Life isn’t Boring

36224447_s.jpg

What makes living worthwhile? What gives value to a life?

This week came the story of a man with a pistol taking the lives of 11 people in a bar. In an Instagram post written during the killing spree the murderer gave his reason for taking the lives of others. “Life is boring, so why not?”

A few days later my wife and I participated in the “Walk to end ALS.” (ALS is an always fatal progressive neurologic disease, also known as “Lou Gehrig’s Disease) We walked in support of a friend from church who has battled the disease for the last four years. Over 30 of our church friends walked together, each with their words, steps and donations saying to our friend, “Your life matters, you matter.”

It is a confusing world. One young man in perfect health decides that his life, and the lives of strangers, are worthless. In a matter of minutes he sacrifices multiple lives on the altar of his boredom. To him, human life was insignificant and disposable.

At the same time another man, cursed with an incurable disease, fights for every precious moment. His love of life and love of others is contagious and encouraging. To him, life is a gift from God, full of meaning and meant to be treasured. 

There can be no denying that it is my friend who has the right perspective. Life is not boring. It is precious. 

Bart

How to Find Nice People

 Deep Creek Trail, Great Smoky Mountains National Park

Deep Creek Trail, Great Smoky Mountains National Park

There is so much rudeness and meanness in the world that I sometimes wonder, “Where have all of the nice people gone?” I do not know where all of them have gone, but based on 6 days of first hand observation I have reached the conclusion that a great many of them are in Tennessee. I have experienced so much kindness, goodness and politeness this week on vacation that I may go into withdrawals when I get home to California.

We have been in the Smoky Mountains this week (which, unbeknownst to most of my California friends, is a huge national park and tourist area) watching the leaves turn orange, red and yellow, listening to Southern Gospel Music at Dollywood, and eating unhealthy amounts of fried food. Wherever we found ourselves, it seemed every waiter or waitress, cashier or attendant took an interest in where we were from and in making us feel welcome. The people reminded me of the dog from the movie “Up”, it was if they all felt that they had just met me and they loved me.

Today we went for dinner at a place called “Elvira’s” a café about a mile from the cabin where we have been staying. We received the typical warm and friendly greeting but this time with a twist. It was given in a distinct Russian accent! The owner of the place, a woman in her 30’s, had emigrated from Siberia a little over 15 years ago. In typical Tennessee fashion, she took the time to share her story with us as we finished our dinner.

She was a linguistics major in Russia specializing in British English. She traveled to America to work on her language skills (She said that at the time her conversational English primarily consisted of, “Pardon me, but can you repeat that?”) She knew very little about our country and her knowledge of US geography was limited to New York, Los Angeles and Texas. She did know that she wanted to see American rollercoasters and therefore eventually ended up in Pigeon Forge, Tennessee at Dollywood. She fell in love with the Smoky Mountains and never wanted to leave.

She moved here, became fluent in the language (She can pull off a perfect southern accent), and eventually became a citizen. Seven years ago she opened her own restaurant. She told us her family marveled that all she had to pay for the government permit was the $20 business license fee at city hall. Her Uncle Sasha couldn’t believe it and kept asking her who else she had to pay off! She spoke with joy at her good fortune in being able to live in America and be an American. Freedom is a gift she clearly appreciates and values.

This appreciation of America was something we saw displayed several times this week. One of the gospel groups we heard sang a version of “I’m Proud to be an American” during their show. The entire audience rose to their feet and sang along. We went to a family dinner show another evening that closed with a medley of “America the Beautiful” and “God Bless America”.  The entire audience, similarly unprompted, also stood and joined in, and applauded loudly. They love their country.

Things in Tennessee were much simpler, slower, and more genuine than they are in California. The area is nowhere near as affluent as Orange County, but the folks here seemed happy, content and grateful. It was a good week. Hopefully I will be able to bring some of the nice home with me.

 

Success Defined. Differently

53101986_s (1).jpg

When I was in elementary school I loved classroom competitions. I looked forward to spelling bees, timed tests and word puzzles. One of my favorite educational games was “around the world.” The desks were arranged in a circle, with one student standing. The standing student would be paired with a sitting student and the teacher would hold up a flash card with a math calculation. The student who answered correctly first “won” and moved on to the next desk. The goal, for me, was to go “around the world”, to defeat every other student in the class. I loved the game, as I rarely lost.

Looking back now, I see the game was stupid. As fun and as challenging as it was to me, it had to have been demoralizing for those in the class for whom math was a struggle. I am sure many of them felt like not trying at all, seeing the “game” as just one more opportunity to be humiliated.

It had a negative impact on me as well. The game fed a warped sense of self, the idea that it was my academic performance that gave me value, that good grades made me special. Educational success, being smart, was a major component of my self-esteem. It left me with a precarious view of self that failure could easily destroy. 

It took me decades to realize that academic successes were nothing to brag about. My school acheivements were primarily due to genetics, not effort. I was the son of a brilliant man who passed his genes on to me. For me, being proud of my GPA would be like a 7 foot tall person being proud of their height. While intelligence and height can be advantageous and beneficial, they are not something anyone earns or works for.

I have finally reached the point in my life where I have learned to measure success differently. What is important to me are the things that I work for the things that do not come naturally, even in my medical practice. While making a correct diagnosis is important, even crucial, I am realizing this is not the best way for me to measure the success of a visit. I now measure success of a patient interaction on the things that take effort, the things that are challenging for me, such as the clarity of my communication and the patient’s comfort and understanding with what I say. If the patient is not satisfied with their care, I have not succeeded.

I need to do this in every area of my life. It is the successes I work for, the changes brought by diligent effort, of which I should be most proud.  When my worth comes from the things that I strive for and not just on the things I am born with, I know I am on the road to being a better person.

 - bart

A Pain Filled Deposition

IMG_0036.JPG

We were seated around the dining table in my office break room, two attorneys, a court reporter and I. A patient of mine was suing someone for injuries sustained in a car accident and that someone’s attorney had subpoenaed me regarding the case. It was a relatively straightforward disagreement. The patient said he had been injured and was experiencing ongoing pain, the defense was arguing there was no way he could have been hurt that badly in the accident.

The defense attorney showed me photos of the cars (there was almost no visible damage) and asked me about my findings and diagnoses for each patient visit after the accident. The patient had no physical findings consistent with an injury at any of the visits, did not consistently follow up with a physical therapist as requested, and had ultimately undergone an MRI of his spine that was perfectly normal. It was clear from his questions he believed this meant that there was no way the patient could be having pain. Brimming with confidence, he proceeded to ask me a stupid question.

“The normal MRI means the patient does not have a radiculopathic pain, correct?”

“No,” I replied.

“But doesn’t a radiculopathy mean that there is something compressing a nerve?”

“No, it means that the patient is experiencing pain in the area supplied by a specific branch of a spinal nerve. There are other causes of such pain.”

“What else could cause the pain?”

“I can give you an answer, but it is going to be a long one,” I replied. As i did I saw the confidence drain from his face.

I went on to give him the long answer. I explained there are many causes of pain that do not show up on an MRI or other imaging scans. I summarized the nature of pain fibers and how they could be activated without physical trauma, how once triggered even normal stimuli could lead to these nerve fibers firing and a patient experiencing severe pain.

In a resigned tone he verbalized the realization that he would have been better off not asking me that question. “I opened a can of worms,” he said.

The mistake he made is a common one. Most people do not understand pain. They understand pain after surgery, when a kidney stone gets stuck, or when a bone gets broken, but when there is no visible cause, they doubt it. If it can’t be seen it with the eyes or in a medical image it can’t be real.

This was the teaching I received when I was in medical school and residency. Patients who complained of pain in the absence of physical findings were filed into one of two categories. They were either crazy or they were “drug-seeking.” They were often treated with scorn instead of compassion.

It took years for me to understand how wrong this teaching was. My first inkling that there was more to pain than I had been told came after I had a knee operation in 1992. Several weeks after the surgery I was standing in the clinic when I had the sensation of something like a hot drop of oil running down my leg. So intense and real was the feeling that I turned and looked to see what was on my leg. The only thing touching my skin was the fabric of my pants. There was nothing there. The sensation was the result of a rogue nerve misfiring and sending inaccurate signals to my brain. There was “nothing” there, but the sensation was real.

My understanding expanded further 17 years ago when I suddenly began to have excruciating, burning pain in my right shoulder and arm. Over a period of weeks I saw 5 different doctors in search of an explanation. MRI scans and nerve tests were all normal. It was the fifth doctor who finally gave me the diagnosis of an inflamed spinal nerve, possibly from a virus. He gave me a diagnosis but could not promise a cure. The pain gradually faded to a persistent tingling but never passed. The pain returned a few years ago, this time deciding to stay, but MRI scans and nerve tests were again normal. The only evidence I can give others for the pain is a description of how it feels. It is “undetectable” but it is definitely real.

Pain of this nature is more common that many realize. Fibromyalgia, a pain condition that impacts as many as 10 million Americans, falls into this category. No visible damage can be detected and no blood tests are abnormal, but the pain can be debilitating. Many patients suffer for years while being told by doctors and others that they shouldn’t have pain. They shouldn’t, but they do.

The current theory is that these unfortunate patients have pain nerves that are overly sensitive. In the same way that some people are always cold, even on a warm day, fibromyalgia patients always hurt. Unlike those who feel cold, fibromyalgia can’t be helped by putting on a sweater. Medications can sometimes lessen the pain but there is no cure.

I cannot cure many of my pain patients, but that does not mean that I do not, or cannot care. I can listen to them and pray for them. Most importantly I have learned to avoid the mistake made by the attorney. When someone says they hurt, I believe them.

- Bart

Empty Promises and Feel Good Intentions

40910929_s.jpg

“How can I get people to believe we are committed to quality?”  The question was posed to me by the newly hired Vice President for Quality Management at the hospital. I was surprised by the question, not because the answer wasn’t important, but because I thought the VP of Quality for a large institution should already know it. I was further surprised that he was asking me. Although I had the fancy title of “Executive Director of the Primary Care Institute” I had only been in that part-time position for a few months and had no experience at all in quality management.

In spite of my lack of experience, the answer came to me in just a few moments. He wasn’t asking me how to manage quality, he was asking me how to get people to believe that quality was a high value for organization. With that realization the answer sprang forth from my lips almost without thinking. “Easy,” I said, “Do something to improve quality of care that is against your financial interest.”

He looked puzzled, so I explained. “When the goals of quality and profitability come into conflict, the one that wins is the one you are most committed to. People I talk to say the hospital is committed to profit, and that quality takes a back seat. If they see you do something that promotes quality, even though it hurts the bottom line, then they will believe you are committed to it.”

I do not think my answer was the one he was looking for, as the expression on his face in response was not encouraging. While my answer may not have impacted him that day, it had an effect on me. My answer taught me that the value of a thing is always measured relative to the value of other things. As people of limited resources, both in time and finances, it is inevitable that we will find ourselves having to choose where to invest our time and money. We cannot do everything so we have to make choices. Our choices reveal our values.

In the last few weeks I have heard many stories of choices made by others. I heard a minister share how a commitment to ministry had taken time away from his son, with heart-breaking consequences later in life. I dealt with a recently hospitalized patient with multiple serious problems who had been rushed into and out of the hospital by her doctors before her condition had been adequately treated. I ended my relationship with two separate hospice agencies who both promised attentive care and consistent communication, who both talked extensively about a commitment to service but neither of whom had bothered to update me on my patients for several weeks.

The minister had said he was committed to quality parenting, the hospital doctors would say they were committed to quality medical care, and the hospice agencies had repeatedly assured me of their commitments to compassionate personalized care, but they all fell short. They did not fall short because they despised the quality to which they expressed allegiance, they fell short because had a higher allegiance to something else. For the minister it was the demands of his ministry, for the hospital doctors is was the desire to get the patient out of the hospital, and for the hospice agencies it was a desire to save time by only communicating when absolutely necessary.

As it easy as it is for me to criticize the minister, doctors and hospice agencies (and criticize them I did), I do so at my peril. I am not immune to the trap into which they fell. Like them, it is not always bad things that get in the way of doing what I should. Sometimes it is a case of good things pulling me away from better things, other times it is forgetting what the best things in life are.

I share with all of them another reality. The world is watching to see what I am most committed to. Their judgment will not be based on the words I speak. It will be based on the choices I make.

-          Bart