The Night I Became a Doctor

I didn’t know what to do. The location of the young woman’s pain was consistent with appendicitis, but the level of pain wasn’t. The classic exam findings of marked tenderness, worse when pressure rapidly removed, and a firm abdomen, were absent. Her blood work was normal, and she didn’t have a fever. I did not think I could justify taking her to the operating room, but I wasn’t comfortable sending her home either. I had only been a doctor for a few months, so I did not have much experience to draw on.

It was 1990 and the medical profession hadn’t yet figured out the value of CAT scans and ultrasounds for diagnosing appendicitis so all I had to go on was my head and my hands. I felt badly that the patient had me for her doctor and worried that I would make the wrong diagnosis. I remembered that the symptoms of appendicitis typically increased over time so I admitted her to the hospital with the plan of checking her every few hours. I figured that the pain would either get better or get worse, and that time would prove to be the best diagnostic tool. I was confident that the answer would come within a few hours. It didn’t.

Six hours later nothing had changed. She still had pain and tenderness over the appendix, and nothing else. I knew enough to worry but did not feel like I knew enough to make a decision. I nervously decided to call the surgeon on call and ask him for advice. He was the Chief of Staff for the hospital and had a reputation for being a no-nonsense jerk with a tendency to yell at stupid interns, but he was the man who would be doing the surgery if surgery was needed. I was afraid he would be bothered by my call, but it was 11 PM and I was pretty sure his mood would only get worse the longer I waited, so I called his answering service.

He returned my page within minutes. In typical intern fashion I launched into a detailed explanation of the patient’s history and physical examination. I had barely begun my story when he interrupted me. “Do you want to take her to the operating room or not?” he demanded. Taken aback, I attempted to explain to him my uncertainty. He wanted nothing to do with my lack of confidence.

“You’re the doctor, I’m the consultant. Be a doctor. Make the call. You say the word and I’ll do the surgery. If you don’t want to do the surgery then hang up the phone and let me go back to sleep. Make the call.”

His words were like a punch in the stomach. It was time for me to “grow up” and be a doctor. The fact that the evidence wasn’t clear was irrelevant. A decision had to be made and it was up to me to make it, right then and there.

I made up my mind as I spoke my reply, “If it was my wife, I would want her in the operating room.”

“I’ll call the OR,” he answered.

A little over 30 minutes later I was standing across from the surgeon as he made the incision in her abdomen. I watched as he reached in with his gloved handed and gently worked to bring the appendix into view. It was not in its most common position. It was swollen and infected but it was tucked behind the cecum in such a way that the cecum blunted the pressure of examining fingers. It would have ruptured before the diagnosis became clear. Waiting would have brought harm.

As he prepared to remove the appendix the surgeon looked up at me. From behind his mask he said, “You made a good call.”

I have never forgotten his words, for they have meaning beyond medicine. I learned a life lesson that night. Sometimes there is no one to turn to but yourself. We can’t always wait for things to be clear. Sometimes being a grown up is about making the best decision we can in the moment and learning accepting the consequences.

- Bart

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Your Doctor Isn't a Robot

News flash- doctors are people. As such, we do people things. Please don’t punish us when we do.

I recently had a patient come in because he had been coughing for three weeks. This year’s cold and flu season was a particularly “coughy” one, so I was not surprised he had been coughing for so long. Although his cough did not worry me, it was obviously a concern to him, so I did my best to address his fears.

Although I did not think pneumonia was likely, it was a possibility. This, combined with his concern, was enough for me to order a chest x-ray. I sent him off to get the pictures taken, making sure to mark the order “STAT” so the radiologist would send a report the same day. A few hours later I sent the patient a message telling him that the results were normal and that he had nothing to worry about. I was confident I had done a good job and that the patient was satisfied.

He wasn’t.

Several weeks later I received a report on the results of the medical group’s most recent patient satisfaction survey. My scores had declined dramatically. I searched the report for an explanation and found it in the comments section. The coughing patient had left a scathing review, saying, “I went in for a cough that has lasted several weeks. Doctor Barrett ordered an x-ray but did not give me anything for the cough. He obviously does not care at all about his patient’s feelings.” Ouch!

In typical human fashion, I had focused on one thing, making sure he did not have a pneumonia. As I was waiting for the results to determine treatment, and as the x-ray was normal, I had notified him of the good news and forgotten to send in a cough medicine. Oops! What to some would be a harmless and understandable mistake was for him a capital crime. Off with my head! (And down with my patient satisfaction scores!)

Such disproportional wrath has become a regular part of medical practice. It is not uncommon for patients to tell me how “bad” another doctor was. A recent patient complained to her insurance about her oncologist because of a side effect from chemotherapy. The fact that the doctor had picked the best medication and prescribed it appropriately did not matter. Her cancer was better, but she had gotten dehydrated and he needed to be punished.

I have heard doctors criticized for saying too much and others for being too quiet. One patient will complain about too long of a wait, the next will complain about a doctor only spending 15 minutes with him (for a 15-minute visit.)

I sometimes think patients do not understand our humanity. We work hard to avoid big mistakes such as incorrect medications and missed diagnoses, but we sometimes make little mistakes such as failing to click the “send” button after entering a medication, forgetting we had a meeting at the hospital and running late in the office, or forgetting a patient’s name.

The best patients understand this and extend us grace and a helping hand. They ask questions when communication is not clear, instead of saying we do not care. They forgive us when we have to check the chart to see what their name is. They save their complaints for serious mistakes and don’t jump to negative conclusions.

The very best patients go even further. They say, “Thank You.”

- Bart

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Ulcers, Easter, and Truth

Truth is at times unbelievable.

By the early 1980’s medical experts were certain they understood the causes of gastric ulcers. As the stomach is an acid secreting organ, and because acid can damage tissues, everyone knew that acid was the reason people got ulcers. Because ulcers were more often found in urban businessmen, doctors concluded that stress had a role. This theory was “confirmed” by studies in rats that showed ulcers developed when rats were wrapped in straight jackets and dropped in ice water, and when research showed antacids prevented these ulcers.

Enter Barry Marshall, an internal medicine doctor in Perth, Australia. Along with a pathologist colleague, Robin Warren, he gathered evidence that ulcers were the result of a bacterial infection. Further, he found evidence that the bacteria was a root cause of stomach cancer. He started treating ulcer patients with antibiotics, with remarkable results.

The medical community refused to accept his findings. They thought they knew the cause of ulcers, and could not believe that a bacterial infection could be the cause. It did not make sense. Bacterial infections were the cause of acute infections, of pneumonias and ear infections and sinusitis and cellulitis. They did not cause chronic infections, and they definitely did not cause cancer. Marshall’s theory was simply unbelievable.

It was unbelievable, but it was true. Convinced of the truth of their claims, Marshall and his colleague fought for their findings. The medical community took longer than they should have to accept their research, but the eventually did. In 2005 Marshall and Warren, were awarded the Nobel Prize for medicine. They changed the world of medicine forever.

Their story came to mind today as I thought about Good Friday and the Easter Story. The Gospel accounts tell an unbelievable tale. The Bible declares that Jesus of Nazareth, a Jewish teacher of dubious parentage, was actually the Son of God. This Son of God, instead of asserting his right to rule and demanding that all honor and worship him, allowed himself to be put to death at the hands of the Romans who governed the conquered Jewish nation. He was publicly executed in brutal fashion, nailed to a wooden cross where he hung until in agony he died.

The story did not end with Jesus’ death,  the New Testament writers report that 2 days later he appeared alive to many of his followers. He had risen from the dead, in so doing proving to the world that he was indeed who he had claimed to be, the Son of God and the savior of the world.

What an unbelievable story.

So much of the story does not make sense. Why would God decide to live as a man? Why would he choose to die? Why couldn’t he just choose to forgive everybody without going through such suffering? How could someone come back to life after two days in a tomb. There are too many “whys” and “hows”.

The story flies in the face of so much that people know. The story is unbelievable.

That does not mean it isn't true.

- Bart

The Unrelieved Agony of a Dying Man

I never planned on being a hospice doctor. I had almost no training in end of life care during my Family Practice Residency. I learned about ethics, about patient’s rights to refuse care and to die with dignity, but caring for patients during the dying process was not part of the program.

One of my first exposures to end of life care in practice was when my aunt died of cancer in 2002. I loved my aunt and had fond memories of her but we were not close. I had not even been told she was dying. It was not until the last few days of her life that I knew how grave her circumstances were. It was then that I received a call from my grandmother. She told me my aunt was in terrible pain and the hospice doctor did not seem to be doing anything about it.

I drove to her home in south Orange County to see first hand what was going on. She was moaning in pain, even though there was a nurse present. My aunt was not fully lucid, and I asked the nurse what medications were being prescribed for pain. I was stunned at the response. I did not consider myself an expert on the treatment of cancer pain but I knew she was on a very low dose of morphine. The IV was delivering only 1 mg an hour, a dose so low that pain relief was extremely unlikely. I did not know much about cancer pain but I knew I could do better, so I volunteered to assume the supervision of her hospice care. I instantly doubled the dose of morphine. When her pain continued, I doubled the dose again. I repeated the process every few hours until she was comfortable. She did not achieve a pain free sedated state until the next day when the dose reached 100 mg an hour.

When she died a few days later my grandparents thanked me for taking care of her. They had watched her suffer for days, and I had changed that. The experience also changed me. After caring for my aunt I made myself a promise. No patient would suffer under my watch. I would personally manage every hospice patient in my practice. I knew I couldn’t save every patient but I could darn sure make sure they did not die in pain.

For the last 16 years I have kept that promise, making house calls and responding to calls from hospice nurses anytime, any day. I have aggressively managed pain, increasing doses as needed, committed to the relief of suffering. I have been consistently able to make all my patients comfortable.

Until the last few weeks. I had a patient whose pain I could not relieve.

He had aggressive lung cancer in his left upper lobe. The cancer had grown upwards into the soft tissues of his chest and shoulder, compressing the nerves that supplied his left arm. Nerve pain is the worst type of pain, and his was resistant to everything I tried. Multiple medications, from narcotics to nerve medications, failed to reduce the agony. I consulted pain specialists, palliative care doctors and radiation therapists in search of a treatment that could relieve his pain. I tried everything, hoping that the next medication, the next change in dosage, would prove to be the one that worked. After each adjustment in medication or dose I called to ask him how his pain was. The answer was almost always the same, ten out of ten. One the rare occasions when the pain went down the relief was only temporary. The pain would peak again in a matter of days.

The last week of his life, as the end was clearly approaching, I encouraged the nurse to get more aggressive with his medications. His dose of morphine reached a remarkable 400 mg every few hours, yet his pain remained. I called the best end of life doctor I know, and he recommended a change to methadone. The pain persisted. We added sedatives, hoping he could find a way to rest. He ultimately passed in his sleep. I can only hope that he did so without pain.

I was a heartbroken when he passed. I mourned the loss of man I considered a friend, of my inability to be at his side in his final days (I was out of town), and most of all, the knowledge that he had suffered so much. I was, and am, grateful in the knowledge that his suffering has ended, but find myself wishing I could have done more.

He suffered. He remained positive and kind to the end, but he suffered every day.

His passing makes me acutely aware of the limits of my profession. No matter how hard I try, there will be conditions beyond my reach, diseases I can’t cure and suffering I cannot relieve. It is the reality of life.

Even more, his pain causes me to again wonder as to the purpose of suffering. It is hard to see the good in circumstances so bad, hard to see the hand of a loving God in the midst of such agony. For this patient and I, it was our shared faith that sustained us. We both clung to the hope that his faith assured an eternity free from suffering, and reminded each other of this hope in our times together.  We also prayerfully shared the hope that God would somehow, someway, use his last days to touch the lives of those he loved, that God had a purpose.

I do not know what these purposes are or might be. The answer may not come in this life. All I can do is focus on the purpose that I know God has for me right now, which is for me to do the best I can to love his family and encourage them. I can share the story of his faith with others, of the hope that we shared, that others may find similar assurance. And I can do all I can to comfort and care for the other dying patients God brings my way.

- Bart

Thanks for reading and sharing. If you are so moved, consider saying a prayer for the man's family. There loss is profound. Comments and questions are always welcomed. I can be reached via the contact button on this website, or followed on twitter @bartbarrettmd.  

The Wealth of a Poor Young Man

Money was tight. He had left a job that met his financial needs because there was no opportunity for advancement, and instead took a job with the promise of a future, getting hired on as an apprentice electrician. Sadly, the contractor’s promises of work proved empty and within a month he found himself working only a few days a week and struggling to make ends meet. To make matters worse the physical nature of the job caused an old back injury flared. He was left wondering if his body would be able to tolerate the demands of an electrical career. Injured backs and pulling cable through tight spaces don't mix.

He is only 27, he has very little money and an uncertain future, yet he is one of the most impressive young men I have met. He is poor, but he has something most men lack. He has values. He is looking not for material wealth or pleasure, but for a job that will one day provide for his family. The mere fact that he wants a family to provide for is unique among men his age. He has no interest in casual sex or one night stands. He is looking for commitment, for a woman to marry.

In spite of his financial challenges he talks little about the things he lacks, or about things he wants to do our buy. He prefers to talk about the people he loves and cares about. Relationships matter to him, and he speaks proudly of his younger brother and his mother and what they mean to him. He is poor but still thinks of the needs of others. He recently moved into a new apartment, and when his parents offered to buy him a new living room set he refused to consider expensive furniture. He walked out of the high priced store store they had taken him to and chose instead to go to a discount store. He did not want them to waste money.

He is a man of faith. He is active in his church, and the ability to have Sundays off was a major factor in his decision to change jobs. He has meaningful relationships with people in the church and participates in a small group every Thursday night.

He has had a difficult life but he is not bitter. His father died of leukemia 7 years ago, a loss that could have made him angry at God and the world. His faith remains strong and his belief in the goodness of God has endured. He has embraced his mother’s new husband, rejoicing in her happiness and welcoming the man into his life.

He is a former patient who has become a friend, and we get together every once in a while over breakfast. When we talk I often think of the many other men his age I have met over the years, men with better pedigrees, engineers, lawyers, medical students and other professionals. So many of them are chasing wealth, prestige and pleasure. Although he is less successful in a worldly sense he stands out for the things he has that others lack- purpose, peace, and character. He is rich in the things that matter, a reminder that there are still good young men in this world.

- Bart

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