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Unlikely serenity

"The greatest wealth is contentment with a little."
-Unknown

I did not want to go to work today. More than usual, I did not want to go to work today. I had been up late doing paperwork, asleep as soon as horizontal, then awake again, barely, in about 3 seconds, a warm cat under my arm, the alarm on my cell phone reading 5:06am, dreading the day. On her way to work, my wife dropped me off at the office. Lately, I just haven't been able to make myself get on the bike. My routine is, I first go look at my route for the day, scheduled the previous afternoon by office administrators. Then I grab my charts, all 40-80lbs of them, and head off to a quiet conference room to meditate for 10 or 15 minutes. This morning, staying awake as I breathed in and out with the aim of emptying my head was a challenge. I use a technique that I learned in a Shambhala meditation center, keeping my eyes open, focusing on a spot a few feet in front of me, concentrating on the breath. All I wanted to do was put my head down on the table and drift off. If I can stop the chatter in my brain for three breaths in a row, that's a huge success. When I'm through, I start making my way through the charts, filling out what I can before the day begins, reviewing what happened during the last visit, anticipating the next. Today, among 13 others, I would be seeing John Mayberry. John is a tough case.

John has been in bed for years. After a car accident left him paraplegic, he has spent nearly all of his time in a room the size of a walk in closet. The room is in what was probably once a storage space in the basement of an Englewood 3-flat.. There are no windows. The air is close. Only one person at a time can be in there with him. His bed takes up about 80% of the space. There is a small shelving unit at his feet with a 12" TV atop. His toes fall outward. He lies there in his underwear and a half buttoned shirt, with an ashtray somewhere within reach. A short, twisting corridor leads to a kitchen even smaller than the bedroom that barely holds a table and two chairs. Whenever I visit, either his daughter or his son wait for me by the stove as I talk to John about how he is doing. Today, I notice that urine collection bag has a little blood in it. The visiting nurse who comes once a week had just changed his catheter so the blood isn't terribly surprising and will probably clear up in another day or two. I look at his left knee which we have X rayed here in his room since the last visit. It is less swollen and not painful, though he says that a spot on the leg below the knee has been bothering him a bit, but only when he has to turn to be washed, or to have bedclothes changed. The X ray showed only arthritis, but I had also shot films of his lumbar spine, and these bones had a ragged appearance. Though it has never been demonstrated definitively, I am sure that John has metastatic prostate cancer. His PSA, the chemical produced in quantity by cancer cells, is sky-high. Years ago, when the elevated PSA was first noticed, he had not one but two biopsies but both had been negative. Over the last six months, the flesh has melted off of him. He is visibly weaker, has developed an early bedsore over his hip, and now this bone pain. Without a positive biopsy, I have been unable to get urology to start treatment for the cancer, though this treatment would have been temporizing at best. John is dying of a cruel disease. However, given a touch of dementia, his mind is not able to hold onto this reality. And despite this heavy, very limited existence, his outlook is surprising.

John is seemingly one of the most content patients I work with. Whenever asked, he always feels fine. He smiles and says he is happy, he has no interest in moving anywhere else. Even when I paint too rosy a picture of a supportive care facility where he could socialize with other residents and tool around in a powerchair. coming and going as he pleased, he claims to have no interest in being anywhere else. He enjoys the meals his family makes him and he likes watching TV. In all the time I have been coming, I have never seen him angry or despondent or scared. In fact, the time I think he seemed most unhappy was when I visited him in the hospital, in a room much cleaner, brighter, airier, and larger than the one to which he is accustomed. In a way, he strikes me as an creature who has grown used to his tiny cage. "Institutionalized" is the word coined in the Shawshank Redemption for people who have become dependent upon their prison cells. I want to take him away from this place and see him living in a building with nurses, bathrooms, showers, where he could peer out his window and see birds. But is this fair? John has taken the situation given him and made peace with it. According to his children, even before his injury, and long before he moved underground, he was content; his outlook uncomplicated. And yet, finding him accepting of a situation that I find unimaginable, I want to believe him damaged. I find it far more believable that in telling me he prefers this place, he is actually expressing his fear of the unknown. Perhaps in this alternative environment that I offer him, his children will never come visit. It will be clean and the walls will lie more than three feet away, but no one will listen to him. They will tell him what he wants rather than asking. Behind his smile, he is terrified. This is what makes the most sense to me. And if I could take you to this place that he lives, maybe this would be what makes sense to you. And if I am wrong, and he is content rather than paralyzed by the thought of change, is there anything that I can learn from him? Or is this just the way he is and has always been, while I am how I am and have always been and will ever be?

Rickets?

My job brings me into a lot of strange houses. This one has to be one of the strangest. What I knew going in was that the patient was self-pay, that is he did not have Medicare, the only form of insurance that The Company accepts. And he was having trouble coming up with enough of a cash payment to make the administrators think it was worth their while to send a physician out. Glancing at his chart, I saw that the patient had what the doctor who saw him before me termed "familial rickets." That is, two of his daughters have rickets as well.

You don't hear too much about rickets anymore. In fact the word itself seems antique. It comes from an Old English word 'wrickken,' meaning to twist because the legs of those with rickets bow inward. Their bones are soft and prone to fractures and their teeth fail to mineralize properly. The most common form of the disease is due to a lack of the active form of vitamin D, either because of deficiencies in the diet or lack of sunlight or both; for a while it was quite common but now we have all but eradicated in this country. But there is another form of the disease that is very rare and inherited. The mutation causing the disease resides on the X chromosome, meaning that fathers give it to their daughters. I reviewed all of this during a lit search on my iPhone as we drove out to see our patient.

There was no heavy ornately barred security door found on most of the nearby homes. In fact there was no storm door at all. There was no doorbell. When we knocked, a boy of about 11 with a challenging expression and no shirt answered. We asked for Henry and he led us through a dingy, sparsely furnished living room, past another slightly older shirtless boy, and into a back bedroom. Our patient was a man of 46, obese, short in stature, with bowed legs, also shirtless, lying on a dirty mattress. He invited us in.

Self pay patients are unusual. And because no one from The Company had visited him in over a year, I figured he had a specific reason for wanting to see us, so I asked him straight out. He gave a direct answer. He was due in court on Monday for a child support hearing and needed a physician's note stating that he was bed-bound and unable to attend. Apparently, as he had grown heavier, he developed back pain, and now in addition to being unable to walk he could no longer tolerate sitting except for short periods. He had not even tried to sit up for the last 8 months. Despite this, he was a fairly cheerful fellow, well-spoken, happily conversant. He seemed to understand how bizarre all of this was. When a third shirtless boy came in asking to use the computer, he breezily said not now, Darnell. The kid kept at it so Henry put an end to the pleading with: "Leave! Goodbye." though his the tone of his dismissal was somehow affectionate, familiar. I almost cracked up.

In order to examine Henry's back, my medical assistant and I had to physically roll him onto his side, not an easy task for a man shaped like a Weeble. Henry walked us through it, so to speak. Apparently, whenever he needs to leave the bed, which isn't often, he calls a couple of larger sons to help pick him up. I had some stationary with me and wrote him a letter on the spot. I could easily testify to his rather lump-like status, and I felt for him. But what I wanted to ask, but avoided doing because we had just met, is what's with all these kids? He has eight! This man who had been on SSI for over 30 years, who had never walked, who was poor as a church mouse, just kept on making babies. And most disturbing, not one but two of his daughters inherited his crippling disease, an outcome that should have been entirely predictable. I can believe that he was never properly educated about his disease. I can even buy this despite the fact that his sister, who also has rickets, passed the disease on to one of her sons. But what I find nearly impossible to fathom is that he never considered slowing down on the baby-making after his first daughter developed the same crippling condition. And while not all of his children live with him, as demonstrated by the child-support suit, both of his daughters do live in his small house. I would imagine this is a way to consolidate SSI checks, about $650/month each, to the point that they can support a household.

Despite what I may think of his choices, the man needed better medical care than he was getting. At this point, though there is probably not a lot to be done about his major diagnosis, he also had untreated hypertension. And if I could help apply for Medicare, which he should be eligible for, we could probably get him a bed with a trapeze set-up that allows him to sit up, along with physical therapy that may help address his back pain. Until we can put all of this in place, I told him that I would come back for free in about a month to check on his blood pressure and see how he was doing.

Diabetics give the best presents

One of the real perks of my job: the rare gift of food. Quite often, diabetics are diabetic for a reason. It's because the stuff they eat is sooooo gooooood! My second to the last patient of the day kept us a bit late but it was well worth our time. A pound cake was just coming out of the oven. She had made it for us, Rose and me, and sent us away with four huge hunks each. It is a little disturbing how naturally our conversation about  techniques for insulin titration was so easily interrupted by mouthfuls of heaven. Hypocrisy? Maybe...

Soc

Someone from AA asked me to help teach his class. More specifically, he asked me to lead a session of his intro to sociology class devoted to health care. He is trying to get his kids to consider societies various institutions from a perspective of inequality. Health care and inequality is big topic and he has given me a lot of latitude in what to present. But as interested as I am in how inequality manifests itself in health care and how health care succeeds or fails in addressing these, I find that I am far more interested in considering the broader question: what is health care? Is it really an institution? What is health? What is a health care provider? With respect to our bodies, aren't we all health care providers? This is a bit slippery, I guess. But perhaps the class and I will get at how, as an institution, health care is different than, say, the auto industry, or the restaurant industry. In a sense, even if we don't go to a clinic or a hospital, or buy vitamins or medications, we all engage in health care. The final outcome isn't a car or a meal, it's us; how long and how well we live. In the end, whether we are paid or unpaid practitioners, that's what we are engaged in: trying to help each other live better and longer.

One of the incredibly illuminating and often frustrating aspects of working in health care is encountering differing belief systems around health. They teach you about this in medical school, and most students were probably something like me, shrugging the topic off and preferring to focus on what I considered to be the meat of medicine: physiology, pharmacology, immunology, etc, etc. And I was, and still am, a pretty progressive, open-minded and patient guy--I like to think. And also a vegetarian, so maybe my meat analogy isn't terribly apt. Anyway, a problem arises when the person across from the table has vastly different tastes, if you will. There are plenty of people out there who do not believe in physiology and pharmacology and immunology. They don't know what they are, and possessing a worldview that works perfectly well for them, have little interest in learning about or working within a system that requires them to accept a mysterious and foreign set of principles. Obviously, this doesn't apply to everyone. Some people, like the perfect little patients on Gray's Anatomy are only to happy to put their full faith in every word that issues forth from MD's mouth. But there are plenty that do not, and there are those that say they do when treatment strategies are discussed, but when the doctor is gone, go and do their own thing. And then there are those who are half in and half out. One of my favorite examples of this is my patient, Martin. I have been seeing Martin for osteoarthritis and chronic pain related to a horrendous injury he suffered years ago, along with hypertension, and a positive TB test that required prophylactic antibiotics. It was very difficult to get him to take medication for the blood pressure though he readily accepted pain medication. Pain is right there in his face and it is clear to him that certain medications do a good job at helping with that. Blood pressure is something else entirely. When we first started working together, we didn't talk a lot about what he thought. I prescribed, he accepted. How often he took the medicine is uncertain. Sometimes his blood pressure was great and other times it wasn't. Finally, wondering if and when he was actually taking it, I asked him: do you believe in high blood pressure? "Yeah, doc. I believe in it?" I asked him why he believed in it. He answered because his mom had it and she had heart problems. So then comes the money question: do you think that you have it? "No. Not really." Why? "Because I feel normal. I don't feel like there is anything wrong." We had been over the whole silent killer thing before, and I think in his particular case, the obstacle is as much denial as it is an alternate belief system. Medicine is wonderful that way. Not only are many people predisposed not to believe in things like cancer you can't see and blockages in vessel deep within their bodies, they don't want to believe in that stuff either. There are plenty of times, like when I am sitting down to dinner, that I don't either. Though I have no real proof either way, I suspect that Martin took the anti-hypertensives and antibiotics (I hope) in order to placate the doctor so he could continue to get the pain medications. Clinical relationships are often about compromise. A more interesting and controversial question would be: "If you don't think that you have high blood pressure, what do you think we are doing when we take those readings off the dial and write them down? Are we screwing up the measurement? Or is it all just a scam designed to make us and the drug companies money?" I think I did ask him that once and he chuckled and deflected and moved onto another topic.

I remember a much sadder case of denial. I was asked to come visit the sister of a patient I had already been seeing for a few months. She stayed in a room just off of the living room, though no one had mentioned her to me and I was not even aware of her existence. Her name was Debra. As soon as I met her, it was plain to me that she was dying. The medical word for her appearance is cachexia. She was wasting away, not simply skinny but weak. Several months prior she had been walking around the house. Now was unable to stand, barely able to lift her torso off of the bed. The family had hired a caretaker, because she needed one, but did not look further into what might be causing such a rapid decline. A little questioning revealed that she had been diagnosed with lung cancer two years prior. According to Debra and her daughter, the specialists had cured the cancer and there was no need to go back. After a few phone calls and faxes to her oncologist, I learned that at the time of diagnosis, the cancer was already in her brain. They gave her radiation, but she did not like the way it made her feel so missed a lot of appointments, and ultimately decided not to return. The doctor may have said that he could no longer see the cancer on imaging studies, or perhaps he even used the word remission. They had grabbed onto this life raft and turned it into a cure. But now after nearly two years, after she had grown ,sicker and sicker, when I asked her daughter if she thought that the cancer might have come back, I received a steadfast "No." They had taken good care of her and provided her with a good diet. She no longer smoked. There were no negative influences in her life so there was no reason for the cancer to have returned. Cause and effect. Game and match. It's the big question that people in medicine are perhaps the most ill-equipped to answer: why? Not how. How is complicated and in times of crisis goes way past everyone; and to those in the grip of disease, often irrelevant. Why? Why me? Where in my life did I go wrong? What did I do to deserve this?

Karl

Dementia is an amazing and horrendous disease in what it takes and what it leaves behind. We saw my patient, Karl, today. He has what some would term "moderate" dementia. He remembers who I am, though not my name, and does not recall the last time I visited. He cannot manage his medications, and despite having been a realtor and insurance salesman, can no longer do simple arithmetic. However, he holds onto languages, and being an immigrant from Lithuania, speaks six of them (English, German, Polish, Lithuanian, along with some French and Italian). He lives upstairs from his brother and his brother's wife. His apartment is dim, colored in shades of brown, is like something out of film noir, where the private detective lives in the back room of his offices. The air feels about a hundred years old. He sits behind a large desk and I sit on the other side like a client asking advice. Behind him are piled books that he can no longer understand. Among them is a binder labeled "medical," into which he has meticulously placed pages from his clinical history. He remembers none of the them. Not his high blood pressure, nor the stent placed in one of the arteries of his heart. None of it ever happened. He has the worried expression of a child who neglected to study for a final exam. But Karl has studied. He is constantly taking notes. When I excused myself to go the bathroom, I found the mirror over the sink covered in reminders, little rectangles scribbled in a trembling hand: therapist comes Fridays 1pm; meals delivered Monday, Thursday 11am; don't forget the mail. There are notes on that mirror dating back to 2008, testifying to a desperate attempt to maintain order in his life, leaving no room to view his reflection. Karl never married. There was no one to outlive. If his apartment is any indication, he made a life in business, filled with clients and files, and a brother downstairs. He is kind, and gentle, and shyly affectionate, and frightened. On my second visit he gave me the note below:

It makes me wonder. Emotions are so highly reactionary, if my own are any indication. When I things are going well and I am confident, my needs are few, and I am in search of adventure. But when times are uncertain, when I feel small, then I reach out for those around me. I look for solace and crave validation and love. This side of Karl. This affection and neediness: was it always there? Or now that parts of him are disappearing and life grows ever more daunting, has this loving, necessitous person emerged, surprising to those who knew him before? I guess this sounds mean. It is a little mean. I like Karl. He is a sweet man. I enjoy him and wish I had more time to spend before his desk. Each time I come he asks me for a business card and before today, I always forgot to carry one. But today I dig one out of my pocket and hand it over. He is pleased. He takes a pen and writes on it the day and date: Thursday, 3/24/2011.

It was a good day. Got up early, biked to work, saw all of my scheduled patients, got done at a reasonable time, biked to yoga, then biked to an AA meeting that I chaired. Boo-yah! That's a good day. A full day. A day worth feeling pleased about, to be sure. However, if I choose to, I can completely eviscerate the experience of any sense of satisfaction. For instance: I don't really like my job and most days I don't even feel that I am particularly good at it. I could have done so much more for my patients today if I would only spend  more of my free time studying. So why am I wasting my time with yoga when I could be learning how to be a better doctor? And just think about all the time I have wasted being a drunk and a drug addict and now with all of this recovery business, think of how much more time I'll be wasting in meetings and step work that I could spend doing any number of things, and on, and on, and on. The M.O. of the perpetually dissatisfied. For a long time I equated dissatisfaction with possessing high standards. I thought that berating myself for the things I had not accomplished was the way to ensure that I did more. But even if that messed-up strategy had merit, I could never berate my way out of being an addict. So despite the heaps of whiny I direct at my addicted self, the reality is that is my reality. Without meetings, step work, the recovery community, service work, whatever serenity I have achieved quickly evaporates, addiction creeps back in, even material achievements vanish, and I am left unhappy and unhoused. Acceptance is the only reasonable course.

What lies beneath

Another on the list of patients who make me anxious is Jonah. He lives in one of the senior high rises, where rent is on a sliding scale of one's monthly income. Jonah has suffered several strokes, the last of which left him with profound right-sided weakness and an difficulty with speech. In the language of medical jargon, we would say he has a dysarthria. He can comprehend language and his brain can form the words, but his mouth won't properly produce them. He slurs and mumbles and is extremely hard to understand. Despite these difficulties, he manages to live on his own, walking carefully through his apartment and relying on a motorized wheelchair to leave. In an earlier life he was a successful mortician with a big family. Now he is solitary, rarely hearing from anyone. What little money he has, he squanders, and is often without a working phone. The building's tenant services coordinator bemoans the fact that his apartment, despite the semi-reliable assistance of a homemaker, is often a shambles and potentially a source of marauding pests. The homemaker has fretted to the coordinator that he drinks, and the coordinator has recounted to me that he brings home "female companions" who wander the halls looking for other clients after through with him. The building wants him out in a big way.

As you might already have gathered, Jonah is very depressed. Through many of our meetings, he sat silently, the hopelessness radiating off of him. Some days I attempted to address and intervene in his depression. On other days, I stuck to his medical problems, or the recurring mechanical problems with his wheelchair, happy to avoid the morass of his sadness. On one day when he seemed particularly distraught, so much so that there was no avoiding it, he recounted an occurrence from earlier that week. His son had come to visit him. Jonah hadn't seen is son in nearly two years. Some friends tagged along for the visit, no one that Jonah knew. For some reason, Jonah left some money, over $200, out on his bed when he went to the bathroom. When he returned, the money and his son were gone. As he told me this, he was near tears. When it came time for me to leave, Jonah asked for two dollars. Was his story all a set-up to ask for this small sum? The weight of his emotions during the telling say no. If it was all an act, what a performance!

So last week, Jonah complained that he felt sick. A little cough, some malaise, his apartment felt warm. In fact, his apartment was warm, and close, and quite uncomfortable. However, he showed me a set of vitals recorded by his visiting nurse the day before and he had run a low-grade temperature with an elevated pulse. His pulse was up with us as well and his blood pressure slightly down. The bottom of his right lung field had some new crackles, so I decided to start antibiotics empirically for pneumonia and get a chest X ray. When the result came in a few days later, it wasn't what I expected.

Similar to Jonah's X ray

His lungs were littered with small nodules while the bones of his right should had a ragged, chewed-on appearance. Without the messy shoulder, the findings in his lungs might be an unusual infection or some sort of reactive process, but taken together, the two findings pointed strongly to cancer.

Now the challenge really begins. The Company doesn't have a hospital affiliation so getting a thorough diagnostic work-up, especially one that will likely involve sophisticated imaging and biopsy. Depending on where the person lives, I pretty much have to make it up as I go along. And with Jonah, I know it will be a special challenge. He has no phone. He will require transportation to each of his appointments. And given his current state of mind, he may be reluctant to uncover the truth. To my knowledge, has no family to lean on as he goes through the painful process of establishing if he will live or die. My challenge in speaking with him, when I finally get ahold of him, will be to project hopefulness without being dishonest. I want him to participate in the tests that follow but I don't want him to do so under the false assumption that everything will probably be all right.

Most importantly, I need to remember to be present for him. This may seem obvious, but I find that when giving bad news, I am often planning my escape. Being in the moment and bearing real witness to the other person's emotions can be incredibly painful. It can feel very out of control. At these times, what I want is to control the whole interaction so that it remains manageable: I give you the news; you react in such a way that I can tell you have taken it in but have not been overwhelmed by it; I reassure you; then I go on with my day. What would certainly be far more helpful to Jonah is if I can provide him with the space to react in whatever way he feels necessary and then return his reaction with acceptance. Even in professional interactions, people really want to be treated like people. And physician/patient interactions because of the weight of the exchange often blur the line between professional and personal. I am starting to ramble. I'll stop speculating. More once I have more to tell.

Sometimes it's a hard world for small things

 One of my patients, a transplant from the one of the south side housing projects, has a soft-spot for cats. In her tiny one bedroom apartment, she houses ten of then, each of them also a refugee from the projects. One of the cats has a broken leg that was never set properly. A couple of others have half-shut eyes. "They were so cruel to them. Just turr-ible." As a doctor, perhaps I should think otherwise, but the most amazing thing about this little old lady with 10 rescued cats is that she has advanced emphysema and requires supplemental oxygen at all times. She has a compressor and one of those incredibly long transparent tubes that coils and uncoils behind her as she walks. She resembles one of those old time scuba divers with the diving bell helmets and air hose, swimming around her living room, with cats instead of colorful fish and worn furniture rather than a coral reef. The cats adore her and seem quite happy and she loves them in her rather stern way. She does not pet them and does not permit guests to pet them. "If you stroke them, they want it all the time. It's too much trouble. It'll take me weeks to get them back right."I quickly learned to leave them be.

You might not expect Chicago's south side to be teaming with wild or semi-wild animals but, man, it's like the woods. There are critters everywhere you look, often, the depressing variety. The streets of Englewood and Woodlawn are rough enough if you are a person. I can't imagine what it's like for a cat or a dog. Nothing is more heart-breaking than strays in the wintertime. When it's so bitter, you hate to remove your gloves, watching a stray pad around the frozen concrete nearly makes me break down. Most of the time, there is nothing you can do. They are skittish and retreat quickly from people. But sometimes when they are especially hurt or desperate or recently lost you can get to them. Lenny and I delivered a couple of cats to the shelter; one that looked as if it had taken a fall (or a beating) and been struck blind. When it came time to remove him from the car and take him inside to animal control, I couldn't get him out from under the seat. It's probably the first time he had been warm in months. Once when we were making our rounds, my sister, a vet student, forwarded me a message from PETA. Apparently when they are not rallying for animal rights, they support a web-posting for animals at risk. Someone had emailed about a couple of strays that were hanging around outside a building on the south side, not too far off our route. Lenny and I spent about 20 minutes looking behind dumpsters and under porches and shrubs but couldn't find anything. Odd luck that, given that it seems like there are stray animals everywhere.

And not just stray animals. Once, two winters ago, we were driving by the entrance to one of the big south side cemeteries. I don't think it was Oak Woods. It may have been Cedar Park. Wherever it was, we were both surprised to see deer resting in the snow. And not one or two, but twenty or thirty, legs pulled beneath them, lying along a hillside next to a monument. We turned the car around and drove inside the gates. As far as I could tell, the cemetery did not abut a big forest preserve, so these deer, at some point must have walked en masse down the street, found the entrance (the park is gated) and walked inside, like a visitor searching out a relative. After parking the car, we walked slowly over to the hill where they were all resting. They were relatively small, much smaller than white tailed deer. And they had stubby conical antlers that were more like horns. We got within thirty feet, then twenty, then ten. Lenny and I were both shocked by how close they allowed us to advance. Finally, when we were five feet away, the closest deer rose to move, and I asked Lenny to stop. Something about disturbing furry wild animals in cemetery during wintertime finally shamed me. His blood and frustrated by the encounter's anticlimactic ending, Lenny let off a bit of steam by executing a running start butt-slide back down the hill. The next day, he announced that he had injured himself slightly.

We also once found a raccoon in a cage. The cage, sitting next to an alleyway and a large overgrown backyard, was barely bigger than he was. The animal smelled musty, like old urine, The cage was borrowed from a local shelter and had a phone number. We called and found out that the cage had been procured to catch a stray cat that someone had been concerned about. "Well what should we do with it?" we asked. "Let it go." Was the reply. Duh. I guess I imagined that we would drive the little guy out to a forest preserve and release him into a more natural environment. But raccoons are so ubiquitous in the city that for all intents and purposes, this was his natural environment. Using a stick to avoid chewed-upon fingers, we propped open the door. Caged raccoon sniffed the air, then, more slowly than I would have expected, ambled over the fence, climbed into the backyard, and disappeared. He was probably pretty dehydrated.

Privilege

We were between patients, driving south of 95th on Ashland. I was on the phone with one of my patients, when:

"Bobby, I'm going to have to call you back. There is a person lying in the street."

At first it looked like someone was peering up at the underside of his car. But the angle was wrong and as we got closer we could see that the person (a she, as it turns out) was in front of the car rather than beside it.

My medical assistant looked over. "Do you want me to stop?"

I always have mixed feelings at these moments. People lying on the pavement are not my cup of tea. I'm more of a: "so how have you been doing since I last saw you?" kind of an operator. We parked a short distance up the street and as I walked back I could see that the woman was struggling to stand up. A man was standing beside her and urging her to stay down. The driver was off to the side on her cell phone, presumably phoning 911; hopefully not modeling immediately previous driving behavior. She alternately looked peeved and distraught. The woman on the ground was about fifty with thinning hair, so thin that I found myself looking around for her wig. Her belongings were scattered: purse in the next lane; hat well behind the car. It didn't occur to me that the distance of her belongings from where she landed might indicate how hard she was hit. The woman was rolling around clumsily, like an infant on a mat. With my stethoscope draped over my neck for legitimacy, I walked over and knelt down beside her.

She looked lost. When I asked her if she had hit her head, she didn't know. "I don't know how I got hit by this car."

"You don't remember?" She shook her head.

Despite my urging to remain on her side, she struggled to a sit up. With her fiinally seated, I could see the enormous knot on her temple. Like a grapefruit, I could practically see it growing. Her ear was split open at the lobe. In my mind, I could hear the hard smack as her head collided with the pavement. The swelling gave her face a lob-sided look, like a forceps baby. Unable to resist, I lightly pressed the knot with my index finger, half expecting it to be bony hard. But it was soft and springy, like a rubber ball. She was easily moving her arms and legs. I studied her facial expressions and asked her to follow my finger with her eyes. Everything looked normal.

"I live right over there." she said pointing. My mom is over there."

The driver asked if she wanted her to call her mother. It took the injured woman a couple of tries but she relayed the phone number. I looked at her a bit more closely. She had some sort of ID around her neck. It didn't look like a work ID. Perhaps she was one of those people who wore her identification around her neck the way a child on a field trip has her phone number pinned to her coat. And now here she was, bleeding on the ground. But given the circumstance, with just this glimpse at her during crisis, it was hard to gauge how in the world she usually was. I recall vividly that feeling of unreality after my bike accident. The day was whizzing by as usual and then it had stopped, and I was apart from it. Passersby peered awkwardly into my disjointed dimension. I felt as if I was looking and listening to the world through a long tube.

After a few minutes, the EMTs showed up and I left. Really, other than reassuring the woman I hadn't done anything. I have no trauma training, hence my hesitancy about stepping forward. At most, I'm a hand-holder. But one thing I do have is a calm around people who are hurt or sick. Looking back, I find that this is an example of the tremendous privilege that my job affords me to play this role of caretaker. Though my capacity to alter outcomes is often meager, just being there to hear people's problems, their worries, their hurts, is a tremendous privilege. Most of the time, rushed and fretting about the next patient encounter when the current one has only just started, I miss it. I miss how amazing it is to sit beside someone and be present as they tell me how it is for them.

What we believe

The mind is capable of accepting anything. Our conception of reality is far more plastic than most of us realize. And yet my sense walking through life is that, though imperfect, my mind is honing in on the real. It is constantly making fine adjustments, like a high powered lens on a microscope, moving incrementally in and out, until the film on the slide comes sharp. And the way I know I am getting closer, perhaps the only way of knowing, is through communication with others and comparison with how they describe their own realities. But is the collective finally a fair arbiter of the true? A whole town drank the Kool Aid. A whole nation embraced Hitler. But without a doubt, one at a time, we are all capable of utter madness.

After a life of psychological stability, one of my patients has succumbed to hallucinations and delusions. She is an elderly woman who lives alone at the end of a line of modest row houses. She has windows on three sides of her home and she is convinced that others are looking in. They are spying on her. They are bugging her home. And they can watch her through the TV. It's a new feeling but she believes it with steadfast conviction. The elephants and Roman soldiers that now occasionally appear in the kitchen, she knows that these are not real. But the people off in the distance with the binoculars and the surveillance equipment, with deep pockets and nothing but time, they are a certainty.

"I swear to God." she says to me. "They are there."
"What do they want with you?"
"I think it's the house. They want the house."
"Why should they want your house?"
"I've lived here for so many years and I've never had this problem. But this house is ripe for it."
"What?"
"Something big is going to happen. I don't know what. But something big."

A towel neatly covers the TV. She wants me to find something to spray over the windows. I look outside and wonder if the high-intensity street lights are bothering her. They certainly aren't responsible for her psychotic break but maybe they are contributing.

What strikes me most is her willingness to let go of one set of bizarre indicators but not another. Roman soldier: ridiculous. Shadowy cell watching her through the TV: unshakable. When I gently challenge her assumptions, she takes a deep breath, looks down, and sighs: "how can I explain this to you?" I wonder at my own very solid-seeming set of life-premises. How reliable are they?

My experience with addiction has taught me an enormous amount of humility when it comes to reality testing. I repeatedly put my mind and my life in serious jeopardy and accepted that such behavior was reasonable. Rather than confronting and perhaps overcoming the things that challenged me, I welcomed a highly toxic escape. The Big Book of AA likens the decision to continue drinking despite often devastating consequences to a man who revels in the thrill of jaywalking busy streets despite repeatedly being hit. The woman I speak of above is responding to a delusion. I was contending with incredible denial, and I continue to do so. The addictive or alcoholic way of responding to problems does not disappear with abstinence. Psychiatrists, I am sure will object with my comparison of delusion and denial. Delusion is certainly more intrusive while denial allows us to continue doing something that on some level we deeply desire. But both result in breakdowns in our ability to recognize what is true. So what is true?

At the outset, I write that the collective may not be the best arbiter of the true. I am sure that a lot depends upon which collective. However, I am of the mind that those practices that bring us closer to a state of serenity are bound to be true, at least on some level. One may argue that the thought of the universe in all of its vastness and silence is highly disquieting. Indeed it is. Yet the peace that we begin to approach when we empty our minds of thought and just accept is...well, it's something. And it appears to be fairly universal, though rarely practiced. Perhaps it is an act of faith, but I have far more confidence that when I am in a place of calm and acceptance, I will see things as they truly are. I believe this fiercely and yet, amazingly, I still resist the practice that will take me there: meditation, prayer, and cultivating balance in my life. I revolt against it. I tend toward obsession, worry, distraction. It's a struggle. The woman suffering with her delusions is a good reminder for me. Do I really want to remain in a false reality? Isn't it time to embrace the real?

Lenny

As I've mentioned, my first medical assistant, Lenny, had an abrupt transition when I arrived. For most of his time with The Company, Lenny had worked with Tyler, a 6' 6" black physician, who was often drunk or hungover and highly unpredictable. I guess I can be criticized for bringing race into it at all, but in a way I think it is relevant as most of our patients are black. Lenny is white and heavy and I am white and skinny. One of my friends said it must be like having the Blues Brothers appear at the door, sort of in the same way they showed up at Aretha Franklin's soul food restaurant. At any rate, it was a very different dynamic than with him and Tyler, even more so because Tyler had a huge, often very loud personality whereas I am on the more reserved side. So it was a change for Lenny and for our patients.

Because Tyler was fired the day I started work, none of the patients had any warning. Afraid of losing customers, The Company asked Lenny to phone all of the patients over the course of the first couple of weeks to inform them of the change. This Lenny did throughout the day. After taking vitals, he would often excuse himself to head out the car and hit a few names while I finished up. Despite his efforts, over the course of three months I think we lost about third of Tyler's group. 

Lenny was very upfront about missing Tyler. They had worked together for over a year, which is to say that they spent the entirety of their work day side by side, either in patients' homes or in the car. That's togetherness. Sometimes they laughed and imitated patients, developing their own inside jokes. On other days, Tyler would sit brooding, not saying a word between stops. Now Lenny is a very nice guy. There isn't a touch of meanness in him. And he's a pleaser. In the jargon of psychology, one would say he is co-dependent, placing the concerns of others far before his own. When the office assigned him to Tyler in order to "keep an eye on him," in many ways it was a match made in heaven. When Tyler tired of coming into the office, Lenny would gather the charts from the office along with all of Tyler's other paperwork, stop-off at his apartment to pick him up, then on the way back to the office drop him off. Never mind that he then has a long commute home at the end of the day. Because Lenny had already told me these facts about Tyler, he would qualify his affection for the man with "despite all of this stuff..." and I completely understood. Most of us have someone in our lives that we adore despite how he or she treats us. We live for the highs and dismiss the lows. And with many of these relationships, alcohol plays into it.

I get the sense that at times Lenny found Tyler's alcoholic craziness rather glamorous. There is nothing like a rebel to draw a person in. If Tyler didn't want to see a patient that had been scheduled for him, he would cancel at the last minute. Or he would ask Lenny to go in alone, take vitals, get the patient to sign the chart so everyone got paid, then come back out. "I don't need to see that patient this month! They can't tell me who I'm supposed to see! I'm the doctor!" If Tyler had grievances with certain Company administrators, he would air them. The lack of formal professional distance with patients and between the two of them along with a bit of fraud served as a measure of their uniqueness. It was the two of them defying The Company and expectations. If at times during an angry outburst, a chart ended up on a patient's roof, it was more funny than horrifying.

So it wasn't surprising that despite strict orders to cut all ties with Tyler, Lenny remained in sporadic contact. They would text and occasionally talk on the phone. Lots of Tyler's communications bore the signs of drunken ramblings. His firing was part of a racial conspiracy. He had been singled out because he was black, never mind that the company owner was also black. Meanwhile things were heating up because The Company had accused Tyler of violating a non-compete clause and poaching some of his old patients. This was a concept that Lenny had a tough time getting his head around. "They should have a right to see whatever doctor they want" he would say. He seemed only able to see Tyler's side of the disagreement. Lawyers were getting involved. Patients were being deposed. Lenny, despite his personal leanings, was being asked to serve as a witness to the fact that Tyler had made photo copies of patient charts as a method for retaining demographic information and Medicare IDs. So it was an ugly moment when Scott, the office manager, called Lenny into his office about a letter their lawyer had been given by Tyler. Apparently, Lenny had sent Tyler an apologetic email explaining that he was being forced by The Company to serve as a witness against him. Oh, baby.

So Lenny was getting it from all sides. The company fucked him by placing him with Tyler. Tyler fucked him by betraying his confidence. As a newly reformed drunk who now had insight into everything, I was probably being preachier than I ought to about the nature of alcoholic behavior. Plus things were chaotic at home. His wife has MS, is dyslexic, and relied on him to hold things together; things being home finances and the management of their three foster children, all of them boys. On an average day, she phoned him 6 or 7 times to talk about how one of the kids was messing up at school, some controversy with a baby-sitter, a late gas bill, or some other way in which she felt overwhelmed or out of sorts. What sustains him, I think, is an abiding faith in God. He is a devout Christian and finds solace in his recognition of the Bible as literal truth.If not a miracle, it struck me as incredible that he was nearly always cheerful, always upbeat, and tolerant of people who often did not have a lot of use for him.

Lenny was not one of the more popular people in the office. Well, that's not quite accurate. Everyone knew Lenny and had an opinion about him. He was, to say the least, a challenge to work with. The door to the office opens, Lenny walks in, and BANG: he's ON! "How's everyone doing?! Hey, buddy! What's going on?!" He's slapping people on the back, inserting himself into conversations, giving sly looks, telling risque jokes, and generally making sure that he is the center of everything. A typical response to him might go: "Lenny, you're too much, boy." or "Lenny, you need to stop running your mouth and get to work." It was much the same way with patients. He was, at times, a bit familiar. He was intensely curious and might, without warning, pick an item off  a shelf to have a closer look. Most patients found him adorable and welcomed this loud though clearly caring and sincere presence briefly into their lives. Every once in a while, there would be a dissenting view. As you might imagine, a common questions we faced was: "what happened to Dr. Tyler? What's he up to now?" Possibly to deflect his own unease about the truth, Lenny would often embellish. "He's working overseas now." "He became a fighter pilot in the navy." Or the answer that became one of his favorites: "He became a veterinarian and is out in the countryside castrating pigs." He said it with a chuckle and I think honestly believed that everyone was on the same jocular plane. Though as we found out, this was often not the case. I would usually intervene and give a cleaned up version of the truth: "He left the company to start his own business." But at least person called the office to complain about the off-color remark. Joking about the fate of a beloved physician, especially with a reference to pig genitals is not necessarily going to go over big. But this was Lenny to a T. He operates on the assumption that of course you would see things from his side.

Priorities

There are those patients I dread visiting. Usually that dread comes from a sense that I am not doing enough for this person. It's a comparison thing. A smarter physician, someone more assertive, with a stronger grasp of physiology and psychology, this person would be making changes that would lead to an improved quality of life for the poor soul unfortunate enough to be meeting with me instead. This is the feeling I have as I head up the walkway toward Ben's place. Ben lives in a garden apartment a stone's throw from the lake. The shades are nearly always drawn. After buzzing us in at the gate, he will have arranged for the door to his apartment to be open. Perhaps it is always open or perhaps he has some device to reach up from the rolling chair where he sits, over the short stairway  framed from 2x4s, to the lock. I'm not sure how he does it. I do know that we always find him sitting at the base of the stairs, looking up at us, in a grubby T shirt and tighty whities usually with a nervous expression. Ben is a man of 70 with a beard like Santa Claus. In body shape, he is a very exaggerated version of the Christmas saint. He weighs 450 pounds if he weighs an ounce. And he doesn't fly through the air. He gets around his studio by edging his roomy desk chair backwards over its creaking casters. He has the litany of diagnoses that you might expect with someone of his age and size: diabetes, hypertension, congestive heart failure, obstructive sleep apnea, osteoarthritis. Along with these more typical burdens, he must also contend with bowels temperamental enough that he fears going out even on those occasions he can make it up the stairs to his power scooter. The contents of his apartment speak to a lonely technical mind. Old computer and A/V  parts abound. Because he has no access to his roof, off to a side he has set up an elaborate if rickety ham radio antenna. Though he has a home health agency, including a home-maker and visiting nurse, the  place is a mess. It smells. Even if I didn't believe it to be part of my mission to make his life a little better, just being in Ben's place would be a real downer.

Ben is a smart, smart guy. He has researched all of his diseases and medications, and even claims to have diagnosed his own sleep apnea back in the '80s, before the phenomena was so well known--perhaps before we were quite so heavy as a society. When I first met him, my number one goal was getting him out of this horrible, depressing apartment and into an assisted living facility. However, I soon learned that because he would likely require more than one able-bodied person to help him with daily activities, he would likely end up in a nursing home. And after a hospital discharge, he had a very bad experience in nursing care. Ben felt as though all autonomy suddenly vanished as he because a thing that things were done to as opposed to a person. Also, he was fairly sure that there were no facilities that would allow him to set up his ham radio equipment, and this was a deal breaker. His point reinforced for me a lesson that I am forever relearning: my priorities, though they may seem totally reasonable (a clean environment that would not serve as a deathtrap in case of a fire or flood, with healthy meals), may totally ignore the very thing or things that make life worth living for someone. If a car enthusiast were to offer me the keys to a $100,000 roadster with the caveat that I could not ride my bike for as long as I kept it, he would be aghast when I handed them back to him. The more subtle point for me is that, even on an objective plain, when it comes to such decisions I often have no idea what I am talking about. When I recommend that Ben enter an assisted living or nursing facility, I do so as someone who has frequently visited such places, but not as someone who has ever lived in one. My knowledge is entirely second-hand. I see support and security; Ben sees and has lived loss of independence and exploitation. I don't mean to indict all supportive living facilities. Clearly there are some very good ones, but there are also some very bad ones. And finally there is the weight (not a pun) of meaning involved in taking that step (again, not a pun). He retains the capacity to make his own decisions, so it is his step to take and the meaning of the decision is entirely his.

This line of thinking brings to mind the notion of surrender. AA first demands that we surrender the belief that we are in control of our use of alcohol. As we move forward in our recovery, we find that there are a great many things over which we must surrender any idea of control. This is the only path to serenity. As odd as it seems to me, I know that I must surrender my own sense of omniscience if I am to be of true service. I call this odd because I do not see myself as omniscient. If anything, I am often awash in the anxious worry that I know nothing at all, or at least that I know far less than I should. But self-deprecation is not the same as humility. In fact, as long as I continue to view myself as the god at the center of my own existence, my mind remains a wrestling match between "I am brilliant" and "I am an idiot;" "I am all" and "I am nothing." If I can give over the idea that I am in control of my path through the universe, I will divest myself of expectations and thereby lose the burden of judgment. As an example, though I should enter each meeting with Ben with the hope that I will be of service to him, we both would be better served to leave any agenda at the door and just try to keep an open mind. I can begin by asking: "What do you hope to get out of our interaction?" and go from there. I can insert my own experience of what helps make people healthier, then get his take on what he thinks of these, then see if there is some common ground where we might work. And finally I must bear in mind that I cannot take credit for the result. I have contributed something to the process but, in the end, I had no control over where our endeavors led. It is not my achievement and it is not my fault. It just is.

Indulgence

This morning I was listening to a radio program commemorating International Women's Day. The host was interviewing an expert on family leave law and comparing the family leave situation as it stands in the US to other industrialized nations. For the most part, we compare pretty miserably. What followed was more reporting on face-offs between state governments and unions over the possible demise of collective bargaining, and all of the other cuts in services that are likely to follow, especially in federally mandated services like Medicaid. Emotionally, I guess I was already primed for a bit of a tailspin. Note to self: don't listen to NPR on the way to a job interview. Consider instead House of Pain or something.

So I may not have been in the right frame of mind to listen to the CEO of my would be employer explain the structure of his business to me. Apparently he has a holding company that controls: a) a home health agency; b) a visiting physician company; c) a medical supply company; and d) an intermediary group that is contracting with the Department of Aging to evaluate the health care needs of all seniors in a geographic region coincident with that served by the rest of his concerns. Second note to self: in the middle of a job interview it probably doesn't pay to suggest to your interviewer that he seems to be engaged in unethical business behavior; and then when he looks at you quizzically, expand on your statement. I might have concluded that it was a testament to my impressive qualifications and sharp skills of analysis and debate that he offered the job to me anyway, IF they had not just last week hired a physician that been fired by The Company (my current employer). Zing!!!

Earlier in the day, I was told by a chipper endodontist that I was looking at 6 root canals on teeth jogged lose during my bike accident. She had to keep track of my bad teeth on her fingers, there were so many of them. Okay, I'm making that part up. I spent the rest of the day after my interview looking at the world rather pessimistically. My attitude was all: "so this is the world we live in." Everyone on that bus is overweight. I am surrounded by adds for cigarettes and luxury items like iPads while we as individuals and our nation as a whole fall further into debt. Our schools are a joke. Nothing happens on time. The past president of our county board is filing for unemployment insurance because he lost the election. The patina of salt from the road is eating away at the underside of my car. In short, we are awash in the consequences of terrible decisions and all we want to do is continue indulging. Then something in my mind changed and I was struck by the notion that our nation needs recovery. Just as I require a radical revision in my world view in order to keep me from taking my next drink or drug, our culture needs a fresh perspective on our collective problems. Is such a thing possible? I have no idea. But the reminder that, if nothing else, real recovery is a viable option for me, allowed me to find balance. And the juxtaposition of the possibility of personal recovery with the entrenched problems of society--this centered me because it served as a reminder that the problems of the world are not my concern. My own well being must come first. Peace without must necessarily follow peace within. I recall vividly when, during college, I heard the Dalai Lama make this point. It seemed preposterous that the world should wait on each of us to clean house before we go to work for the greater good. Now, after so much pain and personal wreckage, it seems far less preposterous.

Now you're thinking with gas!

Interesting day on the job. Speaking of lessons from the last post not quite learned: I was running late and decided to call my somewhat high-strung second to last patient of the day to warn her that it would be another half hour before came by. Her name is not Linda, but I will call her Linda. Linda was fine with our tardiness, though she was distraught about something else. She had been without heat for three days and had "called everybody, including 311 (City of Chicago hot line) and no one will help me!" Now this is one of my favorite patients. Eighty-four years old and answers the phone with: "Praise the Lord!" She says it even before she says her name. So on my way over to her place, I called 311 myself and got a promise from some city operator to pass the claim on to the Department of Aging, who might at some point in the near future send someone over to assist her. No one could attend to it today because it is Casimir Pulaski Day in Illinois--state holiday. Now, I had assumed that the reason that no one would help Linda was that she had no money to pay a proper repairman. This wasn't quite true. When I finally sat down to visit with her, I discovered that she had been calling a repairman who was not getting back to her. However, when she showed me his number, it was next to a the penciled name, "Smookey." When I called the number myself, a voicemail picked up saying that this was Winston but that he had lost his phone and was not able to return calls at the moment. Aha. So she was averse to calling standard repairmen, but apparently not cut-rate neighborhood repairmen. Now, Linda is not an irrational woman. "I'm 84 years old and I did not get here by being stupid!" Indeed not. Though she did not want to go and stay with any of her grandchildren or great-grandchildren while this was all worked out, I could understand why. A young man breezed through the apartment while I was there and, despite Linda's obvious distress, simply replied: "Fine. Okay grandma." The whole place smelled slightly of gas. After another call, I did get ahold of someone on Smookey's or Winston's number who said that he would send a truck out there today. I was on my way out when I decided, perhaps with some hubris, that ought to at least have a look at the furnace. What I know about gas furnaces would fit nicely on a postage stamp, however I do know that wires should not be hanging loose. When I touched a red wire to it's complimentary lead, there was a satisfying arc of electricity followed by the sweet "wumpf!" of burners turning on. I grabbed some duct tape from upstairs, secured the wire in place, then explained to Linda what I had done in case the heat went out again later.

So is the lesson of this little chestnut:
1) Get the facts before you act.
2) You're a doctor; stick to medicine.
3) Don't call Smookey on Pulaski Day. He's not himself.

Bird Cage

Tomorrow morning I will make a run out to the suburbs to fetch a bird cage. A veterinarian friend of my sister will be waiting at her clinic to hand it over. The cage is for one of my patients, a lovely woman of 75 named Kate with a history of bleeding brain aneurysms who keeps a large bird in a small cage. The cage sits in her parlor window right beside the front door, so I see it every day when I walk in. There is barely enough room for it to open its wings. It has one narrow perch and stoops like an old man waiting for a bus. Whereas I have a bleeding heart for anything that draws breath, Kate has little empathy for caged things. I thought about asking her to part with it, but she loves it in her way. The bird is her company. From the piles of mail and personal papers in the parlor, she spends most of her time in there. The bird watches the window and she watches the bird. So rather than trying to find it a more hospitable home, I decided to make her home a bit more hospitable. Hopefully, Kate will accept my offering.

This brings to the fore how housecalls are different than typical doctor visits. I am privileged to so much more information about my patients than if we were meeting in a clinic or a hospital. I walk right into their world. I learn a tremendous amount in two minutes, very little of it medical. How organized is the environment? Are there great-grandchildren running around? How many cigarette butts are in the ashtray? Do they own a treadmill or exercise bike and is it doubling as a coat rack? Is the outer door of their apartment building bashed in? Can I walk right up to their inner apartment door? In one case, could I walk right into her apartment and then her bedroom when she failed to answer the bell? Are there family members drinking beer at 10am and watching The Price is Right? Is all the food in the refrigerator bad? Are there stacks and stacks of unopened incontinence supplies? The good news is that I can view my patients from a closer vantage and interact with them on a much more personal level. The bad news is that what I ought to do with this information, where my role starts and stops is easily blurred.

The bird cage is one example of the blurring of professional boundaries. Another is when I started visiting an accomplished photographer with emphysema who is now living in a warehouse, a real SoHo living space as he called it, that he is slowly converting to a proper living environment. It was drafty and dusty and cluttered with books, prints, developing equipment, and all manner of odds and ends, a very bad set-up for someone with very bad lungs. I started coming in on weekends to help drywall his bedroom. We became friends. But his expectations on my time kept escalating and eventually I had to back off. Now during visits, things can be a bit awkward. Early on in my practice, I took on a lot of responsibility for referring my patients into community support services, specialty care; I made a lot more phone calls to family members. I wrote a lot more letters. Now I find myself doing less. The Company supplies a modicum of support for extending the focus of care beyond the visit itself. There are coordinators who each carry about three physicians, but they are overwhelmed with handling very basic duties, like dealing with pharmacies and handling patient calls. Asking them to serve as social workers and community liaisons is unfair. I have brought my concerns to the founder and CEO. I petitioned for an employee who could serve as an expert on community support services, making sure vision impaired patients are hooked into Lighthouse For the Blind, or that families of patients with dementia are linked up with day programs that offer sliding scale fees. But he was uninterested.

For a recovering alcoholic and addict, accountability is extremely important. Many of us lived with very little of it for a long time. We have to unlearn the tendency to put our own convenience first and foremost and become accustomed to keeping our promises. A big part of that is realizing that we should not promise too much. As much as we may want to be heroes and save everyone, nothing is accomplished when we fail to show up. While others figure out that they still cannot count on us, we internalize the same message about ourselves, and the downward cycle continues. The key to success is starting small and slowly building. As much as I may want to fix all of my patients' problems, my time and ability are limited. I can find a bird cage. I can make a few calls. But I must be sure not to take on more than is reasonable.

Also important is that I try to bear in mind why I am choosing to do something. By bringing her a new bird cage, am I really helping Kate? Perhaps I am helping the bird, though I cannot know for certain what the bird wants. Mostly, I am addressing my own feeling of discomfort when I walk Kate's parlor. I should bear this in mind when I offer her my "gift."

More of the same?

As I mentioned in "Getting Started," the hiring office manager at The Company seemed completely non-plussed by my past. Their history of hiring addicts perhaps explains this. What is surprising is that they were so accepting of this particular foible when I was, in fact, replacing a drunk. And he was not a particularly well-hidden drunk. The doc who preceded me was a come to work drunk sort of drunk. He was a "that's not booze you are smelling, that's my cologne" type of drunk. He was big and loud and funny and charming, and could bluster his way through most obstacles. After a company party he was falling-down-loaded and had to be scooped into a car and sent home. At some point, someone had to have started complaining about him because the powers that be decided that he needed watching, so they began asking for his medical assistant, who was to become my medical assistant, to start reporting back on any suspect behavior in the field. I guess he had a lot to report on. Here are just a couple of the episodes he recounted to me: my predecessor (I'll call him Tyler) once, in a fit of anger, tossed a patient chart onto a porch roof then had to ask for a broom to knock it off. Tyler once made a housecall to a family member of a patient's homemaker from Catholic Charities. When he encountered a number of young men in the home, he at first became visibly nervous then started expounding on how the young men had to keep control of all their "little soldiers," apparently meaning their sperm. The man who told me this story made sure to tell me that he suspected that Tyler had a drinking problem. During my first few months, at least ten people--a security guards at a CHA high rise, patients, family members--after asking why Tyler left, went on to answer their own question by saying that they bet it was because he drank. There is a great lesson here. No matter how well we think we are keeping our dirty little secrets, almost invariably someone knows. It is only our own denial that allows us to continue on with impunity. But getting back to my original point, given all the havoc this man caused, it says a lot that The Company was willing to replace him with another alcoholic.

I could speculate that The Company differentiated between a drunk bolstered and solid in recovery and one who is still out there, and having knowledge and confidence in the power of 12 step work, knew that I was a much safer bet than Tyler. This would be the charitable view and I wish that I could assume it were true, but all of the evidence points elsewhere. They put up with Tyler's behavior for months before addressing it. And they did not address it by performing an intervention or referring him into treatment. They advertise until they are able to fill his post, then as soon as they have me, they push him out. In fact, on my first day of work Tyler also shows up because no one has yet bothered to tell him that he has been replaced. If they had told him before I made an appearance, they would have run the risk that I change my mind, leaving them with unseen patients and that many fewer billable visits. As I was walking out to the company car, I saw Tyler walking toward the building. The office manager who hired me, a rather imposing guy himself, intercepted Tyler and walked him away from me and around the block. Then I guess he gave him the axe, because I didn't see him again, at least not anywhere near The Company. I took over all of his patients, none of whom had been warned that he was leaving, of course. One month he was there, the next he wasn't. Though this was probably nothing new. Looking back through some of the charts, among the patients who had been using The Company for a while, Tyler was only one in a line of docs who came for a few months, to perhaps a year, year and a half, then were replaced.

So the transition was abrupt. All the more so because I hadn't made a housecall since my rather progressive residency days, and then only a few. Luckily, the medical assistant, I'll call him Lenny, knew all of the patients. He helped break the ice and provided a touch of familiarity to what would have otherwise been a very awkward meeting. More on that in the next entry.

150,000,000 and one

Invited by a good friend, I wandered into a digital media seminar just in time to watch the speaker field questions from the audience. Someone asked about her perceived declining quality in written expression; how we are losing any sort of attention paid to grammar, spelling, etc. She asked the speaker if he thought that writing was likely to improve. In fact, he responded, in the short term he expects it to get worse. Right now we are inundated with volume. Volume without standards. But eventually the "cream will rise." Eventually being in "about two years." Though the claim sounded a bit arbitrary to me, what caught me off guard was the degree of volume, if one can use that expression. Anyway, the vastness of the volume. He chose to cite the number of blogs currently in existence. If he is to be believed, there are 150 million. That is roughly one for every 40 people on earth, and that includes everybody. People without electricity or running water--they are included in the 40. How is this possible?! Who reads all the entries? For the vast majority, the answer must be nobody. Indeed, at this point the only follower of my page is a test case created by me. It's an strange thing, to type out ones thoughts onto the internet only to have no one to read them. Perhaps most funny is that because of the content of the blog might be considered a bit libelous, it couldn't tolerate much fame at present. At the very least, I would be out a job and maybe facing a lawsuit.

I might be a bit demoralized were I not more clear in my goals. I am aware that the odds of a substantial online following are slim. I don't need a big readership. Perhaps I don't need any readership. I need the possibility of a few readers in order to motivate me to continue writing. If I need an audience or a potential audience in order to do something I would not do for myself is that ego? And where do I ultimately think this is all going? I would be lying if I wrote that I held out no hope that there wasn't a book in this. Or at the very least, that I might not have a book in me, with these fledgling and well-hidden pages just a small start.

Getting Started

My biggest fear when applying for work, and this seems to be the case for just about everyone in recovery, was how my potential employer would react when he found out that I am an addict. I imagined a disappointed, pained expression followed by a stuttering attempt elicit details about my use, and finally an awkward silence. Then the door. So I did what a lot of addicts do: I kept my past secret until I was asked a direct question. In my case, this question came in the form of an item on a malpractice insurance questionnaire. "Have you ever had a problem with alcohol or drug addiction or been enrolled in a formal program of treatment or addiction?" or something like that. So I let my written response do the heavy lifting of disclosure. I wrote that I had attended a formal treatment program, was now in aftercare, was being randomly drug tested by a professional monitoring organization, etc, etc. A few days later, the office manager and I sat down together. He had my answers in front of him, so I made some breezy statement, something like: "So, you read that I am in recovery?" And he said something like: "Oh...yeah, yeah. I saw that. That's okay." And that was it! All that anxiety and my addiction barely seemed to register as a blip on his radar. I would soon discover why.

Before I get into that, a little bit about what I do. I was trained as a general internist, which means a primary care doctor for adults. The practice where I now work, which for the sake of anonymity I will call The Company, employs physicians to visit patients in their homes. Most of our patients are elderly and all are covered by Medicare. The Company supplies the car, the patients, assembles and stores the charts, and does the billing. Each morning the physicians arrive, review the schedule and the route, prime the charts, and head out. We each even have a medical assistant to drive us around, take vitals, prick fingers, and draw blood when necessary. In a way, the set-up is pretty cush. On the other hand, it can feel like we are just playing a prescribed roll, and in a way we are. It can be pretty monotonous. And having supplied none of the capital, we have no say in how the place is run.

As I mentioned in the previous post, The Company is growing and growing fast. Chicago is the largest though only one of four branches. There are plans for at least six more. Our branch employs 10 doctors, some full time and some part time. Because the pay is so low, it can be hard to recruit. When I took the job, I assumed that I was the only one with a checkered past working there. I thought that I was lucky to have been hired. As it turns out, virtually every doctor at The Company has something of a past. Of the ten now working, there are three (including me) with a history of addiction, one surgeon who lost a big law suit, another who is in the process of being sued and is actively avoiding a summons (more on that later), one who had a sexual relationship with one of his patients, and another surgeon who has advancing Parkinson's and can no longer operate. Another physician recently left who was suspended for fondling one of his patients. It's an interesting crew.

Now I am all for second chances; for selfish reasons, but also because I think that forgiveness makes the world a much more tolerable place to live. However, I think that if you make it a policy to employ people in positions of high responsibility who have made mistakes in the past, you should put in place some system of oversight, or at the very least take advantage of oversight that already exists. When there was a question as to whether one of the formerly addicted physicians was using again, I sat down to speak with the office manager about what should be done. This man certainly did not seek out my advice. Apparently, the doc in question was nodding off during patient interviews and otherwise acting strangely and the whole office was talking about it. The issue seemed pretty straight-forward to me: confront him about your concerns; demand a urine tox immediately, then contact the professional monitoring organization and see how he has been doing. As it turned out, neither the office manager nor the owner of The Company had any idea that such an organization existed. And rather than getting a urine drop and a written consent for release of information from the monitors, they pulled my medical assistant, a rather burly and assertive sort, to "keep an eye" on the doc in question. What it must have come down do is that The Company did not want to risk any sort of legal culpability that knowledge of his addiction might bring and they also did not want to contend with the lost income that firing him would entail.

So, I can tell that I am coming off as bitter. Really, I shouldn't be bitter or harbor resentments. Nothing is more toxic to recovery. Plus I have a job. It may not be perfect, but it keeps me busy and out of trouble for the most part. And as long as I endeavor to take care of my patients as best as I can, I am holding up my end of things, which is all that any of us can do. And not all of the stories that come out of The Company are anger-provoking. A lot of them are very funny. And not funny in a "boy, that's really terrible, how come I can't help but laugh" sort of funny. But genuinely silly and enjoyable to reflect on. I will try to get to some of those soon.

Step 1

In recovery, the first step is to admit powerlessness; powerlessness over alcohol, drugs, sex, gambling, whatever your hang-up may be. You give over any expectation of managing it on your own. I won't go into the sordid story of how I came to be a physician in recovery, at least not in this installment. The synopsis is I gave up [read: I was forced out of] a rather prestigious and influential position and had to go looking for something else. Few are the health care organizations that will consider hiring a doctor early on in his or her recovery, and perhaps rightly so. You may get a wonderful care-giver with an unusual sense of humility and a renewed vitality that only a fresh start can provide. Or you may get a horrific relapse with all the consequent debauchery. I fully expected to have work outside of medicine until I put together an extended period of sober time. Surprisingly, I found a job right off. The company was growing fast and glad to have me. The pay was quite a bit less than average, to which I attributed the position's availability. I soon learned that low pay is just the tip of the ice berg. As I said, step one is all about powerlessness. Letting go of your ego and accepting your place. As painful as it sometimes is, I have accepted that this is where I need to be, at least for the moment. Indeed, this is where I was meant to be. Fortunately, my new job is ripe with fascinating stories. Did I say fascinating: I meant incredible. Hilarious! Tragic. The stuff of truly interesting reading, if I can manage to convey events in a form that does them justice. That is what this blog is for. It's a forum for getting the stories out. It is also, I hope, a way for me to put my life, and this turn it has taken, into perspective. I truly can't wait to see what follows. I hope that you come to feel the same.