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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