Great Doctors, Terrible Outcome


I stood silently by his bedside in the Intensive Care Unit listening to the rhythmic hissing sounds of the ventilator as it repeatedly pushed oxygen into what was left of his lungs. “Poosh, poosh, poosh,” the sound a constant reminder of how sick he was. On the monitor above the bed the tracing of his heart rate kept its own rhythm, an almost mocking evidence of life. Although he felt nothing, I felt a pain deep in my stomach and an ache in my heart. I asked myself, “How did we end up here?”

He seemed perfectly healthy a few weeks earlier when he came to see me in the office for his check up. His blood pressure was good, his heart was strong, his lab work was normal. He exercised regularly and was in near perfect shape for a man in his early seventies. The only blemish on his health record was a distant one. He had once been a heavy smoker but had stopped 10 years earlier.

If his visit had been scheduled a few months earlier I would not have ordered any additional tests, but he came in shortly after a study on lung cancer had been announced. Less than a month before his physical I had been a part of a team of doctors involved in drafting a new lung cancer screening protocol for the hospital. The recent study had shown for the first time that early detection of lung cancer could have a positive impact on survival. The evidence revealed a 20% decrease in lung cancer mortality when patients over the age of 50 with a heavy smoking history had annual CT scans to screen for small tumors. He was the first patient of mine who met the criteria for testing and I enthusiastically recommended the test.

I was stunned when the test revealed a cancer but was hopeful that we had found it in time. That was, after all, the purpose of the test. I referred him to the thoracic surgery team for removal of the tumor. The surgeon, one of the very best at his craft, met with the patient, did the appropriate evaluation and scheduled him for surgery. Everyone was upbeat and hopeful. The day before the operation he played basketball in the driveway with his grandchildren.

The first hint that things might not go as hoped happened in the operating room. The initial plan had been to resect the tumor and leave most of the lung intact. The plan fell to the wayside when the surgeon discovered that the tumor was larger and more invasive than the scan had suggested. The cancerous mass had wrapped itself around the bronchus, the air tube supplying a major portion of the lung. The surgeon had no choice but to remove the entire lobe, significantly more tissue than he had planned. The doctor was disappointed, but was still confident that he had removed all of the tumor and the patient had a good chance at recovery. He sewed the patient up and moved him to the ICU, where all chest surgery patients go after leaving the recovery room. The plan was to keep him on the ventilator for a day or too while the lungs healed and then allow him to breath on his own.

That never happened. The years of smoking had caused another previously unknown problem. Although he was physically active, he had undiagnosed COPD, chronic obstructive pulmonary disease. The combination of the stress of surgery and the chronic disease were too much to overcome. The remainder of his lungs were too diseased to support him breathing on his own. Lung specialists, heart specialists, and other specialists were all asked to help but there was nothing anyone could do. He was never going to get off of the ventilator. It was up to me to inform the family of the bad news.

The conversation with the wife was intense. The question was asked, “What went wrong.” The answer was both nothing and everything. Each and every doctor had done everything exactly right. I had ordered the right tests, as had the surgeon. The surgeon had made no mistakes during the operation and the correct medications and treatments had been prescribed. In spite of our combined efforts  he remained unconscious and dependent on a ventilator. It was a hard message to accept. The wife and I agreed to wait a few more days to give him a final chance to respond, praying for a miracle. It was understood that if no improvement came that we would have to let him go. A few days later we said our tearful goodbyes.

His death was a devastating loss for all who were involved in his care. I found myself wishing I had never ordered the CT scan and grieving the decision to proceed with surgery. I wrestled with the reality that while his death from lung cancer was a certainty, it need not have happened so soon. I will never forget the anguish of his wife as we stood at his bedside, nor the heartfelt tears in the eyes of the surgeon when he told me there was nothing more that he could do. He was a good and kind man and the loss was real.

I have also never forgotten the truth that excellent care does not guarantee good outcomes. Life happens, and death happens, even when doctors do everything right. I am reminded not to assume the worst when bad things happen and to avoid placing blame and pointing fingers. Sometimes our best just isn't good enough, in all areas of life.

- Bart

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A Sunday School Lesson for Grown Ups


Important lessons can come in unexpected places. I learned a crucial life lesson while in training to be a Sunday School teacher. I expected to learn where my class was, how to get supplies, and what the curriculum was. I learned all of these things, but it was during a discussion of how to interact with children one-on-one that the most profound lesson came.

The Children’s pastor told us, “Never praise a child for their appearance. Praise them for their character.”

She based her instruction on the words God had spoken to the prophet Samuel when he was seeking the man who was to be the next king of Israel. Samuel looked to anoint the tallest and strongest man as king but God corrected his thinking saying, “the LORD sees not as man sees: man looks on the outward appearance, but the LORD looks on the heart." (1 Samuel 16)

She told us that we lived in a society that valued superficial achievements and attributes but that we should be different, for a person can be externally beautiful and yet ugly inside, intellectually brilliant but selfish and unkind. There is nothing wrong with pretty dresses, cute bows or cool shoes but these were not things to praise in Sunday School.  Our job was to teach children what God values, goodness of the heart. We were to do this by praising such things as kindness, obedience, generosity and love, those things that all children can do regardless of physical attributes or giftedness. 

I have never forgotten her words, for they have applications for grown ups too. I do not have to look far or wait long to see proof that our world praises the wrong things. In my profession I know many physicians who financially successful and clinically talented yet uncaring and rude. I have patients who were beautiful on the outside and respected in their professions who hide secret additions and abusive behaviors. I live in a culture in which it is possible to be famous and popular, to have millions of followers on social media and millions of dollars in the bank and yet be a selfless failure in important relationships. Many “successful” people are moral failures.

I want to be different. I want to be a success in the eyes of God. To do this will require me to work on my insides, the heart that only he can see. I may make less money and be less successful but is fine with me, for I may make a difference in the lives of others, which is of far greater value.

- Bart

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Cancer Doesn't Care

Cancer does not care what you think or what you feel. It does whatever it wants.


Several months ago a young man came into our office with a strange looking lesion on his scalp. I was not sure what it was but I knew it wasn’t normal. It was big enough and weird enough that I referred him on to a specialist for the biopsy. My worst fears were confirmed when the pathology report came back as a very rare type of melanoma, the most deadly type of skin cancer. I referred the patient to a cancer specialist for ongoing treatment.

The cancer doctor immediately recommended that he see a plastic surgeon for a wider excision to make sure that none of the cancer was missed and to also biopsy a lymph node in the area to make sure the cancer had not started to spread. The patient didn’t want to go. He didn’t want the scar, didn’t want to deal with the recovery, didn't want to believe it was serious. He refused to listen to the oncologist’s warnings not to trust that all of the cancer had been removed in the initial incision. The patient refused the doctor's advise and decided to instead try herbs and holistic medicines.

The cancer wasn’t impressed with the patient’s interest in natural remedies, nor did it care that the patient believed he was cured. It spread anyway, and it spread everywhere. Lungs, liver, and bones all had tumors within a matter of months. The patient is in his early twenties and is too young to die. The cancer does not care. The odds for long term survival are not good. 

Cancer never cares what we want or think. It is a heartless killer. Colon cancer does not care that you are afraid of having a colonoscopy, is not moved by your embarrassment about having someone insert something into your rectum, or worry that you can't take the time off of work. It ignores all of our concerns and attacks who it wants when it wants. It will attack 1 in 20 Americans and do what cancer does. If not caught in time it will spread and it will kill.

Breast cancer does not care that mammograms can be uncomfortable or that you have sensitive breasts. It does not care that no one else in your family has had cancer, or how big or small your breasts are. It will attack 1 in 11 American women and do what cancer does.

Cancer can not be wished away or ignored into oblivion. It does not care how positive your thoughts are. It does not care how many children you have or about your retirement plans. It moves at its own pace on its own timetable. It does not discriminate. It does not care about the color of your skin, your religious faith or what you do for a living. For many cancers it does not care whether you or male or female. It does not care whether you or rich or poor. It can attack anyone and when it does it will try to do what cancer does. It will spread and it will kill.

So what can we do? Like any enemy it is best to attack when the opponent is weak and small. While early detection does not always guarantee victory there are cancers for which it truly matters, such as breast and colon cancer. Smart people get colonoscopies and mammograms done when they turn 50. Smokers can stop smoking, and those who have smoked too long and too much can get CT scans to look for cancer after age 50 as well. When diagnosed with cancer we can listen to our doctors and pursue aggressive treatments, and trust their opinions more than our feelings. We deny denial a chance to harm us. We can do these things because we care about ourselves and our families, even when cancer doesn’t.

- Bart

Thanks for reading and sharing. More importantly, thanks for getting your colonoscopies and mammograms!

Where Have All the Patients Gone


It was time to get rid of some old charts. The garage attached to the converted home that is my office had reached the maximum allowable clutter and we needed to clear some space. Charts for former patients that had not been seen in more than 7 years could be shredded, charts for active patients needed to be saved. I hired a college student for the task, to painstakingly check computer records to see which of the several thousand charts were which.

It became clear early on that it was going to take dozens of hours for the student to complete the task so I decided to help with the job. I realized that I could recognize the names of active patients immediately, and set them aside so the student did not need to deal with them. To that end I spent the afternoon of the fourth of July separating out these charts I recognized. It was an unexpectedly depressing task for I came across many familiar charts that bore the names of former patients I had not seen in years.

I saw the names of babies I had delivered whose families had moved away as well as other patients I had cared for who had gone home to family or followed job assignments out of state. I read the names of several people who had passed away, their names bringing memories of the sorrow of their last days. Some names brought smiles as they were associated with a patient who was quick with a joke or a story.

Some names brought stabs of pain bringing to mind patients who had left my practice in anger, including a vivid memory a patient who was angry that my chart notes had impacted an insurance purchase.  He had once given me an engraved gift for the care I provided his family. This was forgotten when the insurance denied his application. For him, all of the care I had provided meant nothing compared to an elevated premium.  He called into question my character and competence. I never saw him again. Other names, of parents who had left over my position on vaccines or antibiotics, also brought sadness. There were many other patients who had simply disappeared from the practice for reasons unknown.

Some of the negative interactions I recalled caused me to stop and ponder the changes that had occurred in me over the years. I realized that modern day Bart would have handled many of the situations differently. There were times I could have been kinder, could have listened better, could have explained better, and could have been more gracious. I realized that if I had been better, done better,  some of the lost patients might still be a part of my practice.

I sifted through thousands of charts that day, overwhelmed by the reality that so many people had passed through my office doors and humbled by the fact that I had been privileged to care for so many.

Out of the multitude of memories and emotions I confronted that day arose a sense of purpose. I realized that there is never a guarantee that any relationship is going to endure. Each patient encounter my be my final opportunity to love and serve someone. With this in mind it is my goal to practice medicine in a way that honors that reality, to never waste a chance to be kind and gracious. It is my prayer that in so doing I will have a positive and lasting impact, to leave each person with an enduring positive memory, that the sight of my name will one day bring a smile.

- Bart

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The Stranger in the Wedding Pictures


It was intended to be a quick dinner at a casual local restaurant, the kind where you order at the counter and they bring food to your table. We ordered pizza, salad and tri-tip and found a place to sit. Shortly after we sat I realized I did not have my phone, meaning the answering service could not reach me. I got up to walk to the car and see if I had left it there. As I headed for the door a party of about 12 people caught my eye.

They caught everyone’s eyes, for they were a wedding party. A very young bride in a wedding gown, her new soldier husband in his dress uniform, a few bridesmaids and what I assumed were their parents were seated in the middle of the dining area. In the center of their table was a small two tiered wedding cake, with red trim and bride and groom figurines perched perfectly on the top.

Thoughts about them filled my mind as I went to my car. I thought of how young they looked, and remembered how excited I was when Lisa and I were married at nearly the same age. I thought of him in the military and wondered if they would soon be separated. I reflected on the modesty of their celebration. It seemed to me that their choice of venue meant that they must not have had much in the way of material wealth.

They were strangers to me but I felt a strong desire to bless them and encourage them. I knew it would be strange and perhaps awkward, but I decided to give them a gift. I took a few bills out of my wallet and folded them tightly so as to be discrete. As walked by their stable I stopped across the table from the bride and groom. I reached out my hand as I said, “Congratulations!” and combined a handshake with the handing of the gift. I walked quickly away, not wanting to intrude any further.

A few moments after I rejoined my family I heard a voice over my shoulder saying “Excuse me.” It was the bride and groom. In her hands she held a few slices of their wedding cake. “That was so nice of you, we wanted to say thank you!” I was overwhelmed at the kindness of their response, blessed that they had included us, strangers, in their celebration. I was also excited at the prospect of cake for dessert. (It was delicious, confirming my decision to hurry through the healthy portion of my meal.)

The cake was so good that my wife and daughter wanted to know where it was made. Somewhat embarrassed at the additional intrusion I made my way back to their table. “Sorry to intrude, but the cake was so good, my family wanted to know where you got it.”

The bride smiled, and asked if we wanted more! I politely declined, and she said she would write down the number of the bakery. I turned to go but before I could walk away a woman who appeared to be her mom said to her, “Wait! Don’t you want a picture?”

Before I knew what was happening I was posing for a picture with the bride and groom. I was both touched and embarrassed, and said, “Wedding pictures with a complete stranger!” We exchanged names (They are Siria and Damion) and shook hands, and I again congratulated them before returning to my table, unable to repress a smile.

It was one of the best dinners I have ever had. The few dollars I had given them as a gift were more than worth it. How often does one get to share wedding cake with strangers? I doubt I will ever forget their smiles, their grace and their kindness. I know they will never forget me, for I will forever be the stranger in their wedding photos!


Please join me in praying for this couple as they start their lives together. Her life as a young army bride will almost certainly be challenging. Pray for his safety and their happiness and for many years of joy together.