Writing is a struggle
against silence.”
~Carlos Fuentes~
For example, I could tell you about a friend of mine who missed a step in the middle of the night a couple of weeks ago. She tumbled down a flight of stairs and suffered a brain hemorrhage. Her family and friends have kept a bedside vigil ever since, even though the  prognosis for her recovery, short of a miracle, is nil. It’s a tragic story…but it is dwarfed by the magnitude of suffering we witnessed in the aftermath of the disasters that wracked the world last week.
“Write what should not be forgotten.”
~Isabel Allende~
Perhaps the same thing has happened to you. You went mute because your story sounded dull or ordinary or immaterial by comparison. It was unworthy. Unnecessary.
It doesn’t take a natural disaster or a missile launch or a violent uprising to shut storytellers down. We do it to ourselves all the time. We trivialize the course of our own lives, lock away our memories, and dismiss our thoughts, feelings, and convictions because we doubt ourselves. We tell ourselves our story isn’t important.
“Write hard and clear
about what hurts.”
~Ernest Hemingway~
In fact, everyone’s story deserves to be heard. Storytelling is not a contest to see whose narrative is the scariest or saddest or most horrifying. Rather, it’s the pathway to truth as each of us understands it. 
“You can’t make this stuff up.”
~Lee Gutkind~

Monday, September 11, 2017

look for the helpers

Like many Americans, especially those of us who have friends and relatives living in Florida, I have been following the course of Hurricane Irma for the past several days—listening to the data that predict the path of the storm, the projected rainfall amounts, barometric pressure, wind velocity, and expected storm surges. I have been watching the preparations for the storm, the course of evacuations, and the availability of storm shelters.

Image result for hurricane irma

But this is not what interests me the most.

Having this data is like knowing a patient’s vital signs—his pulse, respiratory rate, blood pressure and temperature. It tells us how he is doing, but not how he feels.

More than data from the weather watchers, more than updates on the recovery effort, I’m interested in the human narratives behind Irma.

We were horrified by the images of the nursing home patients in their wheelchairs with flood water up to their waists while they waited to be rescued.


We can only wonder what it must be like for people who lost everything. And had no flood insurance. And now, no job to go back to.

“And so rock bottom became
the solid foundation
on which I rebuilt my life.”
~JK Rowling~
What if you were in a shelter at the height of the storm and you started to experience chest pain, or unrelenting RLQ pain indicative of acute appendicitis, or symptoms of a UTI? Where would you turn for help? How did the doctors and nurses manage without electricity, without water, without sleep? How many lives did they save? How many did they lose?
Like the trees that were uprooted and the homes that were destroyed, the injured and terrified children, and lost pets, unspeakable suffering and deep grief are all remnants of Hurricane Irma.
The stories that emerge in the aftermath of the storm will be as powerful as the storm itself. They will fill volumes if people can find the words to tell them.
“Dance on broken glass,
build castles with shattered dreams,
and wear your tears like precious pearls.
~Anita Krizzan~
If it were possible to bring strength, comfort, solace and healing to everyone affected by this storm...and (while we're on the topic) Hurricane Harvey...and the wild fires out West, and the floods, famines, and injustices that devastate Mother Earth, we would all embrace the power of hope, compassion, and inspiration.


Tuesday, September 5, 2017

the time is now

Warning! Op-ed:

When I closed my practice after thirty years in Family Medicine I told my patients and colleagues I was retiring…when I meant I was quitting.
“Quitting is leading, too.”
~Nelson Mandela~
I didn’t put it quite that way, of course. It wasn’t as though I simply got fed up with things, turned in my stethoscope and tongue blades, and slammed the door on my way out of the office. I wasn’t impulsive about it at all. I agonized over my decision for years until I knew the time was right.
“The moment you feel like
you have to prove your worth to someone
is the moment to
absolutely and utterly
walk away.”
~Alyala Harris~
It had nothing whatsoever to do with my patients. Caring for them has always been my passion. Nor was I defeated by the perpetually long hours that became interminable as I grew older. Nor was I discouraged by the fact that I’d been running behind schedule all day, every day for three decades with no chance I’d ever catch up.
No. What finally did me in was the erosion of my authority as a physician by self-proclaimed intermediaries who had neither knowledge of nor concern for my patients’ wellbeing. When I started out in medicine the problem was oppressive paperwork; now-a-days it’s an oppositional defiant electronic medical record system. A baffling coding and reimbursement system. The ever-present threat of litigation. A pharmaceutical industry that invests as heavily in marketing as it does in research. A health insurance industry whose number one priority is corporate profit…not compassionate care. Aggravations that follow physicians through life like a swarm of angry bees.
“Be the change you wish to see
in the world.”
~Mahatma Gandhi~
Isn’t it about time we restored autonomy and authority to physicians and health care providers...the men and women who have dedicated their lives to delivering compassionate and capable health care to their patients? Isn't it time to put patient care first, again? 
What do you think? Is this the time?
“The time is now.
The person is you.”
~Nido R. Qubein~




Monday, August 28, 2017

only time will tell


As a physician, and at times as a patient, I enjoy the advantage of knowing, before I see a doctor, what questions he will (or should) ask concerning the reason for my visit. This saves time and effort because he doesn’t have to tease out the diagnostic clues that are part of the “history of the present illness.” I hand them to him in perfect order.
“It is much more important
to know what sort of patient
has a disease
than what sort of disease
a patient has.”
~William Osler~
Likewise, I already know what the physical exam should include and how it should be performed. I can predict what tests he will order, and he doesn’t have to go into detail about the treatment he is recommending. I know what he is going to say before he says a word.
Unfortunately, this means I pick right up on it when my own physician slacks off. When he fails to ask the right questions. When he neglects parts of the physical examination. When he fails to follow-up on X-ray findings or blood tests.
This is how mistakes are made…and I know why it happens. Not because he lacks expertise in his field. Not because he is uncaring. Not because he is lazy or unmotivated. (I know him better than that…).
No, there are other forces at work. He is seeing a patient every 10-15 minutes, so he is usually running behind schedule. The history and physical exam must focus solely on what he suspects is wrong. There simply isn’t time to be as thorough as he would like to be.
“It’s not about having enough time.
It’s about making enough time.”
~Racheal Bermingham~
Perhaps he's falling behind on his “productivity quotient” and risks losing his job if he doesn’t pick up the pace.
Or maybe the EMR he is using doesn’t have a bullet for the information he wants to include, so it goes unrecorded.
All the health care mandates and initiatives in the world will not solve the problem of TIME. Time spent with the patient. Time to reflect on his illness. Time to help him heal.
Now is the time for change.
“Lack of time
is actually
lack of priorities.”
~Tim Ferriss~

Monday, August 14, 2017

true story


True story:
A friend of mine has been in terrible pain for over a year. She has orthopedic problems and degenerative disc disease in her back resulting in unrelenting sciatica. She also has a rare autoimmune disorder that requires her to be on chronic steroid treatment. Her initial workup, several years ago, found nothing operable so she has been taking substantial doses of opiates daily since then in a futile effort to control her pain. She can’t drive. She can barely make it up the stairs to her bedroom. She is experiencing a deepening depression because of it.

“You can avoid reality
but you can’t avoid the consequences
of avoiding reality.”
~Ann Rand~
Why hasn’t she gone back for re-evaluation?
Because, as she puts it, “They’ll think I’m a whiner.” She doesn’t want to take up the doctor’s precious time when other patients are worse off. She doesn’t have the language to describe her pain…not the nature of it, not the severity of it, not the timing of it. She tells herself she’s a sissy, that other people wouldn’t complain about it so she shouldn’t, either. She is convinced the doctor won’t find anything wrong and he’ll laugh her out of the office, or worse, he’ll assume she’s seeking drugs. Or, worse yet, he’ll decide she needs surgery after all, and she definitely doesn’t want that.
Her situation illustrates some of the obstacles patients encounter when trying to tell their story--the chief complaint and the history of the present illness.
What happens in situations like this is that the patient lies. He minimizes the severity of his symptoms because he doesn’t want to sound like a complainer or weakling. He may be embarrassed to admit that he can’t keep up with things anymore because he’s afraid he’ll lose his job. Even if he suspects the gravity of the problem, he may be reluctant to learn the truth. For example, the patient with chest discomfort may describe it as indigestion or heartburn in an attempt to dissuade the doctor who is sure he has CAD.
“You’d be surprised
what lengths people will go to
not to face what’s real and painful inside them.”
These are some of the obstacles that serve to confound the patient’s narrative: denial, shame, fear, ignorance, and dread.
To make a long story short, at my insistence my friend scheduled an appointment to see her pain management specialist. I’ll be going with her that day because, as a physician, I know what she's up against. As a writer, I think I can help her tell her story.
“One day I will find the right words
and they will be simple.”
~Jack Kerouac~