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.