Watching a Marriage Die

The message was routine, a request for an antibiotic prescription to take on a trip out of the country. My staff had left for the day so I returned the call myself. The medical portion of the call was straightforward and lasted only a few  minutes so after discussing the antibiotic request I asked her about her family. I knew them all well as I had been the doctor for the birth of her 18 year old daughter. She told me that her kids were fine and that everything was okay with “them.”

Her emphasis on the word “them", referring to he children made me wonder if there might me something wrong with her "us", her relationship with her husband. It seemed she was implying that things weren’t going well in her marriage. I asked her what was going on. She told me it was a long story. I pressed her a little further and she confirmed my fears saying, “We are in the process of getting a divorce.” My heart sank. They had been married for over 20 years!

I asked her what had happened and if there was anything I could do to help. She was sure there was nothing anyone could do. She and her husband had drifted apart. They had little in common now that their children were grown. She was a busy professional trying to advance in her career while he had taken an early retirement a few years earlier. She was seriousness and business, he was having fun. They seldom talked about anything and the romance had died.

They tried a counselor but felt like it made things worse. In the counseling sessions they realized that neither one of them was willing to make the changes the other wanted. The sessions were circular, always keading back to the same place of disagreement. It seemed there was nothing anyone could do.

As she shared the story one phrase she spokejumped out at me. She said, “I have tried to take responsibility for my part of the problem.”

In that statement she revealed the root problem in their marriage (and many others). They believed that they each had “parts.” Their’s was a transactional, contractual relationship. It was a “I’ll do A,B and C and you do D, E, and F” kind of relationship, a relationship based on mutual benefit. If there was no longer any mutual benefit then there was no reason for the relationship to continue. If the other person did not do their “part” the marriage was effectively over.

Their contractual definition of marriage did not allow them to make the sacrifices needed to save their marriage. Marriage is intended to be a covenant, not a contract. In marriage two individuals make an unbreakable commitment. They leave their individual lives behind and become one. There are no longer individual parts, each person is committed to the whole of their relationship. It is a “I’ll do A,B, and C no matter what" kind of relationship, a commitment without limits.

We discussed how difficult this is. There is a natural tendency to want the other side to admit wrong and to work on things as well. As true as this is, it leads to hurt feelings and frustration as the imperfections and mistakes of the other spouse become the focus of attention. Marriages that endure are achieved by those who value the institution of marriage more than they do their own feelings of discontent. It is an incredible sacrifice.

I offered to meet with her or her husband, together or separate, if they wanted to talk further. I hung up the phone and said a prayer for them, their marriage and their children. I pray that they will come to the understanding that as painful as the road may seem, fighting to save a marriage is always worth it.

- Bart

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Fighting for a Patient's Sight

The vision in his right eye had been blurry for several days. It had worsened over the weekend and when he awoke Monday morning only a sliver of the vision remained. Worried, he walked into the office without an appointment, hoping he I could see him. My office staff quickly brought him back into an exam room.

I didn't even need to examine him. His story told the story. I was near certain that he was having a retinal detachment, a true medical emergency. As it had been progressing for several days I knew his vision was in severe jeopardy. He needed to see a specialist immediately.

Without leaving the exam room I logged into the HMO website to process the referral. He was a member of a new network in town, with a limited number of specialists available. I called the office of the only general ophthalmologist on the list. My heart sank when the staff told me the doctor was not seeing patients in the office that day. Who could I find to see him?

Worried, I called the medical group. After several minutes on hold I asked the staff to call so I could move on to my other waiting patients. When I came out of the next room my heart sank a little further. I learned that my nurse had not been able to get a referral but that we needed to wait for a return call from the assistant medical director. Not wanting to wait I searched my email for the number for the Medical Director, deciding to go higher up the chain as it was nearing the lunch hour when reaching a specialist would be near impossible. She gave verbal approval for the patient to be seen by a specialist in an affiliated group. Before I could hang up the phone my receptionist had that office on the phone.

More heart sinking. The receptionist at that refused to even get a doctor on the phone. As the patient was not officially a part of that group and they were not on call, she told me there was nothing she could do. I lost my cool for a moment, saying, “I guess we should just let him go blind!” as I hung up the phone.

The assistant medical director called me back a few minutes later. I quickly briefed him on the case and he promised to arrange a referral to a UCLA affiliated specialist a few miles away. Things started to move. That office called within 15 minutes, offering to see the patient on their lunch break. It had taken over 30 minutes of effort but he was going to be seen within the hour.

I went to lunch thinking that the problem had been solved but I was mistaken. Later that afternoon the eye doctor’s office called back with an update. It was a severe retinal detachment and the patient was at high risk for permanent vision loss in his eye. Emergency surgery was needed but the surgeon did not know if it could be done on time at the local hospital. He recommended that the procedure be done at UCLA first thing in the morning. The problem was that UCLA was over an hour drive away and the patient could not get to and from the hospital. They wanted my input.

My input was that the surgery had to be done locally, even if they had to transfer care to another surgeon. The doctor reconsidered, ultimately finding an assistant surgeon and getting time in the operating room of the nearby hospital for the next morning. I agreed to add the patient to the end of my day for the pre-operative medical exam and clearance.

One more glitch remained that day. After scheduling the procedure, the eye doctor was informed that the hospital did not have an operating room scrub technician available. His office called me again asking again about doing the procedure at UCLA! I was firm, "No! We have been over this, that is not possible!”

I looked at my watch. It was 3:45. If referral to another doctor was going to be necessary, we were running out of time. I pointed this out to the surgical scheduler. “We are running out of time to get help if we need it. I do not want to be rude, but this is ridiculous. This is an emergency surgery, and this is a hospital, someone needs to make this happen. If we cannot get a scrub tech in the next 15 minutes, we are going to need to call another doctor for help.”

They found a scrub tech.

He was back in my office within the hour for the pre-operative visit.

He was frightened. Everything had happened so fast and his world had been turned upside down. He was facing not only the loss of vision, he was also facing 7 days of immobility and weeks of work. It was hard for him to wrap his mind around it all. Worse, he was alone in town and had no support system.

I completed the clearance form and faxed it to the eye doctor’s office. When 30 minutes passed without any further glitches or delays I breathed a sigh of relief.

After the patient left I realized how drained I was from the day. While there was nothing medically challenging about the diagnosis getting the appropriate treatment had taken an incredible amount of effort. Between my staff and I over 20 phone calls had been exchanged in a period of 5 hours.

It wasn't over. 

We called the eye surgeon in the morning to check on the patient's status. The surgery had gone well, but there was a new obstacle. To preserve the sight in the eye, he would need to lie face down on a special table twenty-four hours a day for 7 days, with only one 10 minute break each hour. The table rental was $300 for a week and was not covered by insurance. As he was out of work and already poor, he could not afford it. The secretary at the eye doctor's office said, "This is sad because if he cannot get the table he will likely lose his sight." She acted as if there was nothing anyone could do. I could not believe that we could not step up and cover $300 to save the man's sight. Hadn't thousands already been spend on the surgery?

Multiple more phone calls later, we got the table paid for. That left us with another more basic need. How would he eat? He lived alone and could not cook or shop. Who could help him with meals and basic survival? Desperate again, I called a Calvary Chapel Church near his home. He had told me he had a friend there. I was forwarded to the staff member who oversaw the church's compassion ministry. She was immediately receptive. Two men in their church had experienced similar issues in the last year and she understood what the man needed. She committed to making sure that meals would be provided.

Tears came to my eyes as I hung up the phone. I did not know if we were going to be able to save his sight, but I knew we had done all we could. I was proud of my office staff, and especially grateful to the church. His case reminded me of why we all do what we do. We are here to help people in need, because we can.

I pray his vision will be saved. I ask that you pray as well.

- Bart

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Boomerangs, Broken Windows and Responsibility

Australians lie. There is no purpose or task for which a boomerang is needed or helpful. From my experience they are nothing more than devices of destruction and mayhem. No matter how many times one reads "the instructions" they never come back when you throw them. Even if they did no finger-loving human would want to catch one in flight. The only possible use of boomerangs is as a tool for lessons in personal responsibility. 

Case in point: When my son was about 7 years old one of the boys in the neighborhood had a boomerang. Nate was playing at their house and asked if he could throw it. He had a pretty strong arm for a little boy and he gave it quite a heave. It was traveling pretty fast when it struck the window of their garage. It is basic law of physics that when an irresistible force strikes an immovable object that the boomerang wins. There was glass everywhere. It was time to buy a new window.

I was across the street when it happened and hurried over to survey the damage. I told the neighbor that we would pay for the window. He initially refused but I insisted. I turned to my son and asked him how much money he had in his piggy bank. "Nine dollars" was his hesitant reply. I told him he would be contributing that amount to the repair of the window and tears welled up in his little eyes, "But it was an accident!" 

I explained that even when we accidentally break something or do harm, something is still harmed or broken and someone will need to fix it. The window had to be replaced, that would cost money, and because the damage came from him he was responsible to for it.  We have to take responsibility for the consequences of our own actions even when they are unintentional. This wasn't punishment, it was just the way life worked. We went home and retrieved his life savings and I added the remainder. The neighbor graciously did the repair himself. 

Reflecting back on the story I am reminded that personal responsibility is a lost value. People are often quick to apologize but very slow to make amends. It seems no one wants to be held accountable for their mistakes. I see this all the time. Just this week we received a bill from a medical office. We were surprised because we had been asked to "pay in full" at the time of service had done so. The collections agent explained that they had made a mistake and "forgotten" to charge us for a portion of the services. My response that "payment in full" typically means you have "paid in full" and that we should therefore not have to pay for their mistake fell on deaf and uncaring ears. 

I have made similar billing mistakes in my practice but my worldview is different from that of the other medical office. In every circumstance I bear the expense of our mistakes. Both me and my son can attest that accepting responsibility is costly. Apologies are not. Here's hoping for a resurgence of responsibility in the world.

- Bart

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Doing Right. Getting Fired Anyway

“I don't have to come to you. I can go somewhere else,” her statement was a threat. She did not like what I was saying and she wanted me to know that if I was not careful I would lose her as a patient.

As taken aback as I was by the threat, I was more surprised by the context in which it was made. She had called the service and had paged me after 7 in the evening for a refill of her asthma inhaler. All asthma inhalers have dose counters on them so a patient should never run out of medicine. The medicine itself reminds patients that they are running low. There is no good reason for a patient to need an emergency refill.

Before returning her call I logged into the electronic record to review her chart. A brief perusal revealed that she had not been seen in over a year and, if she was truly out of her inhaler, was using it more than was recommended. If she truly had gone through an inhaler in the time since  her last refill she was either in need of additional medication or not taking her current medications as recommended.

I called with the plan of exploring her level of asthma control and hopefully, to make sure her care was optimal. She had no interest in learning more about her asthma or appropriate treatment. She wanted her refill and nothing more. I pressed on nonetheless, deciding that I would provide good medical advice, desired or not.

I explained asthma treatment guidelines and that her inhaler usage suggested she needed more controller medications. She admitted that she had not been using her medications as prescribed. I entered her refills into the computer and as I did asked her to schedule an appointment so we could discuss them further. I reminded her that she also needed her annual flu shot.

She was surprised, asking “I need a flu shot?” In an incredulous tone. I explained that all asthmatics did, as influenza can cause life-threatening pneumonia in asthmatics. In an effort to make sure she got her needed care I opened the online appointment schedule and asked her when she wanted to come in.

She wasn’t interested. “I work 8 to 6, so I will need to come before then.” It was when I told her we did not have appointments before 8 or after 6 and that she would need to take time out to come to the office. This is what offended her, that I dare to tell her to prioritize her health.

The extra time I had taken, in chart review, in exhortation and in education, did not matter. What mattered was that she felt that she was the customer and the customer is always right. If I did not like it, she was going to take her business elsewhere.

I attempted to explain that she had misunderstood my intent, that I was not trying to talk down to her but was trying to encourage her to get the best care, but I did not get the chance. She hung up on me halfway through my first sentence.

I probably shouldn't be surprised by demanding and entitled patients but I am. I still naively hope that doing the right thing will be appreciated and understood. That is not always the world I live in.

I am going to do the right thing anyway.

- Bart

Is There Anyone We Can Trust?

One of the most quoted passages in Scripture is Paul’s description of the characteristics of a godly life found in his letter to the Galatian church. He calls these characteristics the “fruit of the Spirit”. The list includes- love, joy, peace, patience, kindness, goodness, faithfulness, gentleness, and self-control. These are all and wonderful and desirable attributes but one in particular seems unique from the rest. Faithfulness.

It is the one that can only be measured and assessed over a long period of time. A person who is kind, joyous, good and gentle 99% of the time may rightly be described as having these attributes, but a man who is faithful to his wife 99% of the time is a cheat. Because it requires persistence over time I think faithfulness may be the rarest of the Christian virtues and the most difficult to possess.

I fear it has also become the least valued. In out fast-food, fast-paced world we have come to want what we want and to want it now. Young people fresh out of school want honor and respect. Young politicians closer to high school age than they are to retirement age seek to be president of the United States, while other older politicians ask us to believe that they are committed to positions opposite those they espoused just a few years before. How can we know they will be faithful to their promises?

The fact that so many of the leading candidates fit one of these descriptions is evidence that we have devalued faithfulness. There is no substitute for it. While a person who has been true to his values for decades should be more trusted than someone who had frequently changed, this does not seem to matter to us anymore. This is concerning.

It is of even greater concern to me in the life of the church. As is often the case, in this regard the American church is following American culture. We seek new faces, charismatic leaders who make eloquent statements and emphatic promises. While these leaders may be good and gifted men, and while they may be kind, gentle, patient, joyful and loving, it is hard to know if they are faithful. Faithfulness can only be measured over time.

Later this week I will be speaking to a church group on the topic of faithfulness, looking into the Apostle Paul’s thoughts on the subject. It was a common theme in the letters he wrote to young pastors under his charge. The talk will be the basis of my posts in the coming few weeks as I explore what it is that Christians are to be faithful to. The answers may surprise you!

-          Bart

Those who are interested in hearing my talk on faithfulness can watch it live on my twitter feed this Wednesday, February 24 (@bartbarrettmd) I am scheduled to begin between 10:15 and 10:30. I am planning on uploading the message to my vimeo page later in the week.