After work

It was not a particularly stressful Saturday morning to work in the office. Only three prescheduled physical examinations and a handful of sick children came in by morning’s end.

One child, a 1-month-old, my first patient of the morning, had colic. His mother reported that he wanted to feed constantly; whenever she didn’t give him a bottle he fretted, sucking on his fingers and hands. I had evaluated him one week ago for similar complaints. Since then the child gained 1-1/4 pounds, nearly three times the expected weekly weight gain. Obviously, she was overfeeding him. I suspected that part of the reason might have been because her first child was born prematurely and had a difficult time gaining weight.

Mothers nurture through feeding; a thriving baby exemplifies good maternal care, but sometimes too much of a good thing is not best.

As the morning wound down I ruminated behind my desk and reviewed the remainder of outstanding laboratory reports, signed off on a stack of physical examination forms and phoned in prescription renewals. The medical assistants finished with the filing and departed, locking the front door behind them.

I snugged the bow tie at the base of my throat, picked up my blue blazer and stepped out the side door. It was a short drive to the funeral home. By the time I arrived the lot was nearly filled with vehicles.

Inside people milled about, speaking in low tones, touching one another briefly on the arm or shoulder, exchanging whispered words. Some paused before the large displays of photographs mounted on easels in the hallway.

I stepped into the parlor, signed the guest book and found the end of the receiving line. There were stands of flowers everywhere, roses mostly — pink and red and white — done up in intricate arrangements identified by cards signed by family, friends and well-wishers.

A small silver urn stood in the center of the table; a golden crucifix rested against it. On either side lay two stacks of books — three on the left, two on the right. I noted the author of the two on the right — medical titles reflecting her area of expertise.

Most physicians don’t leave any written creative works behind; she had left two — these two texts, in addition to her two teenaged sons, who stood in the receiving line on either side of their father. Each of the three wore a pink tie. Pink, the color of the ribbon supporting breast cancer research; pink, the color of the delicate rose in full bloom; pink, the color of fading rose petals at the close of day.

My words were inadequate — “I’m sorry for your loss” — followed by handshakes and brief smiles.

“How are things at the office?” the father asked.

“Busy,” I said. “Back to school physical exams, you know. It’s the same every fall.”

He nodded. “Thanks for stopping by.”

I left by the side door and stepped out into the heat of the early afternoon sun.

As practicing clinicians we are granted the high privilege of glimpsing the struggles of families entrusted to our care. For brief periods were share in their triumphs, their joys and ultimately, their grief.

But many times it’s the grief that seems to linger the longest.

2012 © Brian T. Maurer

The journey inward

It is difficult at best to attempt to deconstruct the art of medicine — or even to define it. In my book the art of medicine includes the science of medicine; subsumes it, if you will; but there is so much more to it. While the science of medicine might take place in the confines of a sterile laboratory or in a pharmacologic interaction within the human body, the art of medicine always takes place between at least two individuals, the clinician and the patient. Practicing the art necessitates a skill set largely learned through experience, honed with compassionate practice. It is certainly more than mere technique.

Although Stephen Bartholomew was not writing specifically about the art of medicine in this passage from Physician Assistant: A Guide to Clinical Practice, he captures its sentiment beautifully for the practicing clinician.

“It is an adventure, the journey inward, to the center of our own being, where all the dragons and all the treasures they guard really reside. The destination of such a journey is well worth the price of the adventure. With humor, with honesty, with humility, we receive as much as or more than we give, remembering:” (here he quotes Joseph Campbell in a passage from Hero with a Thousand Faces)

We have not even to risk the adventure alone, for the heroes of all time have gone before us. The labyrinth is thoroughly known. We have only to follow the thread of the hero path. And where we had thought to find an abomination, we shall find God. And where we had thought to slay another, we shall slay ourselves. And where we had thought to travel outward, we shall come to the center of our own existence. And where we had thought to be alone, we shall be with all the world.

“Sahara” © Barry H. Penchansky, M.D.

Humane Medicine — The principle of uncertainty in medical practice

On her physical exam there is nothing amiss to report. Yet something is obviously bothering this child. Uncertain as to which direction to proceed, I take a stab in the dark. more»

Interested readers can now access my latest Humane Medicine column — The principle of uncertainty in medical practice — recently published in the Journal of the American Academy of Physician Assistants.

A marriage of humanity and medicine

Medical practice lay a-bed,
With fever to the core;
Sickness festered in her head,
While death passed by the door.

A string of suitors, all untrue,
Had left her bed of pain,
Parties of the third did woo—
Though not for love, but gain.

Big Pharma promised wonder drugs,
To ease the maiden’s plight,
True colors shown: this band of thugs,
Had raped her in the night.

So there she lay upon the cot,
Delirious, forsaken;
If she once had, she now had not—
Her very soul was shaken.

An ancient door eased open;
Humanity crept in
With tender thoughts unspoken
For dying medicine.

He slipped a hand in her hand,
Caressed the feverish brow;
He lingered by the night-stand,
Then turned the lantern low.

Humanity kept vigil
Close by throughout the night;
The heartbeat, once so feeble,
Had strengthened by first light.

When medicine awoke,
She stared into a face
That whispered words of comfort
And emanated grace.

So medicine was married,
Humanity, the groom;
Their grateful patients tarried
At tables in the room.

Now this is but a fable,
It never came to be—
Though fictions often lead to facts,
And blind men sometimes see.

2012 © Brian T. Maurer

Some things happen for a reason

“We’ve got one more patient coming in,” the medical assistant calls down the corridor.

The words sting in my ears. From where I sit behind my desk, I can see the clock on the credenza: 6:50 PM. By rights, in ten minutes we should be closing up shop and heading home. The last thing I want to hear at this juncture is that I will have to stay past posted office hours to see a straggler.

“The father called at 6:15 PM,” the receptionist tells me. “He said he would be here in fifteen minutes. I don’t understand why he’s late. According to the chart, he lives in town, just a couple of streets over.”

I stare out the front window. The few remaining cars in the extensive lot are covered with snow. Despite several passes by the plough there’s still a good bit of slush on the pavement.

“The temperatures were supposed to drop this evening,” I say. “Maybe the roads are beginning to ice up.”

I retire to my office and finish the last of the charts from a busy day. I’m tired and spent. I would like to go home and have my dinner. I wonder why people always seem to wait until the last minute to call.

The cleaning crew arrives. The father and son team begins to collect the trash from the examination rooms and wipe down the counters with disinfectant. I look up at the clock and shake my head: 7:00 PM.

At 7:05 PM the father stumbles through the front door with a diaper bag and his infant son in the car seat carrier. “Sorry I’m late,” he mutters. “I just got a new car, and already it’s acting up. It quit on me twice on the drive over.”

The medical assistant escorts the father and infant to an exam room. I hear her ask him the reason for the visit. The father starts in, describing the onset of nasal congestion one week ago. Evidently, the child didn’t eat well today. He’s vomited several feedings. Perhaps he needs an antibiotic to kick the cold, the father says. Everybody else at home is sick.

The medical assistant hands me the child’s chart. “There’s no fever,” she says. “98.8.”

I open the slender file. The child is just three weeks old. The father brought him in for the congestion last Saturday. From the note it appears as though the baby might have had conjunctivitis. The father has been putting an antibacterial ophthalmic ointment in the baby’s eyes. I close the record and ease to my feet. It’s now 7:10 PM. With a little luck, I might be out of the office by 7:30 PM.

I recognize the father immediately when I see him. He was in fact a former patient in our pediatric practice, an intellectually limited young man.

“I’m sorry I’m late,” he starts in. “My car is acting up. I can’t understand it, I just got it last week. I had the baby in to see the other doctor a couple of days ago. He told me to come back if the baby got worse. He didn’t eat much today. The little he did eat he threw up. Maybe he needs some kind of medicine to help him get better. What do you think? Does he need a antibiotic?”

While listening to the father’s words, I observe the infant on the exam table. His respiratory rate is in the 80s, he’s retracting with each breath. The area around his mouth looks dusky. I place my stethoscope on his chest and count the heart rate: 180 beats per minute.

I pull the stethoscope from my ears. “I think we’ve got to get him down to the hospital,” I say. “He’s having difficulty breathing. At the very least he needs a chest x-ray and some oxygen.”

The father looks at me and then at his son. “He wasn’t this bad earlier today,” he says. “Honest, he wasn’t.”

I place my hand on the father’s shoulder. “Little babies can get sick quickly over a short period of time,” I tell him. “You did the right thing bringing him in.”

“I don’t think I can take him to the hospital in my car,” the father says. “It quit on me twice driving over here. The roads are slick—”

“Don’t worry,” I tell him. “We’ll get an ambulance to take him down. You can ride along with him.”

“Can I call my mother? Maybe she can meet me at the hospital.”

“Go ahead. We’ll arrange for the ambulance in the meantime.”

I walk out to the front desk and ask the medical assistant to make the emergency call. Our receptionist turns beet red.

“I’m so sorry,” she says. “If I had known he was going to be this late…”

“Forget it,” I say. “If you hadn’t had him come in when you did, he might not have lasted the night.”

A new used car that is on the blink. An intellectually limited father. Icy roads in the aftermath of a winter storm. A belated telephone call at eventide.

Sometimes a string of events portending disaster can lead to a satisfactory outcome.

The ambulance arrives to collect the infant and his father. Soon they disappear into the night. The cleaning people have taken out the last of the trash.

I turn out the lights, step through the side door into the chilly air and throw the deadbolt.

Some things happen for a reason, I think, as I slide in behind the wheel of my car. I hit the switch, and the engine roars to life.

Facing our mistakes

Nowadays, the popular press focuses on medical errors from the perspective of the patient.  Pick up any current patient-focused periodical and you’re apt to find a Doctor So-and-so did me wrong article.  Many times the patient has a valid gripe.

In his recent TED talk Doctors make mistakes: Can we talk about that?, Canadian physician Brian Goldman offers a viewpoint from the opposite camp: How do clinicians react when confronted with the oft-times detrimental effects of errors in clinical judgement?

We know that Sir William Osler made at least one attempt to address this issue head on when he called his residents to the morgue to witness his error in diagnosis.

“Once in a ward class there was a big colored man whom he demonstrated as showing all the classical symptoms of croupous pneumonia. The man came to autopsy later. He had no pneumonia, but a chest full of fluid. Dr. Osler seemed delighted, sent especially for all those in his ward class, showed them what a mistake he had made, how it might have been avoided and how careful they should be not to repeat it. In 30 years of practice since then…I remember that case.”

Over the course of my career I’ve tried to get at such issues by writing about them. I recall one of my early pieces published in the premier issue of Dermanities, Abdominal Pain. Although revisiting it still leaves me feeling a bit queasy, it offers a lesson that I shall never forget.  Or in Doctor Goldman’s words, “Yes, I remember…”

Facing our mistakes is one of the most effective tools that we clinicians have to improve our clinical diagnostic acumen. What a pity that more of us don’t take advantage of it.

“Notes from a Healer” — Flu Shot

It was just a short visit for a flu shot. Short and sweet, filled with impromptu reflections on the human condition—something of value that we aren’t taught in our years of training, these seemingly insignificant snippets of conversation that ultimately serve to cultivate caring relationships in medical practice.  more»

My latest installment of Notes from a HealerFlu Shot — is now online, newly published in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine is an online journal fostering discussion about the culture of medicine, medical care, and experiences of illness. Interested readers can access a list of editorial board members and regular contributors here.

You never know

According to the newspaper obit, this soldier’s one true ambition was to become a writer.

He took four years of Latin in high school to become a better writer, and he had had a number of pieces published in the school’s literary magazine.

He planned to attend college and major in English. He thought he might be able to teach on the side until he could get himself established in print.

Somehow after high school graduation he ended up enlisting in the Army National Guard. He held the rank of private when he died.

His high school friends described him as quiet and polite. He was known for thinking outside of the box, and always had a ready smile.

According to his medical record, with the exception of a minor forearm fracture incurred in boyhood, he was only seen in the office for annual physical examinations; and those became less frequent as he got older.

There was never a hint of depression, never any inclination toward self-destructive behavior. When the news broke, that was why no one could believe that the cause of death was a self-inflicted gunshot wound.

Vita incerta, mors certissima — an ironic epitaph for a young gifted writer with promising talent.

You just never know about such things, I muse, as I gently close the medical record on my desk.

“Notes from a Healer” — A Bad Day

The child is lying face down on the exam table. She’s dressed in a johnny top that’s too short for her lanky frame. Her hair is clipped short, like a boy’s. She’s got a tuft of cotton wadding wrapped around her left index finger; the thumb on the same hand is thrust into her mouth through pursed lips. more»

My latest installment of Notes from a HealerA Bad Day — is now online, newly published in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine is an online journal fostering discussion about the culture of medicine, medical care, and experiences of illness. Interested readers can access a list of editorial board members and regular contributors here.

“Notes from a Healer” — A Remembrance of Things Past

When you feel the strike, slack the line before you set the hook; and then you’ll have him for keeps.  more»

My latest installment of Notes from a HealerA Remembrance of Things Past — is now online, newly published in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine is an online journal fostering discussion about the culture of medicine, medical care, and experiences of illness. Interested readers can access a list of editorial board members and regular contributors here.