Saving Lives by Showing Up

Woody Allen said, “80 percent of success is just showing up.” I am realizing a similar truth in my office practice. 80 percent of success is just letting the patient show up.  You can’t help patients who can’t get into your office. We have experienced the benefit of showing up in dramatic fashion over the last few months.

In the middle of the busiest flu week of the year a young man called our office. He had complaints similar to so many other patients seen during that time, high fever, occasional chills, loose stools and abdominal pain. Our office policy is to see anyone who wants to be seen for anything at any time, so the receptionist worked him into the schedule of our Physician Assistant. She walked into the room expecting to see her umpteenth influenza victim of the day.

He didn’t look like the other flu sufferers, though. He was paler, covered in sweat, and his abdomen was extremely tender. Concerned, she called me into the room for a second opinion. I took one look at him and had him lie down for a repeat abdominal exam. His abdomen was rock hard and he felt pain with the lightest touch. Minimal movement made the pain worse, as even tapping the soles of his feet was agonizing. I knew something was wrong.

“It could be flu,” I said, “but your symptoms are consistent with a surgical abdomen, what we see with a ruptured appendix for example.” I told him that because there was a possibility that he was seriously ill I wanted him to go straight to the emergency room.

The next day his mother updated us on his condition by sending us a message. “Thank you for saving my son’s life,” she said. Tests had shown that not only had his appendix ruptured but that he was septic, with life-threatening bacteria found in his blood stream. Has my receptionist made him wait a day longer, the delay could have been fatal. We all breathed sighs of relief. We knew that his life had not saved by brilliant medical acumen. He was saved because he was allowed to show up.

We had another close call a few weeks later. A man in his 60’s called saying he did not feel well. He was unable to give the receptionist more specific information. He just felt weak and sick. She told him to come on in to the office. As luck would have it, he was also seen by our PA. Although his blood pressure, heart rate and oxygen levels were all normal, she did not like the way he looked. It was my day off, so she called me at home to discuss the case. It was immediately apparent to me that she was unusually worried about him.

“Do you want me to come take a look at him?” I asked, “I am not doing anything and I can be there in 5 minutes.” She did not require convincing. She definitely wanted me to take a look. Attired in jeans and a t-shirt I went in to see him. When I entered the room I instantly understood why she was worried. He just looked wrong. He was pale, and his face was covered with glistening sweat. He looked like someone who was sick, even though his vital signs were normal.

“I am worried about you,” I said, “and in order to make sure you are okay I need some answers, answers I can’t get fast enough outside of the hospital. You need to go the emergency room, because they can get the results quickly.”

I had no idea how quickly the answers were needed. A little over an hour later in the emergency room he on the verge of dying. He went into respiratory failure and needed to be put on a ventilator. Further tests showed the cause, he had blood clots in his legs that were traveling to his lungs. Only the grace of God and the skill of the critical care team saved his life.

The next day in the office the topic of conversation was what would have happened it we hadn’t had him come in right away, or if I hadn’t come to the office, or if we hadn’t sent him to the emergency room. We shared the draining realization that we came so close to losing him. It was clear to all of us that his life was saved because we allowed him to show up.

I wish I could say that this was always the way I practiced medicine, that same day access without explanation or questioning has always been our response. A little over 7 years ago we started offering same day access to sick patients who called before noon. We only began guaranteeing the service to all callers regardless the time they called in 2015.

It is the best thing I have ever done in medicine. I have realized that while I can’t always be right, I can always be available.

Somehow, I think there is a lesson here for all of us. Showing up is important.

Bart

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Learning From "The Greatest Showman"

I have a confession to make. I’ve seen The Greatest Showman four times. One might think that was more than enough, but I have already checked Amazon to see when it will be available on Blu-Ray. Critics didn’t care much for the movie, but my wife and I loved it. The music and the story resonate with me in a powerful way.

It is not the story of the circus and its performers that stirs me as much as it is the story of the Barnum character himself. The movie portrays him as the son of a poor tailor, scorned and mistreated by the wealthy father of the girl he loves. He finds motivation in the man’s rejection and dedicates his life to a single endeavor, showing he is deserving of respect by achieving worldly success.

As a result of this consuming passion no amount of success satisfies him. Making his circus a success is not enough, he needs to be considered a serious producer of art. City wide fame is insufficient, he needs to be known around the world. Touching the lives of those he is close to does not bring satisfaction, he needs the adoration of strangers.

The futility of his pursuit is described in the words of the song sung by another unsatisfied character in the film, the world-famous opera singer Jenny Lind-

“All the shine of a thousand spotlights
All the stars we steal from the night sky
Will never be enough
Never be enough
Towers of gold are still too little
These hands could hold the world but it'll
Never be enough… for me”

This is Barnum’s curse. He is so consumed with the praise of people he has never met that he fails to appreciate the love of those around him, those who should mean the most to him. It takes the burning down of his circus building and financial ruin for him to recognize his mistake. The moment when these tragedies lead him to realize his foolishness is a powerful point in the film, expressed in the song “From Now On”-

"For years and years
I chased their cheers
The crazy speed of always needing more
But when I stop
And see you here
I remember who all this was for"

At the end of the movie we see that Barnum’s transformation is complete. As he sits in the theater, his arm around the woman he loves, he watches their children and sings, “This is the greatest show.”

This scene is profoundly moving for me. I grew up unwanted, unloved and abused, the child of a father held me in disdain. I spent years of my life trying to prove to him, myself and others that I was good enough, that I was worthy of praise. I drove myself to succeed in every area of my life, in education, medicine and even church. Toiling in the shadows was unthinkable, I needed to be the best, I needed recognition.

It took too long for me to realize that the only love and appreciation I needed was from those who love me. My wife believes in me, supports me, encourages me and loves me. Together we have built a family, a home filled with love and laughter. When I stop and consider my wife and my children I realize that they are indeed, “enough” and “I remember who all this was for.”

Forget the praise of the world, ignore the awards shows and the faint, vanishing praise of strangers. The moments of love spent with family are the Greatest Show.

-          Bart

The Hate Filled Language of the Gun Debate

We have lost the ability to disagree with one another.

This is not a new thing, but it seems to be on the rise. I thought incivility of political discourse might have peaked with the last presidential election, but the last week has proven me wrong. The discussion (if one can call it that) about gun control has been hateful, demeaning and devoid of listening. The ability to see goodness and reasonableness in those who don’t take our side seems to have vanished from our society.

Marco Rubio seems to be a decent man. He was caring and gracious enough to attend the Townhall meeting attended by those directly affected by the Parkland school shooting. His presence was not appreciated by many of those in attendance. One student told Senator Rubio that looking at him was like looking at the shooter, that looking at Rubio was like “looking down the barrel of an AR-15.”

Dana Loesch, a spokeswoman for the NRA, was booed at the townhall when she told a story of a young rape victim who believes that she might have saved herself if she had been able to carry a weapon. She was jeered and mocked from the audience.

Wayne LaPierre, the executive vice president of the NRA, showed a similar level of incivility the next day in his speech to CPAC, the conservative political action conference. He said, ” These elites don't care—not one wit—about America's schoolchildren.”

Dana Loesch, the aforementioned victim of audience intolerance, was not above slandering others either. At the CPAC conference she said, “Many in legacy media love mass shootings.”

It seems that both sides of the gun control debate are refusing to believe the best in the other side. While there are disingenuous and dishonest people, while there are some politicians who intentionally mislead and who seek personal gain, the overwhelming majority of Americans have many things on which they can agree.

No one wants innocent people to die.

No one wants lethal weapons in the hands of mentally ill individuals prone to violence.

Everyone wants to be safe and wants their children to be safe.

If we all agree on these points there is no reason for us to hate and demean one another. Thinking someone is wrong does not require us to believe they are bad. Bad ideas can be associated with good and noble intentions. We need to believe the best in one another.

We have common goals, even when we disagree on how to best achieve those goals. If we cannot respect one another and listen to one another the  chance of achieving these goals decreases. 

Bart

Prostate Cancer and Solving Societal Ills

Death from prostate cancer can be agonizingly painful. It spreads to bones, eating them away. Patients feel as if they have fractures all over their bodies. It is a sadly common disease, killing 1 in 50 men. The medical profession has for years sought a solution, tried to find a way to catch the disease in the early stages and prevent the suffering. We have failed miserably.

For a while there was hope. Over 30 years ago someone discovered a protein in the blood, the Prostate Specific Antigen, that was elevated in the blood stream of prostate cancer patients. It was high when cancers were diagnosed, went down as the cancers were treated, and then rose again when cancers recurred. It was a good marker of cancer activity. Eventually doctors thought. “What are we waiting for? Why not use the PSA test to find cancers before they spread? Let’s start testing every man and end the suffering!”

It was a great idea, or so it seemed based on the available knowledge. What no one knew at the time was how many harmless prostate cancers were present in the population, cancers that did not need to be found. Prior to PSA testing, almost all of the prostate cancers diagnosed were deadly, for these were the patients that came in for treatment. Harmless cancers were almost unheard of.

It turned out that these silent harmless cancers made up the vast majority of prostate cancers. When PSA testing became widespread these were the cancers that were most often found. To the surprise of everyone prostate cancer diagnoses increased 600%. There was an exhilaration in the medical profession as people considered how many lives they were now saving due to early diagnosis.

The exhilaration soon faded. It turned out we weren’t saving very many lives at all. The prostate cancer death rate barely budged. In spite of the 6 fold increase in diagnoses the death rate declined a pitiful 5%.

To make matters worse, we soon learned that we were doing more harm than good. As we could not (and still cannot) tell which cancers were deadly, doctors treated every cancer they found. Thousands, if not millions of men with harmless cancer cells in their prostate glands had their prostates removed. Given the extremely high incidence of long lasting complications from the surgery, such as impotence and incontinence, incredible harm was done in the effort to save lives. Most studies suggest that 50-60 men were harmed for every life saved from PSA testing.

I realized the potential for this harm early on. I never endorsed or recommended routine PSA testing for my patients. Over and over again, day after day, with patient after patient, I explained the potential harms. For nearly 2 decades patients argued with me. Some patients got angry. They told me stories of friends and family members who had died from the disease and accused me of not caring. Many left my practice, including some with whom I felt particularly close. It was not easy being a dissenting voice.

It is only in the last few years that the majority of medical societies have accepted the reality that we do not have a good screening test for prostate cancer. PSA testing is no longer recommended.

People are finally acknowledging that the law of unintended consequences once again has come into play. The desire to do good resulted in a great amount unforeseeable harm.

The lessons of the PSA test have far reaching applications. Our society has many ills that plague us, from poverty to gun violence. Debates rage in legislative halls and internet forums. The cry to “DO SOMETHING!” resonates with all of us. It is frustrating to see others suffer needlessly. We want action and we grow tired at the perceived inaction of our leaders.

The prostate cancer story serves as a reminder, we can do much harm in the pursuit of doing good. Simple solutions do not always exist, and we would be wise to proceed slowly as we search for answers. 

Bart

Olympic Burnout

The Olympics are back, bringing with them stories of incredible effort, devotion and sacrifice. Some champions will ascend from the depths of anonymity, while some anticipated winners will fall spectacularly short of the goal. All who contend worked hard, all have exceptional skill and talent. All are possessed with single minded dedication to their sport, all have sacrificed greatly in pursuit of their goals.

These sacrifices aren't limited to the athletes. Each Olympiad brings stories of parents giving everything they could to support their child's dream.  Over and over again we are told tales of families who relocated so their children could train in the best facilities with the best coaches, who borrowed against or spent their life's savings, or who gave up careers and relationships in order to commit hours taking children to and from practices and competitions. The impact on families is immense. Their are neglected children who grew up in their sibling's shadow, who dealt with their parent's frequent absences, and who did their best to make do with a too small portion of parental attention.

I wonder if it’s worth it.

The winners often declare that winning justifies all of the pain, all of the sacrifice, but does it?

Most winners are quickly forgotten. (Quick- name one of the six US men’s track and field gold medalists from 2016.) Non-winners, all of whom make similar sacrifices, receive nothing in return for their efforts. When their 15 minutes of fame are over they often have little to show for it. The hours spent away from family and friends are lost forever, the pains and scars from injuries endure for a lifetime, remaining long after their brief Olympic moments fade out of memory. It seems a very high price to pay.

Perhaps I am growing cynical with age, but winning doesn't mean that much to me anymore. My earthly achievements do not reach Olympic proportions, but I have had moments of fame and success. When I look back on things that I have won, Chess trophies, Academic honors, and over $100,000 on multiple television game shows, I realize that in spite of the momentary elation I felt at the time, none of these "wins" made a significant difference in my life. Most people I meet have no knowledge of the awards from my past. What matters are not the things I have won but the person I am and the person I am becoming.

It is faithfulness and character that matter the most. There are no medals and trophies handed out for being a better person each day, but I believe that if I sacrifice myself daily working to be the person God wants me to be, if I focus my eyes on eternal things and strive to love God and others with all of my heart, that none of my efforts will be wasted. To me, this is the prize worth giving my life up for.

Bart