My First 25 Years in Practice

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25 years ago today, I started my career in private practice. My notes were written in paper charts, I carried a pager but not a cell phone, and I had a head full of hair. Appointments were written in a book, controlled prescriptions were written on duplicate pads, and antibiotics were handed out like candy. HMO medicine was new and so was the group I joined. It was an exciting time.

My practice had a very wide scope back then. I had an active hospital practice and managed the inpatient care of both children and adults at Hoag hospital. I managed septic patients in the ICU, patients with diabetes out of control and with heart failure, often without consulting specialists. I took care of children hospitalized with bronchiolitis, dehydration and asthma attacks. I felt there was nothing that I could not do. One particular patient utilized all of my skills, a young pregnant woman with viral meningitis and pre-term labor. I performed the spinal tap myself, gave medications to stop labor, and managed her inpatient care without consulting anyone. Those heady days are long gone!

Hospital patients are much sicker nowadays. Many of the conditions that previously resulted in hospital admissions are now managed as outpatients. Skin infections, kidney infections and even new onset atrial fibrillation, conditions once thought to be serious, now do not even merit a visit to the emergency room. Those patients sick enough to be hospitalized are now beyond my knowledge and expertise.

For 12 of my early years in practice I provided maternity care and delivered babies. I was perpetually on call, only unavailable when I was out of town. It was demanding and challenging but I loved it. Welcoming new life into the world was one of my great joys, and it is what I miss most about those days. I delivered my last baby in 2007.

My office practice has changed as well. The era of “one problem per visit” is long past. Every visit to my office is now an opportunity to address multiple health concerns. Patients who come in for respiratory illnesses may find themselves leaving with orders for cancer screenings and routine blood work. Other routine visits evolve into impromptu counseling sessions. The result is fewer patient visits per day, but more care per visit. Where once I saw as many as 35 patients a day, my Physician Assistant and I seldom see that many patients between us.

The business of medicine had changed for me as well. In 1994 I was part of a multi-specialty group of over 30 doctors. Neurologists, cardiologists, obstetricians, internists, surgeons and family doctors, we were all in the same building with shared management. The business styles of the doctors proved to be as diverse as our specialties, and there was frequent conflict. The three physicians with whom I shared a suite joined together with me to leave and found our own Family Practice, Beach Family Doctors, I’m 1995. I managed that practice for 7 years.

By 2002 the practice had grown to 5 doctors and I had grown weary of managing it. In February of that year I went on my own, moving into a small suite across the hall from my former partners. Ours was an amicable parting, and we remain friends to this day.

Two years later, when driving back to my office one afternoon I passed a small house on Beach Boulevard. The “For Sale” sign caught my eye and two days later I was standing in the doorway of the home, imagining where I could put up and tear down walls to convert it into a medical office. Escrow closed in February 2004 and I moved into the office November 1st. It has been my medical home ever since.

Much has changed in the last 25 years but the most important thing hasn’t. I wake up every day knowing I will have the opportunity to make a difference in the lives of the patients who come to see me. This knowledge still brings me joy, and it is that joy that will sustain me in the years to come.

Bart

A special thanks to the many patients who have entrusted me with their health over the years. It has been a blessing, a privilege and an honor.  

In

Surprised by Cancer

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The patient’s symptoms defied explanation. He wasn’t sleeping, felt as if breathing was a chore, and had persistent pain in his abdomen that wrapped around into his back. He had been suffering for weeks and was at the end of both his physical and emotional ropes. Multiple physicians had already been consulted, dozens of lab tests had been ordered, and a stomach specialist had even put a camera down his throat to check out his stomach and esophagus. No answer could be found.

I was not hopeful. His symptoms were unusual individually, together they were beyond confusing. As intense as the symptoms were, they did not fit any diagnosis with which I was familiar. After hearing his story and performing a brief exam I sat quietly and thought, completely dumbfounded. Other doctors, similarly perplexed, had told him that he was having anxiety. While this was a possible explanation (and an easy one at that), it didn’t make sense to me. I had seen hundreds of anxious patients over the years, many with physical symptoms, but none whose complaints matched his.

I went over his labs again, looking to see if anything had been missed. His potassium had been off, and I remembered that abnormalities of cortisol production were often associated with changes in potassium levels. It was a diagnosis I had seen only once, and that was over 20 years ago, but I went ahead and ordered the test.

That night I sat at my computer and searched for other possible causes. I read about rare conditions I had never seen before and vaguely remembered from medical school. Nothing fit. I decided that if the cortisol was normal I would blindly look everywhere I could. I knew I would probably not find an answer, but I was determined to be thorough in my search.

The cortisol test was normal, so I decided to order imaging tests. Deciding which tests to order was also a challenge. His symptoms were nonspecific so I was not sure where to start, what body part to image first. Frustrated and uncertain, I decided to order CT scan images from his neck to his waist. I doubted I would find anything but I could at least tell the patient I had tried.

He went in for the scans the next day. The phone call from the radiologist came the day after. “I am not sure why you decided to include the abdomen in your order, but it is good you did,” he said, “he has a 5 centimeter mass on his right kidney.”

I felt the color drain for my face. “Oh crap,” the words came out of my mouth involuntarily. 5 centimeter kidney masses are always cancer. I did not know whether it was dumb luck or divine intervention, but I realized that my decision to take pictures of everything may have just saved his life. Importantly, the scans showed no signs of spread, suggesting we may have caught the cancer in time. I could not explain how or if the cancer was related to his symptoms, but I had found it!

I spent the next few days reflecting on the near miss, on how easy it would have been to not order the tests, to refer him elsewhere or blame anxiety. I realized that I had found the cancer not because I knew what I was looking for or because I understood his presenting symptoms. I found the cancer because a patient was worried that something was wrong and I believed him. 

My reflections included memories of times when I did not believe worried patients as I should have, of concerns I may have dismissed and diagnoses I may have missed. I promised myself to be better in the future. I cannot always know, but I can always listen and I can always care. 

- Bart

In

Can a Christian be Anxious?

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Words are dangerous things. As with a knife in the hands of a surgeon or the grasp of an assassin, whether they heal or harm depends on the manner in which they are wielded. The words of Scripture are no different in this regard. Divinely inspired and intended to further the purposes of the Loving God, when used incorrectly they can wound the soul.

In my experience, some of the most dangerous words in the Bible can be found in Paul’s letter to the church at Philippi-

“Do not be anxious about anything, but in everything by prayer and supplication with thanksgiving let your requests be made known to God.”

Written to encourage believers to focus their hope on God and his eternal purposes, they are at times transformed into a cudgel of discouragement, ignorantly wielded in a manner that bruises the hearts and minds of emotionally struggling Christians. “Do not be anxious,” wrongly elevated to the status of commandment, becomes a measure of faithfulness such that the presence of anxiety is interpreted as a sign of mistrust in God, spiritual immaturity and sin.

For Christians stricken with anxiety disorder, these words can be devastating. Feelings of guilt and inadequacy, already the daily companions of anxiety sufferers, grow in power and intensity at the implication that one’s feelings of anxiousness are a sinful choice.

I have been on both the giving and receiving end of these misspoken words. In the formative years of my Christian faith I attended a church with a Pentecostal bent, a place where faith was more emotional than intellectual, a place where hurting people were “encouraged” to simply “let go and let God.” Prayers for the struggling often included asking God to help them “trust God more” or to be “set free” from sin. I joined in these prayers, ignorant of the impact of my words.

My perspective changed a little over 10 years ago. I was preparing to enter an exam room one day when I felt a sense of dread come over me. Uneasiness and fear took hold. For no reason at all I felt as if something bad was about to happen. These feelings were soon joined by pressure in my chest, lightheadedness and a sense of detachment. My mind began to race and I felt as if my emotions were about to spin out of control.

“What is happening to me?” I thought. I answered my own question as quickly as I had asked it. “I am having a panic attack!”

The intellectual awareness of what was happening gave me the strength to stall the downward spiral. I was able to calm myself partially, enough to allow myself to call my wife and ask her to bring some medication from home. I had the presence of mind to tell my staff what was going on, and to ask them to reschedule some of my patients. It took a while, but with great effort and the calming presence of my wife I was able to finish my work day.

In the weeks that followed additional attacks came. I found myself in fear of the next attack and what it would do to me. I developed other fears as well, including intense self-doubt in personal and professional interactions. With the fears came increased irritability as I struggled to regain a sense of control over my life and thoughts. I saw a doctor, and with the help of counseling and medications learned to deal with a new reality.

I have not been the same since. While debilitating moments of panic have been rare, fear and anxious feelings now greet me every morning. Their voices are quieter some days than others, at times easily drowned out by the clamor of the day, but they are always present. Countless hours in prayer and Bible study have made one thing certain. Telling myself, or being told by others, “Don’t be anxious”, does not help.

It does not help, because the words of Paul (and Jesus in the Sermon on the Mount), were not meant to be used in this fashion. New Testament teaching about anxiety is never directed at the generalized sense of unease associated with a serotonin imbalance, it is directed at the human tendency to obsess and focus on earthly needs in a way that is contrary to a life of faith.

When Paul wrote to the church at Philippi, he was in prison, awaiting a possible death sentence. The church was being persecuted and many believers were suffering for their faith. It would have been easy for them to out of fear turn away from God. To these people, in these circumstances, Paul said, “Do not be anxious… but make your requests known to God.” Similarly, in the sermon on the mount Jesus reminded people not to focus on material needs, but to instead trust in God’s eternal purposes.

Paul was not saying that all anxiety was sin, or that Christians should never be anxious. He was acknowledging the danger that in focusing on the sufferings of this present life Christians can become discouraged. He therefore reminded them of the alternative, to focus on God and his promises.

I do not believe feelings of anxiety are a measure of anyone’s faith. Faith is displayed not in the absence of doubt or fear, but in the choice to trust God and his purposes in their presence. I do not say to myself, “Stop being anxious and trust God.” I instead say, “Yes, you are anxious, trust God anyway.”

These words do not take my anxious feelings away, but they do put the feelings in context. I am reminded that I will not be anxious forever. Eternity awaits, free from both emotional and physical pain. In that hope I find hope, peace, confidence and strength. I also find, strangely, a sustaining sense of joy.

Bart

While the focus of this post has been on Christian perceptions of anxiety it is worth noting that bad counsel is not limited to people of faith. Patients often tell me about family and friends not understanding their struggles, of being told that there is no reason for them to be anxious. I typically smile as I point out that this is why it is called an anxiety disorder. Normal people worry for a reason, people with anxiety disorder are often anxious for no reason at all. 

All patients with anxiety, regardless of faith, should be encouraged to get help. Counseling, in particular Cognitive Behavioral Therapy, is extremely beneficial. Medications, especially selective serotonin reuptake inhibitors, can also be tremendously helpful tools.

 

Life, Death, and a Little Boy Named Alfie

Alfie Evans died today. You may have heard his story. He was in a coma for over a year. His parents wanted life support continued, but a court ruled otherwise. His story and passing illustrate the challenges all physicians face in dealing with death. Here are my thoughts-

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I deal with death on a regular basis. All doctors do, but in my role of Ethics Chairman at my hospital I often have end of life discussions with dying patients and their families. All of these conversations are difficult. I am only called to assist when there is conflict between physicians and families that cannot be resolved or when families cannot agree on how to proceed.

The most common consultation requests are in cases where doctors have concluded that there is nothing more to be done and recovery is impossible, yet families believe hope remains. When they believe additional treatments and life-prolonging interventions will only prolong death and increase suffering doctors recommend stepping back and allowing natural death to occur. Families often believe that letting go is the same as actively killing someone and thus cannot accept the doctor’s recommendations. When these impasses cannot be resolved, they call me.

I have been involved in dozens of these conversations. While each situation is unique they all share common characteristics. Foremost among them are differing views on death and what it means to be alive.

Doctors, in particular critical care physicians, see death all of the time. They see the signs of its coming and recognize its inevitable progression. They know the signs of recovery and survival, and in fact search for these signs relentlessly. They long to cure and heal but learned early on in practice that there are some battles that cannot be won. When recovery and restoration are no longer possible they turn their attention to the good that remains, the ability to provide comfort and dignity as a fellow human being passes from this life.

The families of patients sometimes see things differently. They see someone they love lying in a bed, someone they cannot bear to lose. They know death happens but they cannot believe or accept that it is happening to their loved one at this time. They have heard and read of miraculous recoveries and have profound hope in the power of love and the will to live. They “know” that at any moment things could change, that their family member could return. Even if full recovery isn’t possible, the chance of one more smile, one more word, or one more touch seems worth fighting for.

This hope for a miracle can lead them to see hopeful signs where no hope exists. Reflexive responses such as grimaces, grunts, and the movement of a headare evidence that “she is still in there!” or that “he can hear us!” The grasp reflex, present after only four months of development in the uterus, is interpreted as a reassuring squeeze, instead of a primitive reflex that means nothing at all. These false signs of hope become the evidence that doctors are giving up too early, proof that the fight should continue.

Love, compassion and mercy compel physicians to speak truth in these circumstances. When this truth is not accepted people like me are often the final messenger. My suit and tie and title of Ethics Chairman provide extra gravitas to words others have spoken and communicate a level of seriousness and concern families need to hear. Referencing our shared promise to “Do no harm,” I remind families that prolonging suffering and futile care are things we cannot and will not do. There are times when there is a moral and ethical imperative for physicians to compassionately say, “No.”

These conversations are always difficult but they are times when the burden is more bearable. When the patient is a nonagenarian victim of a massive stroke, bed bound and ventilator dependent, there is a higher degree of clarity. We know that death is only a few years away for the healthiest of 95 year olds, which eases the fear of error. Conversations with multiple patients near the end of their lives give us confidence that it would be cruel to artificially force someone to a prolonged death tube-fed and non-communicative in a nursing home.

The younger the patient is the more difficult these conversations become. There is a dramatic difference between saying goodbye to an elderly grandparent and saying goodbye to one’s little boy. The natural fear and intense emotions that come with a dying child can overwhelm the coping mechanisms of any parent. Desperate desire and gargantuan grief, when combined with the false signs of hope often displayed by a vegetative patient, make it impossible for some loving parents to let go.

This appears to have been the case with the parents of Alfie Evans, the 23-month old infant who died today in a hospital in England. Alfie had a degenerative neurological condition that resulted in severe development delay (he never progressed beyond the level of a 2-month old child). His condition led to severe seizures when he was 6 months old. MRI scans and EEG tests demonstrated significant brain damage was already present at the time of his first seizures. He was placed on a ventilator and a feeding tube was inserted. In spite of aggressive medical treatment the neurologic condition and resultant epilepsy progressed and caused continued damage to his brain tissue.

Over the course of the last 17 months extensive medical testing and analysis was done on little Alfie. Although it was evident to physicians early that recovery was not possible they continued to explore every available option. Ultimately, when later MRI scans showed that brain tissue was decreasing and being replaced with fluids, the medical team reached the appropriate conclusion that continued care was futile. While they could not know with certainty whether or not Alfie could experience pain it seemed clear that if he couldn’t experience pain it was because he had no meaningful brain function remaining. Worse, if he could experience pain, he would experience it with no hope of recovery. Neither option supported continued care. It was time to let him go.

All of this was presented to the family and the doctors said it was time to withdraw life support. The court documents articulately describe his parent’s response-

“The Fathers core dilemma, from which he struggles to escape, is that whilst he recognises and understands fully that the weight of the evidence spells out the futility of Alfie’s situation he is, as a father, unable to relinquish hope.”

Alfie’s family could not let go. A careful review of the case reveals the innumerable obstacles they faced as they struggled to process the tragedy and how they should respond. Alfie was their only child, and they were just 19 and 20 years old. They received an overwhelming amount of outside input from uninvolved parties, some of whom seemed more interested in personal agendas than they did in their suffering. The parents were trapped in the middle of a hurricane of opinions and emotions with no way of escape. It was ultimately the courts who determined the path that would be followed. The decision was made for them. Alfie was removed from life support and died this morning.

Much has been written about Alfie’s case, most of it focused on the issue of parental rights regarding decisions to continue care. I will leave those arguments to others. For me, Alfie and his parents demonstrate a reality that is a part of all medical care. Patients and families are often forced to make decisions they are not equipped to make.

When these circumstances arise it is up to physicians to love, serve and support the patients under their care, to do good whenever possible. When that is no longer possible, to do no harm.

Bart

If you are interested in the details of the case, I recommend you read the judge's decision. You can find it here.

 

Needed: More Small-Town Doctors

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It was a rainy day on the island of Kauai. Sunbathing was not an option, and neither was swimming or snorkeling. The ocean water’s typical clear blue color had been replaced by an unappealing shade of brown. Stranded away from the water we resigned ourselves to wandering through the stores in the Kukuiula Village shopping center near Poipu Beach.

After meandering through stores selling beach themed home goods we wandered into an art gallery that featured photos of scenic locations from around the Hawaiian Islands. I did not recognize many of the images in the pictures and asked the proprietor, a woman who appeared to be in her seventies, where some of them were taken. She answered my questions and then asked some of her own, the standard tourist questions of “Where are you from?” and “Where are you staying?”

After hearing our answers, she volunteered that she had moved to Kauai over 20 years earlier and still felt like she was new. She told us of the small town nature of the island (there are 27,000 permanent residents, only about 2000 of whom live in the Poipu area), and how everyone knew everybody else. She mentioned that there was only one department store on the island and that everyone wore the same outfits because they all shopped at the same Macys.

As there was no one else in the store and she seemed to be in the mood for conversation, I decided to ask her what life was like living on the island. In particular I asked her about the quality of medical care. “It isn’t very good,” she replied.

She told us that the only up to date mammogram machine was on the southwest side of the island, nearly an hour’s drive away from the hospital and over 2 hours away from the village of Hanalei. The hospital on Kauai was not very advanced. It was equipped to handle common conditions and emergencies but was not staffed for more complicated cases. Her husband had been diagnosed with pancreatic cancer a year earlier and had needed to travel by plane to Honolulu for treatment. Their medical care was comparable to that one would find in rural America.

The best part of their health care was their family doctor who had provided their care since they arrived. He was kind and compassionate. She shared that she was concerned about the future of their medical care because he would soon be retiring. She then told us a story of her doctor that helped us understand her fears.

A few years earlier her brother and his best friend had gone out fishing on her brother’s boat. They were about 8 miles off the coast when they hooked a massive fish that weighed over 200 pounds. The friend worked to reel it in while her brother went to get something with which to hit it in the head so they could pull it into the boat. Metal stick in hand her brother called to his friend to pull the fish in a little closer so he could reach it.

“I don’t feel very good,” the friend said. Then he dropped dead on the deck. Her shocked brother radioed the Coast Guard and started CPR. It took a while for the Coast Guard to arrive, too late to do anything for his friend. The Coast Guard took his body away. Her brother returned to the harbor alone. Waiting for him on the dock was his family doctor. The doctor had heard of the tragedy, and concerned for her brother’s state of mind had driven to the harbor to meet his grief-stricken patient.

As the woman told the story it was clear that she had not been surprised by the kindness of their physician. His caring act was what they had come to expect from him, standard practice from their small-town doctor. While this behavior was normal for her physician she knew that it was a level of kindness that could disappear now that he was retiring. She did not know if she would ever find a physician who cared for her that much, a physician she could trust to be there when she needed him.

Her story has stayed with me. I repeatedly find myself reflecting on the power of this small-town physician, the healing and comforting power of relationship and friendship, the importance of simply being “there” when needed.

I think of the times I have been able to care like that, the patients I have known over the last 25 years who have allowed me to be a part of their lives. The house calls made, the phone calls answered, the stories told and the tears that were shared. So often what mattered most were the moments shared, not the medications prescribed.

Our society is moving away from these relationships. Medicine is now practiced according to a set schedule. Interactions with primary physicians are often limited to the hours of 9-12 and 2-5, Monday through Friday, if scheduled in advance.  After office hours and on weekends patients get the stranger in the Emergency Room or the Urgent Care Clinic. The feeling seems to be that people need a doctor, that seeing their doctor is not all that important.

The woman’s story, and my experience, suggest this is not true. There is more to good medical care than knowing medicine. Truly excellent care requires knowing the person who is receiving treatment, a truth small-town doctors know and the rest of us need to learn.

- Bart

 

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