On Being There

I have always loved hospitals.  I love the smell - alcohol and carpeting.  I love the way they look, too - the avocado with milk colored paint on the walls, the worn vinyl chairs, the scuffed walls of the elevators.  In fact, the very happy feeling I always felt when visiting a hospital was really the biggest reason I knew medicine was the career for me.  I didn't tell people that on my admissions interviews, because it sounds deranged.  But it was the truth, and I never examined the why of it until I was well into my life as a doctor.  One day I had an epiphany and realized that my love of hospitals is really connected to my fears of abandonment.  I like hospitals because 24/7, 365, you can go there for help.  And it will be open.  And the people there will do their best.  That is an amazing and comforting thing to me.

 Probably the best story I can relate that connects this abandonment stuff to being a doctor involves me as a little kid, when my family spent every summer in Japan.  We’d visit my mother’s family and drive around the country visiting the historic sites.  There are many festivals in the summer in Japan, so at night there was traditional folk dancing capped off by giant displays of fireworks, shot off from ships at sea.  I have a lot of fond memories of these trips, and at least one moment that changed my life. 

On our way to visit a Buddhist Temple, we stopped for a picnic lunch by the side of the road one day.  A car stopped near us and a pretty young woman got out of the car.  She was holding a small dog, and she put the dog down on the tarmac.  Before the dog knew what was happening, she got back into her car, slammed the door, and sped away.  The dog chased after the car, running as fast as he could.  The car kept going and the dog kept running down the road until I couldn’t see them anymore.

I’m sure as a little kid I cried and pouted about a lot of things but I don’t think I ever cried as much as I did when I saw that woman abandon her dog.  I will never forget how profoundly I felt that dog’s abandonment.  I felt it to the bottom of my nine year old soul, and I think about that dog and that woman to this day.  

My parents remember this incident as well, because neither one of them understood why I was so upset.  My parents both grew up on farms, so maybe they just weren’t very sentimental about animals.  My father grew up during the Great Depression and my mother during World War II era Japan, so maybe they were surprised to find their daughter was such a emotional lightweight.  My mother’s brother in law, who was chauffeuring us around in his car that day, eventually went to a dime store and bought me a doll to see if that would get me to stop crying.  And eventually, I guess I did. But after that day, I knew what it was like to feel very strongly about something.

I feel very strongly about being a doctor, of course.  I don’t know how you could do this job if you weren’t called to it.  Sometimes it’s hard to put my finger on just exactly what keeps me going during the hard times – being a doctor and trying to do my best at it simply gives a lot of meaning to my life.  Recently, though, I was looking through some old family pictures and I found one of my mother and I that was taken right after that roadside lunch in Japan.  My mother looks vaguely irritated with me.  My eyes are red and I’m clutching the doll.  When I looked at that picture it hit me right between the eyes – what I felt watching that woman leave her dog behind and what keeps me true to my profession are not just similarly strong feelings – they are the same feeling. 

I’m talking here about the need to work against cruelty and have empathy for the abandoned.  I cried when I was nine because I couldn’t do anything about that that woman did.  I cried imagining how that dog must have felt – frantic and desperate and alone – thinking that surely she had just forgotten him, surely the car was going to stop when she saw him galloping behind in her rear view mirror.  And instead of crying about the cruelty of life, now I’m a doctor and I help people deal with the cruelty of the diseases they do not deserve to suffer.  And instead of standing by the side of the road feeling abandoned, I protect my patients from abandonment.  Their health may leave them, and their families may leave them, and their wealth may leave them – they may even feel like their God has left them – but I’m not going to. 

I come to work every day, even when I don’t feel like it, because I want my patients to know that I am around.  I stay late if I have to for the same reason.  I may not be a medical genius every day – or even most days – but I’m there.  I answer my pages because I want people to know that I am available. I couldn’t live with myself if I thought I was cutting corners on being there for patients.  I think it’s a big part of why I love being a hospitalist – unlike the clinic, the hospital never closes. Every hour of every day – the patients can count on – if nothing else – the company of other people.  I like being part of that. 

When I was an intern, I showed up and hung around because I didn’t really have anything else to offer.  I listened to people and tried to explain to them what was going on with their medical problems.  Later I learned enough to do quite a bit (of both harm and good), but the moments I remember are not so much interesting diagnoses or remarkable recoveries but the times I spent supporting folks as they dealt with the cards life dealt them.  I’ve come to realize that as good as you might be at medical knowledge and patient care, that stuff is almost trivial.  It’s an intellectual challenge for me and something that might help the patient.  The heart of the matter for me is standing next to the patient, protecting them, educating them and sticking up for them when times are tough.  You have to do that before you can do anything else – and all it takes is the strong feeling that you are committed, above all else, to simply being there. 

For me, the tough thing about being there is that it’s a constant job.  You can’t be there sometimes.  You have to be there time in and time out.  You have to be there when you really don’t want to.  You have to be there when your family and friends really don’t want you to.   Sometimes the sacrifice is easy – you skip lunch, or stay a few minutes late.  Sometimes the sacrifice is really painful.  The thing about it is, though, that your worth and reputation as a doctor is not about what you are doing currently.  It’s about what you’ve been doing all along.  I’m about 20 years into it and I feel like I’m just beginning to see how worth it all of that time and sacrifice was.

Supreme Court Decision, June 26, 2015: Because We Are Worth It.

June 26, 2015 at 12:48pm

Although my hippie brother did a good job teaching me that an open mind was the most important characteristic you could have and made a space for me in my very strict family to adopt a live and let live attitude towards my fellow man, I can’t deny that the general message I got growing up was that what was wrong with being gay was not just that the Bible said so, but also that there was something trashy, seedy, hedonistic and worthless about it. It was a lifestyle that had no integrity of character - Christian or otherwise - and that was why it was not a good idea to “go there.”

Well, aside from the fact that there is no “going there,” which from just being a believer in science I would have eventually realized, what really showed me differently was what happened when I showed up to life as an intern at the height of the AIDS crisis. You see some cold hard truths about human nature and individual character in the hospital, when life and death are on the table and everything gets very, very real in a blood and guts kind of way.

I saw people abandoned by their loved ones because of the stigma of their disease. I saw acts of devotion that were so open, honest and self-sacrificing that they made me ashamed of myself. I saw selfishness and narcissism and I saw acceptance and I saw love. And it was the quality of this love that I will never forget, because I saw some really, really high quality relationships that stood the test of awful illness and came out the other end stronger. I realized what my hetero culture had taught me to think about homosexual relationships was misleading propaganda. There were examples here of the Real Thing and it was obvious to anyone with eyes to see or ears to hear.

There are of course people who mess up relationships and people who aren’t ready for one, and people who get into something only to change and need out - but that happens everywhere. The idea that gay relationships were somehow pear shaped or laughable was a bad seed that got planted in me, and I am forever thankful for the experiences I’ve had, made possible by the people who helped me become a doctor, that allowed me to root out that bad seed.

Today we rooted that bad seed out of the law of our country and I am very proud. I am thinking a lot about Dr. John Carey, who ran the Special Immunology Unit at Case Western when I was a resident there in the mid 1990’s. Dr. Carey died in an accident when I was still in residency, so I think of him with a mix of sadness and happiness. He was the first person I ever met who referred to his partner as his husband, and he did it when he was chatting with me after rounds one day about life instead of medicine. He told me that his husband always set the table for dinner, and even if they were just eating carry out Chinese, or a peanut butter sandwich, they always ate off the “nice china” that he’d inherited from his mother. Because they were worth it, he told me.

We are all worth it. I’ll eat off the nice china tonight in celebration.

Why Graham Chapman Is My Spirit Animal

Here's a link to a SIUSOM podcast in which I discuss Medical Humanities.

http://www.siumed.edu/lib/podcast/SoundQuery2-Todd.mp3

Credible Threat

It was one of those situations where all your questions were answered the minute you laid eyes on the patient.  The ER had described him as having decompensated heart failure and uncontrolled high blood pressure.  He was 'non-compliant' with his medications and needed to be admitted.  I told the doctor I'd be down to the ER shortly, and that we'd tune the patient right up.  This was met with a snort.  "Good Luck," I was told, and hung up on.

Bill was big.  400 plus kind of big, and in a constant sweat, and wearing clothes that hadn't been washed in a while.  He needed a haircut and a shave.  And he wouldn't look you in the eye.  And there was a large ball of tinfoil in his fist.

I don't think it took a great deal of medical expertise to realize that paranoid schizophrenia was Bill's real issue (and if you didn't realize it yourself, it was documented all over his chart) - but his heart and his blood pressure needed some work, too.  So we sent him to the medical floor, where the constant stream of people coming in (the guy to put in an IV, the nurse to hook up his Lasix, the echocardiographer with her ultrasound machine, the chaplain, the med student, the resident, the food server), the beeping of the monitors and the blare of his neighbor's TV whipped his paranoid delusions into a frenzy.  He started telling nurses that he was a CIA operative.  He was sure there was poison going into his vein and pulled out his IV.  His tin foil was taken away from him, leaving him unprotected from the harmful rays of cell phones.

As the afternoon wore on, Bill got more and more out of control.  He told nurses that he was prepared to defend himself "to the death" and pulled a plastic butter knife from somewhere on his person.  They called security.

If I could, like Superman, fly around the world clockwise and turn back time, the rest of the story would go like this.  Security removed the plastic butter knife from his hand and Bill was taken up to the Psychiatric floor, where things were quieter and his medications had a chance to start working, and Bill was attended to by a whole bunch of folks who were concerned about his well being.  He got a little better and left the hospital.

Instead, security called the police.  And the police came and arrested him for threatening the nurses with a deadly weapon, and cuffed him and took him to jail.  All of this was down without any notification or consultation with the physicians who were caring for him.  An intake check revealed that he had a website on which he espoused his many conspiracy theories and discussed his ideas to foil the government plots that had been set in motion against him.  He was deemed a credible threat, and Homeland Security was notified, and some local FBI agents came to the jail to interview him.  Finding him relatively harmless, he was eventually let go.  Not returned to the hospital, for the help he still needed - he was simply sent home.

Home for Bill was the Bel-Aire.  The walls were paper thin there, and a few nights after his release a loud domestic argument in the room next to his agitated him and he began banging on the walls, and shouting threats.  The police were called.  They kicked in his door.  He grabbed a nearby plastic fork from one of the many take out cartons that were strewn around his room.  The police shot him in self defense.  He died.

I don't think it takes any sort of special expertise to realize that jail was not the proper destination for Bill.  He was not a criminal, he was a person with a mental illness.  He was a patient in need of medical care right up to the moment when the police decided to take control of the story of his life and, without too much thought or investigation, end it.

Every time I pass the Bel-Aire, I think about Bill and I feel guilty that I've allowed the police's version of Bill's story stand without countering with mine.  He was literally framed.  The paper reported it as a story about how dangerous it is to be a cop.  I agree - it's dangerous.  But surely we can work together to see people as themselves, not as threats to be eliminated. I wish so much that someone had called me - the patient's physician - instead of taking him to jail or before releasing him from jail.  The police couldn't do anything about Bill because Bill was not a law enforcement problem.  He was a patient.  He was my problem, and I was willing to help - in fact I was in the very midst of helping when he was taken away in handcuffs.  I'm still really angry that Bill's life ended the way it did.