The Lord taketh away

Finding cancer is the worst. It never goes well. I remember one week in the hospital, I admitted 4 patients with new cancer diagnoses. There was the 80 year old with metastatic colon cancer with bowel obstruction. There was the family man with multiple myeloma. There was the young father with AIDS associated lymphoma. There was the college coed with AML. Everyone had a tragic story. Everyone had a bad hand to play.  

Last month, I found four cancers. Three of my patients thanked me, and I can't figure out why. Why are you thanking me? You have terminal pancreatic cancer. Why are you appreciative of my effort? You have metastatic breast cancer. This is not the time to thank me. This is not the time to be grateful. You should blame me. Why didn't I see this coming? Why didn't I stop this from happening? Don't thank me. Don't. You have every right to be wallow in self-pity. You have earned the right to be furious. Don't be grateful. 

I realized that I really have no understanding of what it means to have cancer. I cannot understand why people are thanking me, as if there is anything to be thankful for. I am Job's messenger crying out 'All that you have and all that you love is lost, and I alone have escaped to tell you!' 

And I watch as my patients rend their garments and worship, 'Naked I came from my mother's womb, and naked shall I return. The Lord giveth and the Lord taketh away. Blessed be the name of the Lord.' And much as I imagine Job's servant, I am dumbfounded.

Don't become a doctor #19 - biased

I have many gay patients. One travels over an hour to see me because he says I'm the only doctor who treats him like a person. One sees me because he has a crush on me. In real life, I've had gay men hit on me, so I have some basis for comparison. I don't do anything specifically to draw in gay patients. They just find their way to my practice.

In my heart, I have a lot of sympathy for my gay patients. It's a tough world out there, and being gay doesn't make it any easier, and especially now that there are so many doctors who let their faith and beliefs dictate the care they will provide. One of my gay patients told me how his previous doctor told him that he deserved to have HIV because of his sinful lifestyle. Wow. Yikes.

It's not my job to preach. It's not my call to say who is damned and who is saved. I don't get to look at a person and decide he is guilty or innocent. My job is to deliver medical care. And sometimes that means giving women birth control. And sometimes that means teaching a teenager about condoms. And sometimes that means talking to my pregnant patient about abortion. And sometimes that means that I see people who do things or believe things that I don't like. And that doesn't even cover gays. I like gay people. I can't believe we have devoted so much time and energy to trying to deny rights and freedoms to people who love each other.

I have a patient, he is a convicted rapist. He served his time, and now works a part time job and is 'retired'. He has several chronic medical conditions. His past doesn't mean that his diabetes doesn't need to be treated. He is still human, and still deserves to be treated like one.

If you cannot put your biases aside, and treat all people as deserving of medical care, and care for them without judgment, then you're probably best off staying away from medicine. You are not a priest. You job is to provide medical care appropriate to the patient, not your biases.

Indignation

There are some days where you discover what kind of doctor you are, and then some days where you discover what kind of person you are. I saw someone else's patient in the clinic for a sick visit, and her chart was a mess. Her medications were jumbled and erratic. Her diagnosis list was cluttered and with multiple duplicates. She had labs and diagnostic tests that were not reviewed. I managed to get a few things straightened out, her chronic medications sorted, and hopefully, she will do fine, but it's hard not to feel a little indignant.

In reality, what does indignation get you? Nothing. That smug feeling of self-satisfaction and superiority, it is comforting in the moment, but it does not give the patient a better outcome. It doesn't lower A1c. There is pride in your work, and it's good to have a sense of ownership and pride in what you do, but indignation? It is worth the paper it's written on.

There is always someone who will do a better job, and someone who will do worse. That never changes. Wanting to do better is great, but being better because you've pushed everyone else down doesn't actually improve anything.

Playing under protest

There's a term in baseball called playing under protest. What happens is that a rule is incorrectly applied and the manager of a baseball team protests. If the officials do not side with him, then the team formally protests, but the game continues. They are playing under protest. And the League office will review the game afterwards, and provide an ultimate judgment.

My life has been one long game under protest. When I was younger, I had planned to kill myself. That was the plan. But instead, I was called, By God Himself. Most people wait lifetimes for such a calling. However, I was disappointed. I did not want to live any longer. I didn't want to continue on the path that I was going. Instead, I would push forward, sent on a mission that I didn't ask for.

If I had to play, then I would be a doctor. I was asked to care for the people of this world, and I would do that through medical science. That was my calling. I worked hard for it. I got my MD. And I am still playing this game of life, achieving all kinds of notable things, doing all kinds of good works. I have provided lifesaving care to the sick, I have held the hands of the dying, comforted those in sorrow, and fought against injustice and inequity in the medical system. I have used my office to care for these corporeal vessels, gifts to us from God, and I have done so without judgment, indignation, or evangelization. I have done good things for this world in my life.

But I didn't want to live, and so far, I have yet to find a reason to continue living. Oh, I'm not depressed, and I'm not going to kill myself now. But I find no value, meaning, or satisfaction in my life itself. I love my work. My work is valuable and meaningful, and I am exceptionally good at it, but it is the task that was demanded of me. So, I continue under protest, hoping that at the end of this, I might get an apology or at least an acknowledgment that my protest had merit.

Survivor's guilt

I had a day in clinic last week that hurt, emotionally. It was like my scheduling staff actually were trying to inflict psychological harm, because the morning was entirely booked with widows and widowers. I had 10 patients, all of whom were single and lonely, abandoned by their spouses who died.

Widowed patients are sometimes hard to see, but it's particularly bad when half those widows' spouses died under my watch. It's particularly painful to see the wife of Mr M, such a gregarious and lovable guy, a guy who had a massive coronary event and died at home, and now, his wife comes in like clockwork, every 6 months. Her medical problems have all gotten better, now that she is no longer subject to his bad habits of going out to restaurants all the time or indulging in sweets. She puts her faith in me that I am providing solid medical care, but really, her sample size to rate my performance is miserable. I killed the only other patient of mine she knows.

Mrs H is also so upsetting. She talks about her husband every time she comes in. He was a gentleman with such refinement and character, who never had a stern word. Even when he was angry, his words were like Socrates. She reminds me all the time that she has nothing to live for. She doesn't mean that in a bad way, and she's not even depressed, but that the efforts I put into extending her life, they are efforts she is ambivalent towards. If she died tomorrow, she would be fine with that, because the love of her life is dead.

One of my staff tells me that I should feel honored. Here are people that have been acutely exposed to my lack of ability to prevent the hand of fate. But they saw what I was able to do, and they want to continue with me. They are saying in each visit, "It's not your fault. That is life." I feel like really, they are silently consoling me. Because I mourn their losses too, because they are my losses also.

Greener grass

I think part of the difficulty with having a job you love is that it makes it very difficult to think rationally about major life decisions. I really do love my job, but my life is otherwise like plain yogurt. It has no flavor. I get no pleasure out of it.

So here I am, with every possible reason to move and start fresh, live an honest to God adventure, but I am at the same time deeply conditioned to patterns and caution. The same things that make me good at being an internist are simultaneously the qualities that lead me to live a bland and milquetoast existence. 

Recently, I had a couple patients retire and move. They've been with me for several years, and I will really miss them, but I will not miss them as much as I will envy them, because for some people, life is an adventure. But not for me. 

Don't become a doctor #18 - Meaning

When I am on the Internet, I often hear young people thinking about going into medicine because they are looking for meaning. This is a rather altruistic and noble vision, to pursue a career that benefits the world and humanity, and it is one that I held when I was younger, but it is sadly very naive, and very misleading.

Like many teenagers, I really struggled with the question of why do I exist and what is my purpose. It is really the first time we are aware that our lives can have a purpose. So I sought out a raison d'etre. I wanted a mission. Medicine really appealed to me because I could heal the sick, and the role of healer is full of meaning and purpose. If I could just put on the cloak of physician, then I too could have meaning, by extension.

However, the ugly truth is: a job is a job. There is nothing more or less meaningful about any job, and all jobs have meaning and purpose to someone. A plumber gives us running water and sanitary disposal of waste water. Without this, cholera would still be a worldwide killer. A janitor lets us have clean and safe facilities to use, whether at our work or places we visit. A chef prepares food for us for nourishment and pleasure. Every job offers some level of purpose. So the key is not finding a job full of meaning. Having a job full of meaning does not make YOU meaningful. It only gives you responsibilities and expectations.

In residency, I responded to a code for a lady in her 20's. I hadn't been phased by codes in a long time, but she was so young, and with so much life ahead. And somehow, I managed to bring this one back. Even though it was probably more luck than skill, it felt good. It felt like without me, she would be dead. I put everything I had into her case. And that good feeling, it lasted for about 15 minutes before I asked a terrible, terrible question of myself. "What if that was why I was put on this earth, to save that one person? What the fuck do I do with the rest of MY life?"

I know plenty of docs with amazing skills who have saved many more than I ever will, but they hate their lives and are going through the motions, locked into a profession that demands a lot of time and energy and dedication. I have avoided this by making sure I was able to answer to answer one simple question: is what I do meaningful to me? Do I love what I am doing? That is how you find meaning.