I mean, here I am again at 12:49 am, awake, answering pages about ridiculous things that can wait until the morning. One patient has even paged me 3 times FROM THE EMERGENCY ROOM WAITING ROOM. I finally told her that she was abusing the system- that I was not her personal concierge doctor, but instead a fellow on-call after a 19 hour and counting day. She was calling to complain about her pain- in between doctors being in her room to see her!! And she screamed at me and told me I was rude when I did express my discontent.
People are so needy out there for hugs, and they often ask for them from us. But it's really not our role- to provide pick-me-ups to anyone who feels like having us paged at 3am. That's where the line gets crossed. And that's where I question- just for a moment- whether this is worth the work. My pager is not a hotline for the emotionally unwell. It is supposed to be for emergency, gastrointestinal-related calls. I mean, do most of you, my readers, at 2am think "I can't sleep, let's page a doctor for some lovin'!" I pity these patients, and now I have spoken to over 50 of them this year between 6pm and 7am on my call nights. Always asking questions that are non-urgent- and keeping me on the phone as long as they can.
I fear that I am getting less patient, that my compassion is being drained by this sleepless exercise in patience and preservation. It's dark, cold December. And this is the 12:49am of a first year fellow.
Friday, December 19, 2008
Tuesday, November 25, 2008
Pyscho Drama
A young patient of mine suddenly decided to start speaking to the wall. He was angry, or so says his girlfriend who is next to him. So he yelled at the wall. This didn't seem too out of the ordinary at first. I mean, how many times, in the car do we mumble "are you kidding" to ourselves in traffic, or even worse things aloud, with no audience except an empty passenger seat and the radio. But then the yelling continued. He started to lash out at the wall, to humiliate the wall. And soon into this she realized that her boyfriend was having one of those moments, where one "loses it" and acts crazy. But in his case, the craziness continued on, and she called his mother who was unsuccessful at talking him down from this imaginary ledge.
Three weeks later this man is in my company. He spent the past two weeks on an inpatient psychiatric ward with frequent episodes like the one I described above. He was on 8 different antipsychotic medications. None worked. And after a few weeks they checked his blood labs and found, to their surprise, that many things were awry. The labs had been checked on admission to the psychiatric hospital and were normal. Now his liver tests were abnormal, and he was quickly shuttled over to my hospital for further evaluation. And after a few days of testing, including an careful eye exam which revealed the problem, and a liver biopsy which cemented the diagnosis, we had unfortunate news: there is nothing we can do for his psychosis.
The disease is Wilson's disease in which copper accumulates in tissues. This manifests as neurological or psychiatric symptoms and liver disease. Early in the disease, several treatments, most of which are geared towards chelating (adhering to and ridding the body of) copper are used. But in severe Wilson's disease, very little can be done for the brain, which can have irreversible damage.
So why do I share this story, other than its fascinating allure? For one, the patient was 23, and for those 3 weeks, while his brain worsened, he was diagnosed with schizophrenia, depression with psychosis, and several other psychiatric illnesses. And don't forget, those initial labs were normal. It is so easy, in medicine, after the fact, to start pointing fingers. This could be an essay about how the psychiatrists dropped the ball, or about how shitty things happen to young people- but really it's just an eye-opener for my readers: in medicine, one needs to fight every day not to corner people into their diagnoses. That's how we miss things. One needs to think outside the box- and be willing to be wrong. After all, it was the psychiatrists who sent him to us as soon as they realized there was more to the story: a metal accumulating in his organs, and driving him mad.
Three weeks later this man is in my company. He spent the past two weeks on an inpatient psychiatric ward with frequent episodes like the one I described above. He was on 8 different antipsychotic medications. None worked. And after a few weeks they checked his blood labs and found, to their surprise, that many things were awry. The labs had been checked on admission to the psychiatric hospital and were normal. Now his liver tests were abnormal, and he was quickly shuttled over to my hospital for further evaluation. And after a few days of testing, including an careful eye exam which revealed the problem, and a liver biopsy which cemented the diagnosis, we had unfortunate news: there is nothing we can do for his psychosis.
The disease is Wilson's disease in which copper accumulates in tissues. This manifests as neurological or psychiatric symptoms and liver disease. Early in the disease, several treatments, most of which are geared towards chelating (adhering to and ridding the body of) copper are used. But in severe Wilson's disease, very little can be done for the brain, which can have irreversible damage.
So why do I share this story, other than its fascinating allure? For one, the patient was 23, and for those 3 weeks, while his brain worsened, he was diagnosed with schizophrenia, depression with psychosis, and several other psychiatric illnesses. And don't forget, those initial labs were normal. It is so easy, in medicine, after the fact, to start pointing fingers. This could be an essay about how the psychiatrists dropped the ball, or about how shitty things happen to young people- but really it's just an eye-opener for my readers: in medicine, one needs to fight every day not to corner people into their diagnoses. That's how we miss things. One needs to think outside the box- and be willing to be wrong. After all, it was the psychiatrists who sent him to us as soon as they realized there was more to the story: a metal accumulating in his organs, and driving him mad.
Friday, November 14, 2008
In your eyes
I just saw the French film "The Butterfly and The Diving Bell" which is among the most beautiful movies I've ever experienced. For anyone who doesn't know, it's the story of a man who has locked-in syndrome and can only communicate by blinking one eye. So I got to thinking about how patients communicate, or are treated by myself and my colleagues. I cannot tell you how many times I've watched a doctor or nurse enter a patient's room in an intensive care unit, and assume that they cannot hear what they are saying. I have heard flippant conversations about people spoken literally over their bodies. I have also seen much more respectful and respectable acts. I have seen hospital transporters carefully lift a hand of a patient on a stretcher over a chest to make a patient's arm more comfortable. I have seen patients try to express themselves despite a tube in their airway. I have seen patients with Brocas aphasias unable to find words but understanding everything said to them. And I have seen patient suddenly erupt in anger as they begin to process a new diagnosis- one patient even called one of my early mentors a "bitch" even though she was very thoughtfully and patiently discussing his care. In each of these scenarios, the common theme is the struggle to convey thoughts and feelings about the most difficult topic: one's health.
The truth is, doctors do receive formal training in these topics. I spent countless hours with mock patients counseling them through bad news. I spent an equal amount of time in my own clinic in residency actually breaking that news. I never took these moments lightly- when I had to look someone in the eye and let them know that, on that day, their life was changing forever. And there was always a moment, after I did my talking, of silence. A lot of doctors are uncomfortable by this silence- but even 60 seconds of silence gives a patient a moment to consider what has transpired- a moment to feel. And then, after that had passed, I would take a deep breath. Sometimes anger would follow. Sometimes tears. But most often, I was impressed by how brave people are when they need to be. Like the hero in "Butterfly," who when confronted with an impossible situation rises above it to learn to communicate and express himself, many patients are more than capable of doing the same. But will doctors allow for that crucial minute of silence that enables them to do so?
This chapter is insightful http://www.actabiomedica.it/data/2008/1_2008/wilde_menozzi.pdf and touches the issue gracefully. I read materials like this in medical school and they helped me tremendously. But what helped me most of all was taking that deep breath, and looking into a patient's eyes, waiting patiently for what transpired, and being willing to roll with whatever came my way after that moment passed. Close your eyes and imagine a moment like that. Maybe your 50, or 90- and someone tells you that you are sick. Someone tells you that you are going to get sicker and may or may not recover. Do you want them filling the next moments with forced empathy? With words or encouragement? Or do you want a moment to breathe- and to go deep inside your self. Maybe even just to blink.
The truth is, doctors do receive formal training in these topics. I spent countless hours with mock patients counseling them through bad news. I spent an equal amount of time in my own clinic in residency actually breaking that news. I never took these moments lightly- when I had to look someone in the eye and let them know that, on that day, their life was changing forever. And there was always a moment, after I did my talking, of silence. A lot of doctors are uncomfortable by this silence- but even 60 seconds of silence gives a patient a moment to consider what has transpired- a moment to feel. And then, after that had passed, I would take a deep breath. Sometimes anger would follow. Sometimes tears. But most often, I was impressed by how brave people are when they need to be. Like the hero in "Butterfly," who when confronted with an impossible situation rises above it to learn to communicate and express himself, many patients are more than capable of doing the same. But will doctors allow for that crucial minute of silence that enables them to do so?
This chapter is insightful http://www.actabiomedica.it/data/2008/1_2008/wilde_menozzi.pdf and touches the issue gracefully. I read materials like this in medical school and they helped me tremendously. But what helped me most of all was taking that deep breath, and looking into a patient's eyes, waiting patiently for what transpired, and being willing to roll with whatever came my way after that moment passed. Close your eyes and imagine a moment like that. Maybe your 50, or 90- and someone tells you that you are sick. Someone tells you that you are going to get sicker and may or may not recover. Do you want them filling the next moments with forced empathy? With words or encouragement? Or do you want a moment to breathe- and to go deep inside your self. Maybe even just to blink.
Thursday, October 30, 2008
Will to live
A patient asked me today what the difference was between dying and living the final month of her life in the hospital. It was a good question and got me thinking about a concept I have discussed with some of Boston's best palliative care experts during my residency and fellowship. The concept is one of prolonging death vs. ending life- and this is the single most important concept in the US healthcare system today, and one of the least discussed. Let me explain:
First, the facts:
1) Medical care at the end of life consumes 10-12% of the total health care budget and 27% of the Medicare budget.
2) 7-30% of total Medicare budget is spent in the last year of life
The Dartmouth Atlas Project published a few years ago studied the records of 4.7 million Medicare enrollees who died from 2000 to 2003 and had at least one of 12 chronic illnesses. This study demonstrateed that even within this limited patient population, Medicare could have realized substantial savings—$40 billion or nearly one-third of what it spent for their care over the four years—if all U.S. hospitals practiced at the "high-quality/low-cost" standard. The study painted a picture of the health care system in disarray over the treatment of chronic illness.
Basically, there are no recognized evidence-based guidelines for when to hospitalize, admit to intensive care, refer to medical specialists or, for most conditions, when to order diagnostic or imaging tests, for patients at given stages of a chronic illness. Lacking this, two factors drive decisions:
--Both doctors and patients generally believe that more services—that is, using every available resource such as specialists, hospital and ICU beds, diagnostic tests and imaging etc.—produces better outcomes.
--Based on this assumption, the supply of resources—not the incidence of illness—drives utilization of the services.
In effect, the supply of hospital beds, ICU beds, and specialty physicians creates its own demand, so areas with more resources per capita have higher costs per capita.
SO what does this ALL mean in english? Patents without living wills have thousands of dollars of healthcare expenditure in their final days, often regardless of their prior preferences as family members dictate their care, and little of this healthcare lends itself to a better quality of life, better outcomes,. So think about this: Would you rather, in your final days, with a debilitating condition, let nature takes its course, or have medicine prolong your death? If the answer is the former, time to sign a living will. No matter what your loved ones say, you'd be suprised how difficult it is, in the final hours of a family member's life on earth, to own responsibility for pulling back treatments, tubes, machines... and the living will takes all of the guilt and puts it squarely where it belongs: on the shoulders of the patient, years before they lost themselves to the inevitable.
First, the facts:
1) Medical care at the end of life consumes 10-12% of the total health care budget and 27% of the Medicare budget.
2) 7-30% of total Medicare budget is spent in the last year of life
The Dartmouth Atlas Project published a few years ago studied the records of 4.7 million Medicare enrollees who died from 2000 to 2003 and had at least one of 12 chronic illnesses. This study demonstrateed that even within this limited patient population, Medicare could have realized substantial savings—$40 billion or nearly one-third of what it spent for their care over the four years—if all U.S. hospitals practiced at the "high-quality/low-cost" standard. The study painted a picture of the health care system in disarray over the treatment of chronic illness.
Basically, there are no recognized evidence-based guidelines for when to hospitalize, admit to intensive care, refer to medical specialists or, for most conditions, when to order diagnostic or imaging tests, for patients at given stages of a chronic illness. Lacking this, two factors drive decisions:
--Both doctors and patients generally believe that more services—that is, using every available resource such as specialists, hospital and ICU beds, diagnostic tests and imaging etc.—produces better outcomes.
--Based on this assumption, the supply of resources—not the incidence of illness—drives utilization of the services.
In effect, the supply of hospital beds, ICU beds, and specialty physicians creates its own demand, so areas with more resources per capita have higher costs per capita.
SO what does this ALL mean in english? Patents without living wills have thousands of dollars of healthcare expenditure in their final days, often regardless of their prior preferences as family members dictate their care, and little of this healthcare lends itself to a better quality of life, better outcomes,. So think about this: Would you rather, in your final days, with a debilitating condition, let nature takes its course, or have medicine prolong your death? If the answer is the former, time to sign a living will. No matter what your loved ones say, you'd be suprised how difficult it is, in the final hours of a family member's life on earth, to own responsibility for pulling back treatments, tubes, machines... and the living will takes all of the guilt and puts it squarely where it belongs: on the shoulders of the patient, years before they lost themselves to the inevitable.
Wednesday, October 15, 2008
Cool
So I found this old piece I wrote last year in the middle of an overnight Emergency Room shift when things finally slowed down and it pertained to my last posting so why not continue a theme about addiction ;) Let me know your thoughts.
It's 3:58 in the ED and I'm thinking about how easy it is to spin a human in the wrong direction.
Bed 15 has lower back pain, an almost sure sign of drug addiction or seeking behavior when it presents at 2am. He had surgery 4 years ago- and still dabbles with cocaine. I think of my 9 month old, of how fragile her hair feels on my fingers when I run them through it every morning as I kiss her cheek. I wonder if he was ever held like that. What happened to this man? Who didn't give him what he needed, and how old was he when he didn't get it? Or did he have it all- and just make the mistake, one Thursday in 1989, of snorting a line of cocaine for the first time and liking it enough to try again. Bed 14, his neighbor, is convinced that she's going to die. She has sickle cell disease and comes in every 3-4 weeks with full body pain. Someone told her once, somewhere, that this is the common presentation of sickle cell "crisis" for which the treatment is pain medication and fluids. There is no good way to tell if the patients are actually feeling pain, and no good way to determine whether her misshapen red blood corpuscles are clogging arterioles throughout her body. So we treat her, over and over again, every other week or so. I wonder what she's really here for. When I touch her knee in an effort to examine the joint, she flinches. Was she abused once? Was it a family member?
My daughter's smile saves me from this awful thought, the way she looks at me definitively when she says "dada". The way she won't let me give her bites of dinner anymore because she's decided that now is the time for her to do things herself. What else will she do alone in this lifetime? Will she be safe? Will the consequences of her actions, and what comes her way lead her on a path of darkness? Will I give her enough tools to know herself and to be aware of her choices? Will she seek the highs that life provides without narcotics?
Room 4 is an elderly woman with a fever that has been explored for a month without a diagnosis. She has undergone procedure after procedure, blood draw after blood draw. She's been on multiple medications, the most powerful antibiotics, and her fever persists. Her husband is angry. He stands beside her, holds her hand. He looks at me with discontent and distrust as I enter. Her eyes are the same shade as my daughter's. I picture my little one, at age 63, and I hope that beside her will stand a man as honorable and kind as the man before me. I hope she finds a living guardian- a watchdog to be her advocate and her champion in times of need. These are the family members so often misinterpreted as "getting in the way," and yet these are the ones who save the lives of their loved ones by second guessing and demanding the truth and a plan and some action. Will my daughter be this strong willed? Will I teach her to be? Will I even need to?
I think of how easy it is to hold my baby in one arm; that each of us was as light once. Each had people make choices for us, until they were old enough to start making them for themselves- and so began a journey down the path of choices- choices ranging from utterly miserable and unfortunate and in the dark to self aware, and happy. And patients who travelled both roads are crowding the ED tonight with concerns and hopes. The concerns are different room to room. But both are, perhaps, hoping for the same thing- to return to a place, at 9 months old, where they could be be healthy; where they could be held- and told the right things, and treated the right way, and given the choice again to make a life for themselves, fingers running through their innocent hair, every tear wiped away with laughter and joy- with care- by someone who cared.
It's 3:58 in the ED and I'm thinking about how easy it is to spin a human in the wrong direction.
Bed 15 has lower back pain, an almost sure sign of drug addiction or seeking behavior when it presents at 2am. He had surgery 4 years ago- and still dabbles with cocaine. I think of my 9 month old, of how fragile her hair feels on my fingers when I run them through it every morning as I kiss her cheek. I wonder if he was ever held like that. What happened to this man? Who didn't give him what he needed, and how old was he when he didn't get it? Or did he have it all- and just make the mistake, one Thursday in 1989, of snorting a line of cocaine for the first time and liking it enough to try again. Bed 14, his neighbor, is convinced that she's going to die. She has sickle cell disease and comes in every 3-4 weeks with full body pain. Someone told her once, somewhere, that this is the common presentation of sickle cell "crisis" for which the treatment is pain medication and fluids. There is no good way to tell if the patients are actually feeling pain, and no good way to determine whether her misshapen red blood corpuscles are clogging arterioles throughout her body. So we treat her, over and over again, every other week or so. I wonder what she's really here for. When I touch her knee in an effort to examine the joint, she flinches. Was she abused once? Was it a family member?
My daughter's smile saves me from this awful thought, the way she looks at me definitively when she says "dada". The way she won't let me give her bites of dinner anymore because she's decided that now is the time for her to do things herself. What else will she do alone in this lifetime? Will she be safe? Will the consequences of her actions, and what comes her way lead her on a path of darkness? Will I give her enough tools to know herself and to be aware of her choices? Will she seek the highs that life provides without narcotics?
Room 4 is an elderly woman with a fever that has been explored for a month without a diagnosis. She has undergone procedure after procedure, blood draw after blood draw. She's been on multiple medications, the most powerful antibiotics, and her fever persists. Her husband is angry. He stands beside her, holds her hand. He looks at me with discontent and distrust as I enter. Her eyes are the same shade as my daughter's. I picture my little one, at age 63, and I hope that beside her will stand a man as honorable and kind as the man before me. I hope she finds a living guardian- a watchdog to be her advocate and her champion in times of need. These are the family members so often misinterpreted as "getting in the way," and yet these are the ones who save the lives of their loved ones by second guessing and demanding the truth and a plan and some action. Will my daughter be this strong willed? Will I teach her to be? Will I even need to?
I think of how easy it is to hold my baby in one arm; that each of us was as light once. Each had people make choices for us, until they were old enough to start making them for themselves- and so began a journey down the path of choices- choices ranging from utterly miserable and unfortunate and in the dark to self aware, and happy. And patients who travelled both roads are crowding the ED tonight with concerns and hopes. The concerns are different room to room. But both are, perhaps, hoping for the same thing- to return to a place, at 9 months old, where they could be be healthy; where they could be held- and told the right things, and treated the right way, and given the choice again to make a life for themselves, fingers running through their innocent hair, every tear wiped away with laughter and joy- with care- by someone who cared.
Tuesday, October 14, 2008
Who's job is it anyway?
This week I have had 3 patients with alcoholism. The first is a man who bled from varices, small veins in his esophagus. The second is a woman who drank so much in such short amount of time (3 months) that she went into liver failure. The last is a young man (25 years old) who drinks 24 beers a night and had bloody bowel movements for 2 weeks and ignored them until his mom threatened to kick him out of the house unless he came in. These three patients have very different stories, backgrounds, problems- but the common theme is alcohol. Alcohol ruined their lives- and alcohol ruined their bodies. And in each case I was called to fix them.
So here's the question: Alcoholism is a disease unlike others because the beginning, middle and end of the disease lie with people's choice to partake in a substance that is dangerous, mind altering, and one that eats stomachs, livers, blood, the brain, the heart- and other organs for lunch. This isn't like cancer or a heart attack- people literally choose to pick up the bottle again and again. Often times patients come in to the hospital several times before alcohol starts to really do its damage. Indeed on a given Saturday night, the emergency room is swamped with drunks- sometimes college kids who aren't yet hooked, but often by homeless men and women- many of whom have educations and had jobs and families lost to temptation and addiction. Given this- is it my job to stop the bleeding? Is it your job to pay for me to do so if these patients (2 of the 3 in my case this week) don't have insurance?
A friend of mine who works for an insurance company tells me that soon premiums will be significantly higher for smokers. The moral: If you choose to ruin your own body, you can pay the lions share of your health bills instead of your smoke-free neighbors. As a doctor it's tempting to agree with this policy. Why not make people more responsible for their habits- if those habits cost (in dollars and time) society at large.
The problem with this thinking is the dangerously slippery slope it represents. Why stop at smoking? Why not make alcoholics pay? And what about those rumors circulating that obese people will soon pay more for airline tickets? Should they pay higher premiums, too? And now that we're penalizing, how about anyone who ever sat on a tanning bed. The minute they get a melanoma diagnosis, should they poney up $2000 extra a month for 10 years to cover the cost of malignant melanoma in a small percentage of the melanoma population? Should I pay for a high carb diet? Should someone who recovered from a cocaine addiction pay for a heart attack 30 years later that may or may not be related? Should a man who slept once with a prostitute in Vietnam and contracted Hepatitis B be penalized monetarily forever more? And on and on the scenarios go...
It is indeed my job to fix whatever problems come my way, at any hour, on any patient. I swore an oath to that affect when I graduated from medical school. But somewhere in the next 50 years we are going to need a oath for everyone to live by- one of less recklessness and one of taking care of ourselves. We can barely afford to care for our sick compatriots now- and with the economy on the fritz- business has never been better at the liquor stores. Still, we are completely backwards in our thinking if we try to penalize with money after the fact. Many alcoholics spend their money on alcohol and don't have a lot left for insurance. Those obese folks could use some education and some support- like free gym memberships, or 1/2 hour extra a day at lunch to take a swim in a pool located at their workplace- now there's an idea. Most studies have shown that money towards health education pays off. As soon as a multi-million dollar campaign in India to educate truckers who were spreading HIV/AIDS throughout the country by unprotected sex with prostitutes was launched, the rates plummeted. And when that campaign was no longer funded- you know the rest.
To my alcoholic patients I had this to say after I "fixed" them this week: stop drinking or you are going to pay. And I wasn't talking for a second about money.
So here's the question: Alcoholism is a disease unlike others because the beginning, middle and end of the disease lie with people's choice to partake in a substance that is dangerous, mind altering, and one that eats stomachs, livers, blood, the brain, the heart- and other organs for lunch. This isn't like cancer or a heart attack- people literally choose to pick up the bottle again and again. Often times patients come in to the hospital several times before alcohol starts to really do its damage. Indeed on a given Saturday night, the emergency room is swamped with drunks- sometimes college kids who aren't yet hooked, but often by homeless men and women- many of whom have educations and had jobs and families lost to temptation and addiction. Given this- is it my job to stop the bleeding? Is it your job to pay for me to do so if these patients (2 of the 3 in my case this week) don't have insurance?
A friend of mine who works for an insurance company tells me that soon premiums will be significantly higher for smokers. The moral: If you choose to ruin your own body, you can pay the lions share of your health bills instead of your smoke-free neighbors. As a doctor it's tempting to agree with this policy. Why not make people more responsible for their habits- if those habits cost (in dollars and time) society at large.
The problem with this thinking is the dangerously slippery slope it represents. Why stop at smoking? Why not make alcoholics pay? And what about those rumors circulating that obese people will soon pay more for airline tickets? Should they pay higher premiums, too? And now that we're penalizing, how about anyone who ever sat on a tanning bed. The minute they get a melanoma diagnosis, should they poney up $2000 extra a month for 10 years to cover the cost of malignant melanoma in a small percentage of the melanoma population? Should I pay for a high carb diet? Should someone who recovered from a cocaine addiction pay for a heart attack 30 years later that may or may not be related? Should a man who slept once with a prostitute in Vietnam and contracted Hepatitis B be penalized monetarily forever more? And on and on the scenarios go...
It is indeed my job to fix whatever problems come my way, at any hour, on any patient. I swore an oath to that affect when I graduated from medical school. But somewhere in the next 50 years we are going to need a oath for everyone to live by- one of less recklessness and one of taking care of ourselves. We can barely afford to care for our sick compatriots now- and with the economy on the fritz- business has never been better at the liquor stores. Still, we are completely backwards in our thinking if we try to penalize with money after the fact. Many alcoholics spend their money on alcohol and don't have a lot left for insurance. Those obese folks could use some education and some support- like free gym memberships, or 1/2 hour extra a day at lunch to take a swim in a pool located at their workplace- now there's an idea. Most studies have shown that money towards health education pays off. As soon as a multi-million dollar campaign in India to educate truckers who were spreading HIV/AIDS throughout the country by unprotected sex with prostitutes was launched, the rates plummeted. And when that campaign was no longer funded- you know the rest.
To my alcoholic patients I had this to say after I "fixed" them this week: stop drinking or you are going to pay. And I wasn't talking for a second about money.
Wednesday, October 1, 2008
Shhhh it's a secret
Here are 10 things doctors think (and will never tell you).
10. You are going to die, and probably at age 76. One of the intriguing things about being a physician is that every illness has a beginning, a middle and an end. To patients, they have symptoms, they come in, they either get fixed or get worse. To us, the beginning holds the clues, the middle is where we meddle and the end is hopefully a successful remission of the illness, if not complete eradication. But in the end, something is going to begin that we can't stop. The middle may be a day or less, or months to years. But there will always be an end. This is apparent to us on the first day of anatomy when we meet our cadavers. And this is what makes doctors able to deliver terminal diagnoses with some regularity. It's not an easy fact. But it's life, and your doctor knows this and thinks about this more than most patients. For what it's worth, the average age of death in the US is 72 for males, 80 for females averaging 76.
9. We like it when you show that you care about yourself. This may seem like a no-brainer, but it is inevitably easier to take care of people who are making efforts to take care of themselves. We live in an interesting era- where malpractice lawyers eat doctors for lunch and patients read internet material and consider themselves experts. It's tough to be a doctor today, trust me, but nothing is more rewarding than the patient who shows up on time, and has made an effort to get better. I cannot tell you how many of my patients in my continuity clinics during residency skipped appointments, showed up 30 minutes late for a 30 minute appointment, stopped taking their medications-those who tried earned my internal respect. All were treated respectfully externally.
8. We're tired! I've written about the work hours before- but docs are beat. By the end of a day delivering health care we're emotionally exhausted and standing and bending and running around all day is tough. The good doctors will not try to hide this.
7. We are grossed out sometimes. So in my 2nd year of med school I rounded one night in the emergency room and a woman came in carrying her eye with the nerve dangling from her socket- I had to leave the room to avoid throwing up. Ever since then- many eye-related diseases weaken my knees- but this is one thing I can get over when I think from the patient's point of view.
6. MANY narcotics users are abusers. With the exception of patients with documented causes of their chronic pain, or patients with debilitating illness (cancers, etc) that require oxycontin, oxycodone, dilauded, morphine, fentanyl patches, or any others in the family of the most abused drugs in history- most patients prescribed these medications for unclear causes are abusing them and should be off of them. Almost all of my colleagues believe this to be so. Unfortunately, many of them prescribe them anyway.
5. We would do it again. I have asked many of my colleagues if, knowing what they know now about how tedious a path medicine is, from the start, they would pursue this path again. Most say a resounding yes. The truth is, we love our patients, our knowledge and our work. If we didn't, we'd never do this!
4. HOWEVER, we'd like to retire young and have second lives. The truth is, medicine takes a lot out of doctors, and most of us would love to pursue other passions as well. The problem is, the job takes up a LOT of time and energy- and there is a wave of young retirement among 50-60 year old docs and second careers which has left some hospitals with very young staffs and few senior physicians.
3. We hate malpractice lawyers. This may seem obvious, but every time I see an add from an ambulance chaser soliciting that "bad doctor" who "needs to be punished" I want to scream: 'you went to school for 3 years, did no residency or fellowship, made $150,000 the year you graduated (I am still making less than $60,000 4 years out), and don't have to deal with vomit and feces and blood and death all day!!'
2. We love to hear about patients' lives. The pleasure in my day, besides meeting amazing people and helping them feel better, is hearing their stories, and learning from them. Every time a patient recommends a book or a website I check it out. Most of my physician colleagues also embrace the chance to learn from our patients. You are our connection to the world at-large, and we are grateful.
1. We are afraid that health care in America is in BIG trouble. It's not just the uninsured, the insurance companies, politicians and CEOs who are worried about the crisis that is upon us, we docs worry about not being able to take care of all of you. We talk about it, read about it, vote according to it, keep up with it- we know that at the end of the day we are going to be in high demand, and that you may not have the means to pay for the services required to keep you healthy. These are scary times- and your doctors are equally scared.
10. You are going to die, and probably at age 76. One of the intriguing things about being a physician is that every illness has a beginning, a middle and an end. To patients, they have symptoms, they come in, they either get fixed or get worse. To us, the beginning holds the clues, the middle is where we meddle and the end is hopefully a successful remission of the illness, if not complete eradication. But in the end, something is going to begin that we can't stop. The middle may be a day or less, or months to years. But there will always be an end. This is apparent to us on the first day of anatomy when we meet our cadavers. And this is what makes doctors able to deliver terminal diagnoses with some regularity. It's not an easy fact. But it's life, and your doctor knows this and thinks about this more than most patients. For what it's worth, the average age of death in the US is 72 for males, 80 for females averaging 76.
9. We like it when you show that you care about yourself. This may seem like a no-brainer, but it is inevitably easier to take care of people who are making efforts to take care of themselves. We live in an interesting era- where malpractice lawyers eat doctors for lunch and patients read internet material and consider themselves experts. It's tough to be a doctor today, trust me, but nothing is more rewarding than the patient who shows up on time, and has made an effort to get better. I cannot tell you how many of my patients in my continuity clinics during residency skipped appointments, showed up 30 minutes late for a 30 minute appointment, stopped taking their medications-those who tried earned my internal respect. All were treated respectfully externally.
8. We're tired! I've written about the work hours before- but docs are beat. By the end of a day delivering health care we're emotionally exhausted and standing and bending and running around all day is tough. The good doctors will not try to hide this.
7. We are grossed out sometimes. So in my 2nd year of med school I rounded one night in the emergency room and a woman came in carrying her eye with the nerve dangling from her socket- I had to leave the room to avoid throwing up. Ever since then- many eye-related diseases weaken my knees- but this is one thing I can get over when I think from the patient's point of view.
6. MANY narcotics users are abusers. With the exception of patients with documented causes of their chronic pain, or patients with debilitating illness (cancers, etc) that require oxycontin, oxycodone, dilauded, morphine, fentanyl patches, or any others in the family of the most abused drugs in history- most patients prescribed these medications for unclear causes are abusing them and should be off of them. Almost all of my colleagues believe this to be so. Unfortunately, many of them prescribe them anyway.
5. We would do it again. I have asked many of my colleagues if, knowing what they know now about how tedious a path medicine is, from the start, they would pursue this path again. Most say a resounding yes. The truth is, we love our patients, our knowledge and our work. If we didn't, we'd never do this!
4. HOWEVER, we'd like to retire young and have second lives. The truth is, medicine takes a lot out of doctors, and most of us would love to pursue other passions as well. The problem is, the job takes up a LOT of time and energy- and there is a wave of young retirement among 50-60 year old docs and second careers which has left some hospitals with very young staffs and few senior physicians.
3. We hate malpractice lawyers. This may seem obvious, but every time I see an add from an ambulance chaser soliciting that "bad doctor" who "needs to be punished" I want to scream: 'you went to school for 3 years, did no residency or fellowship, made $150,000 the year you graduated (I am still making less than $60,000 4 years out), and don't have to deal with vomit and feces and blood and death all day!!'
2. We love to hear about patients' lives. The pleasure in my day, besides meeting amazing people and helping them feel better, is hearing their stories, and learning from them. Every time a patient recommends a book or a website I check it out. Most of my physician colleagues also embrace the chance to learn from our patients. You are our connection to the world at-large, and we are grateful.
1. We are afraid that health care in America is in BIG trouble. It's not just the uninsured, the insurance companies, politicians and CEOs who are worried about the crisis that is upon us, we docs worry about not being able to take care of all of you. We talk about it, read about it, vote according to it, keep up with it- we know that at the end of the day we are going to be in high demand, and that you may not have the means to pay for the services required to keep you healthy. These are scary times- and your doctors are equally scared.
Thursday, September 25, 2008
Round and round
Life as I know it is one of dependance on other people's time. Most jobs don't rely wholeheartedly on schedules of only a few- but in medicine, it's all about the attending. For those who don't know this, the atteding is the top of the pyramid. Yes, there's the CEO, the chair, the chief- but most of us don't see them on the wards with any regulariy. We see the attending. And when we see the attending is one of the most interesting components of hopital life.
Even since I graduated from medical school in 2005, lots has changed. The 80 hour/week mandated work rules were put into place which were supposed to create a safer working environment for doctors and patients. Stories of car crashes following 40 hour shifts and accidents (most notoriously the case of Libby Zion- beautifully summarized here http://www.washingtonpost.com/wp-dyn/content/article/2006/11/24/AR2006112400985.html) led to these changes. Hence us young trainees actually leaving the hospital at decent hours and having a semblance of a life outside of medicine kicked off officially one year prior to my starting training as a medicine resident. This was seen by most young docs, at the time, as a terrific move. The post-call intern was relieved of duty, on most days, at a reasonable hour. Calls were never more than 24 hours long except in the ICU where they lasted up to 36 hours. Night float residents were assigned to cover all admissions after 8:30pm until 7am, allowing interns to go home and sleep a bit. (We never got out at 8:30- more like 1am).
But here I sit, less than one year graduated from my residency- and I am beginning to wonder if those reduced hours helped me or hurt. And this leads back to the attending. The truth is- with all of those hours NOT being worked by the interns and residents, someone had to step in and work harder. That someone was the attending. I have informally been polling my attending physicians on a multitude of services for 3 years and have universally found the same response to my inquiry about whether or not the work hours have affected their lives: BIG TIME. Doctors already average >60 hour work weeks once they are attendings. Those in the teaching hospitals where I have worked for my post-med school career average >80 hours. The increased hours are due to a bunch of factors. Doctors in academic settings are under extreme pressure to bring in money for the hospital. This can be in the form of grants or in clinic time. Some specialties, like gastroenterology and cardiology are procedure oriented and thus have lots of billable services. Others, like nephrology, endocrinology, neurology- are solely office visit based and are "supported" by their money making counterparts. Whichever division an attending works in, he or she has a packed schedule- and one which requires lots of hours for a combination of grant writing, lab research, clinical research, teaching duties, clinic time, and now more and more committee obligations. The attendings bring home the bacon- and the attendings work for it.
So how does this affect me? Why do I care (other than the fact that one day not too long from now I'll be "attending" myself?) Well, last week I got home at 8:45pm 3 times and at 7pm 2 other times. This was because my attending couldn't round with the team until 5:30pm due to her responsibilities in the endoscopy suite, and when she did, rounds were interrupted by phone calls from her patients, and her secretary. Rounds were interrupted by her co-grant writer calling just before a deadline. And when she taught- we looked at the clock. We didn't want to- but we are spoiled now on 80 hour weeks. We are spoiled by 15 minutes with our kids before they go to sleep, and spoiled by the ability to eat a 9pm dinner. We want out at the end of a 14 hour day. And while 10 years ago out wasn't an option- we new-generation doctors know that out is as important as in the hospital.
And all of this isn't only due to the 80 hour work rule- soon to be amended to 56 hours of maximum work a week per resident- but someone has to do that work, and no one is feeling sorry for attendings. After all, they bring in the bacon.
Even since I graduated from medical school in 2005, lots has changed. The 80 hour/week mandated work rules were put into place which were supposed to create a safer working environment for doctors and patients. Stories of car crashes following 40 hour shifts and accidents (most notoriously the case of Libby Zion- beautifully summarized here http://www.washingtonpost.com/wp-dyn/content/article/2006/11/24/AR2006112400985.html) led to these changes. Hence us young trainees actually leaving the hospital at decent hours and having a semblance of a life outside of medicine kicked off officially one year prior to my starting training as a medicine resident. This was seen by most young docs, at the time, as a terrific move. The post-call intern was relieved of duty, on most days, at a reasonable hour. Calls were never more than 24 hours long except in the ICU where they lasted up to 36 hours. Night float residents were assigned to cover all admissions after 8:30pm until 7am, allowing interns to go home and sleep a bit. (We never got out at 8:30- more like 1am).
But here I sit, less than one year graduated from my residency- and I am beginning to wonder if those reduced hours helped me or hurt. And this leads back to the attending. The truth is- with all of those hours NOT being worked by the interns and residents, someone had to step in and work harder. That someone was the attending. I have informally been polling my attending physicians on a multitude of services for 3 years and have universally found the same response to my inquiry about whether or not the work hours have affected their lives: BIG TIME. Doctors already average >60 hour work weeks once they are attendings. Those in the teaching hospitals where I have worked for my post-med school career average >80 hours. The increased hours are due to a bunch of factors. Doctors in academic settings are under extreme pressure to bring in money for the hospital. This can be in the form of grants or in clinic time. Some specialties, like gastroenterology and cardiology are procedure oriented and thus have lots of billable services. Others, like nephrology, endocrinology, neurology- are solely office visit based and are "supported" by their money making counterparts. Whichever division an attending works in, he or she has a packed schedule- and one which requires lots of hours for a combination of grant writing, lab research, clinical research, teaching duties, clinic time, and now more and more committee obligations. The attendings bring home the bacon- and the attendings work for it.
So how does this affect me? Why do I care (other than the fact that one day not too long from now I'll be "attending" myself?) Well, last week I got home at 8:45pm 3 times and at 7pm 2 other times. This was because my attending couldn't round with the team until 5:30pm due to her responsibilities in the endoscopy suite, and when she did, rounds were interrupted by phone calls from her patients, and her secretary. Rounds were interrupted by her co-grant writer calling just before a deadline. And when she taught- we looked at the clock. We didn't want to- but we are spoiled now on 80 hour weeks. We are spoiled by 15 minutes with our kids before they go to sleep, and spoiled by the ability to eat a 9pm dinner. We want out at the end of a 14 hour day. And while 10 years ago out wasn't an option- we new-generation doctors know that out is as important as in the hospital.
And all of this isn't only due to the 80 hour work rule- soon to be amended to 56 hours of maximum work a week per resident- but someone has to do that work, and no one is feeling sorry for attendings. After all, they bring in the bacon.
Sunday, September 14, 2008
Consider This
To anyone who has been awaiting this entry- my apologies for my absence. I had to think through my goals for this blog a bit and also figure out a few technical issues which are now resolved. Welcome back!
I met the most amazing woman this afternoon in the hospital. She is 67 and looks 45. She is beautiful in spirit and in person. Her husband was kind and concerned (appropriately) about the pain in her abdomen. She has been bleeding with every bowel movement for 3 weeks. She has lost 15 pounds since this began. She is in crampy pain and she is uncomfortable. She can hardly walk due to the pain and she is weak and her blood counts are low from the bleeding. She has ulcerative colitis. We have started steroids and she will improve- but not before the steroids make her jittery, and sleepless, and not hungry, and if she’s unlucky, even psychotic. But despite all of that- she is very much herself and wishes to go home as soon as possible so she can see her daughter and help her buy a crib for her first grandchild. She was a teacher until she retired. And she has a glow about her that radiates something warm, kind, knowing. The truth is, this is not her first flare. She takes all of her medications. She may or may not respond to the pills and IV streroids and she may need an operation which would cure her- but leave her without a colon and instead with a permanent ileostomy (a bag for her feces) either temporarily or permanently.
So think about this: One day you get sick. Not a flu- or a cold- but painful, bloody diarrhea. You go so many times to the bathroom in a day that you have to move your desk closer to the bathroom. You are afraid to tell anyone except your husband. Six months later you gather the courage to seek medical help. You undergo a colonoscopy and no one tells you that the prep the night before is much worse than the study. Weeks later you get a call that you have colitis. A year later, after the drugs that several doctors have tried for those 12 months don't work you are given a choice: Be sick with a chance of rupturing your bowels at some point, losing weight, an increased cancer risk, infection risk, risk of pain, etc. or have a surgery that leaves you with a bag that many patients find humiliating- but most learn to live with. After all, that bag fits snugly under a shirt- and many of you have passed someone with an ileostomy on the street today without knowing it.
These are the choices we present to patients every day. And I marvel at the braveness by which people make their choices. It's no easy task, being a patient. It may be the hardest job in the world. Doctors struggle to define who does it well. To some of my peers, the "good" patient is "compliant" and "listens." I find those doctors arrogant. For me, the best patient is one who chooses to be informed (when that is possible) about their choices- and then makes a choice for themselves based on what they believe is best. People are too different to lump into "good" and "bad" and sometimes doctors need to remember that someone who doesn't agree with THE PLAN may still be right. This is part of the confusing relationship that is doctor/patient. We are there to inform you and serve your body best. Your job is to trust us- but not blindly- and to use the information as best you can. In so many ways this relationship can go awry- and I struggle every day with various patients to make certain I am doing right by them despite how they may act, what they may say, (or do).
Tomorrow I am going to recommend surgery to my new patient. From our early discussions it sounds like she will agree that this is best for her based on her support structure, religious beliefs, views on health care and her body, access to ongoing care, desire to be better, ability to tolerate a surgery, and other factors that she and I will weigh together when discussing the matter. And no matter what she chooses, I will honor her wishes, and support her. After all, honor is exactly what doctors should be striving to uphold.
I met the most amazing woman this afternoon in the hospital. She is 67 and looks 45. She is beautiful in spirit and in person. Her husband was kind and concerned (appropriately) about the pain in her abdomen. She has been bleeding with every bowel movement for 3 weeks. She has lost 15 pounds since this began. She is in crampy pain and she is uncomfortable. She can hardly walk due to the pain and she is weak and her blood counts are low from the bleeding. She has ulcerative colitis. We have started steroids and she will improve- but not before the steroids make her jittery, and sleepless, and not hungry, and if she’s unlucky, even psychotic. But despite all of that- she is very much herself and wishes to go home as soon as possible so she can see her daughter and help her buy a crib for her first grandchild. She was a teacher until she retired. And she has a glow about her that radiates something warm, kind, knowing. The truth is, this is not her first flare. She takes all of her medications. She may or may not respond to the pills and IV streroids and she may need an operation which would cure her- but leave her without a colon and instead with a permanent ileostomy (a bag for her feces) either temporarily or permanently.
So think about this: One day you get sick. Not a flu- or a cold- but painful, bloody diarrhea. You go so many times to the bathroom in a day that you have to move your desk closer to the bathroom. You are afraid to tell anyone except your husband. Six months later you gather the courage to seek medical help. You undergo a colonoscopy and no one tells you that the prep the night before is much worse than the study. Weeks later you get a call that you have colitis. A year later, after the drugs that several doctors have tried for those 12 months don't work you are given a choice: Be sick with a chance of rupturing your bowels at some point, losing weight, an increased cancer risk, infection risk, risk of pain, etc. or have a surgery that leaves you with a bag that many patients find humiliating- but most learn to live with. After all, that bag fits snugly under a shirt- and many of you have passed someone with an ileostomy on the street today without knowing it.
These are the choices we present to patients every day. And I marvel at the braveness by which people make their choices. It's no easy task, being a patient. It may be the hardest job in the world. Doctors struggle to define who does it well. To some of my peers, the "good" patient is "compliant" and "listens." I find those doctors arrogant. For me, the best patient is one who chooses to be informed (when that is possible) about their choices- and then makes a choice for themselves based on what they believe is best. People are too different to lump into "good" and "bad" and sometimes doctors need to remember that someone who doesn't agree with THE PLAN may still be right. This is part of the confusing relationship that is doctor/patient. We are there to inform you and serve your body best. Your job is to trust us- but not blindly- and to use the information as best you can. In so many ways this relationship can go awry- and I struggle every day with various patients to make certain I am doing right by them despite how they may act, what they may say, (or do).
Tomorrow I am going to recommend surgery to my new patient. From our early discussions it sounds like she will agree that this is best for her based on her support structure, religious beliefs, views on health care and her body, access to ongoing care, desire to be better, ability to tolerate a surgery, and other factors that she and I will weigh together when discussing the matter. And no matter what she chooses, I will honor her wishes, and support her. After all, honor is exactly what doctors should be striving to uphold.
From the air
Today I’m writing from a plane. I tend to get a lot of good thinking done on flights. This one is from Chicago where I spent the weekend at an advanced endoscopy training. I spent much of yesterday placing endoscopes into pig stomachs and practicing on tools that deliver staples, sutures, rubber bands, and other goodies to bleeding vessels, or polyps, or tumors. We doctors need to practice- and trust me, better on a pig than on you. Still, most of what we do for the first time is with real patients. Many people still believe that one should avoid the hospital altogether in July since those of us practicing are so new. But this has been disproven in the literature which is summed up in this article: http://www.newsweek.com/id/144227/page/1. In some ways, I found in residency that July may be the safest time of year to come in since the amount of supervision is high. I assumed nothing in July during my Junior and Senior years- I double checked all of the interns’ work. Every resident does this- and in that way, July patients get very careful workups, lab checks, etc. that they should be getting all year round, but may not in later months, when assumptions are made, for better or for worse, about the level of knowledge gained by an intern by, say, February. The intersection of earning independence and others taking for granted that you don’t know everything yet is the toughest one to cross in residency- and most of my friends and I struggled with that as we bridged from intern year to managing the team as Juniors.
It is at these moments of quiet, abord this plane admiring my view of the clouds and the remains of hurricaine Ike (which has unfortunately destroyed the homes and uprooted the lives of many Texans this week), that I reflect on my life from the 30,000 foot view. Everyone needs moments like that- where you simply stop the madness of the busy days, and tasks, and stress- and ponder. I don’t think we do enough of that. When patients and I discuss difficult things- the death of a family member, a new illness, a lost job- sometimes my urge is to fill the void of those moments with encouragement, with words. But I am learning, as I get slightly further along in my career, that silence is the most powerful tool at times. It doesn’t always take a plane ride to find that moment. Luckily for me- I have found one now and I find myself thinking of how I got here and I will share a bit of that.
My career in medicine probably began before I knew it. At five, my favorite book was an old set of Encyclopedia Britannicas my parents kept in the living room. Chapters on how to make soap sculptures were fun for Sunday afternoons- but even better were the diagrams of anatomy. I remember well tracing the brain over and over with tracing paper- and somehow feeling proud that I could copy it so that it looked real. In elementary school I loved my science classes. I begged my parents for just about every pet I could have and I spent days with my fish tank, measuring the pH of the water. I guess I was pretty nerdy in my private time- but outwardly I played soccer and hung out with friends and was very much an active boy.
In high school I started to see that my appreciation for science could one day lead to a career. I didn’t really work that hard and I certainly should have gotten an earlier jump then- since now, in my 30s, I wish desperately every day that I could be done training and actually making money and making decisions for myself. But I credit my high school biology teacher, Mr. Howard, for his constant enthusiasm. It was in him that I started to see that science wasn’t just a fun hobby- it was a way of thinking- and in many ways I thought scientifically. Still, musical interests, sports, girlfriends- all sort of distracted me from diving in head-first and I was not the quintessential pre-med student in college. For one, I majored in English. This was a terrific decision. Young doctors-to-be, you will spend the rest of your studying medicine- take a few years in college to branch out a bit. I wrote poetry and short stories in college, and a thesis on Raymond Carver’s (who permanently changed how I see the world). And I had fun. Maybe too much fun- as I realized that I was not the top of my class, and that medical school would be a challenge to get into. I didn’t apply when I graduated from Cornell in 1995. I waited for life experience- for the right moment.
What I did not know is that the moment wouldn’t be for six more years. Looking back I partially blame this on my own insecurities in my ability. Partly, though, I think circumstances- my parent’s divorce at 23, an accident that year that left me completely dependent on others for 3 months, jobs in research that excited me- all delayed the inevitable. But after 5 years of waiting, I took my entrance exam for medical school in 2000 and applied that year. I remember the day I interviewed at Thomas Jefferson Medical School, In Philadelphia- with a woman my uncle (a gynecologist) had worked with for years. She is an incredible doctor- a neurologist named Dr. Madhu Khalia who became my good friend a few years prior when she on sabbatical in Boston where I lived. It was she whose encouragement at that time motivated me to go for it- and she who I still credit for understanding that sometimes, those of us who chose this long path, need some help to find it.
I’ll save medical school and residency for other entries- as I know, throughout this blogging experience, I’ll cover the whole story. What I can say now, with authority, as we approach our destination, fasten seatbelts, follow the relentless rules of the less and less friendly skies- (which happen to cost more and more)- is that I am happy to be a doctor, and that all of this hard work is worth it: even a weekend far away, one of my only weekends off in a while spent not with my wife and daughter, but with pig stomachs. Oh, and before I stop writing this, I do wish to share that time with my family is the most important thing to me, by far, and that which I get to enjoy the least. That is the single biggest sacrifice of being a doctor so far- time. More on this tomorrow.
It is at these moments of quiet, abord this plane admiring my view of the clouds and the remains of hurricaine Ike (which has unfortunately destroyed the homes and uprooted the lives of many Texans this week), that I reflect on my life from the 30,000 foot view. Everyone needs moments like that- where you simply stop the madness of the busy days, and tasks, and stress- and ponder. I don’t think we do enough of that. When patients and I discuss difficult things- the death of a family member, a new illness, a lost job- sometimes my urge is to fill the void of those moments with encouragement, with words. But I am learning, as I get slightly further along in my career, that silence is the most powerful tool at times. It doesn’t always take a plane ride to find that moment. Luckily for me- I have found one now and I find myself thinking of how I got here and I will share a bit of that.
My career in medicine probably began before I knew it. At five, my favorite book was an old set of Encyclopedia Britannicas my parents kept in the living room. Chapters on how to make soap sculptures were fun for Sunday afternoons- but even better were the diagrams of anatomy. I remember well tracing the brain over and over with tracing paper- and somehow feeling proud that I could copy it so that it looked real. In elementary school I loved my science classes. I begged my parents for just about every pet I could have and I spent days with my fish tank, measuring the pH of the water. I guess I was pretty nerdy in my private time- but outwardly I played soccer and hung out with friends and was very much an active boy.
In high school I started to see that my appreciation for science could one day lead to a career. I didn’t really work that hard and I certainly should have gotten an earlier jump then- since now, in my 30s, I wish desperately every day that I could be done training and actually making money and making decisions for myself. But I credit my high school biology teacher, Mr. Howard, for his constant enthusiasm. It was in him that I started to see that science wasn’t just a fun hobby- it was a way of thinking- and in many ways I thought scientifically. Still, musical interests, sports, girlfriends- all sort of distracted me from diving in head-first and I was not the quintessential pre-med student in college. For one, I majored in English. This was a terrific decision. Young doctors-to-be, you will spend the rest of your studying medicine- take a few years in college to branch out a bit. I wrote poetry and short stories in college, and a thesis on Raymond Carver’s (who permanently changed how I see the world). And I had fun. Maybe too much fun- as I realized that I was not the top of my class, and that medical school would be a challenge to get into. I didn’t apply when I graduated from Cornell in 1995. I waited for life experience- for the right moment.
What I did not know is that the moment wouldn’t be for six more years. Looking back I partially blame this on my own insecurities in my ability. Partly, though, I think circumstances- my parent’s divorce at 23, an accident that year that left me completely dependent on others for 3 months, jobs in research that excited me- all delayed the inevitable. But after 5 years of waiting, I took my entrance exam for medical school in 2000 and applied that year. I remember the day I interviewed at Thomas Jefferson Medical School, In Philadelphia- with a woman my uncle (a gynecologist) had worked with for years. She is an incredible doctor- a neurologist named Dr. Madhu Khalia who became my good friend a few years prior when she on sabbatical in Boston where I lived. It was she whose encouragement at that time motivated me to go for it- and she who I still credit for understanding that sometimes, those of us who chose this long path, need some help to find it.
I’ll save medical school and residency for other entries- as I know, throughout this blogging experience, I’ll cover the whole story. What I can say now, with authority, as we approach our destination, fasten seatbelts, follow the relentless rules of the less and less friendly skies- (which happen to cost more and more)- is that I am happy to be a doctor, and that all of this hard work is worth it: even a weekend far away, one of my only weekends off in a while spent not with my wife and daughter, but with pig stomachs. Oh, and before I stop writing this, I do wish to share that time with my family is the most important thing to me, by far, and that which I get to enjoy the least. That is the single biggest sacrifice of being a doctor so far- time. More on this tomorrow.
Thursday, September 11, 2008
All In a Day's Work
36 hours awake now- and still writing. Well, I actually snuck in a nap around 2am (19 hours ago) when my ICU patient was as tucked as we could get him for the night (or morning- they tend to blend together these days). But don't worry, this isn't a woe-is-me opportunity to elicit sympathy from non doctors and "been there" from those in medicine. In fact I'm enjoying the quiet.
Hospitals are not quiet places. In fact, I am bombarded by more pagers, beeps, buzzers, alarms, overhead alerts, ambulance sounds (if I step outside for one second), elevator door dings and other noises than I ever expected. This is among the things one doesn't know when they sign up for the life of a doctor: The noises are always present and reliably annoying. Once, a few years ago, I was senior resident on a medical team and we were all in an elevator and I blurted out "Do you hear that?" And everyone listened intently- until I added, "that's the rare sound of silence," which was met with knowing smiles. The med student asked, "Do you guys get headaches a lot around here?" I had never really thought about it. I had indeed had a slew of headaches since medical school, maybe one or two a month which was new for me- and then I started to realize that almost every nurse I knew carried Tylenol in their bag, and that almost every colleague of mine was asking for Tylenol from a nurse at some point. I had never drawn the conclusion that all of those noises took off from their respective machine, only to make a turbulent landing somewhere between my inner ear and the part of my brain that is supposed to make sense of such sounds- and the result was not pretty. In fact, by the end of a shift, doctors, nurses, techs and other who work the halls of the hospital aren't in the best shape. We have bloodshot eyes, and we are often irritable. It is commonplace for folks to lose the most basic communication skills and small arguments between nurses and docs, docs and docs, nurses and nurses, anyone and a complaining patient are not uncommon, especially as the day wears on. This article is interesting and skims the surface of what has now been widely recognized: Hospitals are WAY behind on creating a business environment in which people respect some basic rules of working together (oh, and I happily disclose that I have no affiliation with the company):
http://www.lftinc.com/content/about-our-company/newsletter/detail.jsp/q/id/15
And this MSNBC article, while a tad sensational for my taste, is really interesting and touches on what is happening to change the hospital environment:
http://www.msnbc.msn.com/id/25594124/
In all fairness to myself and my overworked, underpaid colleagues (I'll touch on trainee payment and how much debt I'm in another day), hospitals are also stressful places. Where else, in a day, do you come across the sick and dying on almost every floor. Commonplace are sights that are frightening- tubes coming out of places that shouldn't have tubes, blood, people the color of Big Bird, or Oscar The Grouch, as yellow and green as yellow and green get. I always wonder, when I see people bring their children to the hospital, what nightmares they might have from an afternoon in those halls where I have spent every day for years. This is not a place for people unprepared for the truth about the human body: It breaks down. It is as frail as a leaf. It isn't built to last forever.
So I suppose this is all sort of somber (OK, downright depressing) this evening. And in order to remind myself, and you, why anyone would do this, I will leave you with this:
A mother of a mentally retarded man sat on his bed with me yesterday and asked me if I would mind explaining to him what he was doing in the hospital and where he was heading next (a rehabilitation center). I began to speak with him (which I had done daily in her presence) and he nodded as I spoke about his condition and his treatment and that he was improving and would return to his mother's home soon and play checkers again and play with his dog again and watch Baywatch DVDs and live happily. As I reminded him of the things that he loved in life- all of which he shared with me in these past weeks, all of which peppered the walls of his room in the photos that his mother brought and posted- he smiled broadly. When I was done there was silence. The mother dried a tear from her eye. This has been a terrible week for her. She has been living in a hotel next to the hospital since their home is hours away. She has come every day and kept a log of what we say and had to meet well over 50 doctors caring for him in these weeks and seen team after team press on his belly and seen the looks of kindness and compassion and sometimes awkwardness on the faces of his caretakers who want to connect with him but somehow can't. She dried that tear and probably hoped that for an instant he might forget this terrible month-long admission and remember fresh air and sky and fun. She hoped. And in that silence and his smile I knew that he had made this connection. And he pointed to the wall and said "My dog!! I'm gonna see my dog!"
Hospitals are not quiet places. In fact, I am bombarded by more pagers, beeps, buzzers, alarms, overhead alerts, ambulance sounds (if I step outside for one second), elevator door dings and other noises than I ever expected. This is among the things one doesn't know when they sign up for the life of a doctor: The noises are always present and reliably annoying. Once, a few years ago, I was senior resident on a medical team and we were all in an elevator and I blurted out "Do you hear that?" And everyone listened intently- until I added, "that's the rare sound of silence," which was met with knowing smiles. The med student asked, "Do you guys get headaches a lot around here?" I had never really thought about it. I had indeed had a slew of headaches since medical school, maybe one or two a month which was new for me- and then I started to realize that almost every nurse I knew carried Tylenol in their bag, and that almost every colleague of mine was asking for Tylenol from a nurse at some point. I had never drawn the conclusion that all of those noises took off from their respective machine, only to make a turbulent landing somewhere between my inner ear and the part of my brain that is supposed to make sense of such sounds- and the result was not pretty. In fact, by the end of a shift, doctors, nurses, techs and other who work the halls of the hospital aren't in the best shape. We have bloodshot eyes, and we are often irritable. It is commonplace for folks to lose the most basic communication skills and small arguments between nurses and docs, docs and docs, nurses and nurses, anyone and a complaining patient are not uncommon, especially as the day wears on. This article is interesting and skims the surface of what has now been widely recognized: Hospitals are WAY behind on creating a business environment in which people respect some basic rules of working together (oh, and I happily disclose that I have no affiliation with the company):
http://www.lftinc.com/content/about-our-company/newsletter/detail.jsp/q/id/15
And this MSNBC article, while a tad sensational for my taste, is really interesting and touches on what is happening to change the hospital environment:
http://www.msnbc.msn.com/id/25594124/
In all fairness to myself and my overworked, underpaid colleagues (I'll touch on trainee payment and how much debt I'm in another day), hospitals are also stressful places. Where else, in a day, do you come across the sick and dying on almost every floor. Commonplace are sights that are frightening- tubes coming out of places that shouldn't have tubes, blood, people the color of Big Bird, or Oscar The Grouch, as yellow and green as yellow and green get. I always wonder, when I see people bring their children to the hospital, what nightmares they might have from an afternoon in those halls where I have spent every day for years. This is not a place for people unprepared for the truth about the human body: It breaks down. It is as frail as a leaf. It isn't built to last forever.
So I suppose this is all sort of somber (OK, downright depressing) this evening. And in order to remind myself, and you, why anyone would do this, I will leave you with this:
A mother of a mentally retarded man sat on his bed with me yesterday and asked me if I would mind explaining to him what he was doing in the hospital and where he was heading next (a rehabilitation center). I began to speak with him (which I had done daily in her presence) and he nodded as I spoke about his condition and his treatment and that he was improving and would return to his mother's home soon and play checkers again and play with his dog again and watch Baywatch DVDs and live happily. As I reminded him of the things that he loved in life- all of which he shared with me in these past weeks, all of which peppered the walls of his room in the photos that his mother brought and posted- he smiled broadly. When I was done there was silence. The mother dried a tear from her eye. This has been a terrible week for her. She has been living in a hotel next to the hospital since their home is hours away. She has come every day and kept a log of what we say and had to meet well over 50 doctors caring for him in these weeks and seen team after team press on his belly and seen the looks of kindness and compassion and sometimes awkwardness on the faces of his caretakers who want to connect with him but somehow can't. She dried that tear and probably hoped that for an instant he might forget this terrible month-long admission and remember fresh air and sky and fun. She hoped. And in that silence and his smile I knew that he had made this connection. And he pointed to the wall and said "My dog!! I'm gonna see my dog!"
Wednesday, September 10, 2008
Day 1
Welcome to my blog- which is really a brief daily journal of my life as a young doctor in training. I am a fellow in a Boston academic teaching hospital. I am in my 12th year of training including college (4 years), medical school (4 years), residency (3 years) and now fellowship. I make less money than most of my friends. I have very little time for my family or friends- but I love what I do, and I care about my patients and learning as much as I can in order to be a well-trained physician. (More on this another day). For now, let me give you a flavor of what to expect from this blog:
So tonight I was called to see a consult on a man in the intensive care unit (ICU). He has chronic pancreatitis from alcohol use and frequently comes in and out of the hospital when he decides to drink himself into a stupor. But this admission was different. He presented with his usual nausea and vomiting, which the medicine team treated with various medications- but on the second day of the hospitalization he felt weak, fainted while walking down the hall, and quickly deteriorated into a cardiac arrhythmia (heart was beating very irregularly) and subsequent cardiac arrest (Code Blue). He was stabilized by a rapid response team and placed on a ventillator. (Yes, the stuff we see on TV does actually happen every day in hospitals.)
I was called to see him in the ICU to help the many teams caring for him decide what was next. But soon after I arrived it became clear to me that everyone was watching him through tunnelled glasses. The pulmonologists were busy deciding whether or not he had aspirated his blood and vomit during the cardiac arrest. The kidney doctors were worrying about the state of his kidneys and his ability to clear toxins from his blood in the form of urine. The cardiologists were worried about the state of his heart. The surgeons were concerned about blood surrounding his pancreas. But all I saw was a dying man. Only 42, this guy- but certainly dying. Doctors were scurrying about- charts in hand. Some were arguing quietly outside the room. A med student was pushing gently on his stomach. Tubes and lines dangled from him like tangled fishing lines. I was there to push and pull and write my note and take part in this giant random production, and I did so reluctantly. But all the while I was mindful of the inevitable truth to this alcoholic man: he would be dead by tomorrow, and there was nothing we could do to stop that. No medication. No surgery. No hail mary pass. Nothing.
The secret of medicine is that when you step back from the room, and look at the big picture, you see amazing things. Everyone is often working separately- but together there is a symphony of ideas. Everyone had the same goal today- fix this man. But no one can do more than their part. It's like the 5 minutes before a show- when each instrument is tuning up- and the cacophony of sounds that fill the air are somehow exciting and make sense even though the notes are random and out of sync. So rarely, however, does anyone step back. That moment, in American Beauty- when Kevin Spacey lies dead at his kitchen table and Wes Bentley's character (Ricky Fitts) stares into his reflection in a perfect pool of still blood- that is the moment we need to capture more of. There is, I have no doubt any more, beauty to be found in death. There is a natural, inevitable, silent awe that overtakes you. The first time a patient died before me I was terrified. Eventually I realized that it is the one absolute guarantee in life, and the one moment that is unique in every way to each person. The day I made that realization I stopped fearing death altogether.
So my patient will not live through the night- but I gained something valuable from meeting him- in the saddest of circumstances, and for that, I will forever be grateful. Now off to sleep- I worked many hours past the rules this week (they say 80 hours is appropriate- but get mad at us if we clock 81) and I'm tired.
Ask me questions- send me thoughts- I'd love to hear from whomever is out there.
'Night
So tonight I was called to see a consult on a man in the intensive care unit (ICU). He has chronic pancreatitis from alcohol use and frequently comes in and out of the hospital when he decides to drink himself into a stupor. But this admission was different. He presented with his usual nausea and vomiting, which the medicine team treated with various medications- but on the second day of the hospitalization he felt weak, fainted while walking down the hall, and quickly deteriorated into a cardiac arrhythmia (heart was beating very irregularly) and subsequent cardiac arrest (Code Blue). He was stabilized by a rapid response team and placed on a ventillator. (Yes, the stuff we see on TV does actually happen every day in hospitals.)
I was called to see him in the ICU to help the many teams caring for him decide what was next. But soon after I arrived it became clear to me that everyone was watching him through tunnelled glasses. The pulmonologists were busy deciding whether or not he had aspirated his blood and vomit during the cardiac arrest. The kidney doctors were worrying about the state of his kidneys and his ability to clear toxins from his blood in the form of urine. The cardiologists were worried about the state of his heart. The surgeons were concerned about blood surrounding his pancreas. But all I saw was a dying man. Only 42, this guy- but certainly dying. Doctors were scurrying about- charts in hand. Some were arguing quietly outside the room. A med student was pushing gently on his stomach. Tubes and lines dangled from him like tangled fishing lines. I was there to push and pull and write my note and take part in this giant random production, and I did so reluctantly. But all the while I was mindful of the inevitable truth to this alcoholic man: he would be dead by tomorrow, and there was nothing we could do to stop that. No medication. No surgery. No hail mary pass. Nothing.
The secret of medicine is that when you step back from the room, and look at the big picture, you see amazing things. Everyone is often working separately- but together there is a symphony of ideas. Everyone had the same goal today- fix this man. But no one can do more than their part. It's like the 5 minutes before a show- when each instrument is tuning up- and the cacophony of sounds that fill the air are somehow exciting and make sense even though the notes are random and out of sync. So rarely, however, does anyone step back. That moment, in American Beauty- when Kevin Spacey lies dead at his kitchen table and Wes Bentley's character (Ricky Fitts) stares into his reflection in a perfect pool of still blood- that is the moment we need to capture more of. There is, I have no doubt any more, beauty to be found in death. There is a natural, inevitable, silent awe that overtakes you. The first time a patient died before me I was terrified. Eventually I realized that it is the one absolute guarantee in life, and the one moment that is unique in every way to each person. The day I made that realization I stopped fearing death altogether.
So my patient will not live through the night- but I gained something valuable from meeting him- in the saddest of circumstances, and for that, I will forever be grateful. Now off to sleep- I worked many hours past the rules this week (they say 80 hours is appropriate- but get mad at us if we clock 81) and I'm tired.
Ask me questions- send me thoughts- I'd love to hear from whomever is out there.
'Night
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