When Marriage is About Winning, Everyone Loses

His marriage was in trouble. He and his wife had not spoken for over a month. He left the house early and come home late in order to avoid any interaction. I asked him what the cause of the problem was and he told me a story of his wife’s unreasonableness, vindictiveness and spite. He had made a small mistake, broken a small promise and his wife had labeled him as a terrible person. He was not considering divorce but he did not see any way forward. His wife was immovable in her anger.

What he did not know was that his wife had been in to see me a few weeks earlier and she had told me an entirely different story. As he described it he had intentionally deceived her, not broken a small promise. She told a story of incredible deceit and malice which culminated in terrible heartbreak.

As I listened to him relate his version of the story I found myself wondering what the truth was. The stories were so directly contradictory that reconciling them into one consistent narrative was impossible. As I did not know who to believe I struggled to give him advice. I ended up giving him generic advice to pursue counseling and to love his wife as best as he could.

Our conversation lingered in my mind after he left the office. I had known the family for years and was the doctor who delivered their youngest daughter. They had always seemed like nice people, she was the sweet wife and mom and he was the hard working business man. They both had talked of church and faith and a happy home life. I wondered how much of what I had been told in the past was true and what was false.

I thought of how in each of their stories there was clearly an effort to paint the other in a negative light. In the areas where their stories aligned they had each emphasized the parts that made themselves look good and the other look bad. It was as if they were more concerned with looking good in my eyes than they were about resolving their differences and solving the problem. I was certain that they had both made serious mistakes, had both been vindictive and both needed professional help, but neither of them were interested in dealing with these issues. They wanted the other person to change.

It seemed that the one thing neither of them was thinking about was how their actions were impacting their daughter. I wondered how she was doing, what damaging lessons she was learning about love and marriage. I wondered if, like me, she was hearing partial truths and and partial lies from each of her parents, if she was being asked to take a side in the dysfunction. She was the only innocent party in the dispute yet she was the one who was going to be harmed the most.

I wonder how many of the families I see are similarly damaged. We live in a world where few people are willing to first look at themselves when conflict arises. Sacrificial love, which should be the foundation of every marriage, is becoming increasingly rare. Winning has become the essential marital value in America.

Sadly, when winning is the value, everyone loses, especially the children.

Bart

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A Dying Patient, Deceitful Doctors

He was dying. There was no cure for his pancreatic cancer, no way to halt the inevitable, so he lay in his hospital bed and waited, day after day after day. Every three days or so he received a blood transfusion. His initial surgery for the cancer, performed two years earlier, included the removal of a section of his small intestine. This was followed by radiation treatments that damaged the area where the intestines were sewn back together, causing a large, bleeding ulcer.

Under normal circumstances an ulcer like his would be treated with surgery. Terminal pancreatic cancer is not a normal circumstance so the decision was made to treat him with periodic transfusions, keeping him alive until the cancer killed him. In addition to bleeding the ulcer also prevented him from eating a normal diet. He was severely malnourished and his strength had faded away. His weakened condition made it difficult for him to walk and his need for repeated blood transfusions rendered him too sick to be discharged from the hospital. He was resigned to spending his remaining days in a hospital room, occasionally moving from his bed to a chair. It wasn’t much of a life but he didn’t have long to live anyway.

He was in a VA hospital, transferred there after he reached the lifetime maximum on his private insurance plan. He went from the personal care of a private hospital to the impersonal care of the Veterans Administration. At the VA inpatients did not have a personal physician. They were cared for by a team of doctors in training. The team consisted of a third year Internal Medicine resident, two Internal Medicine interns and two medical students, all supervised by an attending physician. On the first of every month the team changed and the patient was introduced to a new group of doctors, all of whom were new to him, none of whom had ever read his chart. As he was a chronic patient his chart was several inches thick and contained over a year’s worth of his medical information. It was so thick that no one bothered to read it.

I took over his care in January 1989, my final year of medical school. After hearing his story form the other doctors on the team I expected him to be the stereotypical grumpy vet. He was anything but. He was kind, appreciative and gracious. He had accepted his fate and come to terms with his condition. He expected little from the care team and was grateful for any conversation. I genuinely liked him.

One night when I was on call I decided to be the first person to read his entire medical record. It was a slow night so I poured myself a cup of coffee and started flipping pages. I reviewed the records of blood transfusions, lab results and the portion of physician notes that were legible. As I thumbed through the pages I came across a pathology report from the Mayo clinic.  As I reviewed the report my jaw dropped and my heart skipped a beat.

He didn’t have cancer. The pathology report from the Mayo clinic was a second opinion on the specimen from his original cancer surgery. The expert review stated that the correct diagnosis was chronic pancreatitis, not pancreatic cancer. He did not have a terminal disease, he had not needed the surgery, nor the radiation. He had been completely misdiagnosed. Even more troubling was the date on the report. It was over 2 years old.

I sat back in my chair and wondered what to do. All of the treatment decisions and recommendations for the last two years had been based on a lie. He had been told he was incurable so he had never been offered curative treatment. He had wasted away from a bleeding ulcer because he was told he would soon be dead from cancer. He didn’t have cancer, which meant that if he regained his strength he could have surgery to treat the ulcer. If the ulcer could be treated, he would no longer need blood transfusions. If he no longer needed blood transfusions, he could go home.

I called my senior resident and showed him the report. “We have to tell him,” I said, “this changes everything!”

His response stunned me, “You can’t tell him,” he said firmly. He explained that the decision would be up to the attending physician as he was the one who would be held responsible and liable for the information and its consequences. The resident was concerned about malpractice liability, afraid that the patient might be angry when he learned of the misdiagnosis. He did not want anyone mad at him for informing the patient and he did not want me to inform the patient either.

I was not at all happy with his response. It seemed to me that the patient had a right to know the truth and that we had an obligation to tell it to him. In my mind there was nothing to discuss or debate. I shared these feelings with the attending physician at rounds the next morning. He was as unconvinced at my argument as the resident had been. He felt that the patient had potentially reached the point where he was not going to survive, with or without cancer, so there was nothing to be gained by telling the truth.

I refused to accept his answer. I knew they felt that it was not a medical student’s place to challenge the opinions of superiors but I felt responsible to the patient. I pushed for additional review from the hospital ethics committee. My persistence paid off. An ethics consult was requested.

Later that evening I found myself with 7 physicians crowded into a room that comfortably held 5 people. I was the least experienced person present but I was the one presenting the patient’s case to the ethics committee of the VA hospital. They listened attentively to all I had to say as I presented the patient’s case to them and as they listened to the concerns of my resident and attending. It did not take them long to reach their decision. The patient had a right to know everything about his care and diagnosis.

The next morning I told the patient his correct diagnosis. I told him that he did not have cancer and that if he regained his strength he might be a candidate for surgery to cure his ulcer. He was appreciative and gracious. I ordered a nutrition consult to see what we could do to improve his overall health.

It was too late. The patient died a few days later.

Although my efforts did not change the course of the patient’s treatment or the ultimate outcome my experience with him did have value. It changed me forever. I made myself a promise that what had happened to him would never happen to a patient under my care. I vowed to be thorough, to be complete and to be diligent. No chart would be too thick, no history too exhaustive, no patient too complicated to ignore or dismiss. I realized that there would be patients for whom quality care would require uncompensated hours of chart review and I promised myself that when those patients came to me for care I would invest those hours.

Almost 20 years have passed but I have not forgotten my promise. Two weeks ago a new patient came to see me for the first time. He brought with him a list diagnoses that included congested heart failure, diabetes, hypertension and chronic pain along with an extensive list of medications. In keeping with my promise, I scheduled him for an hour long appointment. During that appointment I logged into the hospital system and reviewed his lengthy history. Halfway through my review I came across an echocardiogram report. The report described a perfectly functioning heart. The diagnosis of heart failure, one that he had carried with him for 8 years, was incorrect. The diagnosis had been handed down from one doctor to the next, unquestioned, for all of that time. I did not hesitate to tell him what I had found.

I ordered additional testing and referrals so we could plan a new course of treatment. As I filled out the referral request and entered the medications into his chart I was again reminded of the patient from the VA, and I was grateful for the lessons he taught me. Good medicine takes time. Good doctors invest as much time as is needed.

-Bart

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Can Anybody Make America Great Again?

Donald Trump says he wants to make America great again. This is a catchy slogan and a worthwhile goal but it lacks clarity. While Mr. Trump has repeated the slogan ad nauseum he has yet to offer meaningful details on two important items. He has not defined what it was that made America great in the first place or what steps he will take to restore the greatness that has been lost. I don’t believe Mr. Trump has an understanding of either point. His world view is too simplistic and his understanding of history too limited.

He is not alone in his struggle to define the essence of American greatness. This election cycle has seen many definitions. On the Republican side the tendency has been to emphasize the founding documents of our nation and the principles espoused therein. On the Democratic side the emphasis tends to be on our history of fairness and equal rights. Both sides generally agree that the American economy has been exceptional in the past and should be in the future. Who is right? How do we make America great?

I have come to the conclusion that both sides are wrong in their explanations and in their solutions. American Greatness began not in a document or a policy but as all greatness does, in the hearts and minds of people. The greatness that led to the war for independence arose from the hearts of men and women who believed that men had unalienable rights that came from the Creator, not from a king. The unyielding belief in the value of every man ultimately gave birth to the nation. It was belief in something greater than led to greatness itself.

Every great deed done by Americans, from freeing the slaves to fighting tyranny in two World Wars, was done not for economic gain or personal reward. Greatness came about because there was a shared belief in doing what was right, as well as a shared belief that rightness was defined by the Creator. Deeply held beliefs that rightness was both desirable and attainable led men to set their personal interests and safety aside and fight for what was right. Moral clarity led to clarity of purpose and national success was the result.

I believe it is the loss of moral certainty, the disappearance of common definitions of right and wrong as defined by Someone Greater than us, that has resulted in America’s decline. We are becoming a nation where pleasure and self-preservation have become the greatest values. Doing what is right and good is no longer a primary consideration in the minds of most Americans. A recent survey of Millennials gives credence to this new morality (or amorality). When asked how they would make an important moral decision, only 22% of those surveyed said they would choose based primarily on what was right. A plurality said they would choose solely based on what was in their personal best interest.

A nation of individuals pursuing individual goals will never achieve greatness. A nation that demands excellence from neither its leaders or its people cannot hope to excel. If we want to make America great again, we will need to rekindle the desire for goodness and greatness in our hearts. We need to desire rightness and goodness more than pleasure and comfort, so much so that we are willing to sacrifice ourselves in the pursuit of the right and good. Then, and only then, can we make America great again.

-          Bart

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As Serious as a Heart Attack

A knock on the exam room door interrupting a patient visit is usually one of two things, a call from another physician or a patient with chest pain. It wasn’t a doctor. It was about a longstanding patient in his 60’s who was having chest pain. I took the call expecting to speak with the patient but instead found myself talking to his wife, (he was playing the part of the stereotypical male and had refused to call me) she was calling from home worried about him. He was driving back from work with pressure in his chest and in a cold sweat.  The symptoms were so concerning that I was puzzled they were even calling me. “Tell him to pull over and dial 911,” was my firm advice.

A few minutes later another knock came. This time the patient was on the phone. He told me that the pain had resolved and he was feeling better. As the pain was gone and he was only minutes away I told him he could come to the office for an evaluation.

When he arrived I inquired further about the nature of his pain. “It isn't really pain,”he said, “it is a pressure, like I have to burp. When I burp I feel better.” He went on to tell me that he had experienced pain like this in the past and that he had been previously diagnosed with acid reflux. He was confident that it was not heart related. He was still pain free and he denied any exertional component to his pain so I thought he might be right. I ordered an electrocardiogram anyway.

I went in to see the next patient while the nurse hooked him up to the ECG machine. A few minutes later I had the report in my hands. There were some mild changes in the lateral leads, minor enough to be possibly normal but significant enough they could be associated with decreased blood flow to the heart. He was comfortable and still certain it was indigestion so I decided to compare the ECG to one done previously.

He reported having an ECG done prior to a previous surgery so I logged into the hospital system to search for the report. I couldn't log in! I found myself locked out of the system due to a password problem. I had the staff call the hospital support desk while I went back to the other patient. I had decided that if the ECG findings were different from the previous one I would need to send him to the emergency room. If the findings were not new I would treat him for indigestion and send him to the cardiologist.

Twenty minutes later I still couldn’t log into the hospital system and did not know what to do. I decided to search for his paper chart in the garage attached to my office to see if there was an ECG from several years earlier. I found the chart and opened it to the ECG section. There I found a very faded ECG. It was perfectly normal. The changes on his ECG were new. I realized it might be his heart after all.

I went back into the office to share the news with him. When I walked into the room he told me the pain was returning. I quickly gave him a dose of nitroglycerin and an aspirin and had my nurse call 911. Within minutes the medics were on the seen and loading him on to a gurney for the trip to the emergency room.

The next day I received the report from the hospital. The major artery to the left side of his heart had been 95% blocked. The cardiologist had performed an angiogram and placed a stent. Remarkably, he was already on his way home. As I read the report I was struck with how close he had come to having a heart attack. His insistence that it was indigestion could have easily resulted in a missed diagnosis.

His story reminded me of some fundamental medical truths-

  1. Denial is a dangerous thing.
  2. All chest pain is serious until proven otherwise
  3. Never trust a computer when you need it.
  4. Men, especially married men, are often stupid. (just ask their wives)

- Bart

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Missing at the End of Life- Courage

I talk about death a lot, almost every day. With healthy patients I talk about the need for advance care planning and the need to prepare for the unexpected. One of my common questions is, “If you walked out of my office today, fell and hit your head and suffered brain damage, have you made it clear to others what your wishes would be?”

The answer is almost always, “No.”

I then talk about “advance directives,” legal instructions about how one would want to be treated if something happened and they were unable to speak for themselves. I typically hand the patient a Durable Power of Attorney form that includes a section in which patients can clearly state which essential functions they equate with an acceptable quality of life. I tell them, “If you and I went to a local nursing home and walked the halls, the chances are that we would eventually see someone who was so debilitated we would say, Don’t ever let me end up like that!” I say that if we were asked why we would not want to be in such a debilitated state we would say. “Because they can’t _________” and that we would fill in the blank with those functions we believed essential, such as the ability to communicate, recognize our family, feed ourselves and do personal hygiene. My description is usually met with nods of agreement, as I have learned that most people have a clear understanding of what an unacceptable quality of life would look like for them.

While there is near universal acceptance of the idea that life can reach a point where it should no longer be prolonged it is still only a fraction of patients who take the time to write their wishes down. Less than half of the patients with whom I have these conversations takes the time to fill out the forms I give. I do not know if it is due to denial, forgetfulness or laziness but  regardless of the motive, the result is the same. Most people have not clearly communicated their wishes regarding end of life decisions. When terminal events occur, too many families find themselves in the hospital discussing life and death decisions with a doctor they have just met. As these conversations are uncomfortable and difficult patients can and should make their wishes known.

Sadly, I have learned that even clearly communicating one’s wishes is not a guarantee that they will be honored. I once had a patient who was terminally ill and who had clearly stated her wishes regarding end of life care, so much so that she had completed paperwork instructing physicians and paramedics to never resuscitate her if she went into cardiopulmonary arrest. As clear as her wishes were, her family did not follow them when the time came. Fear and panic set in and those wishes were not communicated to the paramedics when they arrived. Against all of her known wishes she ended up on a breathing machine in the ICU.

Her case reminded me that it is not enough for physicians to discuss end of life issues with patients. We need to encourage patients to have discussions with their families as well. Frank discussions need to be held so that everyone knows exactly what they will do when the moment arises. Patients need to be certain that family members not only know their wishes but are committed to honoring them when the time comes.

Physicians need to do their part as well. We need to be committed to supporting our patient’s wishes and making sure they are honored. On too many occasions I have seen physicians continue treatment in order to appease the demands of unsupportive family members. The adage seems to be that dead patients don’t sue but their families can. At times some doctors are more interested in avoiding a lawsuit than they are in honoring a patient’s wishes.

It is easy to criticize doctors for continuing needless care but there is plenty of blame to go around. Hospital administrators and lawyers need to step and support physicians and make it easier for them to do the right thing. Efforts need to be made to change the culture of healthcare around the end of life. Death needs to be treated as a normal outcome of life. It cannot and should not be viewed as a sign of failure. The clearly stated priority for terminally ill patients needs to change from doing everything possible to prolong life to doing all we can to provide comfort and dignity at the end of life.

This change will require courage. Patients will need to have the courage to face their mortality and plan for the end of life. Families will need to have the courage to face their fears and to honor their loved ones. Physicians will need to have the courage to lead, even when the journey is difficult.

Bart

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