Wednesday, February 28, 2007


It’s been known for centuries that the clothes make a man. Dress him up in a military uniform, he’ll look majestic and formidable; put him in a clown suit, he’ll look like a fool. A man wearing glasses appears more intellectual than a man without them, while a man wearing a tank top and baseball cap appears less intelligent than a man without them. If looking put together didn’t make such a big difference, people wouldn’t be willing to spend so much money for just the right look. In the hospital we don’t worry about such vanities, but like anywhere else, in addition to relying on impressions we are susceptible to them. We also feed them: by placing all of our patients in hospital gowns and accessorizing them with iv poles, we make them look, well, sick.

The power of a hospital gown is really quite remarkable. A grown man, independent and strong in his home environment becomes feeble and helpless when gowned and hospitalized; his power turns out not to be stored in the locks of his hair but in the cotton cloaking his body. I’m always amazed at the degree of patients’ transformations at the time of their discharges. The same patients who minutes before look pale, fragile, and older than their years, when returned to their street clothes suddenly appear young and fresh, entirely rejuvenated both in body and spirit. Occasionally, if I’m feeling a little bit uneasy about a discharge, I’ll be reassured by a repeat visit to the patient’s room just as he or she is leaving; dressed for the road and sitting calmly on the side of the bed chatting with family, the patient will look like a different person from the one on morning rounds. Somebody looking so good couldn’t possibly be sick enough to need hospitalization, I tell myself.

A patient sent home a day earlier is something to value these days when economic pressures demand shorter hospital stays. Indeed, many services that previously required hospitalization now are routinely being performed at home: chemotherapy, subcutaneous blood thinners, iv antibiotics. If we really want to get patients home faster, though, the answer may not lie in medicine at all, but in fashion. Just last week the Oscars showed us that people can look fantastic when done up with the right makeup, hairdo, and gown. A careful look at this country’s hospital gowns is in order – surely with the right designer and enough sparkles and feathers, a gown could be created to make the sickest of the sick look positively bright. With hospital stays running a minimum of $1000 a night, there should be budget room to spare. We’ll empty out our hospitals faster than John Edwards can say malpractice. A cosmetic fix rather than a curative one, you say? Well yes, absolutely, as Americans we should play to our strength, and besides, as a beautiful country we should look the part. Our female patients will love us, and the men will discover sides of themselves they never knew. Best of all, our hospitals will be able to guarantee, with absolute certainty, that each and every patient will look better going out than they did coming in. That, my friends, would be something in which the American healthcare system could truly take pride.

Friday, February 23, 2007

Dying on schedule

This weekend I watched The Barbarian Invasions, a Quebecois film about the last days of a man dying from cancer. The man’s son, an investment banker in England, flies home to help take care of his father, going to extraordinary lengths to ensure that he dies as happily and comfortably as possible. Thanks to the son’s efforts, the father’s final days of life are a veritable love fest filled with lavish foods, intravenous heroin for optimal pain control, extended visits from family and friends, video messages from his daughter who is out at sea, and time spent at a peaceful and breathtakingly beautiful lakeside cabin. Then, on a final starlit evening, after all have said their farewells and as if it were the most natural conclusion to a life well lived, the father’s aid helps him end his life with a lethal dose of heroin. The son holds his father’s hand and everybody else looks on approvingly. This, the film boldly seems to state, is dying at its best, on one’s own terms and on one’s own schedule.

Is it such a ridiculous proposition? All of life’s other important events—weddings, graduations, birthdays, celebrations of any kind, really, occur on a schedule. They are better that way: the food stays warm, the band gets booked, the necessary preparations are made, and most importantly, the guests show up. Even in medicine, which deals with problems unconfinable to working hours, we are able to arrange most things on a schedule. If you want to see your doctor, you make an appointment, hoping you’ll still be sick when you finally get to see him. If you need surgery, the surgeon will give you a date and time. An MRI of the head? Book it in advance. Even for our hospitalized patients, it’s rare that a service is provided without the patient first being put on a schedule of some sort. Emergency procedures and surgeries are risky and stressful for everybody, so scheduling them is almost always better, even if the scheduling is for later in the same day. Waiting until a problem becomes emergent is simply bad medical practice.

Emergencies do still happen, of course. In medical school, on explicit instructions from the attending surgeon and in a futile attempt to speed up a surgery, I once hijacked a patient from the ER, commandeering his stretcher and carting him up to the OR myself. Although I got high fives from the surgical residents for this, the nurses and OR staff were less than pleased. I was thoroughly chastised, in fact, and told how much it actually slows things down when patients are carted around without the proper paperwork, before the nurses have had a chance to give each other report. I apologized, but the rush from flying that patient around the hospital at full speed lingered.

Yes, unpredictability and spontaneity make life fun and exciting, but is death really the time when we want them? For healthy people clairvoyance is more likely to be a curse than a blessing; knowing the date and time of one’s death well in advance would certainly precipitate bizarre and unwanted psychological side effects, such as wanton recklessness, or mad last minute attempts to cheat death. For people who are actively dying, though, it seems that the more transparent the process, the easier. Families of dying patients are certainly always hungry for more information about what is happening with their loved ones. Physicians, though, are often less than forthcoming, uncomfortable with predictions and quick to explain that they don’t hold crystal balls. Would we want them to? Surely if dying meant catching an airplane to the other side, we would want to know what time it left so that we could show up to the gate on time with our bags packed. The Vikings buried themselves in their ships because they seem to have considered boating to be one of the best ways to travel to the afterlife; maybe it’s just the Viking in me that thinks knowing a departure time might be nice. Granted, some hopes might be shattered by definitive knowledge of impending death, but after all, those hopes would have been false anyway. For most people, I suspect that knowledge would provide peace and comfort.

At least some warning certainly would be nice. It is the sudden, unexpected deaths that are hardest for families to absorb. People who rapidly go from healthy to deathly ill leave a path of destruction in their wake, giving friends and family no time to adjust to the change in condition or to let them go. The Grim Reaper is perhaps one of the most feared characters in the human imagination, but at least if you see him lurking in the background, you have time to say some final good-byes. A close friend of mine whose mother recently passed away told of how her father called her home from work early on the day of her mother’s death. Her mother was just holding on when she arrived home and seemed to have waited for her to arrive before letting go. Having a chance to say that final good-bye meant a lot to my friend. They were fortunate, but death can be quite difficult to predict, and her mother might have passed suddenly, without notice. There might easily have been no warning.

Often there is none; death comes swiftly and abruptly. A young man, a father, can be perfectly healthy playing basketball one moment, and lay dead on the floor the next. Alternatively, a dying person, having made his final peace, might lie around for days or even weeks in waiting. The farewells are finished, the permission from family members to pass has been granted, and the personal demons have been worked out, but upon closing the eyes, nothing happens. The person experiences terminal insomnia, the most insufferable kind. Who is to begrudge that person a little heroin as a sleep aid, just to help keep his flight to the other side, or to shorten the layover? Who has the right to tell him that he must toss and turn on his death bed?

Most people, I suspect, would answer that God does. But, even conceding God for a moment, is it really He who determines when people live and die? As physicians most of us consider our patients to be in our hands while they are still alive, not God’s; that is, their diseases are ours to cure, or to fail to cure. When we extend lives we certainly don’t feel guilty about keeping God waiting. Why then, can we not hasten death, or put it on a schedule? Great care would have to be taken that it was truly the dying person’s schedule and nobody else’s, but why must we obsess so about securing those final days or hours of life? In the film, at an earlier point when the father admits fear of dying, his caregiver questions him about it and concludes, “It’s not the present you cling to. It’s your past life. That life is already dead.” She makes a valid point—unless you have urgent unfinished business, the process of dying is not about living. Hours spent dying are like hours spent on an airplane: they are to be passed, not necessarily enjoyed.

Phrased in the more familiar language, I suppose I am asking, do we have a right to die? Conversely, do dying people have an obligation to endure the entire natural course of their death, as a final rite of passage? For many people, their religious convictions state that they do. For those with more flexible belief systems, though, hastening death may be a reasonable option. I don’t think I would ever schedule my own death, but for those who prefer an earlier flight to the other side, well, I wish them a peaceful journey. And, in case their plane falters, I’ll be right behind in my Viking longship.

Thursday, February 15, 2007


I’m disgusted with myself. I’m in the middle of a week of vacation and I’ve failed to accomplish anything. I’ve written nothing for my blog, I’ve read one chapter in Rand’s We The Living and a few haiku, I’ve seen one movie (Garden State, which was great until the cheesy ending ruined it), and I’ve watched some uninspired television. I did successfully cook this chicken curry casserole dish of my mom’s yesterday that was fantastic, but other than that I’ve basically spent the whole vacation sleeping. I feel lame even admitting it. Vacation is rare and precious—it’s supposed to be a time to escape residency and remember what it feels like to be a real person, but so far I’ve squandered it behind shut eyelids.

I think the problem is one of pressurization. You know those teddy bears in a can, that pop out when you pull off the lid? That’s the kind of pressurization that I’m talking about. One of the most interesting phenomena in medicine is actually pressured speech, which is seen in some of the psychiatric disorders. You get these people who have just this intense desire to speak, so that they can’t even get the words out of their mouths fast enough. They’re horrible to interview, because as the physician you can’t get in a word edgewise, much less get them to stop talking. You simply have to examine them through the noise, hoping to catch a heart sound or two when they pause to gulp for air. I don’t have pressured speech, but I do suspect that my current hypersomnia is due to pressured sleep. For the last three months, I’ve been averaging about 5-6 hours of sleep a night, which I thought was sufficient, but apparently not. My body, it seems, was just waiting to enter hibernation. (Hmm, maybe humans are more closely related to bears than previously thought. Anybody else been having cravings for raw fish?)

The question, though, is how I was able to pressurize my sleep. Why didn’t I just fall asleep every night for the last three months, instead of all at once now? The answer, I think, is pressurized time. When you’re working eighty hours a week, you don’t really want to spend your free time sleeping. In fact, you really don’t want to spend your free time sleeping. So, the time pressurization trumps the sleep pressurization and you slowly sink yourself deeper and deeper into sleep deprivation. Now that I’m on vacation, though, with time to burn, my sleep can has popped open and I’ve gone comatose.

Pressurized sleep, it turns out, is actually some of the sweetest sleep around. Maybe we should pressurize other things to make them better. Any ideas? (Stay clean on me people, stay clean.)

Monday, February 12, 2007


The Barley Field

Up the barley rows,
stitching, stitching them together,
a butterfly goes.

--Sora (1648-1710) (trans. Harold G. Henderson)

Pretty, no? I'm sure he was practicing for the OR.

Harold G. Henderson, An Introduction to Haiku. New York: Doubleday and Co., 1958.

Monday, February 05, 2007

Playing the favorite

It is the cardinal sin of parenting to divide affection unequally between one’s children. The favored child certainly may flourish, but the disfavored one, starved for attention and encouragement, is assured of failure to thrive. Just as for twins in the womb, when even the slightest imbalance in blood flow can lead to devastation for the malnourished infant, so too for children in a home can parental favoritism disrupt and destroy the growth and development of the neglected child. Hiding it is of no use, for children will not be deceived; they are exquisitely sensitive to any tempering of the affection that is their birthright. Even an abusive parent, if that abuse is consistently applied, is more tolerable to a child than a parent who dotes partially, as the latter’s bias ruins the sibling bond that otherwise makes almost any hardship bearable.

So too with medicine, we should not play favorites among our patients. Regardless of race, religion, class, sex, mental capacity, or disposition, all patients should be granted the same high professional level of care – that is one of the bases for our fiduciary contract with society. We must work to overcome any personal prejudices. Additionally, we must strive to provide the malodorous patient, the tedious patient, the verbose patient, the histrionic patient, the belligerent and verbally abusive patient, and even the patient who refuses treatment with an equal quality of care to that of our most likable patients, regardless of whether doing so requires extraordinary persistence and patience. Because many of these patients, like children, are unable to care for or think for themselves, it becomes our duty as physicians to protect them from their own poor decision-making. For them we must employ a paternalistic model of medicine. Anything less, besides being immoral, would both compromise the integrity of our profession and erode the fabric of our society.

Yet, it happens from time to time that we encounter a patient who strikes some deep chord within ourselves, a patient whose disease ignites within us a powerful rage of indignation. Perhaps the patient is the mother of a medical student, or a physician herself; perhaps a high school teacher, a professional musician, a writer, or a social worker. Someone whose entire being radiates kindness, warmth, and understanding. For this person, we want to do more, to give more, to fight harder. But is it wrong to do so? Must we deny our desire to go above and beyond the call of duty in her care in order to make sure that we do not favor any particular patient? The answer, I think is no. To do so would be to deny one’s humanity, like passing on life-sustaining food when starving or holding back tears when they ache to be shed. No, I say, let us embrace our desire to nurture, to fight for the patient; let us play the favorite! Let us proofread her orders an extra time, search the literature for any new treatments of her condition, spend the time with her that we want and let her know that we care. Because by doing so, in addition to acknowledging our own humanity, we will learn what it means to be great physicians. And that knowledge is something that we will be able to use to elevate the care that we provide to all of our patients, no matter how beloved to us they are.