A Jerk Like Me

The email seemed downright mean, albeit efficient. In just two paragraphs the patient managed to criticize my attitude, my responses, my office staff, my computer system, my scheduling system, my treatment of patients and my overall business acumen. Although I was taken aback at the meanness of the message it was the basis for the outburst that most caught me off guard. The email was written in response to a brief message I had sent. My message was, “You are overdue for a visit, please schedule a visit so we can process your refill request.”

I had typed my message quickly in response to an email query from the patient asking me to clarify a previous message. His message seemed straight forward and to need only a brief reply. I was obviously mistaken.

My initial response to the email was defensive. I had done nothing wrong to my knowledge and if there had been an error it was clearly unintentional. The patient had no reason or right to be demeaning. As I thought about what to reply a thought came to my mind. “If your motives are pure, why worry about defending yourself? Why not ask the patient what you can do for him?”

I called the number in the chart and followed up with a brief email saying any failure to communicate on my part was unintentional. To make sure he knew I was sincere I included my personal cell in each communication. We finally connected after a few email and phone tags and he shared with me why he was unhappy. He had struggled with our online system  and he wanted me to know how bad it was. There were a number of system failures and it took a while for him to share them all.

As we talked to things became clear. First, he had indeed struggled with our online system. It is glitchy at times and he had definitely been glitched. Secondly, he was someone who desired excellent service. Excellence was his goal in his business and he expects the same from others. What's wrong with that?

Sometimes excellence is not possible. His struggles were the type of understandable and inevitable communication difficulties associated with email and computers in general, the frustration that comes when we quickly type out questions and answers. Because the communication was about something personal, and because it took of too much of his time it was easy to see each mistake as a personal affront, as an insult to his time and person. In his frustration and impatience he reminded me of… me.

For years I demanded excellence from every vendor, service provider and business with whom I interacted. If I was paying for a service I expected the very best. It took me years to realize that perfection is impossible and that excellence is an elusive goal. I thought I was a professional pursuing excellence. Everybody else saw me as a jerk.

On the majority of occasions I complained about unmet expectations I did so ignorant of how hard the other party had worked to meet my needs. I did not take the time to understand what they were up against, what the standards were in the industry or how much time my demands required. I fear that on many occasions I reacted negatively when someone had done all he or she reasonably could have done to respond to my requests. It never dawned on me that I wasn't paying for perfection, that if I wanted perfect performance from the person handling my medical billing or processing a referral it would cost me a lot more than $20 an hour! How unreasonable I must have seemed to others.

I still struggle with adjusting my expectations. Balancing a desire for excellence and a commitment to grace requires constant effort. I have learned that the effort is absolutely worthwhile. As I grow more patient and understanding my stress levels drop and I still manage to meet the goals I set for my practice. I am also considered to be less of a jerk.

I pray that my patient will learn the lessons I have learned and continue to learn. It is much better to be considered kind and gracious than it is to be viewed as excellent and demanding!

-          Bart

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Funny, Smiling, and Dead in a Moment

She was funny. From the moment she arrived in the emergency room she kept the nurses and doctors entertained with quips and jokes. She was seriously ill but she was full of life. Within minutes she was gone.

She came into the emergency room complaining of fever, cough and fatigue. She had been feeling poorly for a few days, ill enough that she had gone to another emergency room a day before. They had not found anything so they sent her home. When she failed to improve she and her husband decided to try a different hospital. It was early evening when they came to hospital where I worked. I was the resident on call that night.

Her oxygen level was on the low side and she did not respond to the breathing treatments she received so even before he saw the x-ray the ER doctor decided she needed to stay the night in the hospital. He called me down to the ER to handle her admission. I spoke with the ER doctor briefly, reviewed her chart and went in to say “Hi.” She was smiling and upbeat as we talked. While we were talking I received word that the xray results were in. I left the room to review the films.

I was shocked at what I saw. Her entire left lung was filled with fluid. Instead of the dark open appearance of air the whole left side was entirely white. It was the worst case of pneumonia I had ever seen. We all realized that this delightful lady was much sicker than we had thought. She was deathly ill. I quickly arranged for a bed in the ICU. Within the hour she was in the unit and IV antibiotics and oxygen were flowing. She was still smiling.

Then her oxygen levels started to drop. Her breathing became rapid and for the first time her smile was replaced with a look of concern. We made the decision to intubate, to put a breathing tube down her throat and connect her to a ventilator to improve oxygen delivery. The attending asked me to perform the procedure. A sedative was administered and I moved to the head. I reassured her as I tilted her head back to allow for placement of the tube.

My face was 12 inches from hers. I held the laryngoscope in my left hand and the endotracheal tube in my right. Right at the moment when I moved to insert the laryngoscope into her mouth her eyes rolled back into her head. I heard the ominous tone of her heart monitor as it turned flatline. This wonderful 40 year-old woman had just died right in front of my eyes.

I continued on and inserted the tube as resuscitation efforts began. After a few hectic moments filled with the chest compressions, shocks and IV medications a pulse was restored. Her pulse came back, but she didn’t. The infection was overwhelming. It took a few days for cultures and tests to explain what had happened. She never had a chance.

She had been on prednisone, a powerful anti-inflammatory steroid, for quite some time to treat a form of arthritis. Unbeknownst to her the prednisone had weakened her resistance to stomach acid and an ulcer had formed, eroding deeply into the lining of her stomach. Eventually it eroded all the way through and acid and stomach contents had seeped into her chest cavity, carrying with it deadly bacteria. By the time she arrived at our hospital she was septic and bacterial toxins were taking over her body.

Within hours of the resuscitation in the ICU her organs began to shut down due to the septic shock. She was comatose. All of us on the medical team knew it was over. Her heart continued to beat and the machines continued to supply oxygen but there was no hope. She was gone.

The reality of her condition was impossible for her husband to accept. She had been so alive just days before and he could not comprehend how the woman he loved could be gone so fast. In his grief he was angry, demanding and defiant. He repeatedly insisted that something be done but there was nothing anyone could do. Many of us tried to talk to him but it took several for him to understand that she was gone, days spent alone at the bedside of a woman who was no longer there.

I have never forgotten either of them. They come to mind whenever I deal with the unexpected loss of a young patient. They remind me of the fragility of life and the inevitability of death. They remind me that every moment with the ones we love is precious, that every breath is sacred. They remind me to hug my wife, to tell her I love her every day, to thank God for her and to cherish her, for we all can be gone in a instant.

-          bart

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When Sex is Dirty, We Lose

The world has changed. Things that were once completely unacceptable have become commonplace. Behavior once universally deemed shameful is now openly displayed. I have known this to be true for a while but there are still times when the magnitude of acceptable depravity catches me off guard.

I typically screen movies for content before buying a ticket as there are certain things I choose not to see. I subscribe to a website that describes potentially offensive content and use the descriptions as a guide, with a particular goal of avoiding sexual content. (It is my personal belief that in so doing I honor my wife.)

We recently saw a movie that contained sexual content for which I was not prepared. Their was a scene at the end of the movie that I missed in my pre-movie review. In the scene a young woman promises to allow herself to be used in a vulgar fashion by the protagonist. The act in question was repulsive to me and my wife and, prior to the movie, I thought it was repulsive to others as well.

The scene shattered my illusion. As we walked out of the movie disgusted we both expressed amazement that the act in question was not only portrayed as possible, but desirable. We realized that the film makers must have believed that the audience would agree with their portrayal. How could this be?

I think what we saw was the natural cultural outcome of a lack of moral clarity. Right and wrong are no longer clearly and consistently defined in our culture. In fact, the opposite is now true. We live in a world that values pushing the envelope, that believes moral restraint is something to be rejected instead of embraced. What we observed is the natural consequence of the abandonment of moral standards. If there is no good to be pursued there is no evil to be avoided and the perverse becomes normal.

What is most tragic is what people miss when they reduce sexuality to nothing more than a service one person performs to or for someone else. Love is missed. Intimacy is lost. Marriage loses meaning and loses relevance and stability. 

We went home that night glad that we are different. For thirty-three years we have pursued love, grace, and honor in our relationship with each other. We view intimacy as a sacred gift given to us by our Creator and we have nurtured and protected that gift. The result is a bond that is beautiful and unbreakable, a bond that will endure. A bond that too many others seem to have lost.

- Bart

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Poisoned by a Doctor! (And other Accusations)

“You doctors just want to give me poison and I am not going to take it!” I have been accused of many things in my 20 years of practice but intentional poisoning was something new and the patient's words surprisingly harsh. He was angry from the moment I walked into the room. He was first offended when I questioned his reasons for not taking the medications his cardiologist had prescribed. He had experienced some slight swelling of his legs, decided that this side effect was too severe and made the decision on his own that the medication was unsafe. He was convinced that the doctor had put his health in danger and that I wanted to do the same.

When I explained that this was a relatively common side effect with this medication he became angry. “Why would you prescribe a medication when you know there are side effects?” He was nearly shouting and his faith was contorted in anger. He was MAD!

“Because it is an effective drug and the side effects only happen ten percent of the time!” Was my reply.

He would have none of it. It was his opinion that no doctor should ever prescribe any medication if there were any side effects. I tried to explain to him the nature of side effects and how they were outweighed by the benefits of treatment. I spent the next 20 minutes trying to explain to him the nature of heart failure and why medicines were crucial for his health. I explained how the medications worked and why the side effects were reversible or manageable. He argued with me every assertion I made. He told me that doctors were dishonest people who cared more about money than they did people, unscrupulous individuals who would just as soon poison someone as treat them.

I finally gave up. As calmly as I could I told him that if he was going to refuse care for his heart failure that I would not be his doctor. If he didn't trust me it would be impossible for our relationship to continue. I explained that my preference would be for him to remain a patient and be healthy but that remaining a patient and being healthy would mean following my instructions. He continued to argue with me so I opened the exam room door and gestured for him to leave. “You will need to find another doctor,” I told him, and sent him on his way.

After he left I composed a letter summing up what had happened (detailed documentation is required when a patient is dismissed) and put it in the mail. I reviewed our conversation and concluded  by saying,

“You made it clear that you do not trust doctors, myself included. The physician/patient relationship has trust as its foundation. Your good health and medical treatment is dependent on you following expert medical advice. Our lengthy conversation today proved to me that you are unwilling to do this.

If you wish to remain a patient in my practice, you will need to accept and follow my recommendations, and schedule appropriate follow up visits. If you are willing to follow my recommendations and respect my judgment and opinions, please schedule a visit to move forward with your care.

If you plan on continuing to argue with my recommendations and refuse to comply with treatment plans, I must insist that you seek care elsewhere.”

I had my staff send the letter via certified mail, convinced that I would never see him again. Which is why I was so taken aback when I saw his name on the schedule 5 weeks later. I entered the room cautiously, prepared for another conflict.

It never came. He was incredibly apologetic from the outset. I asked him what changed his mind. He told me it was the letter! He realized that I was serious about his health and decided right then that he didn’t want to see anyone else. 

His dramatic change of heart was something else I had not seen in 20 years of practice. I was truly impressed with his humility and told him so. We agreed on a new medication plan for his heart and blood pressure and arranged a follow up visit. It was a very pleasant encounter.

It was also educational. He taught me that people can change, even those who seem intractable and unreasonable. He reminded me of the power of forgiveness and the beauty of a fresh start. I am actually looking forward to our next visit.

- Bart 

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