Fin

 I've kept this blog up for several years, despite the fact that I haven't posted in years. I keep thinking to myself that I'm going to come back to this and start writing again, but I don't have the stomach or energy for it. 

 It's a lot of things. It's the changing landscape of medicine. I wrote the whole "Don't be a doctor" series about some of the hidden pitfalls of a career in medicine, but those pitfalls have fallen to the wayside of tremendous market forces driven by decreasing reimbursement, legislative interference, private equity, and a host of other factors that have made the career less than appetizing. 

It's also the loss of professional identity. Somewhere around 10-15 years ago, people stopped being doctors and started being people who practice medicine. The thing about being a doctor is that it's part of who you are, not just letters after your name. It changed into something less-than. People cared more about work-life balance and less about the words that were spoken in a sacred oath during graduation. 

Sure, COVID also sucked. I think all of us who were practicing medicine at the time walked away with a healthy dose of PTSD. I distinctly remember the day in May that I did my first inpatient shift in 2020 during the pandemic, and I said to myself walking into the hospital, "If I die, then it's from being a doctor, and I can't be angry about that."

But overall, I think that I just am not the person I was when I started this blog. My colleagues would laugh at that statement, as I am still the most indignant and insufferably self-righteous person they know, but I decided a few years back to give myself some grace, that not every battle is worth fighting. Odd words from the man who would die on every single hill in front of him. 

Maybe I'll come back one day. Maybe I'll turn to Medium or Threads or some other more modern format. The blog at the end of the day is such an archaic format. I started this like 20 years ago. It's a different world now. 

 Thanks to all of those who read these posts and found them helpful. I'm glad that some folks found value here. I'll leave it up, if only to defend my copyright, but at least right now, I've no plans to come back to blogging. 

If you're sad about that, don't be. I still go on long and painful tirades on social media, but all my socials are private. My blathering is now reserved for friends and family. 

COVID Burnout

I still have a lot of patients who are unvaccinated. At the beginning of 2021, I was very sympathetic. this was the first mRNA vaccine in mass production. We knew so little about COVID, and even less about a vaccine for it. It was only natural to have some concerns. But the risks (morbidity or mortality from infection, or infecting others) was a big enough motivator that getting the vaccine seemed like a straightforward choice. 

Now a year since I have been fully vaccinated, my sympathy is gone. The entirety of what we are experiencing with COVID at this point is because of the unwillingness of people to get vaccinated. I watch people suffer, have horrible complications, and die from COVID because of no other reason than obstinance. 

And it's not the death and suffering that bothers me the most, nor is it the strain of health care systems buckling under the weight of COVID cases. What bothers me the most is watching my friends and colleagues who have lost their passion for health care. We all went into medicine because caring for others means something to us. It might not have been the primary motivator, but you cannot survive in medicine if you do not value caring for others. 

And so I watched those who were materially motivated fall away from medicine. And then I watched those valuing their own health above others fall away. And now I am watching people who love caring for others drop out of health care, because they have entirely lost their passion. 

You can't call it burnout at this point. Burnout is a slow cooker. COVID is an incinerator. 

And I want you all to realize that we are approaching a moment where you will call EMS and no one will come. You will go to your doctor's office and no one will be there. You will go to the ER and no one will help you. And this is the only result of the path we are taking.

I was talking about this with a colleague, and he suggested we should get the nurses some gifts. I was polite enough not to slap him.

I'm not a yeller

I had a patient who avoided seeing me for several months because his diabetes was worse and he was worried about what I would say. "I knew I was going to get yelled at."

So I asked a real straightforward question: "What makes you think I'll yell at you? It's your life. I don't have to live it." I have all kinds of advice and recommendations, but at the end of the day, I only experience maybe an hour of their existence over a year's time. 

I get this a lot from COVID un-vaccinated patients. They think I'm going to berate them. Not really. I am interested in giving them knowledge, and context, and compassion. People make their own decisions, but I want that decision to be well informed. When people tell me, "Well, I hear a lot of things..." then I want to talk about it. I am a doctor. It's literally my job to give you health information individualized and personalized to you.

One of my patients still isn't vaccinated, and he knows everything about why he should, but he is just totally terrified of needles. And he knows he needs to get vaccinated but just can't get over the hurtle. Let's work on this together.

Rituals

It's so cliche that you already know how it happens. The doctor walks up to the family member and says, "We need to talk. Please come with me." The person is ushered into a room and asked to sit. If they don't sit, then they are encouraged to sit.

"I have some bad news." Colloquially known as a warning shot, this is the clue to the person that this is bad. There will be no 'good news, bad news' game here. It's only bad. Next comes a formula repeated in every hospital in the country. A recitation of facts about what happened, and at the end, telling the family member that their loved one has died. The doctor says, "We did everything we could, but we couldn't save him, and he died." There are accusations, and shock, and tears. Tissues are provided. Hugs sometimes or a hand on a shoulder.

While it seems like a cliche, it serves a purpose. When people experience a situation they know, then it helps to provide structure to the process. It's no different than a Catholic mass. There are no surprises. You know exactly what is going to happen, what people will say, and when it will end. So when faced with terrible circumstances, it's reassuring to know that there is a structure to it, and a role to play. The doctor knows what they're supposed to do, and the family knows as well. So while reciting the words and gonig through the ritual, a person has for a brief moment the chance to truly grieve, cloaked in the words and actions already predetermined.

If you're looking for advice on breaking bad news, then there are lots of formulas. I think that SPIKES is as good as any. I do have a few tips.

1. Make sure you say that you did everything you could. In fact, use that exact phrase. "We did everything we could."
2. Make sure you say that the patient died in no uncertain terms. Not "passed", not "lost". Something like, "We couldn't save him, and PATIENT died."

You would not believe, despite saying those exact words, how many people will question you on those two points. And that's natural. Don't be defensive. The human creature can only process so much trauma at one time. People want to make sure that everything was done. People want to make sure that their loved one is indeed dead. It's not blame. It's shock.

Pencils and crayons, part 2

The word "acumen" means a quickness of perception and discernment. In medicine, someone with clinical acumen is sharp and fast to an accurate diagnosis with minimal effort or information. A doctor will walk into the room, take a quick smell and a glance, and pronounce to the patient, "You have a bleeding peptic ulcer." The patient and all the house staff are astonished at the quickness and the veracity of the diagnosis, and sure enough, the endoscopy proves him right.

The reality is that the doctor could smell the distinct odor of melena, and observed upon walking into the room that the patient was eating a plate of hot wings his wife had brought in, and had a beer belly. It was a pretty safe bet that he had an ulcer.

Acumen comes from the Latin word for a sharp point. And so, just like sharpening a pencil, clinical acumen needs to be sharpened too, but it's hard to keep sharp, easy to dull, and sharpening itself takes work. Because the way most of us physicians keep our acumen sharp is honed on the bodies of the dead and dying left in our wake.

I won't miss pancreatic cancer again because Mrs R is dead now, and maybe I could've done something to stop it if I'd only found it sooner. I won't use steroids to treat acute arthritis if I haven't ruled out a septic joint, because I've seen what happens to an infected joint that gets steroids.

Keeping a pencil sharp takes some effort, not much but some. Keeping a crayon sharp is an exercise in futility. At the end of the day, it's not just the sharpening that takes work, but we have to strive to be something worth keeping sharp.

Pencils and crayons

Getting compliments from patients can be funny. I like to get compliments, don't we all, but in my heart, I know that most of the time, these praises are unearned. I didn't do anything marvelous or spectacular. I did the doctor equivalent of a teeth cleaning, and for that, the patient is singing my praises to everyone they know. It's not earned. I'd rather get praise that I earned.

Lot of patients don't have good relationships with their doctors, for whatever reason. Sometimes, it's the patient having unrealistic expectations or demands. Sometimes it's the doctor not communicating well or not providing good care. Sometimes, it's just personalities not harmonizing. There are lots of reasons that a patient and a physician don't end up on the same page.

For this patient, I did nothing. I was assuming care for the person after their previous physician left the area. We talked about his medical issues and medications, about the clinic policies and my own personal policies, and then I did my exam. He was so shocked at how thorough my physical exam was (it was actually pretty cursory and mediocre), how detailed my history-taking was, and how well I explained what was happening next. He thanked me, and proceeded to sing my praises to my staff and then to his wife in the waiting room. But the reality was that the care I delivered was perfectly mediocre. It was dinner at Applebee's.

My MA was surprised. "What did you do in there?"

My reply: "When all you’ve ever known is crayons, then a pencil is gonna seem pretty awesome."

Evidence

When I was in medical school, we spent a lot of time learning about evidence. The only way we could make good decisions was to base them off of good evidence. And so, we learned about what constituted evidence, how to critically appraise evidence, how to consider the risks and benefits, what are the ways to understand different methodologies and practices, and how to understand hidden biases.

So when I first saw the Covid studies coming out in the early Spring, I was really shocked, because we were setting global health policies on extremely shoddy evidence. Half the time, we were basing direct patient care that day on what new preprint* had just come out. None of us really knew if HCQ had done anything whatsoever. We were reacting, based on bangs and flashes, like an animal scared by lightning.

And colleagues assailed and harangued me for doubting the wondrous effects of HCQ, based on the anecdotes they had heard. And when we were scolded as a profession for hoarding and stockpiling HCQ for personal use, several colleagues got defensive and belligerent, clearly caught with their hands in the cookie jar.

I've been surprised by how people act during this pandemic. I have seen a lot of questionable things done, and the reality of the situation is that when you don't know what to do next, then sometimes people will do anything, because anything is something, and something is better than nothing. There's a reason why I have that quote, "ut aliquid fieri videatur". Sometimes in medicine, we do things not because it's right, but so that we look like we did something.

*A preprint is a submission to a journal for publication, not yet peer reviewed.

Daughters

When I was early in my career, I was working with a medical student and we walked into a patient room. This was my first day on rotation, picking up my list from a colleague who told me that the family was very needy, and patient was ready to go to subacute rehab in a day or two. Instead, when I walked into the room, there were two daughters seated bedside. They greeted me by saying, "How do I spell your name? I want to make sure we get it correct when we sue you."

Anyone who's worked in medicine for long enough knows the story of daughters. My nurse doubted me, but over the last several years, she has seen it too. Every hospice patient, every terminal situation, every tough cancer case, there's always a daughter in the room, demanding answers.

Rather than get defensive, I sat down with the two daughters and said, "Let's talk. Tell me what's bothering you." And I listened for thirty minutes about how they didn't have any answers, about how their father continued to worsen slowly and wasn't getting better, and finally about how their father had a solitary pulmonary nodule on the CT scan before and nearly died from an aggressive lung cancer. Sure enough, he was deteriorating. His mentation and cognition were dimmed from numerous acute medical issues, and he never recovered from the aggressive chemotherapy that sapped his body and mind. I listened, and I agreed. I didn't have answers. I didn't know what this nodule was. I didn't know if their father would ever leave the rehab facility.

By the end of that thirty minutes, I examined the patient, barely conscious, and then said good-bye to the daughters after going through the details of the plan that lay ahead. I hugged them both, and while they fought back the tears, they both thanked me profusely, telling me that I was the best doctor they'd ever met, and how that time spent with them meant so much.

My student was totally awestruck. He had no idea that such a chance encounter in the hospital could lead to such a profound moment for a family. We stepped into the nursing station for a moment while I talked to the patient's nurse about modifications to the discharge plan. While writing some orders, I turned to my student.

"I did nothing skillful in there today. I sat and I listened to two daughters who care very deeply for their father, and who desperately want answers. The lesson you should take away from this case is--"

"We should listen to our patients and their families?" my student suggested.

"What? No. The lesson is that if you go into a room and see daughters at the bedside, get yourself ready. You're about to get rocked."

This is the job (it always has been)

We live in a Covid world now, and it's a different reality than what existed for the last 50 years. We got a little taste of it after 9/11 with all of our bioterror scares, and a hint of this when SARS happened. But now, we are full-on living in a pandemic reality. Lots of people go into medicine for a variety of reasons, not all of them altruistic. Some people want to acclaim and prestige. Some want the lifestyle and income. Some want to help people. Some want to save themselves.

There's no "right" reason for being a doctor, but there are plenty of wrong ones, and by wrong I mean that the reason will not sustain reality. Times will get hard, and when that happens, the thought of donning your white coat and fighting disease, it loses its luster. And people will complain that this wasn't what they signed up for. They didn't sign up for risking their lives every day, putting themselves in harm's way with numerous possible chances to catch a deadly and highly contagious disease. But I have bad news for those people. This is the job. It always has been.

It's the same job that people faced when SARS hit and whole hospitals were quarantined, and health care workers died without any loved ones ever seeing them for that last time. It's the same job that people risked catching AIDS every day before anyone knew just how AIDS was transmitted. It's the same job that billions all over the world still face with the dangers of tuberculosis, ebola, and numerous hemorrhagic fevers. And now it's Covid. There will always be something. When Covid is done, there will be a new disease, a new risk.

One of my colleagues has refused to see patients in person. I get it. It's a scary world out there. Every patient represents another chance at contracting a potentially fatal illness. But at the same time, we're doctors. This is what we signed up for.

The right answer

I have an elderly patient at the end of her life. Her medical condition is deteriorating slowly but surely, and she doesn't know what she wants to do, or if she does know, she's not great at telling me.

Of all the things that could possibly end her, the malady is dysphagia. She can't swallow. The answer is to put in a PEG tube and start enteral feedings. The alternative is hospice. Either choice in her situation is reasonable. She could go either way, and no one could fault her for it. But she doesn't know, and asks me what she should do.

I wish I could tell her what to do. I wish there was a right answer. I know what I would do in her situation. I'll be damned if someone's sticking a feeding tube in me. Fuck anyone who tries to prolong my solitary existence. I was ready to exit this world at the age of 17, so the thought of shooting for 100 is nauseating to me. But she's not me and I'm not her, and I can't tell her what the 'right' decision is.

Sometimes, medical paternalism is nice. Sometimes, I really want to tell this wonderful person that I know what to do, and that I know the right answer. But I'm not God. I can only guess.

Within our lifetime

I saw a patient recently who was diagnosed with AIDS in the 80's. This is somewhat of a rare find, because for so long throughout the 1980's and 1990's, HIV/AIDS was a death sentence. He reminisced to me of his many friends who have all died, and now he lives a fairly solitary life. His community was eradicated not only by the disease but also from the hate and stigma.

And I realized that for so many people today, the 1980's AIDS epidemic is not even a memory. The vast majority of millennials were babies when fear of AIDS was raging through the US. It seems like some vague memory rather than reality. And we have chosen to quietly let those memories slip away, and I think that's sad, because it is useful to remember sometimes what this country was capable of, both good and bad. People seem surprised by this current political climate, but it is not very surprising to me.

I remember in the early 80's people began to notice that gay people were dying at an alarming rate and at very young ages, overcome by very unusual infections. And eventually, it was discovered to be due to a new virus called AIDS. No one knew how it was spread or who had it. There was no visual test or identifiable features. The only thing people seemed to know was that it affected gay people. And so I was openly encouraged to avoid gay people, because I might catch AIDS. It's a hell of a thing to tell a 7 year old.

I remember when Ryan White became a household name, this fresh faced white boy from middle America who was labeled as an innocent victim of the AIDS epidemic, as if others had somehow deserved to get it. But Ryan cemented in my mind that it was possible for me to get AIDS as well. And everyone clutched their children a little tighter. And even with convincing evidence that AIDS was due to HIV and was only spread through blood or sexual transmission, people feared association with gay people. Homophobia was in the casual vernacular. Using "gay" casually is such a bizarre reality to me now, when for so long it was an insult. And on the opposite end of the spectrum, seeing "faggot" fall away from casual vulgarity seems odd, when for so long it was just another insult on par with "bitch" maybe. When Paula Deen admitted that she had used the N word back in the 60's, and people crucified her for it, for a moment, I had some sympathy for her, because I've called plenty of people a faggot to their face. I still use 'gay' these days, and I know the 'correct' term is LGBT(QI etc etc), but 'gay' is very much to me a great term. It was for so long a word that inspired fear and hatred and mistrust, and to see it now being used for identity and inclusion, that is good for this world.

Even with prominent heterosexuals coming out as HIV positive in the early 1990's, it was still a gay disease. I remember rumors flying that Magic Johnson was secretly gay. I also remember when he played in the all star game, and so many other players discouraged him from playing for fear of spreading the disease. And I remember Greg Louganis coming out both as gay and HIV+, and the firestorm of controversy he suffered for cutting his head but still competing at the 1988 Summer Games, a comeback performance that was so inspiring that he remains as one of only 4 Olympians from those games I still remember (Carl Lewis, Jackie Joyner-Kersee, and Flo Jo).

When the AIDS quilt project started, it was really the first time I realized that the people being diagnosed with AIDS, they were people. They had parents, lovers, children, families, friends, jobs. People longed to remember them, and when I found out that the reason the AIDS quilt was started was because so many of them went unburied or placed in unmarked graves, I realized that so many people had so much hate, and were willing to apply it indiscriminately, even if that should mean disowning your own flesh and blood.

When HIV treatment first came out in the late 1980's, I recall the restrictions and requirements. Doctors had to ration medication, and patients had to be 100% compliant with AZT therapy (zidovudine), a medication taken q4 hours ATC (around the clock). Think about that for a minute. Your survival as an HIV patient was contingent on you proving to your doctor that you took a pill 6 times a day every day.

I remember that because the AZT schedule was so restrictive, people became suspicious of any person taking medications in public. Suddenly, HIV patients had to secretly take their medications and hide the bottles. I remember that even being tested for HIV was tantamount to an admission of guilt. It was such a significant factor that regionally and nationally, laws still exist regarding consent for HIV testing. And in part because of HIV, we have HIPAA to protect the confidentiality of medical records.

I don't know what it's like to be gay, but I know the story of HIV from within my lifetime. And to let these memories fade would be a disservice to all the dead young men who suffered not only from the disease, but from society's cruelty to their plight.

Don't become a doctor #21 - haunted

When I was in medical school, a friend of mine asked me if I saw any ghosts in the hospital. No. I don't believe in ghosts. "It seems to me that doctors are always haunted by so many ghosts." I thought my friend was so very quirky, but she was so very correct. We are all haunted by ghosts.

My first ghost was a wonderful elderly lady s/p colon cancer resection and prolonged abdominal ileus. I placed an NG tube, like I'd done numerous times before, and she aspirated, went into respiratory failure, and ended up intubated. My next ghost was a woman with terrible breast cancer who suffered every moment that I kept her alive until her body failed. I have all these shadows hiding in the periphery of my vision: the colon cancer that we didn't find soon enough, the breast cancer that didn't respond to any treatment, the heart attack that happened the day after I did a complete physical, the elective orthopedic surgery who died on the table, the blood clot that I didn't prevent. And it would be nice if these shadows were just that, painful memories that hide in the darkness, but they are more than that. These shadows had names like Evelyn and Erik and Nancy and Steven. They had spouses and parents and children and friends. They had jobs and lives and purpose. And they haunt me because I took those things away from them.

In reality, I didn't kill them. Bad things happen. As long as a doctor is not incompetent or negligent, then there is always a chance that even the most benign circumstance could end badly. Life is not fair. In fact, I've written about this no less than twice already: Perfection and Guilty. And living with the choices you make, that takes some adult sized diapers sometimes, but it's not quite the same as knowing that you took part in an event that resulted in the death of a person. And you have to talk to that person's children or spouse, and tell them what happened. How do you do that without seeing the ghost over your shoulder? If you can't deal with the shadows of your mistakes having names and faces, then medicine may not be for you.

The story of diagnosing cancer

At this point in my career, I'm well experienced at walking a family through the process of a new cancer diagnosis. From the patient side, it's a whirlwind of confusion and waiting and vagaries, but the process itself is usually the same. So from the doctor side, here is the story of diagnosing a cancer.

It always starts with one abnormal finding, something fairly innocuous, but difficult to explain. "Not sure what this is" and "We need to do more tests" are the words I tell you, and I have no evidence that it's cancer, but something doesn't sit right. I have a hunch. I go through all the millions of possibilities to explain this one finding, and in the end, I just have a gut feeling about it. "I'm not going to get a good night's sleep until I chase this down" is what I tell you, as I send you off with some labs to repeat in a few weeks, or a follow up x-ray. And two weeks later, it's still off, and maybe worse. It's a PSA of 7 or a lung nodule that's a little larger. There is a lot of mental debate, and maybe the workup starts, or maybe recheck it in another few weeks, or some more tests. The descriptions get more concerning, but still very vague: "I'm concerned that we need to rule out some serious possibilities" or "we need to take cancer off the table."

There is always that one alarming finding. Maybe the PSA comes back 157. Maybe you find bony metastatic disease. Maybe your abdominal CT reveals diffuse retroperitoneal lymphadenopathy. And if your doctor is anything like me, then maybe he throws something against a wall or maybe she curses loudly and kicks something. The language gets much more alarming. Maybe I'll be cautious and say something like, "I'm not sure what this is, but I'm really worried that this is cancer." Maybe I'll be much less optimistic and say, "At this point, it is almost certainly cancer. The only question is what type and can we treat it." Whatever words come out of my mouth, I am still guessing, because I don't have a biopsy, and I can't be sure.

There is no room for uncertainty now. I have to know, beyond the shadow of a doubt. I must have a piece of it. So I call up the surgeon or the interventional radiologist and tell them I need a stat biopsy. And normally the surgeon would say, "Screw you!" and maybe he does say that, but he readjusts his schedule, and he adds on this case, delaying or even bumping surgeries he's planned for weeks, ends up coming home late and missing his daughter's soccer game. He curses my name, but he does it because this could be cancer, and he knows the stakes.

The pathologist may get a chance at it with frozen section, where they look at it during the surgical biopsy, but more often than not, we have to wait for pathology to do their magic, and that will be 5-7 business days. And we're all waiting. Those knots and butterflies, I have them too. And so I try to keep you busy. I try to get the medical oncologist and radiation oncologist set up. I get the PET scan done. I try to keep the wheel turning so that these next two weeks of waiting can pass a little quicker. And I'm holding out hope that I am wrong, that this whole workup was a big false alarm.

The pathologist gets it and does all kinds of stains and treatments and manipulations of it, and probably they could tell me after 3-4 days that it's most probably cancer, but they know what's at stake. They have to be sure. So they keep testing it until they're sure, and then after that, they test it more to figure out what weak spots this cancer might have, where we can target therapies. They produce an exact report, but as soon as I read, "Carcinoma" then I've seen what I needed to see.

Now finally, you sit down with me and I tell you, in no uncertain terms, that this is cancer. I can tell you this because I went through many steps so that I was sure, and the pathologist went through even more steps so that she could be sure. We are sure, but you will still ask, "Are you sure?" It's not a dumb question. I asked too. And it will seem like a surprise to you, this process that you were intimately involved in, but it's always a surprise. And I am surprised too, because I was hoping so hard to be wrong. I was hoping that any number of people slipped up, and that this is one tremendous farce. And that is why I had to be sure, so that when you are sitting in front of me, crying and asking me deep, painful questions I can't answer, like "Why?" then I can I can give you the one certainty I have: this is cancer, and of that I am now sure.

Game face

I got into an argument with another provider. I really disagreed with his care. I saw his patient, and she didn't know that her diabetes was ragingly out of control, that her kidneys were actively failing, that the fatigue and dyspnea she'd been having for the last few weeks were heart failure. It was all news to her.

If you've working in any service industry, you know that what goes on in front of clients is very, very different from what happens behind closed doors. That shouting match you had with your co-worker is described as a 'friendly debate.' The flagrant incompetence of your staff is described as, 'Oh, she's still getting things figured out.' When we're standing in front of the people we're serving, we are trying to convey a sense of competence, so that they can have confidence in the care they're receiving. And sometimes, it's tempting to use this colorful language with diagnosis and management. We simplify and generalize and minimize and suddenly, terminal cancer becomes 'a concerning finding' and overwhelming sepsis becomes 'a serious infection.' In an effort to portray confidence, we create a false narrative of the events unfolding.

So when I saw this patient and told her the rather unpleasant truth, that she had multiple major medical conditions all doing terribly, she was stunned. And when I talked to the other doctor, I did not have any nice things to say, because looking competent and being competent are not the same things. And if you're going to put on a game face, then you'd better have the game performance to back it up.

Privileged #7 - comfort

In medicine, we are allowed to be involved in people's lives in a way that few other professions are. And sometimes, that can hurt. I had a former patient who was a lovable and gregarious gentleman with many unhealthy habits, so it was no surprise to me when I got the notice that he'd been admitted to the hospital. I checked the hospital records, and his room was listed as in the ICU. That's not super unusual. Sometimes, the hospital fills up and it's the only available bed, but I had a bad feeling, and so I checked his chart. He'd had a cardiac arrest and was currently on a ventilator.

I don't always visit my patients, but when someone is actively dying, I make the effort. I wanted to see him, see if I could help, and maybe assuage some of the guilt I was feeling. So after clinic, I headed over to the hospital, but I had a couple errands to run. I stopped by the cleaners to pick up my shirts, and I grabbed a few groceries for dinner. By the time I arrived at the ICU, things were fairly quiet. I made my way to his room and noticed that the lights were off and the monitors off. Before I could go in, the ICU nurse stopped me. She was one of my favorite ICU RN's, from an older generation of nursing when the job was brutal but humanizing. We'd shared many a dark moment in the unit, and this would be one more. 

My patient had coded about 60 minutes ago and died. They had only just finished getting him cleaned up for family to visit with him, pulling off all the wires and tubes and needles and tags. She was just finishing up her charting, since she was the code nurse for the event. 

I was devastated. I had just missed him. If I hadn't run those errands, I would've been there, but I wasn't there and for the dumbest reason. I couldn't have changed the outcome, and I wasn't the ICU doctor anyway, but he was still my patient. I should have been there, and I wasn't, because I needed to pick up my shirts before the cleaners closed. 

While I was standing there thunderstruck, the nurse pointed to the door behind me. The family was gathered in there. I hadn't seen any of them because they were waiting until the nurses finished cleaning him up. "You should go in," she said. So I screwed up my nerve and walked in to find twenty people jammed into a space meant for ten. There were sons and daughters and grandchildren and siblings, and at the head of the conference table was my patient's wife. I walked up to her and started to apologize profusely, but she didn't let me finish. 

"Oh doctor, I'm so glad you're here. Thank you so much for coming. It would've meant so much to him that you came." She then introduced me to her children and her grandchildren. I had expected wailing and sobbing, but they all had such a bittersweet expression, like they understood that this was the end of a beautiful moment, like the ending credits of a movie. They shared stories of his life with me, the life that I had never seen, the one that didn't involve A1c's or blood pressures or cholesterol levels. They laughed and cried. 

"Do you want to see him?" she asked me. Yes, of course. She let me go, while the family returned to reminiscing of better times. I left the conference room and went back to his ICU room. I held his cold hand and said my goodbyes. The family let me have my time, and I felt almost greedy that I should be the first to say my farewells. 

I came to the hospital expecting to provide support and comfort, and instead, I was the one who was comforted by this family who adopted me for one brief moment. I understood then that I was not a stranger in his life. I had been a part, however small it may have been, and was welcomed into the intimacy of his life. Since then, I've had other patients die, and I've grieved with spouses. I have several patients who've lost spouses who were under my care. They still come to see me, a testament to their faith in me, and when I see them, we share a little memory and a moment, and I can't help but feel so lucky that I am welcomed into their lives, and so honored that I should receive such trust.

Don't become a doctor #20 - treating the source

​I am fond of telling people that all the advances of modern medicine account for maybe about 3% of the improvement in the health of the human condition. The other 97% of the betterment of humanity can be credited mainly to three things: clean drinking water, sewers, and immunizations. There are some other things too, like labor laws and pollution controls, but pretty much everything we do now in modern medicine is the equivalent of sprinkles atop an ice cream sundae. Your toilet has done more for the betterment of humanity than I ever will.

And really, the future of the improvement of the health of humanity doesn't lie in anything I can do or modify. If I wanted to make the biggest impact in the improvement of the health of humanity for the betterment of the general public, then I would institute universal basic income and mandatory pre-K through 12 education. I can do a lot of things right now: I can treat hypertension and diabetes, I can diagnose and treat complicated medical conditions, but I do not have a pill to treat poverty. I have no prescription for socioeconomic oppression.

Mrs B can't afford her medications. She has Medicare, yes, but she pays a monthly premium for a supplemental plan that only gets her out of pocket expenses down to $10-15 per prescription. How is that going to help her pay for the 8 pills I am prescribing? Best case scenario, that's $80 a month, but she only gets $800 from Social Security, and she spends $500 of that on rent. She literally cannot afford to be healthy. I see her every 3 months for what purpose? The diseases I am treating are not the principal problems of her life. Another $300 a month would make her far healthier than another diabetes medication. Having a blood pressure under 150/90 isn't going to get her electric bill paid. I asked her about it once. 

"I understand that you can't afford to do a lot of the things I'm recommending, but then why keep coming to these doctor appointments? You can save your copay." She was speechless for a moment, like that was even an option. The thought of NOT seeing the doctor is anathema to her. She wants to be healthy. She wants to do better. But she is swimming upstream without a paddle, and that paddle looks suspiciously like another $300 a month in her budget. I do a lot of counseling and education for her, because maybe she can keep up serious lifestyle changes, and maybe that will be an adequate replacement for lisinopril. 

I have a sickle cell patient who is frequently in the ER or hospital. She can't stay in school, can't hold down a job, can't have any semblance of a normal life because for her, a normal life involves spending on average 2 days a month in the hospital or ER. How is she supposed to better herself when she cannot access the tools by which people better themselves? Whenever I see her, I encourage her that she needs to work on avoiding triggers for a crisis. She needs to bundle up warm in the winter. She needs to stay really well hydrated in the summer. She needs to keep active, but not too active. She needs to wash her hands so she doesn't catch any colds. Her life is a constant vigilance to prevent her own body from betraying her. When does she have time for bettering herself, when all of her time and energy is put into avoiding being sick?

In America we always talk about pulling ourselves up by our bootstraps. But really, that assumes you have boots. If you don't have boots, then what? Forget boots, what if you don't have feet? We do not have equal standing in any respect. We do not have equal opportunity, equal adversity, or equal ability. If we do not share equally for the potential of success, then how can we expect people to be successful? So I don't spend much time with the successful. I spend most of my time with the losers on the battlefield of life: the injured, wounded, and crippled from chronic stress or poverty or oppression or injustice. They're the ones calling out for a medic.

The job of physician sometimes involves interfacing with a cold and uncaring world on behalf of someone unable to change their circumstance, and trying to make an improvement in a system that is fundamentally flawed. If you're not prepared to roll that rock up that hill, then think about something else. Because that is what I love about my job, that I get to fight for things that mean something, even if I'm not going to win.

Flight plans and unexpected turbulence

One of my patients recently found out that he has a terminal condition, and he is thunderstruck. He refuses to accept that this is the end. He says to me, "I can't just give up!" He tells me that he is going to beat this thing and win, and that he still has a fighting chance. But he doesn't. And I really want him to come to grips with this, because I want to make the end as pleasant as I can, and not misery.

And that's the problem of thinking of disease like a sporting event or a battle, because ultimately, everyone dies. Even if you win the game, the game is over. This is something you learn to come to terms with in internal medicine. Maybe a pediatrician or a subspecialist can insulate themselves from this reality, but my job is to try to extend longevity as much as can be reasonably done. I don't save any lives. All my patients are going to die, and likely while I am at the helm.

When thinking about life, I always preferred the metaphor of flying a plane. Every plane goes up, and every plane lands, and we want to go as far as we can, as comfortably as possible. And we don't get to choose our plane. We could get a Cessna, or a G6, or a Concorde, or even a 747. There's no choosing. We get the plane we get. But regardless of the plane, we're mostly all are trying to fly as far as we can and as comfortably as possible.

There are factors that we can modify. We can avoid bad weather or change our flight plan or change altitude or throttle. Maybe we know to do these things, because we got an airline transport pilot licence, and then we paid for good fuel, rigorously checked the flight plan, and had the best mechanics look over the plane with a fine tooth comb. Or maybe we never got a pilot licence because it was too expensive. Or we started out in a terrible airport surrounded by terrible weather conditions. Or maybe we didn't have any radar or doppler, and had to trust our gut about the weather. And maybe we didn't even know that these were things to worry about till we were already halfway through our fuel. Or maybe we decided to have some fun and did a whole bunch of air stunts, not realizing that it might cause stress damage. There are so many modifiable factors, and we can try our best to maximize our chances of flying far and smoothly, but in spite of our best planning, we could have a catastrophic failure of some little hydraulic tube that changes all of our plans.

And if something catastrophic happens, then it's not guaranteed that we are doomed. Maybe we can recover and still complete our flight plan. But some catastrophes we know will have no recovery, like if the fuselage gets ripped in half or a wing tears off. We're not going to make it to our destination. We're going to crash.

As a doctor, if I know we're going to crash, then my job changes. I'm no longer trying to help us get to our intended destination, but now I am trying to get us close to a nice landing spot, and help us land as smoothly as possible. Because there are bad crashes where no one walks away, and there are 'good' crashes where the survivors look back and think how lucky this was, given the circumstances. And so I'm pointing out to ease up on the throttle, avoid this weather cell, aim for this strip of highway, radio ATC and let them know of our situation, so there can be resources ready to meet us on the ground: medical personnel, fire crews, police to clear the scene. And I can't do any of those things if the pilot is not ready to concede that yes, this plane is crashing and we have to make the best we can of this terrible situation. No one wants to crash. But if that's your only choice, then I can help.

What comes next

​One of my patients had a major event, and very nearly died. It was very touch and go, and after several months, she is finally on the path to recovery, and I was a little surprised that she pulled through, because of all of my patients, she is the most accepting of death. She's been a widow for years, and we frequently have talked about how she is ready to go. So I was surprised to see her clinging to life with such tenacity. She is not going without a fight, the person I had thought to be the most eager to have her ticket punched. 

Life is funny sometimes like that. On the news sometimes, you see people ready to commit suicide, and at the very moment they are ready to leap, they grab onto the edge desperately. There's a line in "Crime & Punishment" by Dostoevsky where he says:

... where was it that I read of how a condemned man, just before he died, said, or thought, that if he had to live on some high crag, on a ledge so small that there was no more than room for his two feet, with all about him the abyss, the ocean, eternal night, eternal solitude, eternal storm, and there he must remain, on a hand's-breadth of ground, all his life, a thousand years, through all eternity - it would be better to live so, than die within the hour? Only to lie, to live!

I don't know what comes in the next life, but I don't have much expectation for what remains for me in this one. Maybe I will have a different perspective when I am in my eighties, but if I look at my life honestly, I am already coasting in neutral. I really wonder if when my time comes, will I also grab onto the edge?

5 minutes

There is a lot of research and publications about different interventions during patient encounters. A brief smoking cessation intervention, a brief psychological assessment, a brief social stressor history, a targeted exam to identify depression, get up and go, cognitive evaluation, MMSE, MoCA, GAD7, PHQ9...

When I went to a productivity seminar, the speaker noted something very straightforward. The only truly fixed quantity we have in life is time. Everything takes time. Sleep takes time, eating takes time, fun takes time. There is nothing in life that we do not value with time, and there is only a limited time that we have, in a day and in a life.

I have 15 minutes to make a change in a person's health. That is my fixed quantity. In that time, there are things that have to happen, things that can be quicker or slower, and when everything is tallied up, I have -3 minutes. It is no longer a question of which brief intervention I can fit in, but what required thing can I cut out? Can I skip diabetes management this time? Can I ignore the BP until next visit?

So when I am less than enthusiastic about your presentation on a 5 minute intervention on fall risk or a new screening tool for domestic violence, please understand that I agree it's important, but is it more important than a BP of 185/105? Is it more important than signing a patient up for a patient assistance program?

n=1

We are constantly talking about all of these people in this country who are dying from medical errors. According to a recent publication, it is the third leading cause of death in the US. But who is doing all this killing, because it's certainly not me, right? I haven't killed anyone because of any mistakes. But statistically, I have to be a part of this number. I made some little something somewhere, that when added up on a balance sheet, pushed someone from the "alive" column" into the "dead" column. But it's hard to know what to do about this, personally. As a system, there are lots of things that organizations do, like tracking and labeling, human factors engineering, checklists, etc. etc. But what can I do?

In medicine, we talk a lot about "n=1" studies. In a research protocol, n is the number of participants in a study. The bigger the n, the more powerful the study to make a conclusion. But in practice, it is those n=1 studies that influence our behavior. I missed a cholangiocarcinoma whose only significant finding was a mildly elevated alkaline phosphatase. That was my only clue, and I dithered. And now, I'm suspicious of every alk phos elevation, constantly wary of missing this diagnosis. But it is a fairly uncommon cancer. I'll see tons of breast and colon and prostate and lung cancers in order to see one more cholangiocarcinoma. Of the 454 cancers found yearly per 100,000 population, cholangiocarcinoma makes up 1-2 total. There will be 452+ other cancers that I am going to see before I see another one. But here I am, fretting about a mildly elevated alk phos, wondering if I should get an MRCP.

A friend of mine described being a doctor as being continuously haunted by ghosts. There is always some ghost of a previous patient hanging over you, reminding you of your mistakes and failings. And it takes a fair bit of bravery to count up those ghosts and look for any patterns.