What to Do, When There is Nothing to Do

It was nearly midnight when the call came. Spencer was in pain and the hospice nurse was over an hour away. Could I come and give him a dose of morphine? They knew the answer before the question was asked. Of course I would come. I had made that promise the moment Spencer enrolled in hospice with incurable brain cancer. I could not save him, but I knew I could keep him from suffering.

I rolled out of bed, threw on some clothes and headed out the door. My heart was heavy as I drove the few miles to Spencer’s house. It was a rainy night, which seemed strangely appropriate. I pulled into the driveway, exited my car and walked, slowly, to the door. I was somberly welcomed into the home, the wave of a hand directing me to where Spencer lay in bed.

I had not seem him in a while, and was shaken by his appearance. It had been a year since the day the neurosurgeon had called me with the diagnosis of inoperable brain cancer. They were going to do all they could to prolong his life, but another year was all they could hope for. “All they could do” included high dose steroids, which caused Spencer to gain considerable weight. His face was so puffy he was nearly unrecognizable. He was no longer able to speak and I could not tell from his eyes if he was even able to recognize me.

Quietly I reached for the vial of morphine on the table to his side. I drew up the dose into a syringe, rolled down the top of his pants to access his muscle, and gave him the injection. I set the empty syringe down on the table and sat, looking at him, wondering what to do or say. I fought back tears. I lost that battle and teary-eyed, took his hand. I asked if I could say a prayer. I asked God for comfort and peace, said, “amen”, then leaned over and kissed him on the forehead. “I love you Spencer,” I said, and quietly left. That was the last I saw him. He died a few days later.

He was 5 years old.

I thought of Spencer yesterday as I was driving away from the home of another hospice patient, a woman just 2 weeks older than my wife who was dying from uterine cancer. Although the original diagnosis was made years ago, until February of this year she had considered herself cured, attending to her life with no thought of the cancer growing within. It was then that she came into the office for two red lumps that had appeared on her abdomen. They had grown rapidly and were quite tender. She thought they were skin abscesses. They weren’t. A CT scan brought the worst possible news. They were metastases. The cancer was back, and it was every where. In addition to the lumps on her skin it filled 90% of the space where her liver should have been. The hope the initial oncologist gave, of perhaps another year of life, proved to be false and a second opinion from the City of Hope quickly took it away. There was nothing anyone could do. We enrolled her in hospice, committed to making sure her few remaining days would not be days of suffering. That was just a few weeks ago.

Her husband called me late Saturday morning to tell me she was emotionally done, too tired to fight any longer. She wanted to go to sleep and not wake up. He wondered if there was anything I could do. I was at my son’s house only 5 minutes away from her home when I got the call. Something in the tone of his voice told me I needed to be there. I left my son’s and went straight to her home.

Her husband met at the door, his gesture toward his wife similar to the one Spencer’s mom had given me so many years ago. She was in a hospital bed near the door. An empty chair was pulled close to her, near enough to hold her hand or caress her face. It was her husband’s chair. I sat down and looked at her.

She was clearly uncomfortable. Her speech was clear but slow, every few words followed by a long pause, as if she was gathering the strength to continue each sentence. Her eyes were tinged with yellow, a sign that her liver had succumbed to the cancer and begun to fail. I knew she did not have much time left, days at the most.

With her husband listening on I developed a plan. I put in a call to the hospice nurse instructing her to begin giving morphine around the clock, a dose every few hours. I added a sedative to help her rest. She was not going to suffer, not if I could help it. I finished my explanation, took her hand and asked if I could pray for her.

She and her husband responded in unison, “Please!” Unsure what to say, I prayed as I did with Spencer, asking God to give her comfort and peace. I asked God to welcome her into the home which He had prepared for her. There were six wet eyes as I said, “Amen.” I let myself out, wondering if I would ever see her again.

I won’t. The hospice agency called me just 5 hours later. She was gone.

Both patients remind me of a lesson I learned a long time ago. Even when there is “nothing” more I can do, there is often still something I can do. I can love, I can give comfort, and I can pray. I can shed some tears, hug my wife, and thank God for the gift of life with which I am still blessed. And I can press on, willing to accept the pain and sorrow, committed to sit at the next bedside, take the next hand, and say the next prayer, knowing that as a Family Doctor this is my calling.

Bart

In Assessing Patients, There’s No Place Like Home

“Why would he want to live like this?”

It was his first visit to the office, yet I was taken aback at the extent of his suffering. Wheelchair bound after a stroke, unable to speak or walk, it seemed to me his was miserable existence. Even worse he had a chronic bone infection that could not be cured, a continually seeping wound that caused persistent pain. And then there were the bedsores, I wondered why he hadn’t yet given up.

In spite of this his wife assured me that he had a good quality of life. She told me that he enjoyed his kids and grandkids and took great joy in his time with them. I wondered how this could be true. At that visit (and the several that followed) he seemed subdued, almost depressed. At each visit his interaction with me was minimal, only an occasional nod or mouthed word. I never saw a smile or heard a laugh. My heart broke for him.

A year later I made a visit to his home. It was difficult for his wife to bring him to the office and I had offered to come to the home to check on a wound for which he was receiving treatment. It was the least I could do.

His wife met me at the door and escorted me down the hall to their bedroom. He was propped up in bed, leaning against several pillows. He looked up when I entered the room with a response that was shocking to me. To my great surprise, a huge smile spread across his face and he enthusiastically extended his hand in greeting. He was happy to see me! An involuntary smile came over my face as I took his and shook it. I told him it was good to see him, and it truly was.

As I shook his hand I took a moment to survey my surroundings. On the walls of his room I were many framed photographs of him in dune buggies and go karts. He was a car nut! Every vehicle pictured was one he had built himself. I had no idea of the man he had once been. It was clear that he had lived a very active life. I commented on the pictures and asked a question about his interest. My surprise increased when he replied. he gave a one word answer but the word he spoke was clear and appropriate. I cracked a joke, and his laugh was full and genuine, his smile infectious..

His wife told me the stories behind some of the photos, at times turning to him to verify she was getting each tale right.. With nods and occasional words, he agreed with most of her descriptions and made it clear when he didn’t. As she talked and he responded I realized something- he was truly happy. He was able to communicate with the woman he loved, and the family he adored. He participated in the conversation, and even made me laugh. His life was better than I could ever have imagined.

It was a humbling experience for me. My initial impressions and conclusions about his life and functional abilities had been totally wrong. The judgments I had made in the office, arrogantly made over the course of brief interactions, were completely inaccurate. I realized that if I had not visited his home I would never have known him or understood him.

I left his home a different doctor than was when I entered it. I entered certain of my ability to make assessments regarding the quality of a patient’s life. I left realizing my foolishness, newly aware of the importance of seeing a patient’s quality of life first hand before reaching conclusions. It was a visit I will never forget.

There really is no place like home.

• Bart

A Case of Mistaken Identity

I receive several letters and notes from specialists every day. Most are dry summaries of patient visits, many provide no helpful information, and some are illegible. Almost all of them are forgettable, but  letter I received a few months ago from a local gastrointestinal (GI) specialist is one to remember.

The note was an angry rant about a mutual patient. In great detail the specialist described the actions of my patient, behavior that so offended the GI doctor that he had thrown him out of his practice. It was clear from the letter the the doctor expected me to agree with him about the unreasonableness of our patient and that his dismissal was warranted.

Except it wasn’t warranted at all.

The patient had undergone a colonoscopy and a few weeks later called the GI doctor’s office asking for results. The physician had his staff tell the patient to come in to have his questions answered. The patient did not see the need to take time off of work and pay a co-pay to be given information that could be easily given over the phone or in a note. He repeated to the staff member his reasoning and his desire to be given his results. The doctor adamantly refused. The doctor’s logic, explained in the letter I received was, “It takes time to give results, and I deserve to be paid for my time!”

While I understand the desire for physicians to be paid for the work they do, this physician’s greed caught me off guard. He absolutely refused to tell the patient his test results! His solution to the impasse was even more amazing. He told the patient to call me so I could give the results to him. (Apparently he was not at all concerned about me gettin paid for my time!)

I opened the patient’s chart and searched for the colonoscopy results. They were perfectly normal. The patient’s question was answerable in only 8 words. “Your colonoscopy was normal. Repeat in 10 years.” Even if the specialist had spoken r-e-a-l-l-y s-l-o-w-l-y, the answer would have taken less than 10 seconds. I tested this theory by picking up the phone and calling the patient myself to tell him the results. It took less than 10 seconds. Unfortunately, listening to him complain about the rudeness and arrogance of the doctor took a lot longer. 

I hung up the phone and thought about the specialist. I wondered how he came to be so disrespectful of patients. I pondered how he could be so blind to his arrogance and how he came to be so selfish and uncaring. It seemed to me that his self-worth and self-esteem were completely wrapped up in being financially successful, so much so that patients had become nothing more than dollar signs. It seemed that being paid for the care he provided was more important than caring. His identity was so connected to money that he could not “give away” even a moment of his time.

The doctor is an extreme example of a problem in society today, the problem of misplaced identity. Too many people measure themselves according to their finances. When we define ourselves according to our finances, when we seek personal worth in material things, we will never have enough and we will never be satisfied. 

I feel sorry for the doctor. I awake each day to the very real possibility of making a difference in the life of someone who is hurting. When we recognize these opportunities to love and serve others and seize them we find a joy money cannot buy. When we find our identity in God and in loving his children, we find peace and contentment.

Bart

Christian Doctor, Atheist Doctor

“You are a man of strong faith aren’t you?” It was not the first question I expected from my doctor but it was not totally unexpected. The conversation at our previous visit had been lengthy and he had asked many personal questions. As personal questions directed at me often end up with faith as part of the answer his question was rhetorical.

His response to my brief answer in the affirmative caught me off guard. “I am a committed atheist,” he said with a smile on his face. His tone was not confrontational, it was simply a declaration of fact, as if he was saying, “You are who you are and I am who I am.”

I decided to expand on my answer so he could understand the important role faith played in my life. I told him that I frequently taught the bible and spoke in church, and that I had led a men’s Bible study group that morning before coming in for a visit. I then added, “While my faith is strong, it is more intellectual than emotional. I have a passionate faith, but not an emotional one. I don’t feel particularly close to God and I am not the type of person who “hears” God speak to me. My faith is more reason based.”

My use of the word reason triggered a memory for him. He told me that he had at one time been a student in a Catholic seminary studying to be a monk. During the course of his studies he began to have serious questions about his faith. When his doubts reached a crisis level he sought out the counsel of the priest who was his mentor. The priest’s response to his doubts dealt his faith a mortal blow.

“Faith,” said his mentor, “requires you to set aside reason.”

I was appalled at those words and told him so. “I cannot disagree with him more! That is completely false. If faith cannot stand up to reason, what is it worth?”

I shared with him my belief that the truth was in direct opposition to the view espoused by his teacher. Reason is at the heart of Christian faith. I told him of the Christian apologist, Nancy Pearcy, who makes the bold claim that Christianity is the only worldview that is “Total Truth”, the only belief system that viably explains all of the observable world from the origin and complexity of life as well to the nature of humanity and the presence of evil.

“But there are still questions that faith cannot answer,” he replied.

“Of course there are, but I have reached the conclusion that while God has not given me all of the answers that I want, he has given me all of the answers that I need in order to have faith.” He nodded in understanding and I added, “Your worldview requires faith as well. Perhaps even more than mine. There are questions that as an atheist you cannot answer.”

“Absolutely,” he replied, “I have no idea of how quantum physics works!”

We shared a laugh. And the visit went on.

When I left his office I reflected back on our conversation with a sense of amazement. Nothing had been resolved, no one had been convinced or persuaded, but something important had happened. Our understanding of one another had grown as had our respect for one another. I found myself wishing that more disagreements could be discussed this way.

Bart

My First 25 Years in Practice

25 years ago today, I started my career in private practice. My notes were written in paper charts, I carried a pager but not a cell phone, and I had a head full of hair. Appointments were written in a book, controlled prescriptions were written on duplicate pads, and antibiotics were handed out like candy. HMO medicine was new and so was the group I joined. It was an exciting time.

My practice had a very wide scope back then. I had an active hospital practice and managed the inpatient care of both children and adults at Hoag hospital. I managed septic patients in the ICU, patients with diabetes out of control and with heart failure, often without consulting specialists. I took care of children hospitalized with bronchiolitis, dehydration and asthma attacks. I felt there was nothing that I could not do. One particular patient utilized all of my skills, a young pregnant woman with viral meningitis and pre-term labor. I performed the spinal tap myself, gave medications to stop labor, and managed her inpatient care without consulting anyone. Those heady days are long gone!

Hospital patients are much sicker nowadays. Many of the conditions that previously resulted in hospital admissions are now managed as outpatients. Skin infections, kidney infections and even new onset atrial fibrillation, conditions once thought to be serious, now do not even merit a visit to the emergency room. Those patients sick enough to be hospitalized are now beyond my knowledge and expertise.

For 12 of my early years in practice I provided maternity care and delivered babies. I was perpetually on call, only unavailable when I was out of town. It was demanding and challenging but I loved it. Welcoming new life into the world was one of my great joys, and it is what I miss most about those days. I delivered my last baby in 2007.

My office practice has changed as well. The era of “one problem per visit” is long past. Every visit to my office is now an opportunity to address multiple health concerns. Patients who come in for respiratory illnesses may find themselves leaving with orders for cancer screenings and routine blood work. Other routine visits evolve into impromptu counseling sessions. The result is fewer patient visits per day, but more care per visit. Where once I saw as many as 35 patients a day, my Physician Assistant and I seldom see that many patients between us.

The business of medicine had changed for me as well. In 1994 I was part of a multi-specialty group of over 30 doctors. Neurologists, cardiologists, obstetricians, internists, surgeons and family doctors, we were all in the same building with shared management. The business styles of the doctors proved to be as diverse as our specialties, and there was frequent conflict. The three physicians with whom I shared a suite joined together with me to leave and found our own Family Practice, Beach Family Doctors, I’m 1995. I managed that practice for 7 years.

By 2002 the practice had grown to 5 doctors and I had grown weary of managing it. In February of that year I went on my own, moving into a small suite across the hall from my former partners. Ours was an amicable parting, and we remain friends to this day.

Two years later, when driving back to my office one afternoon I passed a small house on Beach Boulevard. The “For Sale” sign caught my eye and two days later I was standing in the doorway of the home, imagining where I could put up and tear down walls to convert it into a medical office. Escrow closed in February 2004 and I moved into the office November 1st. It has been my medical home ever since.

Much has changed in the last 25 years but the most important thing hasn’t. I wake up every day knowing I will have the opportunity to make a difference in the lives of the patients who come to see me. This knowledge still brings me joy, and it is that joy that will sustain me in the years to come.

Bart

A special thanks to the many patients who have entrusted me with their health over the years. It has been a blessing, a privilege and an honor.