Immortality, wednesday

My first appointment in clinic is a woman I’ve never met before with stage IIIC ovarian cancer, a terminal diagnosis. She’s had numerous operations in the preceding seven months for diagnosis and staging of her cancer and resolution of her repeated intestinal obstructions. She is nauseous and had vomited that morning, but as she sits before me, with an ostomy pouch on her left side, we can hear her bowels move. She does not apologize and I do not flinch as her bag fills: We’re both happy for the downward flow.

We talk for a while, and I review her chart. I’m not really sure why she’s seeing me. She’s seeing her Gyn/Onc doctor every other week for monitoring her chemotherapy. So her medical needs were being cared for, except for her high blood pressure, which isn’t much of an issue in someone with a terminal diagnosis.

‘What can I do for you today?’ I ask, as I can see no obvious reason for her visit to me.

She asks for refills on her blood pressure meds. I see that her blood pressure is too high this morning, but the risks of side effects from new medications outweigh any benefit of blood pressure control during her brief lifespan. I write the scripts exactly as she had received them previously. Then sit back in my chair and look at her.

I’m not sure she understands the nature of her diagnosis or that the chemotherapy she’s receiving is only palliative.

‘What,’ I ask, ‘is the goal of your chemotherapy?’

‘To make me feel better, I think.’

‘Okay,’ I say. ‘So you understand that the cancer is not curable? That they are giving you the chemo with the hopes that it will improve how you feel in the time you have left and maybe extend that time by a bit.’

‘Yes,’ she says, and then silence, staring at me, mouth closed. I’m silent too, thinking about how to proceed.

‘Ma’am, has your oncologist or anyone discussed end-of-life issues with you?’

‘No,’ she says, and silence again.

‘Well, I’m just meeting you, so I don’t know that we need to have a full discussion today, but one thing I try to discuss with my patients—all of them really, but it’s especially incumbent upon me when they have cancer or some other life threatening condition—is what you want to have happen when your heart stops beating—when you die. Now, it’s going to happen to all of us, my heart and yours, and the default—the obligation—for us at the hospital and for fire-rescue is to try and restart your heart.’

I pause. She says nothing.

‘When we try to restart your heart, it isn’t a gentle massage. We’ll break a lot of your ribs in the process. Then we’ll shock the heart to try and restart it: It’s a lot of electricity and it burns the skin. The goal of all that is to get the heart beating so that we can put a tube down into the lungs and start the ventilator, start the life support machines. If someone does not want to be on life support, all the other things are pointless. For someone otherwise healthy, they may only be on life support for a day or two. But for someone like you, someone whose heart has stopped as part of a terminal illness, the life support will likely continue until your other organs start to fail.’

I pause again. She continues to stare quietly at me, not saying anything.

‘The other thing that I feel we should talk about, is that there is going to come a point when the chemotherapy is going to be stopped, when it won’t be effective at prolonging your life or helping your pain anymore. When that time comes, and maybe before it, I think we may want to get you involved with hospice. Hospice is an organization that specializes in controlling your pain and making you comfortable. They help you and your family deal with everything that occurs when you are dying.’

‘I’m familiar with hospice,’ she says, noncommittally, her silence finally broken for a moment, but then it returns.

‘These are not decisions that need to be made today,’ I said, ‘you can discuss them with your family or oncologist, or you can just think on them for a while. I don’t have any reason to think any of this is eminent. But when the time comes, I don’t want you to make a rushed decision. I think it would be good for you to have some time to ruminate on these things.’

Still silence.

‘Do you have any questions for me?’ I ask.

A moment more of silence, then she says, ‘How old are you?’

‘Ma’am?’

‘You talk like a really old doctor, but you don’t look old,’ she says. ‘No one else has been willing to talk to me about this.’


And so it begins…

Immortality, encroached

Having come to appreciate the nature of my mortality, I was delighted that, now a physician, I would be immune from the ravages of death and disease. A sort of professional courtesy, if you will.

As physicians, we walk among the infirm and dying. We joke while bringing a stopped heart back to its regularly scheduled beating. We gossip while draining the fluid from around a lung, allowing it to reinflate. The accoutrements of our profession are pathogens, toxins, and cancers. If we were not immune, we’d surely parish.

Like Vampires, we watch legions of men die before us and around us and we go on, untouched.

We tease one other when we test positive for tuberculosis and laugh while refusing treatment. Our youth and immune system allow us that luxury, and we tolerate the yearly chest x-ray follow-ups as a token of our humility to infection control.

But in our hearts, we know we’re immune to the things that kill mortal men.

---

So you cannot imagine my confusion when my colleague and friend was diagnosed with endometrial carcinoma. A straight forward enough cancer, a simple surgery to remove the offending organ, but still—one of our own had been stricken.

Whenever anyone takes ill, people are struck with a certain confusion. There is the default searching for a criminality in those that fall ill: an attempt to explain their disease because of a vice or—at minimum—a payback for some Karmic insult.

When it’s a group of doctors, we make our attempt valiantly and with a great deal of authority. Unfortunately, we also have to admit when the offended (offending?) party just had a bad roll of the dice. When the person is an especially good person, noble and kind, well, it just turns your stomach a little.

It turns your stomach, mostly, because it makes it difficult for you to castigate them; to exile them for bringing the stench of death into the sanctity of the doctors’ lounge; of removing the necessary illusion between us and them.

We visit them at bedside and joke, pretending everything is normal, because at the bedside, everything almost is. For us anyway. The proper order is restored: We are standing by the bed, looking down at the patient lying there. The patient used to be one of us, but is now an object to us. An object to treat and—hopefully—to save.

When the object tries to become too familiar, we laugh uncomfortably and make our exit—making subtly certain that we have made new distinctions, remapped the lines that separate them from us.


And we regain our immunity.

Immortality, denied

I came to fully appreciate the inevitability of my own death when I was 22 in Paris, having just completed The Book of Laughter and Forgetting by Milan Kundera.

All of us know we’re going to die. Everyone knows everything that starts must end. We know the circle of life is really a line segment. But each of us has tricks—both intellectual and emotional—that allow us to pretend that none of this is actually the case.

If we do contemplate our own demise, we immediately shift the focus onto what will live on after us: our children, our stories, our works, our foundation. In sum: our legacy.

And the promise of an afterlife is so very sweet. So very, very tempting. An easy out—as it were—but logistical hogwash. And unnecessary for anything. We want to live forever, that’s reasonable. But we have no need for eternity, and many reasons to limit our lives to discrete quantities.

I remember the raw anger and frustration I felt that summer, dealing with the inevitability of ceasing to exist. Of understanding that I would one day be in the ground, not thinking, not dreaming. Every Parisian corner I turned, I saw the work of men and women who were dead—who had been dead for centuries. Not only the works that hung on the walls of museums, but the brick work of the bridges, the fencing around the gardens, everything around me was built by dead people.

The quick despondency I fell into was the childish frustration of a seven year-old boy who was denied what he had been promised for Christmas. I had been promised the new Shogun Robot, wings and a halo, and singing songs with Jesus on fluffy white clouds for all eternity. I wasn’t going to get any of it, and I was pissed off.

As I was starting to grasp some acceptance of this, my family had dinner near the Pompidou. The Centre Pompidou was the one building that I found hopeful in Paris. In a city dedicated to the dead, it seemed the one building that looked forward, that welcomed the coming generations.

We strolled past it on the way back from dinner. About a half block away, as we approached the sculpture garden, a crowd started to gather. We thought there might be a street performer, but when we got close we saw a guard trying to cover the torso of a woman who had jumped from the Centre’s observation deck into the sculpture garden.

She was wearing tight, fashionable blue jeans and red stiletto shoes. She had dressed up for her own suicide.

She had sqeezed into those jeans, fastened the straps of those heels, climbed her way up to the observation deck in her fabulous heels, looked out over Paris, and jumped into the sculpture garden.


What idiocy.

In the fury of not getting the gift she wanted, she smashed the gift she had.

Next Week: Immortality

It's easier to be friends than lovers, and you shouldn’t try to mix the two

‘I don’t get,’ I said, ‘how you ask me to fuck you and then make me the asshole the next morning.’

‘I was weak.’

‘Yeah, well, I was drunk,’ I said, ‘and I’d think you’d have found the strength to say no by the third or forth time. It wasn’t like I tied your wrists to the bed rail.’

‘Yeah, you did.’

‘Okay,’ I admitted, the tension broken for a moment, ‘but only once. And I wasn’t the one that took off your clothes while I was trying to fall asleep.’

In between, glory, dreaming of—but sometimes just—underneath

Of course, maybe it’s generous of me to assume such things are my own failings. And maybe today I'm not feeling as generous.

This is an audio post. You can stream it or download it.

A Bridge Too Far

In 1987 my girlfriend loved, in the way that all girlfriends in 1987 loved, Peter Gabriel’s In Your Eyes.

And I strived, like all the boyfriends in 1987 strived, to be the master of the mix tape.

Mix tapes were an extension of one’s personality. They could be soothing, cloying, obstinate, humorous, aloof. Messages were constantly sent, hopefully pictographically rather than overtly, such as Weezer’s You’re My Best Friend.

When I mixed tapes, I tried to never give anyone precisely what they wanted. Instead I gave them that and then tried to gauge what they knew they are capable of and showed them they could go one step further. Including something more than was bargained for.

So when I made the tape, I put In Your Eyes between the Psychedelic Furs’ Into You Like a Train and Prince’s Scarlet Pussy. When she listened to it, she told me it made her feel like taking a bath.

‘A warm, bubble bath with incense and candles?’ I asked.

‘No,’ she said. ‘It makes me feel dirty, like I’m unclean.’


This was a time I misgauged both what someone was capable of and what they imagined me to be. But it was also, admittedly, an extension of my personality. I’ve tried to gravitate around people who push me beyond what I expect of myself and it’s served me well. Though it constantly makes me feel inadequate, I enjoy the challenge of digging out those inadequacies. And like Jesus, I do unto others.

This makes me, admittedly, exhausting to be around.

Every major relationship I’ve had, there has been at least one late-night, after-party, post-coital, cooing where I was asked, ‘What am I going to do with you?’


Apparently the answer turned out to be: Send me to med school.


But I am still getting the question, so it was not a complete answer.

Confidential to SW

The Albanian is back, and it appears that the NGLTF owes me another toaster.

Uncynical Wednesdays: The Truth about Doctors

and everyone else as well.

The Teaches of Peaches

In my clinic this morning, I saw a patient who usually argues with me about her care, arguing that my approach was wrong, no matter what problem she had.

This isn’t the typical, ‘Is there some way I can take fewer/cheaper medications?’ or ‘How important is this test/medication?’ It’s complaining about the approach to the problem. If I recommend a test, she wants therapy without any workup at all. If I suggest a therapy, she wants a battery of tests before taking so much as an aspirin.

She approached her health care the way persnickety people approach a menu. ‘I want the Cobb salad, but with no lettuce, and a double helping of ACE inhibitors, no x-rays, but I’d like a pulmonology referral and an MRI. And I want the dressing on the side.’ It’s tricky explaining to a patient why the treatment plan they came up with from reading the internet is inappropriate. It’s often like explaining to a teenager why they can’t have a flame thrower.

This woman was fairly sick when I met her, uncontrolled diabetes and high blood pressure as well as a few other miscellaneous unresolved problems. (Her last physician allowed her to dictate the treatment plan. Which is, admittedly, much easier than trying to actually control her illnesses)

Over the past year and a half, we made progress on her problems, even she admitted that. But every time I saw her, she would give me these exasperated sighs to let me know she thought of me as an incompetent fool who was simply a tool to get to her prescription drugs.

Today, even though I was over an hour late for her appointment, she was peaches with me, smiling and agreeing with everything I suggested.

I couldn’t figure out why things were going so smoothly, but at the end of the visit she explained the difference. She had been in the ED two months previously.

‘They asked me if I had some illness and I told them that I didn’t know, complaining that my doctor had never tested me for it. They asked me who my physician was. When I gave them your name, they chastised me. They said I had a good physician and that I was lucky to have you.’

I wasn’t sure what I was happier about, the compliment or the lack of argument.

A Perfect Week

I’m putting on my boxers and jeans, first one leg, then the other, and I feel a hand caress my back and hear the words ‘you’re perfect.’

‘No,’ I say, fastening my jeans and throwing on my tee. ‘I’m not.’

‘Well, you’re perfect for me.’

I put on my shoes, grab my keys and head for the door, saying, ‘give it a week.’

Cut

About two years ago, I got off a plane from New York and made a phone call.

‘I’ve been a bad boy,’ I said when the phone was picked up.

‘What’s that supposed to mean?’

“Just that,’ I said. ‘I was a bad boy in New York.’

‘Are you telling me you cheated on me?’

‘I fooled around a little,’ I said, thinking of the couple of ED docs from Lexington, Kentucky I had met at KGB bar.

‘You get off the plane and call me with this? You don’t even say hello or anything. Just that you cheated on me?’

[Silence, then I speak]

‘It’d be easier to say I Love You than Yours Sincerely.’

‘Don’t try and quote Costello at me. I recognize it. It’s transparent and not very clever.’

It’s then I realize exactly how stupid I’ve been and say the painfully inevitable, stupid comment.

‘At least I’m being honest and upfront. At least I’m not lying about it.’

‘Erik, you can’t get extra-credit when you’re cheating.’

Just Call Me the Love Doctor

Many of the emails I receive are from people asking romantic advice. Last week, I received this one:

‘Dear Doctor Erik’ writes Joe from Duluth, Minnesota, ‘Can you give me some tips for a first date. I can get dates, but they never want to go out with me again. What am I doing wrong?’

For Joe, in Duluth, here are five simple tips for a first date that you can print out and save in your wallet:

1. If you and your date might return to your place for a nightcap, make sure there are not used condoms visible in the waste basket.

2. Everyone likes a compliment as well as reassurances about weaknesses. Try to reassure people by commenting on their best feature, such as: ‘You have beautiful eyes; they really draw attention away from your nose.’ Or ‘You are so adventurous. Most people wouldn’t have the courage to wear that.’

3. Some people consider tardiness rude. Try to show up within an hour of the time you agreed to meet.

4. Don’t control the whole evening. Give options and choices. ‘Would you prefer going bowling or my buddy Tony’s poker game?’

5. If you get bored, I’ve learned it’s considered rude to say so. It’s better to say the Haitian food didn’t agree with you and you have to get home right away. You can drive to a pick-up bar after you drop your date off.

Uncynical Wednesdays:

So the reporter is telling me about how people react when they recognize him.

‘At the gym,’ he says, ‘no one talks to one another and I didn’t think anyone recognized me. But when I was in the shower, this guy says, “aren’t you that guy from tv?” and when I say yeah, three other showering men say that they thought that I looked familiar. Then the first guy says, “You look a lot bigger on television,” and everyone agrees with him. And I’m trying to rinse off and get my naked ass out of there.’

This, to me, is a great story. It’s hard to dislike someone who can tell a story like that.

And I don’t dislike him. He’s personable and nice and everything you want from a performer. As he says, he knows his place. His job is to smile and read and make nicey-nicey with the other people on screen.

I just wish they didn’t call it the News.


Growing up, we used to get both the morning and afternoon papers. When Gannett bought our local newspaper, we supplemented our reading with The Christian Science Monitor. When I moved back to Miami as an adult, I received The Miami Herald on Sundays for local events and arts, and The Wall Street Journal Monday through Friday.

This is to say that television journalism was never that close to my heart to begin with. Sure I watched when Cronkite gave his farewell to America and felt a little choked up. I stayed up watching coverage on election nights and during hurricanes in Miami. But the television news felt like a medium that was in decline before I was born.

---

So you can see this journalist/reporter/on-air talent has little chance of redeeming local news in my mind, even less so because I have not been forthright about the purpose of my talks with him.

The game I have been playing with him is unfair. He’s on-air because he’s likable and can read. People like likable people. There’s nothing wrong with that.

But for me, journalists are not supposed to be liked. My fight is not with him, but the viewers who watch people like him, who get confused and think that what’s important is what a kidnapper told his victim or what sexual misconduct a four-star general committed.

The news isn’t news because it’s what we want to hear. It’s news because it’s what we need to hear. I’m not against inspirational stories or human interest pieces that help illustrate broader issues. And I used to watch Entertainment Tonight, back when it was demarcated as separate from the news.

To me that separation is important. This is important news and we are going to take it seriously, and here is something entertaining and enjoyable but does not have important consequences.

But maybe I’m just an asshole.

---

Quite a few years ago, when television news was falling one rung lower on its decent into uselessness, Maria Shriver was given a ‘news-show’ and she interviewed Sandra Bernhard who, characteristically, was giving her a bit of a hard time. Bernhard turned the interview around and asked Shriver if she considered her show news or entertainment.

‘I consider it news,’ Shriver said.

‘Really?’ Bernhard asked, trying to figure out why anyone would be interviewing her on a news program. Then she lit up again and leaned in conspiratorially and said, ‘Nosey news, but news none the less.’

Last week was the last poor week of my life.

Admittedly, to me poor means that cute little French restaurant around the corner can only be visited once a month and I only send the minimum payment on my credit cards. (This was only acceptable because I knew this week would eventually come.)

I became a senior resident last month, which allows me to moonlight at the hospital. When I moonlight, I am paid as a physician, rather than a resident. Moonlighting, I make in a day what takes me a week to make as a resident.

Our schedules are demanding enough that I can only squeeze in a day or two per month, but that is all it takes.

Now, understand that I have given up gainful employment for nearly ten years of my adult life, instead going into a quarter of a million dollars debt in student loans.

I will not pay off these loans until after I retire.

If you go into medicine for the money, you are a fool. Go into banking or plumbing if money is your goal. The money is better. The hours are much shorter. The emotional stakes are lower. And the training is briefer.

But still-Congratulations me!

e-philosophy

This email was forwarded to me by my mother:

The following is the philosophy of Charles Schultz, the creator of the "Peanuts" comic strip. You don't have to actually answer the questions. Just read the e-mail straight through, and you'll get the point.

1. Name the five wealthiest people in the world.
2. Name the last five Heisman trophy winners.
3. Name the last five winners of the Miss America.
4. Name ten people who have won the Nobel or Pulitzer Prize.
5. Name the last half dozen Academy Award winner (sic) for best actor and actress.
6. Name the last decade's worth of World Series winners.


How did you do?

The point is, none of us remember the headliners of yesterday. These are no second-rate achievers. They are the best in their fields. But the applause dies. Awards tarnish. Achievements are forgotten. Accolades and certificates are buried with their owners.

Here's another quiz. See how you do on this one:

1. List a few teachers who aided your journey through school.
2. Name three friends who have helped you through a difficult time.
3. Name five people who have taught you something worthwhile.
4. Think of a few people who have made you feel appreciated and special.
5. Think of five people you enjoy spending time with.


Easier?


The lesson: The people who make a difference in your life are not the ones with the most credentials, the most money, or the most awards. They are the ones that care.

I’m not even going to touch the fact that Charles Schultz is being tacked onto this as a cheap enticement to read something that has nothing to do with him, because that’s obvious.

This thing is a card trick.

In the first list, we’re asked to name specific people who the questioner is thinking of. In the second list, we are asked to think of people who have done vague things that we found important.

If we are to make this fair, the first list should ask us to name 5 people who are wealthy, have won academy awards, or whatever achievements you would like.

Or the second list should include asking us to name 5 soldiers that died defending our country, 2 inventors of vaccines that allowed us and our parents to survive childhood, 4 politicians that funded public school systems, 4 people from the HR department that hired and retained the teachers who aided your journey through school.

We should be expected to name our mother’s obstetrician, the minister of our friends who helped us through a difficult time, the person who had a crush on us in high school but was too embarrassed to ever tell us about it, 7 people who were not chosen for jobs or promotions that we received.

And if caring was really a lone criterion for making a difference in our lives, stalkers would be more important than even our mothers.


The real lesson: we are stupid and cruel creatures who are capricious about attentions, focusing on our tiny lives more than the good of our country and our fellow man.


Well, actually that’s not a reasonable conclusion, but it’s no more unreasonable than the other lesson.

Sloth

I am currently taking care of a patient that disgusts me.

This is something that I’m rather ashamed of and something I’m struggling to deal with. I usually have a pretty high tolerance for people. I take care of a lot of people who most of you would not be willing to talk to, let alone touch. But my job necessitates that I sometimes put my hand in their mouth, inspect their butt crack, and touch their rashes and boils.

I have a patient who killed his wife and children. He used a machete. That man is a delight compared to the patient I am dealing with now.

This patient is in the hospital because, quite literally, he is too lazy to breathe. He weighs about four-hundred-and-fifty pounds and does nothing but press his call button all day long, asking the nurse to hand him items that are on his bedside table, not two feet from his hand.

Now, I know, because you are kind, you are thinking that this poor man is really so debilitated that he cannot lift his hand to get the tv remote, but that is not the case.

When his food tray comes, he leaps up and you see nothing but flashes of wrists and elbows until all that remains is an empty tray and scattered empty containers. He then lulls into his heaving mass and subsides into an enormous mound on his bed.

But then, after he shits, he refuses to wipe himself.

Now, I know, because you are kind, you are thinking that this poor man cannot reach around his enormous gut to wipe his ass, but you are wrong. I had the occupational therapists check his reach.

He simply refuses to wipe himself and rings his call bell to make the nurse do it for him.

He seems to know that we cannot simply leave him unwiped, as the bile in his shit will eat away his skin, and we cannot allow him to start developing skin ulcerations. And so the nurses wipe his ass for him. Remember, this man is too lazy to even breathe.

But to be fair, it is not really simple laziness. It is called Obesity Hypoventilation Syndrome and it is not terribly uncommon. The sagging mounds of fat on his chest push down on his lungs. His gargantuan abdominal fat pushes up on his diaphragm. The rolls of neck fat occlude his upper airway. It really does take tremendous strength and effort to push all that adipose tissue out of the way to fully inhale. I have many of these patients; I feel sympathy for many of them.

But not this man.

He wasn’t cooperating with physical therapy to regain his strength and rather than improving in rehab, he was worsening. His breathing was shallow, and he was heading toward requiring intubation.

When the senior physician tried to explain the situation to him, he didn’t want to offend him and so he told him: ‘You have Obe— Well, you have a syndrome that makes it difficult to breathe due to of all of your fa— You see, your breathing is difficult because you have a syndrome that is associated with hypoventilation.’

And this man said: ‘Sounds like you guys don’t know what I have or what to do about it.’

It is, I confess, one of two times in my career that I became so angry at a patient that I walked out of their room. This senior physician knew exactly what the problem was and how to treat it, but was simply too nice to fully confront this man. To make matters worse, the patient was sabotaging our efforts to help him, even when I explained the matter more directly.

Still, we did what we could. Some of it was easy stuff. If he sat up, the weight of his gynecomastia (the clinical term for ‘man-tits’) would fall off his chest and, simple physics, less weight to lift, easier to breathe. But when we sat him in a chair, he rang the call bell every five minutes, demanding to be put back into bed so he could lay down.

We have a small crane to assist getting him into and out of bed. The other day, his food was ready, and he hopped out of the crane to get to it, breaking it, and sending two nurses to the emergency department when the recoil snapped part of it off and struck them.

I wish I were joking.

---

Because some of my patients are friends and relatives of people who work at the hospital, I often give them nicknames. It helps protects their privacy and confidentiality when I am discussing them in areas that are supposed to be secure, but can have other personnel within earshot.

The nicknames are often based on some diagnosis: Rhabdo Guy, Heart Lady, The Pancreas. Some are based on prominent physical trait, minus any articles: Mole, Leg Scar, Neck— not The Mole or The Neck. Some nicknames are based on other associations: Mrs. Cross might become H.B. (for Hot Cross Buns); Kevin Ebler might become The Elf (Ke-Ebler); A plumber might become Larry (sounds like a plumber’s name); a pretty young woman might simply be Simpson (Jessica).

This man, this fat, lazy, self-destructive man, I simply referred to as Mulgrew.

I’m sorry I don’t have a post for today,

but I spent all weekend trying to decide whether or not I’m self-obsessed.