A MasterCard Weekend. Priceless.

Some life goals are noble, some are selfless and some seem silly. All are important to the person who sets them. As I accept the reality of my 55th birthday (and eligibility for the senior discount at Sizzler and IHOP) I am blessed in knowing most of my life goals have been met. I have a wonderful marriage, incredible children and a rewarding career. This week I was able to do something I have wanted to do since I was a child.

When I was a kid baseball was one of the few sources of joy in my life. I collected baseball cards, cherished each Dodger card and even memorized the stats on the back. I read every baseball book in the local library including biographies of Hall of Famers and histories of the game. One of my most embarrassing childhood memories was the day in 5th grade that I was so engrossed in the biography of Cleveland Indians pitcher Bob Feller that I sat right through the pledge of allegiance.

After cartoons on summer Saturdays was the Major League Baseball game of the week on NBC. Tony Kubek did the play by play and Joe Garagiola was the color man. I learned about all of the teams and the players and knew all of the ballparks in all of the cities. Two ballparks stood out from all of the others, Fenway Park in Boston and Wrigley Field in Chicago. Fenway had the Green Monster in left field. Wrigley had the bricks and the ivy on the outfield walls. Wrigley also had the distinction of being the only baseball stadium without lights. Every game at Wrigley was a day game. Attending games at each stadium has been on my to do list for almost 50 years.

I made it to Fenway in 2015. Last spring Lisa and I took a trip to Cape Cod. While there we took a day trip into Boston and I was able to go to the ballpark. It was a wonderful experience. The only thing missing was my son, who shares my love of baseball but wasn't on that trip with us. Fenway left me with a strong desire to make a trip to Wrigley with my son. The challenge was finding a time we could go. He married 4 years ago and just started his legal career. A long vacation together wasn't feasible. If we were going to make a trip to Chicago it would have to be a weekend trip just for a ball game, which wasn't practical. I am a frugal person and did not think I could justify spending money on round trip airfare and hotel just to see a baseball game.

A few months ago I changed my mind. I decided that a weekend with my son going to one of America’s greatest ballparks was worth the cost. The potential of a lifetime father/son memory was something I could not resist. I called my son and made plans to go to Chicago for two days over the Labor Day weekend. Friday afternoon Nate and I boarded a plane to O'Hare. We woke Saturday morning and walked the mile from our hotel to Wrigley Field. We arrived early enough to walk around the stadium, joining the crowds viewing the statues of Cubs greats outside. Every name had meaning to me- Ernie Banks, Billy Williams, Ron Santo and Harry Caray. We lined up early to enter the stadium as soon as the gates opened.

Our seats were a few rows up in the second section on the first level, behind the screen looking down the third base line. We settled in and took a moment to survey our surroundings. There is less foul territory than at modern stadiums and lower walls so we were close to the playing field. We soaked in the sights, looking out across the field to the ivy covered walls, down the foul lines where the brick walls seemed just inches away from fair territory, above the centerfield wall to the large manual scoreboard, as green as the monster in Fenway, and beyond to the bleachers built on the roof-tops across Waveland Avenue. My son and I had made it, we were at Wrigley field. My son said, “It’s kind of silly, but I could tear up right now.” He was not alone.

Nine exciting innings later, after many close plays and a few heartbreaking mistakes, the Cubs lost by a run. Thousands of unhappy fans headed for the exits. We joined them on the journey but did not share their emotions. It had been a wonderful day.

We returned the next day to sit in the bleachers. We arrived at the stadium 3 hours before the game and took our place in line. The bleachers at Wrigley are general admission, no assigned seating. We wanted to get their early enough to to get good seats. We ended up in the second row in left-centerfield. Perfect seats with a perfect view of the action. The game started slow but featured a 9th inning comeback by the Cubs that sent the game into extra innings. We stayed long enough to see Aroldis Chapman the Cubs reliever hit 100 mph on the radar gun and then made our way to the exit for the walk back to the hotel and the Uber ride to the airport. As we walked we talked about our two day whirlwind of a trip. I decided it was a MasterCard weekend. The airfare, hotel and game tickets had cost well over a thousand dollars, but the opportunity for me to spend a weekend with my son at Wrigley was absolutely priceless. Lives are sometimes measured in moments and memories and this weekend was filled with wonderful ones.

- Bart

When the Doctor Makes a Difference

I didn’t want to go in to the hospital. It was my internship year and I was tired from being on call every fourth night. It was my night off and I wanted to be home with my wife and son. 100 hour work weeks are hard on a marriage. I wasn’t in the mood for more work so I was not happy when my pager went off and I saw the number of the labor and delivery unit in the display. I called back and was told that one of my clinic patients was in labor. The resident on call was calling me to see if I wanted to come in for the delivery.

I was not obligated to respond. No one expected residents to come in on our nights off and the policy was that doing off-night deliveries was entirely optional. There was a resident physician on call in the hospital whose job it was to manage the obstetrical unit so my presence was not needed. I had every right to decline the request but in spite of my exhaustion I knew staying home it wasn’t an option. I had made myself and my patients a promise that I would attend every delivery I possibly could so I sighed the deep sigh if the sleep deprived and told my wife I was going back to the hospital. I scrounged around for a set of scrubs and headed out the door.

I sleep walked to my car, drove to the hospital and took the elevator to the 5th floor obstetrical unit. I made a right turn when the doors opened and headed down the hall towards her delivery suite. As I walked I could see that the door was open to her room with a current drawn for privacy. Curtains are a poor noise barrier and I could hear her cries of pain as I approached. Epidurals had not yet become routine and she was going through the last stages of labor medicated only with narcotics. It was clear that the narcotics were completely inadequate. I knew her well enough to know pain was not her only challenge, I detected fear and anxiety in her voice.

As I pulled the curtain back to enter I saw the on call doctor standing near her bedside. From a medical standpoint her presence rendered mine completely unnecessary. A doctor was needed for the delivery and a doctor with the skills and knowledge to care for the patient was present. I briefly wondered why I had felt the need to come and whether it mattered.

The patient’s response made my wonder disappear. She looked up at me as I entered and a look of relief come over her face. “Thank God you are here!” she said. She calmed instantly and I realized that what mattered to her in her time of need was not that some doctor was present, what mattered was that her doctor was present, the doctor she trusted.

I have never forgotten that moment. In those few seconds I realized a new career goal. It was no longer enough for me to be a good clinician, to simply get the treatment right.  I decided that I wanted more. I wanted to make a difference in people’s lives, not solely because of my medical knowledge and expertise but because of who I was as a person and the relationships I built. I wanted to have an impact on patients not solely for the care I provided, I wanted to make a difference because I was a caring provider.

The goal of making a difference has proven to be a challenging one. My own fears, insecurities, and stress can make it easy to overlook a patient’s emotional needs. The mental focus required to make a challenging diagnosis can at times cause me to lose sight of the big picture. It is easy at times to be “just another doctor.” My patients deserve more, and because of that pregnant patient 25 years ago, my patients get more.

-Bart

PS: After writing this post I decided to see if I could find the patient on Facebook. I did, and I sent her a message. The baby boy I delivered that night is now a man of 25. In spite of the years the patient remembers the night well and how grateful she was when I arrived. She wrote, "The anxiety wondering if someone whom I did not build a relationship with, someone who was well qualified but unknown to me was to deliver my child scared and worried me. I was truly concerned that you would not get there and appreciated it more than you might have known. The fact that neonatology was called due to meconium and a concern of NICU, I was a small disaster of nerves and prayers. Seeing you walk in calmed me and reassured me that all would be right with the world that early morning.  God placed you in my life for just that reason. Again thank you for being who you are and what you chose to do."

Thanks for reading, and a special thanks to all who take the time to share and let others know about the blog. Comments and questions are always welcomed.

Best. Business Decision. Ever.

I needed a day off but couldn’t take it. I had been in solo practice for 3 years and business was steady. I loved my job, my office and my patients but wanted some time for myself, some time with my wife and some time to write (my book, Life Medicine, was in the planning stages.) I wanted to take a half-day off in the middle of the week but did not have anyone to cover me. A regular day off would just make the rest of the week terrible as I tried to catch up. I could arrange coverage with other physicians for the occasional day off or vacation coverage but a regular day off seemed out of reach.

I thought about hiring a Nurse Practitioner or a Physician Assistant but I did not have either the business to pay someone a full-time salary or the space for someone to work in the office along side of me. I thought about trying to hire someone part-time but the same problems remained. Who would want to work only one half-day a week? Desperate, I reached out to a colleague to see if the Physician Assistant they employed might be available to cover one morning or afternoon a week. I received a sympathetic “No” as a response.

“I do know someone though,” my colleague said, “I have a neighbor who is a PA who has been out of work for a while. She might be interested.”

I figured I had nothing to lose so I made the call. The woman who answered the phone was very pleasant when I called. She had taken time off when her children were born and now that they were school-aged she was thinking about reentering the work force. She was a little leery about her skills after being out of work for 5 years but wanted to reestablish herself. I invited her in for an interview.

The day of the interview she called to cancel. One of her sons was sick with the stomach flu and she had no child care. “You can bring him with you to the interview if you like,” I told her, “I don’t mind.” She was pleasantly surprised at the offer and agreed to come in.

A few hours later she sat across from me in my office. Her 6 year-old son sat quietly on a blanket she had laid out on the floor, playing with toys while we talked about the job. She was interested in the opportunity but nervous about how everything would work out. “What do we have to lose?” I said,” if it doesn’t work out, we shake hands and part friends.” She liked that logic and accepted the position.

That was 11 years ago. Brandie Walton, the PA I hired is still with me. I remodeled the office two years ago and she now works full time. She has been the perfect PA, kind, gracious and knowledgeable. She has also become a friend, colleague and source of stability and encouragement to me and all of the employees. We share similar views on life, faith, and service to patients. We cannot imagine ever working with anyone else.

Since she started full time in January we have found ourselves reflecting back on how our journey together started and the path that we have walked these last 11 years. At the time I hired her neither one of us could have imagined how the practice and our professional relationship would grow. The initial decision we both made to trust one another and work together has been one of the smartest decisions we ever made. We have been truly blessed.

Bart

PS: An update on the little boy on the blanket- He left for college last week! His big step is a reminder of how much time has passed and the source of this reflection. 

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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