Friday, December 28, 2007


Practicing in a teaching hospital has its privileges. The latest technology is readily available. There is always a willing, even eager helper. As a general rule there is a collegial relationship between the attending staff (physicians who teach the residents) resulting in the liberal use of the "curb side consult", several physicians offering thoughts on the diagnosis and treatment of difficult cases. This results in a high level of competent care for the patients.

There are also a few drawbacks. One is the constant testing. My kids frequently remark that they will be glad when they are no longer tested. School, I know, seems like a journey from one exam to another, but life is a series of tests too. One of the draw backs of constantly working in a training setting is that every patient encounter, is a proctored examination. Let me illustrate.

As a second year resident it became my job to supervise one of the interns who was so book smart it was frightening. Adam would answer questions with direct quotes from textbooks. I suspect that his memory was photographic. Like most interns Adam lacked judgement.

One Saturday when we were on the labor and delivery unit together, I sent Adam back to the delivery room with one of our most arrogant attendings. There were two ways to preform every procedure, Dr. Jones' way and the wrong way. This appeared to be a routine laboring patient about to delivery her second baby. Adam had been on the obstetrical service only a week but I thought surely he has seen Dr. Jones do another delivery. Besides, all he had to do was help drape the patient, pass instruments to the attending physician and look attentive.

Once the baby's anterior shoulder was out, Dr. Jones always requested the nurse to push 10 units of pitocin in the IV line. Instead of questioning this practice prior to the delivery, it was after the fact when Adam said, "Gee, Dr. Jones, I thought you weren't suppose to do that because you might trap an undiagnosed twin?" Please try to understand that this occurred more than twenty five years ago when there was no such thing as routine sonography.

"Dr. Parker," Dr. Jones replied to Adam, "Any obstetrician worth his salt would know if there were twins by now!" As he was speaking Dr. Jones placed his hand on the patients abdomen and palpated the large mass that was indeed, the second twin.

A few expletives, some nitrous oxide, and minutes later holding a healthy second twin we had all learned something. The process for stopping a very strong contraction and delivering a second twin by breech extraction was etched in my memory. Adam was beginning to process the need for questioning in a less accusing manner before someone above him took action. And Dr. Jones. Well, in the next two and a half years, I never saw him push pitocin prior to the delivery of the placenta again.
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Thursday, December 27, 2007

Health Care 101

News about health care costs soaring is common place. Not infrequently I hear physicians complain about reimbursement, specifically what insurance companies pay physicians for their services.

There are two sides to every coin and the issue of health care costs is no different. I recently heard a patient complaining about the cost of his angioplasty. An angioplasty is a very technical procedure where a cardiologist removes the blockage in one or more coronary arteries that supply blood to the heart muscle. "Why, I could have purchased two jet skis for what this procedure cost." Keeping my thoughts to myself I mused that if he had purchased the jet skis instead of having the angioplasty he could have had a heart attack on the lake.

The other side of the coin is the fact that insurance companies, large hospital and physician groups along with equipment and drug manufacturing companies are making unconscionable profits. I learned how to spell "unconscionable" when I wrote a letter to a company about their product. On the market for years, this product had been sold to physicians for $30 for a 10 dosage vial. That is three dollars a dose. When the medication received FDA approval for a new, more widely needed indication the company began to sell it in a single dose vial for a price of $60 each. I guess I should also thank this company for allowing me to brush up on my math skills. It took me a few minutes to calculate that this was 5000% increase in their profit.

Health care cost inflate the cost of most of the goods and services we buy as employers are forced charge more so that they can afford to pay more for health insurance premiums. You are paying for someone's health care every time you purchase a car, visit your accountant or bring home a bag of groceries. As an intern I was told that health care cost could not reach 12% of our gross national product. That was 26 years ago and today health care represents almost 25% of our GNP.

I don't have an answer to this problem. This blog has been sitting in my list of posts for almost six months because I disdain a complainer who cannot offer constructive solutions. I am very unpopular with my colleagues because I don't believe the solution is to pay doctors more money. Instead the solutions to these problems lie with all those involved, physicians, hospitals, and drug companies returning to the business of caring for patients instead of making a business of patient care.
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Sunday, November 11, 2007

Here again

"Time flies," is my thought looking at the two months that have lapsed since I last wrote a line here. Possibly you thought that I had retired. I considered it. No, not from writing. I plan to do more if I ever do retire. I did spend some of this time contemplating what it would be like to leave medicine. As I have with most monumental decisions I made a list of pros and cons. What is it that I love and what is it that I hate about what I do.

I love the patients. Even the many of the annoying ones have moments of gratefulness. This still surprises and delights me.

I hate paper work. I can see that becoming paperless is more efficient and I hope I live to enjoy a day when everything is on a computer. I know, the power may go off. To let you in on a well kept secret, we lose pieces of paper too.

I love the thrill of making a diagnosis. Putting the pieces together, talking to the patient, doing the exam, ordering the tests and coming up with the answer.

I hate giving people a bill. I would welcome a single payer health system that would allow me to practice the best medicine on all who would trust me to be their physician. The problem is that this would also bring a severe rationing of care because cost.

I love seeing people get better. Better has different definitions depending on the patient and their disease. For some it is a complete recovery. For others it is acceptance of the condition that will be with them until they die.

I hate the fact that medicine takes up so much of my time. Little is left for pursuits outside of the practice of medicine. When I take the time to write I feel I am stealing from my family. Everything that I have done outside of medicine feels this way.

I love the challenge of my work, at least the part of that work that is direct patient care. As long as that is the majority of what I do, I will continue. And continue to feel blessed to have such a vocation.
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Saturday, September 15, 2007

Like ...

Ever think about what salvation looks, smells or feels like? That was one assignment at a workshop I attended over the past three days. My image of salvation is a cold glass of iced tea on the hottest of summer days. Having just finished mowing the lawn and standing sweat soaked under the shade of a large oak tree, I am unexpectedly handed a glass that is all beaded up with cold moisture. After taking that first big gulp of refreshing liquid I touch the chilly glass to my forehead. There is the faint aroma of mint mixed with the taste of lemon along with a delightful sweetness in the back of my throat. Swallowing, my parched body demands that I move the cool of the glass from my forehead back to my lips as my tongue begs for more.
Like ...SocialTwist Tell-a-Friend

Tuesday, September 11, 2007

Things that unite

"This 37 year old Asian American female accountant who is a unmarried mother of two ..." And so it begins, the medical history where I record answers to all of the questions I have ask about age, race, occupation, sexual orientation, number of sexual partners, level of exercise, diet, allergies, recent travel history, family history, social history, good habits and bad. This is what a physician does, ask questions and listen carefully to the answers.

Often there is more information than I need. Occasionally I worry that some of this information will prejudice my judgement. In an effort to prevent such bias I try to remember what I hold in common with my patients. All of us wish to love and to be loved. We all become hungry when we are not fed, tired when we are over worked, cold when we are exposed without adequate protection. All of us have skin. Cut it, regardless of color, and we all bleed. Oh yes, and we all get lonely. This seems to be the case now more than ever before.

On this day, the anniversary of a cataclysmic event in history, when some would separate us in to countries, religions, cultures, and generations, may we all remember the above. It is not trite to say for the sake of peace "many more things unite us than divide."
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Monday, September 10, 2007

Rest, part II

"If it were easy then anybody could be a doctor." Those words resonate in my mind daily even though it has been thirty years since I heard them for the first time. My neuroanatomy professor made this pronouncement after each assignment given. The neuroanatomy course was one of the most demanding of the basic sciences, the last lecture course of the first year of medical school. We never saw the professor during the lectures. The course was on closed circuit TV. His hands, the pro sections of the brain and spinal column and diagrams were all that we ever saw. His voice was like the voice of God. Meeting him I was surprised he appeared so ordinary.

I also recall the words of a colleague, a favorite endocrinologist, when I was begging him to see a patient sooner than his office schedule would allow. "I cannot create time!" he declared.

No, humans cannot create time. The Divine did, ordering it in such a way, with light and dark, winter, spring, summer and fall to give natural periods of rest. In our attempt to be like gods we have discovered electricity and harnessed it into a nonstop flow of activities, ideas and information.

So what could be more powerful than turning off the lights, unplug the appliances, even the oven, for a few hours a week? Think of it as conservation. The energy you save may be more than just your own.

Yes, if it were easy anyone would do it. Just like the words of my neuroanatomy professor pushing me to study, this is a challenge to arrange my week in such a way that there is time for a period of rest or Sabbath.
Rest, part IISocialTwist Tell-a-Friend

Saturday, September 8, 2007


On the way to work this morning at 5 AM I am overcome by the number of cars already on the freeway. Being old enough to remember when most of the world slept at night, I recall a time when there were no twenty-four hour retail stores and "7-Eleven" was a convenience store that opened at 7 AM and closed at 11 PM. My kids refuse to believe that television stations ever went off the air much less accept as a fact that the programing day ended as early as 10 PM. Many businesses now operate around the clock and if the store is not open the web site can be accessed twenty-four/seven.

In my daily life I find it difficult to escape human made sound. I miss darkness where the only light is that of the moon and the stars. I cannot feel nor do I hear the earth breathe. The result: I feel as if I am holding my own breath. The rhythm of life is interrupted by synthetic sound and artificial light.

When does humankind rest? The earth has existed for eons without constant mortal attention. Could the restlessness of the human race be exhausting all of creation?

Friends discuss keeping sabbath, a period of rest.

I have heard the lecture.

I need the lab.
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Wednesday, September 5, 2007

In the operating room

I spend the better part of my Wednesdays in the operating room. This time of year the residents, interns, graduate nurses and nursing students are still relatively new at their assigned tasks. The operating room remains a bit intimidating to me, a seasoned practitioner. I am sure that these new individuals are terrified. I try to think back to my first day in the operating room on my surgery rotation in medical school.

I had been suturing in the emergency room regularly for almost two years, so I felt a surge of excitement when the resident I ask me to scrub for a case already in progress on my first day. No one explained to me what had happened prior to my arrival. The case was a coronary artery bypass graft requiring the big vein from the leg. While one team of surgeons readied the heart another team harvested the vein from one leg.

I was being asked to scrub so I could help the team suture the incisions in the leg from the vein harvest. There were twelve to fifteen people around the patient. Right after I pulled my gloves on I contaminated myself by going to the wrong spot around the patient. This meant that I would have to begin the process of gowning and gloving again distracting the scrub nurse even longer. She was not happy.

As one of the circulating nurses tied the second gown she whispered, "If that is the worst thing you do, you will be the best medical student we have ever had in this OR." She gave me a knowing look. This has happened before.

I went on to gown and glove a second time with no problems. All my previous suturing experience served me well and I was able to help repair the incisions on the patient's leg. The scrub nurse who had been so angry with me when I had to regown and glove had an improvement in her mood. She taught me the names of all the instruments and how to past them to the surgeons. For the next four weeks, when I was not allowed to help with the actual surgery, she let me stand in her place and pass instruments. Not only could I see what was happening, I felt useful and I never had to study the names of the instruments. I knew them.

The surgery rotation that most in my classmates dreaded, unless they wanted to become surgeons, ended up being one of my best rotations. My attending physician wrote me a wonderful letter of recommendation. Yet, the experience would not have been as rewarding for me, if two operating room nurses did not have the patience to teach me how to function there.

It is good to be reminded that none of us are born with all knowledge. One thing that makes the knowledge that we do acquire better is the ability to share it graciously.
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Monday, September 3, 2007

Labor day

Several weeks ago I overheard a conversation between my two teenage sons. My eldest son had a summer job at a local bookstore. One evening after he explained to his brother how tired he was and how much he disliked his job the younger one replied, "Well, duh, that is why they call it work."

Despite the fact that I am often exhausted and despite the fact that there are some unsavory aspects to my job, I would rate my job satisfaction as high. Part of this comes from the fact that practicing medicine is challenging and rarely routine. Yet, much of the fulfillment from my work comes from the approval I receive from my patients. I have found a sincere "Thank you," to be a great reward.

Medicine is not just a series of diseases to overcome though battling disease is a large part of my work and I enjoy the effort involved in making a diagnosis. For me practicing medicine is to participate in healing. Often this is to diagnose diseases and prescribe appropriate treatment. At other times practicing medicine is providing comfort when all the treatments are done.
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Saturday, September 1, 2007

September dawns

As September arrives I find myself thinking of change. Fall is coming. This is the final quarter of 2007. Who will be migrating as the seasons change? This picture along with many other wonderful watercolors are located at
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Friday, August 31, 2007


There is a monster(1) lurking in our midst. In medicine, especially obstetrics, ninety eight percent of the time this monster is unseen waiting for the time when chaos strikes. Here is an example:

One Sunday evening I was caring for a patient whose bag of waters had ruptured but labor contractions had not begun. This being her fourth child and the baby's head not yet engaged in the pelvis, I chose to remain in labor and delivery for the evening. The unit was relatively quiet as it was a weekend. The residents and I were reviewing some information and discussing one of their clinic patients.

Suddenly the nurse caring for my patient called out on the intercom: "I need a doctor in here STAT!" Yes, we do use that word and it usually makes my heart go cold when I hear people I trust speak it. On the weekend night shift most of the nurses have seen more than I when it comes to complicated obstetrics.

The two residents and I rushed into the room where we found the nurse on the bed with the patient pushing the baby's head up into the uterus off of the umbilical cord which had prolapsed or worked its way out into the vagina and beyond. On admission the patient had refused placement of an I.V. since she used natural childbirth for her other three deliveries and was planning to do so with this one.

"Call anesthesia. We will meet them in the operating room." I asked in a voice only slightly louder than my normal one. I opened the bedside drawer, extracted an IV kit, prepped and then jammed a large IV catheter in to the big vein in the woman's arm just opposite the elbow. In a voice much more serene than my racing heart told me to use I ask the husband to go to the front desk for clothes to wear to the operating room as I began pushing the bed out the door. We moved toward the operating room with the nurse still on the bed holding the baby's head up.

Now there were six people helping, the nurse anesthetist was drawing up medication and I was talking to the patient. "I know this is not what you planned for your delivery but to save your baby's life we will need to do an emergency C section. The head is on the umbilical cord and it will compress the umbilical cord cutting off oxygen to the baby if you delivery the baby through the vagina. We must deliver the baby as soon as possible."

The patient was staring at me with her wide eyes. Terrified but saying nothing she nodded. In an effort to calm the patient and get everything in place I began explaining to the patient that the anesthesiologist would be giving her some medicine through the IV and she would soon be asleep. We had been listening to the baby's heart beat which remained normal, unlike mine that was pounding wildly in my chest, as we moved the patient into position on the operating table. One resident and I pulled on gowns and gloves as the patient's abdomen was prepped with a splash of antiseptic and draped with a sterile sheet open in the middle.

This is the most dangerous part. The patient must be completely asleep with a tube in her airway before any surgery begins. I have seen over anxious surgeons try to make the incision before the anesthesiologist gives the O.K. Once the patient could no longer see me because of the drape I took the scalpel from the scrub nurses as I kept talking in my calmest voice. "We will be taking very good care of you and your baby while you are asleep. When you wake up you will be in the recovery room with your baby." This could be a lie if the baby is having problems at birth but I usually take the chance and say something calming to the patient. A nurse was holding her hand. I felt it was too traumatic for the husband to watch his wife while the anesthesiologist placed the endotracheal tube in her throat.

Once she was asleep and the endotracheal tube was in place and her airway secure, it took only a minute to make the incision and deliver the baby, an eight pound boy who came into this world screaming his head off. Great! That is what babies are suppose to do. I talked with the dad who was now at the baby warmer staring at his new born son as the pediatric team checked the baby over.

Mom was doing fine, though unaware of all that was happening as she slept under the general anesthesia that had been required for her delivery. This is the happy ending. The one where the chaos monster was thwarted by an extremely skillful group in labor and delivery. "Seven minutes," the nursing supervisor called out. It had taken us seven minutes from the time the nurse noticed the umbilical cord prolapsing through the cervix below the baby's head until the baby was safely delivered. It was seven minutes that I felt like screaming my head off but had managed to do as I had been taught and calmly proceed.

Now I am thinking of times when the chaos monster could not be contained. Times when babies for whatever reason had been stillborn, born prematurely, or born with birth defects. Times come to mind when parents of children I have delivered died of disease or injury. Children I had delivered that have been hurt by unstoppable disease. Two young men I have known from birth have died in car crashes. These were times when nothing, it seems could be done in the face of this monster. Chaos reigns. I want to scream my head off or run away as fast as I can.

In this moment when chaos has retreated I realize that screaming, running and loosing sight of who I am and what I am called to do only increases chaos. It is not I alone but the whole of labor and delivery that stood against this monster. By remaining calm and working together the power of the chaos monster is diminished until the day I longer for when the chaos monster ceases to exist.

1. I am indebted to the Rev. Jimmie Johnson of Waco, Texas for fleshing this monster out for me in a sermon preached at Austin College in Sherman, Texas.
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Thursday, August 30, 2007


The last ten days have flown by and again I need to apologize for how this blog is floundering as I work, rest, play and regroup.

A gift that I have given to my favorite young doctor friends when they graduate from the residency program and become full fledged colleagues is that of a clock. Usually something small and obscure that would fit well in their new office to help them monitor the day as patients are being seen. I have one in my office that sits on my bookshelf. I can look just over a patient's head and see it.

With the clock there is a message that goes something like this: "In your chosen profession you will have an abundance of many things but there will never be enough time. Your time will have to be divided between work and home, patients and family. You will never have enough for either, let alone enough for yourself. My hope is that this clock will remind you of these facts and help you spend your day wisely for time is far more precious than gold."
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Monday, August 20, 2007

On work and love

Forgive me. The past four days have been busy ones as I have been juggling family, the practice of medicine and my own needs for rest. I have let this blog flounder.

The school year is fast approaching. My eldest son will be a senior in high school and my younger son a sophomore. They are both beautiful young men. Each stands over six feet tall and both are quick to grin not just with their lips but with their eyes.

These days I often look at them and wonder, "When did you move in to my house?" Almost instantly as if reading my mind, one or the other, sometimes both of them together, will crack a joke and they will giggle reminding me that they are just super-sized little boys. The same ones that use to climb into my lap and snuggle.

Time has flown by. While I have been able to call myself a physician for twenty-five years, I have been a mother for less than eighteen. I feel the first title has deprived us of much time with me as the other.

Medicine is a demanding vocation often robbing from other areas of life. For that reason alone I hate what I do. I have wondered if it would not be better for me to be single and without children. Yet, without children I would not appreciate the most important aspects of life. Work is important but love is much more so. Love is the ultimate reason for work. My hope is that somehow my sons see this and that they understand.
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Thursday, August 16, 2007

Physician patient relationships

Joan died eight years ago. She was my patient for at least ten years prior to her death. As with many of my patients Joan taught me a great deal.

The first time I saw Joan, she had recently undergone a mastectomy for a fairly aggressive breast cancer. She was not the type of person to go to the doctor until it was absolutely necessary so a breast lump went undiagnosed for several months. She was suspicious of the medical community as a whole and she told me point blank how much she disliked doctors at our first meeting. The surgeon who was treating her for her breast cancer insisted that more doctors be involved and Joan had a fierce desire to beat the cancer so she did as the surgeon ask.

I immediately like her. Joan had a quick smile and it punctuated our entire discussion of her medical history, even when she was telling me why she did not go to the doctor often. By the time I had finished the examination and talked to her a bit more about my plan of treatment, I knew that we had a relationship. Not just a relationship as the law would define it in the Medical Practice Act but a relationship because of a mutual respect.

I saw Joan at least every three months for several years. My kids were born and hers grew to be teenagers. We never saw each other outside my office but she knew the names of my kids and had seen their pictures. I knew the names of her children and her husband and had even met them on various visits. She never failed to ask about my family nor I hers. She enlisted me for all kinds of referrals for family members.

And we listen to each other. Really listened. She saw the bone tired working parent of an infant and a toddler. I heard the worry in her voice as she discussed the latest escapades of her teenagers. At each visit we had a few moments to be friends. When she was free of disease we celebrated together. When the cancer recurred we gave each other strength to continue the fight.

When no more treatments worked, Joan asked me to talk with her husband about hospice even though I was not the primary doctor treating her cancer. She felt that I knew her weariness. Two days later she was admitted to hospice care. I made a house call three weeks before she died. We had talked several times on the phone but I decided one last visit in person was necessary - for me. I needed to tell her what a wonderful patient she had been and what a privilege it was to be her physician.

I have had several such opportunities now with patients who are near the end of life. Much of what we know as physicians is learned from our patients. Just as Joan was honest with me from the beginning, she taught me that it was acceptable, no expected, to be honest even in the end.

Physician patient relationshipsSocialTwist Tell-a-Friend

Wednesday, August 15, 2007

Giving thanks

I am exhausted by an unexpectedly difficult day, an unusual case, and a brush with death. Forgive me for not writing more. I need some time to process this one. I believe what happened today was a bit of a miracle. Years of training on the part of physicians, nurses, technicians, came together in a way that saved a life. I am grateful.
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Tuesday, August 14, 2007


A small envelope arrived today. The handwriting could have been my grandmother's. The return address belonged to a long time patient who I have seen for years. This woman has never had any big medical problems. It has all been small stuff, routine wellness care for the most part. She has aged a great deal in the last few years. She and I had a telephone conversation about how often she needed to be seen a few months ago.

In the card, the same meticulous script reads "Dear Dr. ______, Thank you very much for caring about me. It is too hard for me to get downtown these days and I have found a doctor closer to my home. Thank you again for all the care and concern you and your office have given me all these years."

I will call her tomorrow. She has made my day. I overheard a discussion about success today. This is how I would like to define it. A patient who felt that I cared about her. May it be so with all my patients everyday.
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Monday, August 13, 2007


For the word "physician"the American Heritage Dictionary gives three definitions: 1. A person licensed to practice medicine; a medical doctor. 2. A person engaged in a general medical practice as distinct from surgery. 3. A person who heals or exerts a healing influence.

"Doctor" on the other hand has seventeen definitions. When used as a verb the range of meaning is everything from "return to the original working condition, repair, mend" to the definition "tamper with; falsify"

When asked what it is that I do, I refer to myself as a physician. I would like to believe that is true. I hope that I have never tampered with or tried to falsify any part of my patients. I am quite sure that many times my part in a patient's recovery is minuscule, perhaps only as a witness that it is taking place.

There are many elements required for healing to occur. Sometimes a physician is needed. It is important to realize that medicine is not the only thing required. In realizing this, good physicians are guided by a desire to exert a healing influence even when there is little that medical science can do.
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Friday, August 10, 2007

The best medicine

Once again I am arriving late to this blog. It is Friday, really Friday, at last.
Determined to find something to offer today that is uplifting I bring this picture and the hope that for a least a few moments this weekend you too can stop and take in some of the breath taking beauty that is available in the world around us.
Healing comes in many forms. Frequently the best medicine doesn't taste like medicine at all. We may be healed by the beauty of nature, the sound of music or the presence of someone we love.
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Thursday, August 9, 2007


Perhaps, if you have been reading these pages, you have noticed a change in the time of my posts. This has come from the fact that the flood of ideas that launched this blog has at least for now been reduced to a trickle. And I also find myself suffering from fatigue.

Fatigue comes in many forms. There is the bone deep weariness that comes from hard physical labor over long hours. I experienced some of that this past weekend on call for my group of four physicians. In our specialty some of our work always happens at night.

There is also a fatigue that comes from experiencing too much. Today is an example. Early this morning I saw a patient who is very young, early pregnant and has the heart of an eighty year old. If she continues her pregnancy her risk of death is greater than 50%. As I discussed this with her she began to comprehend what this means. She will have to make a decision to terminate her pregnancy if she wants to be able to raise her three year old daughter.

Around midday I see a patient younger than myself who is battling recurrent cancer. Many medications have worked, for a little while. Each time the disease has returned after a few months of treatment. Realization that this is a disease that she will have to live with and more than likely die from, has arrived.

The end of the day was spent with someone in whom I have just made the diagnosis of a sexually transmitted disease. Physical healing will take a matter of days. Emotional healing, well, that will be much longer in coming.

A good night's sleep has cured the fatigue resulting from my nights on call. Treatment of the spiritual and emotional fatigue requires more effort. In fact I find it is a constant battle. One of the reasons for writing is to help. Somehow putting my experiences down in black and white localizes the pain while I search for a cure.
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Wednesday, August 8, 2007

Grand rounds

Today my morning began with Grand Rounds. Most of the time this meeting is neither grand nor do we make rounds. It is a get together, over coffee and donuts, to discuss the latest tribulations and triumphs of our medical community. This sharing of experiences among physicians is essential to the practice of good medicine.

Twice a month this conference consists of something called a CPC. Early in my medical career, while I was still spending hours every day listening to basic science lectures, I happened on my first CPC. That stands for Clinical Pathological Conference. As a lowly first year medical student, I found this to be an exciting meeting. If I can't attend one each week, I try to read the one in the New England Journal of Medicine. For someone intereted in medicine they read better than a well written mystery.

There is an interesting cast of characters. First there is the Presenter, usually a resident physician who has taken care of the patient. The Presenter outlines the case by reciting the medical history, reviewing the physical examination and initial laboratory testing but stops short of giving the diagnosis.

Next the Discussant steps up to the podium. Usually one of the senior residents or attending physicians, this person has the job of making the diagnosis. For those of you who are not physicians, coming up with a diagnosis is not as easy as the Internet would have you believe. Part of the problem is there are usually several diagnoses to which the signs, symptoms and test results point. This list of possibilities is called the "differential diagnosis." Listing the different diagnostic possibilities and why each is possibly the condition from which the patient suffers is the largest portion of the program. Not only is it an excellent learning tool for those present but it is also the Discussant's chance to show off.

Finally, the pathologist or radiologist appears. The most smug person in the room, this doctor has the answer. That is why certain people go into those specialities, they get the last word in the case. Drum roll please... Usually a slide appears on the screen with the final test, the results of which yield the diagnosis.

I realize that I am attracted to these conferences not just for the knowledge of medicine that I gain. I have also learned a great deal about what it takes to be a good physician. One has to be a good listener, thoughtful, diligent in looking at all the information, especially that information provided by the patient. More than just a little research in textbooks and medical journals is required. Some humility is also indispensable. No one can know everything, often other physicians have to be consulted. Occasionally after a brilliant presentation, the Discussant is found to be wrong.

Yes, unlike what other venues teach, you can be wrong and still be a good physician. That may not be what most get from these meetings but it is one of the aspects that I stress with the residents. Medicine is not an exact science. The good practitioners keep looking. Not just for the correct diagnosis but also for the most effective treatment for each individual patient.
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Tuesday, August 7, 2007

Too busy, too tired

All day I have been thinking I will sit down
And write something for this blog.
The end of the day is here.
I have been too busy and I am too tired.

Today was a day filled with work and family,
With me trying to juggle the two.
It was a day when people who hardly speak the rest of the year
Ask me to commit to volunteer work for the next nine months.
It was the day after I had been on call for four nights straight.

So, tonight will be a night when I relax,
Play the piano, read part of a novel.
It will be a night when I go to bed early,
When my sleep will have no interruptions.

Tomorrow my mind will be reset by rest.
I will again have ideas and energy for this blog.
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Monday, August 6, 2007


A friend recently described to me how horrified she was watching her two and a half year old son play with a group of children at a local fast food restaurant. Her concern was over the fact that he was being exposed to all kinds of germs that could potentially make him sick.

My friend is correct in her observation that her son was coming in contact with all kinds of bacteria and viruses many of which his immune system had never before encountered. A minor illness may indeed be the result. I tried to reassure her. Most current immunology research would have us believe that challenges to our immune system when we are young may lessen our chances of developing certain diseases when we are older.

These conditions are called autoimmune diseases. Examples such as type 1 diabetes, Crohn's disease, and rheumatoid arthritis occur when the body's own defense cells that are suppose to attack infectious invaders such as bacteria and viruses attack the body itself. There have been several studies showing our twenty first century fetish with cleanliness could be hurting us and increasing the risk of developing such illnesses. It may also be producing guerrilla pathogens like methylcillin resistant staphylococcus auerus, a bacteria resistant to most common types of antibiotics.

Reflecting on all this, I began to think about "social sanitation" and how it hurts us as well. By social sanitation I am referring to practices which keep us isolated in groups of people who look, act and think as we do. Growing up in what I call Small Town Texas, my friends and I were cautioned by our parents to avoid those different from ourselves. Not only were all my friends Caucasian, they were Protestant, mostly Southern Baptist, and all our parents with only a rare exception were employed by the oil industry.

There is a certain security in similarity but in the twenty first century where our world is shrinking to the point that diverse cultures are required to come together to solve our common problems this behavior is much like the avoidance of common germs. If our only contact with people who have different beliefs and behaviors is in an effort to convert them to ours, how can we truly understand each other.

Living in a more cosmopolitan area than I growning up has given my children advantages that I did not have. Their friends are from many different backgrounds. They understand different religions, political view points and different lifestyles not because they read about them or watched a television show but because of experiences with their friends.

Yes, these exposers to different lifestyles often result in my sons questioning of many of my beliefs and some of our family practices. Yet I am hopeful that from their experience of a wider world my sons have been protected from many of the prejudices that weaken my own generation.
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Saturday, August 4, 2007

Why blog?

While I began this endeavor of a daily blog on a whim, the more I write, the more I find myself committed to continuing. So if you have happened on to these pages by accident or you have been invited here by myself or someone that you know, today, I am going to share some of my purpose for writing.

My goal is to spend an hour each morning, Monday through Saturday writing. While I have kept journals before, I have never had any discipline or routine. You, my audience, will give me what I have never had before which is accountability.

My primary purpose is to share what life is and has been like for me as "the Local MD." Using the letters that my medical degree permits me to add after my name will not limit these pages to the moments of my life in which I am practicing medicine. The title does mean that being a physician is so much a part of who I am that it now colors ever other aspect of my existence. I do not always find this beneficial.

As human beings I am confident that more aspects of our lives join us than issues we encounter divide us. There is much that we as human beings hold in common. For me, growing up in small town Texas, reading was my first glimpse outside my own sphere. The many books that I read in my youth not only entertained me but they informed me about a world much greater and very different from my own. In some part my desire to write comes from an appreciation for those who have written so that I might read.

As a group, I have found physicians very reticent to share their deepest thoughts. When physicians blog it is usually about research or to complain about some aspect of the insurance industry. Those are worthy topics but not as interesting for me as more personal aspects of practicing medicine.

For the past several years I have been inspired by some in the religious community. Within this group of mainline clergy, many younger than myself, I have found a refreshing honesty with each other and with those outside their vocation. This has challenged me to take a step back and look with as much critical vision as I can muster at who I am and what I do. I find this not only essential in my caring for patients but in caring for myself as well.
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Friday, August 3, 2007

Three more working days

T.G.I.F. Thank goodness it is Friday! For most of America, Friday signifies the end of the work week. Joy permeates the work place as almost everyone prepares for the weekend. As a physician on call my weekend sentiments are summed up by the phrase "only three more working days until Monday."

Weekends on call can be back achingly busy or mindless dull (less so with Internet access) but the fact is I will eat with, sleep with and carry my beeper to the bathroom for the next seventy two hours. Since I am in a specialty that requires me to be close to the hospital it is difficult to make plans that cannot be dropped at a moments notice.

There was a time in my life when having a beeper and later, when they became available, a cell phone, gave me a feeling of importance and limited freedom. My services were so necessary that I must be accessible twenty-four hours a day. Today beepers and cell phones are common place and there is much less mystic surrounding those who carry them. Now I look forward to times when I am not required to be readily available and I can turn these devices off or leave them at home.

There was also a time when my beeper going off or the phone at home ringing made my stomach lurch with the thought that some disaster required my attention. Now I am more calm, a veteran of twenty years of on-call nights, weekends and holidays. I still reach a point, especially when I am tired that the sound of my beeper causes a wave a nausea to come over me. I may be pleasantly surprised to look at the message and find something that can be cured with a phone call.

In twenty plus years of private practice have also learned to look around, seeing the plight of others. The nursing staff, ward secretaries and house keeping are right there with me. With much less freedom than I, they are required to remain in the hospital at their post for their entire shift while I get to leave when the task is done. Even outside the hospital a number of stores are now open twenty four hours a day requiring clerks to staff them. Many in the service sector such as police and fire personnel work nights and weekends. What about those women and men in Iraq? I bet they would love to get some time off on Monday.

With three more working days until Monday, I am lucky to have a job which is rarely routine and frequently intellectually stimulating. There will also be at least one and probably several very grateful people who will need my services this weekend. Next weekend? Someone else will have the beeper and I will be thankful for the time for fun.
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Thursday, August 2, 2007

Art and science

Several years ago to begin a remodeling project in our kitchen, I called an electrician to make sure that the existing wiring would be adequate for our needs. Our house was about thirty years old and an addition had been built on prior to our ownership. After a thorough inspection the electrician took us around the house showing us areas that were problems along with his proposal for fixing them.

Once the electrician had completed his presentation, my spouse began to tell him that we had a different plan. I began to laugh. This experience was so much like practicing medicine that I could not believe it. "Now, I don't do electricity," I said to the electrician. "People come to me for problems with their health." Yet I was struck by the similarity of situations. I knew from experience that I would either pay this man to do what he deemed best or get another electrician. He was there as the expert in his field. In hiring him we were asking him to assume some of the responsibility for the safety of the electricity in our home. Mistakes in his craftsmanship could result in a power outage in the least and a major house fire at the worst.

Patients often come to my office with a predetermine plan for treatment. What they would like to do is based on their symptoms, reading and/or talking with friends and their desired outcome. I listen to what they have to say and the process they have been through to come to those conclusions. This often helps me in making a diagnosis and planning treatment. At that point I often ask the patient if she is willing to trust the me to be the doctor. In most instances the patient will give me a chance.

However this is where the similarity between electrician and physician ends. Electricity is a constant. It behaves in a predictable way. Patients are not carbon copies of each other which happens to be one of my favorite aspects of medicine. Even a "text book case" is going to be different from what is in the textbook because each patient is an individual. I explain this to patients by trying to list for them as many possible outcomes as I can before they begin treatment. The some of the art of medicine is to do this in such a way that the patient will trust that his will be the best possible outcome. In some part of the success of a treatment is derived from the patient's expectations. I always include the fact that even if the risk of a complication is one in a million, if they have that complication it really doesn't matter what happened to the other 999,999 people.

Yes, medicine is a science. More and more with each new test or treatment physicians can be technicians. In the skill that comes with increased knowledge in the science of medicine I pray that as physicians we will continue to excel in the art of medicine as well.
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Wednesday, August 1, 2007

Knowing the question

To make a diagnosis a physician needs to know how to obtain the appropriate information. This information often comes from listening to the patient. Occasionally it is acquired in the process of examining the patient. Less often the answer lies in the tests that are ordered, blood work, x-rays and the like. Sometimes the most important information comes when the physician asks the patient questions. These questions maybe about symptoms the patient is experiencing but at times there is information that is more important than symptoms. Here is an illustration.

One of the most brilliant physicians I have ever worked with is Dr. Lane Gentry. At the time I was a medical student Dr. Gentry was practicing infectious disease. Later he became Chair of the Department Medicine and Chief of Staff at the primary teaching hospital affiliated with Well Known Medical School. For me Dr. Gentry was an outstanding role model. I learned more about practicing medicine in the 30 days that I spend on Dr. Gentry's service than in the previous three years of my training. Dr. Gentry was a master at knowing the right question to ask.

Each Friday in our city of three million, a city wide infectious disease conference was held. The conference was attended by physicians from all over the city and represented the most difficult infectious disease cases of the past week. The auditorium was always packed.

The ultimate stump the professor routine was the format. If the patient was well enough to attend he or she would be on stage where a resident physician would present the events leading up to the diagnosis. At this conference as well as working with patients in the County Hospital I got my first up close look at diseases as tuberculosis, bacterial meningitis, hepatitis, and HIV/AIDS, which then did not have a name since the cause had not yet been identified.

I will never forget the conference that began with a elderly, tall, thin, African American gentleman sitting on stage. He looked as if he would like to smile but was too intimidated by the fact that about a hundred and fifty men and women in white coats were staring at him. He was well dressed in coat and tie appearing as if he was on his way downtown to a desk job in one of the high rise office complexes.

The resident physician began by introducing the patient to us as Mr. DW (initials or chart numbers only were used). The patient was brought to the doctor by his family who thought he needed medical care. When ask directly the patient had no complaints. The family's complaint was the Mr. DW had begun to "look older." When ask to be more specific his daughter said that his ears were wrinkling and so was his forehead. This seemed to happen overnight. Over the next several weeks many tests had been done and the diagnosis was obtained.

Now it was up to the five infectious disease doctors seated on the front row who had never met the patient to come up with the diagnosis. Sometimes the questioning could go on for an hour as each took their turn. Dr. Gentry immediately raised his hand. "May I ask the patient a question?" Dr. Gentry ask the resident.

"Certainly," came the resident's reply.

"Sir, do you ever eat armadillos?" Dr. Gentry's asked.

Immediately Mr. DW replied, "Everyone I can catch!" his smile finally breaking through.

"Mr. DW has cutaneous leprosy," Dr. Gentry stated to the audience. "The test that made the diagnosis was a skin biopsy of his ear." Sure enough, the microscopic slide was then projected on the screen, revealing the bacteria found on the skin biopsy. Mr. DW had begun his treatment with the appropriate antibiotics and the wrinkled skin would begin to disappear.

Knowing the questions. The answer is easier to find once the right question is asked.
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Tuesday, July 31, 2007

The technology

Technology overwhelms me. By this I mean two things. One is that I find it intimidating. The other is that for all technology has given us, it has also taken something from us. Let me give you an example.

When I was a medical student twenty seven years ago there were three machines in the labor and delivery area that could be hooked up to a pregnant patient to listen to her baby's heart beat continuously and monitor uterine contractions. This machine is called an electronic fetal monitor. The hospital I am describing had at the time the busiest obstetrical unit in our country. There over fifteen thousand babies a year were assisted into this world by physicians, residents and medical students of Well Known College of Medicine. Today electronic fetal monitoring is the standard of care in all hospitals and is being used in most deliveries.

While in medical school, I delivered forty babies in the month I was on the obstetrical service and yet I cannot remember a single one of those patients being monitored electronically. I listened to the baby's heart beat with a fetoscope (A special stethoscope developed in the late 19th century.) or a fetal doppler (A newer invention borrowed from vascular surgery that amplifies the sound waves of blood flow through the baby's heart. The electronic monitor utilizes this technology.) that I held next to the mother's abdomen. I also had to put my hands on the mother's abdomen and feel the firmness of each contraction of the uterus while looking at the second hand on the clock to see how long the contraction lasted. Of course the mother could tell me how hard the contractions were and how long they were lasting. This conversation was another way that I "monitored" my patients in labor and I could monitor the patient's level of anxiety in the process. Frequently this conversation involved not only the patient but her support person(s) as well, filling in some of her social history.

Today, fetal monitoring is high tech and serves several good purposes including constant surveillance of the baby's heart rate and the mother's contractions. There are a number of companies that make fetal monitors competing in a high dollar market. Hospitals must have the latest system, not only for monitoring the labor of the mother and the well being of the baby but also for recording as a permanent part of the medical record a second by second account of what takes place while the patient is there.

This bit of technology reached new heights in the hospital where I practice a few years ago. The vice president in charge of nursing services presented our new system to the quality assurance committee. "This state of the art 'Name Brand Monitor System' will record every second of the laboring process, " she declared proudly. "And the nurses will be able to view it in the nurses' station, the conference room and the break room. They will be able to chart directly from any where there is a computer terminal." I could see the nurses would be spending less time at the bedside and more time in front of a computer screen. An added benefit would be the cost savings of allowing one nurse to take care of several patients. Much more cost effective, at least according to hospital administration, than the one on one nursing care the old way required. "The residents will be able to see what is happening in their call rooms," the nursing VP continued. Remembering my days as a resident the "call room" was a closet like room where you might grab a few minutes sleep between patients. "Doctors, you will have these screens in your office or at home if you choose," she beamed at us sitting back in her chair.

The vice president of nursing services was satisfied. We should all be relieved and reassured. Our hospital would have the most up to date equipment to care for our patients. Breaking the silence I facetiously said, "I always find it comforting when we have one more piece of equipment between the caregiver and the patient," I knew that this state of the art monitoring system was one reason that there would now be less face to face contact with the patient. Who needs to ask about or feel contractions? You can see them on the monitor. Who needs to put hands on the pregnant abdomen or listen directly to the fetal heart? The monitor is doing this for us. At least this is what the presenter wanted us to believe.

I some times joke, face to face of course, with patients, "I am waiting for is the transporter beam and we can skip the laboring process altogether. 'Beam the baby out, Scotty!' " And I will probably be able to do this from home.

My point is not just about the delivery of a baby. I am concerned here about the very technology I am using to write this post. I enjoy the Internet. I have fun finding and viewing different sites which is one of the reasons I began my own blog. I am addicted to email. I enjoy the contact that the Internet gives me with friends old and new, seen and unseen. There is a down side, however. When I spend more time staring at this screen, I am spending less time looking someone in the eye. Reading email is fine but being present listening to what a friend is saying, or not saying, is a far better use of time.

So, if your choice in the next moment is to read another of my posts or to turn and talk with a friend, hit the exit button. That post will be there when you return.
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Monday, July 30, 2007

My understanding

When tragedy strikes the aftermath is a void that begs to be filled. In what should be a holy silence many voices compete. One voice always seems to claim knowledge of God's purpose in such events. I call this the voice of cause/effect theology. It is the way scientists are trained. You remember in physics, "for every action there is an equal and opposite reaction."

As a physician, I am often tempted to participate in cause/effect theology. Patients and their families are quick to accept it. This explains why they are sick. "He got hepatitis because of his alcohol abuse." "She has lung cancer because of her cigarette smoking." Kneeling before the altar of knowledge and reason patients want to believe that science and good clean living can offer them eternal life.

Yet, what about the man who has never tasted alcohol only to find out that he has abdominal pain because his liver is eaten up with cirrhosis? Or the woman who is dying of an aggressive lung cancer but she never touched a cigarette? The logic of cause and effect says nothing in these situations. Using this theology where are words for the parents of a child with leukemia or the mother whose baby is stillborn? I have taken an oath to strive to alleviate suffering where ever I encounter it. Realizing that pain and death are inevitable, I struggle along side my patients to find hope.

In the wake of the death of a close friend's son last week, a Proverb I memorized in my youth helped fill the void. "Trust in the Lord with all your heart and lean not on your own understanding.1"

Sitting with my friend in the wake of this tragedy, the ancient Hebrew writer silenced all other voices. The power of the moment is not in what I am able to understand. In the face of such grief my understanding is paltry. Even my ability to trust is often as weak as my understanding. Strength in these situations does not come from inside myself. Strength comes from the object of my trust named "Lord" by this ancient writer. For me this "Lord" binds us, patient, friend, sufferer, and caregiver together in such a way as to make hope possible.

1. Proverbs 3:5 The Hebrew Bible
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Saturday, July 28, 2007

Choosing medicine

The work week ends with the realization that if I were only practicing medicine that would be busy enough, but my life is full of other things. At home there are people waiting (or not waiting because they grew tired of waiting) to begin the weekend. I am usually the last one out the office door on Friday afternoon, not because of a patient, since they like to get home early also , but because of the fact that my medical practice is more than just caring for patients. No one cautioned me about how crazy life would be when I applied to medical school.

A few months ago my oldest son asked me why I went to medical school. My reply was "That is a good question." Yes, I explained, I put down those standard answers on my application: "I love people and hate money." No I didn't say it like that but that is what I wanted the admissions committee to believe. I had not yet realized that they had been in my shoes at one time.

While I thought about my answer with my son's wide, seventeen year old eyes staring at me, I realized I wanted to find the truth and tell it to him. "Well," I began, "I worked in a research lab when I first got to college and I was no good at it." A true statement: I was only smart enough to keep the glassware clean and in the proper place. I thought a moment more. "Next I was a teaching assistant and even tutored the non-science majors but I didn't care for that either." I could only remember one student who even pretended to care about what I had to say.

"Between my junior and senior year in college I worked in a nursing home," I continued. It was the last available job in my home town that summer. I fed and bathed patients who could not do these tasks for themselves. I assisted the nursing staff and of course since I was only there for three months I found that the most difficult patients were on my schedule every morning. Tammy, Roberto, and Florence are three patients I still recall. There are a dozen more faces that I remember clearly. Florence and I had the same birth date separated by 67 years. I realized that for the other orderlies and aides, this was the pinnacle of their medical career. They laughed when I said I was going to medical school. Not in a hurtful way. They were full of realism. Nursing school had been a dream for a few of them but any higher educations was beyond their economic reach.

Everyone at the nursing home liked me and guess what, I liked them too. At that point in my life it was the best job I ever had. Despite the fact that I was young and inexperienced I felt a bond with those caregivers. I found I actually enjoyed being with people who were sick, old, paralysed, lame. I felt useful. I loved all of them. And they were grateful for my care. From the experience of that summer job my career was born. I returned to college in the fall with a goal and I never looked back.

When my acceptance letter to medical school arrived the following winter, my premed advisor called me in shock. "I have a letter here that says you have been accepted to Well Known College of Medicine." I had the same letter and the truth be known I was in shock myself. I suspected then what I know now. While Professor Premed Advisor got credit for my acceptance into medical school, the patients whom I cared for and the orderlies and aides that I worked with that summer are the people who were responsible for my success.
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Friday, July 27, 2007

These words

This morning I am struck by how much pleasure seeing my own words in print has given me. Yesterday was not the first time I have enjoyed seeing my thoughts streaming out across the page. In my life, which now spans more than half a century, there is much experience from which to draw. Over the years I have recorded some thoughts and experiences in various journals. Very few times have I ever invited anyone to read them. Now I am not only leaving this journal open but I am inviting people to read it.

So this space feels more than just a bit sacred to me. As I write, I imagine how a preacher must feel stepping into a pulpit. These words maybe mine but the essence of what I say comes from outside myself. Much of what I hope to write here comes from my experience as a local MD. Of course there are other facets of my life that will cast insight into these pages but being a physician is a very important part of who I am.

My sense is that conversation is indispensable. I hope that if you happen on to this space and something resonates with you, you will be compelled to leave some of your words here also. Again, if we are not here for each other, then why are we here?
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Thursday, July 26, 2007

The Local MD

Having now been a physician in private practice for twenty-one years, twenty-six days and about an hour and twenty minutes, it occurs to me that I have become what in medical school was often a derogatory term, the local MD.

The presentation on rounds often went something like this: "This 45 year old Caucasian male was seen last week by his LMD, and diagnosed with a viral upper respiratory infection..." At that point everyone knew that the LMD had missed the diagnosis. Otherwise the poor patient would not have ended up in a tertiary medical center with three consulting specialist, a fellow, a resident and four medical students at his bedside.

What we, the medical students, the resident, the fellow and even the attending hospital physicians did not realize is that we would never know John Smith as well as the LMD. We would never speak to his wife using her first name. We would never be able to recall the names of all his children and know where they were in the world. We would never remember his favorite hobby let alone joke with him about it. Nor would we shed a heart felt tear when we gave him the diagnosis of the aggressive small cell carcinoma of the lung that had landed him in our midst and would kill him in less than three months despite our aggressive treatment that was the best medical science has to offer.

At that point in my life I was very proud to be even the lowest ranking person on the team that was on the cutting edge of the diagnosis and the treatment of the gravest of conditions that plagued mankind. I felt so very lucky that I was being initiated in to this sacred fraternity. That I would soon be able to write "MD" after my name. I am still proud of my vocation yet I believe there is a wisdom that has only come with those twenty-years of practice.

Today I realize what people want most of their physician is that he or she is someone who cares. Yes, we all want "everything medical science has to offer." Yet, what most of patients need is someone who will listen with their heart as well as with their head. Physician eyes are important, not only for seeing signs of disease in the body but for making contact with the patient's eyes where we are often allowed to see into their soul. All of the technology in the world will not replace a warm clasp of the hand or sitting at the bedside to share a few moments of the day along with the test results.

So, I have created this blog. In large part it is a place for me to put my feelings. My hope is that at least some of these posts will resonate with others out there. Not just physicians, but others in caregiving vocations and even those for whom we care. If we are not here for each other then why are we here?
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