What to Do, When There is Nothing to Do

It was nearly midnight when the call came. Spencer was in pain and the hospice nurse was over an hour away. Could I come and give him a dose of morphine? They knew the answer before the question was asked. Of course I would come. I had made that promise the moment Spencer enrolled in hospice with incurable brain cancer. I could not save him, but I knew I could keep him from suffering.

I rolled out of bed, threw on some clothes and headed out the door. My heart was heavy as I drove the few miles to Spencer’s house. It was a rainy night, which seemed strangely appropriate. I pulled into the driveway, exited my car and walked, slowly, to the door. I was somberly welcomed into the home, the wave of a hand directing me to where Spencer lay in bed.

I had not seem him in a while, and was shaken by his appearance. It had been a year since the day the neurosurgeon had called me with the diagnosis of inoperable brain cancer. They were going to do all they could to prolong his life, but another year was all they could hope for. “All they could do” included high dose steroids, which caused Spencer to gain considerable weight. His face was so puffy he was nearly unrecognizable. He was no longer able to speak and I could not tell from his eyes if he was even able to recognize me.

Quietly I reached for the vial of morphine on the table to his side. I drew up the dose into a syringe, rolled down the top of his pants to access his muscle, and gave him the injection. I set the empty syringe down on the table and sat, looking at him, wondering what to do or say. I fought back tears. I lost that battle and teary-eyed, took his hand. I asked if I could say a prayer. I asked God for comfort and peace, said, “amen”, then leaned over and kissed him on the forehead. “I love you Spencer,” I said, and quietly left. That was the last I saw him. He died a few days later.

He was 5 years old.

I thought of Spencer yesterday as I was driving away from the home of another hospice patient, a woman just 2 weeks older than my wife who was dying from uterine cancer. Although the original diagnosis was made years ago, until February of this year she had considered herself cured, attending to her life with no thought of the cancer growing within. It was then that she came into the office for two red lumps that had appeared on her abdomen. They had grown rapidly and were quite tender. She thought they were skin abscesses. They weren’t. A CT scan brought the worst possible news. They were metastases. The cancer was back, and it was every where. In addition to the lumps on her skin it filled 90% of the space where her liver should have been. The hope the initial oncologist gave, of perhaps another year of life, proved to be false and a second opinion from the City of Hope quickly took it away. There was nothing anyone could do. We enrolled her in hospice, committed to making sure her few remaining days would not be days of suffering. That was just a few weeks ago.

Her husband called me late Saturday morning to tell me she was emotionally done, too tired to fight any longer. She wanted to go to sleep and not wake up. He wondered if there was anything I could do. I was at my son’s house only 5 minutes away from her home when I got the call. Something in the tone of his voice told me I needed to be there. I left my son’s and went straight to her home.

Her husband met at the door, his gesture toward his wife similar to the one Spencer’s mom had given me so many years ago. She was in a hospital bed near the door. An empty chair was pulled close to her, near enough to hold her hand or caress her face. It was her husband’s chair. I sat down and looked at her.

She was clearly uncomfortable. Her speech was clear but slow, every few words followed by a long pause, as if she was gathering the strength to continue each sentence. Her eyes were tinged with yellow, a sign that her liver had succumbed to the cancer and begun to fail. I knew she did not have much time left, days at the most.

With her husband listening on I developed a plan. I put in a call to the hospice nurse instructing her to begin giving morphine around the clock, a dose every few hours. I added a sedative to help her rest. She was not going to suffer, not if I could help it. I finished my explanation, took her hand and asked if I could pray for her.

She and her husband responded in unison, “Please!” Unsure what to say, I prayed as I did with Spencer, asking God to give her comfort and peace. I asked God to welcome her into the home which He had prepared for her. There were six wet eyes as I said, “Amen.” I let myself out, wondering if I would ever see her again.

I won’t. The hospice agency called me just 5 hours later. She was gone.

Both patients remind me of a lesson I learned a long time ago. Even when there is “nothing” more I can do, there is often still something I can do. I can love, I can give comfort, and I can pray. I can shed some tears, hug my wife, and thank God for the gift of life with which I am still blessed. And I can press on, willing to accept the pain and sorrow, committed to sit at the next bedside, take the next hand, and say the next prayer, knowing that as a Family Doctor this is my calling.

Bart

In Assessing Patients, There’s No Place Like Home

“Why would he want to live like this?”

It was his first visit to the office, yet I was taken aback at the extent of his suffering. Wheelchair bound after a stroke, unable to speak or walk, it seemed to me his was miserable existence. Even worse he had a chronic bone infection that could not be cured, a continually seeping wound that caused persistent pain. And then there were the bedsores, I wondered why he hadn’t yet given up.

In spite of this his wife assured me that he had a good quality of life. She told me that he enjoyed his kids and grandkids and took great joy in his time with them. I wondered how this could be true. At that visit (and the several that followed) he seemed subdued, almost depressed. At each visit his interaction with me was minimal, only an occasional nod or mouthed word. I never saw a smile or heard a laugh. My heart broke for him.

A year later I made a visit to his home. It was difficult for his wife to bring him to the office and I had offered to come to the home to check on a wound for which he was receiving treatment. It was the least I could do.

His wife met me at the door and escorted me down the hall to their bedroom. He was propped up in bed, leaning against several pillows. He looked up when I entered the room with a response that was shocking to me. To my great surprise, a huge smile spread across his face and he enthusiastically extended his hand in greeting. He was happy to see me! An involuntary smile came over my face as I took his and shook it. I told him it was good to see him, and it truly was.

As I shook his hand I took a moment to survey my surroundings. On the walls of his room I were many framed photographs of him in dune buggies and go karts. He was a car nut! Every vehicle pictured was one he had built himself. I had no idea of the man he had once been. It was clear that he had lived a very active life. I commented on the pictures and asked a question about his interest. My surprise increased when he replied. he gave a one word answer but the word he spoke was clear and appropriate. I cracked a joke, and his laugh was full and genuine, his smile infectious..

His wife told me the stories behind some of the photos, at times turning to him to verify she was getting each tale right.. With nods and occasional words, he agreed with most of her descriptions and made it clear when he didn’t. As she talked and he responded I realized something- he was truly happy. He was able to communicate with the woman he loved, and the family he adored. He participated in the conversation, and even made me laugh. His life was better than I could ever have imagined.

It was a humbling experience for me. My initial impressions and conclusions about his life and functional abilities had been totally wrong. The judgments I had made in the office, arrogantly made over the course of brief interactions, were completely inaccurate. I realized that if I had not visited his home I would never have known him or understood him.

I left his home a different doctor than was when I entered it. I entered certain of my ability to make assessments regarding the quality of a patient’s life. I left realizing my foolishness, newly aware of the importance of seeing a patient’s quality of life first hand before reaching conclusions. It was a visit I will never forget.

There really is no place like home.

• Bart

My First 25 Years in Practice

25 years ago today, I started my career in private practice. My notes were written in paper charts, I carried a pager but not a cell phone, and I had a head full of hair. Appointments were written in a book, controlled prescriptions were written on duplicate pads, and antibiotics were handed out like candy. HMO medicine was new and so was the group I joined. It was an exciting time.

My practice had a very wide scope back then. I had an active hospital practice and managed the inpatient care of both children and adults at Hoag hospital. I managed septic patients in the ICU, patients with diabetes out of control and with heart failure, often without consulting specialists. I took care of children hospitalized with bronchiolitis, dehydration and asthma attacks. I felt there was nothing that I could not do. One particular patient utilized all of my skills, a young pregnant woman with viral meningitis and pre-term labor. I performed the spinal tap myself, gave medications to stop labor, and managed her inpatient care without consulting anyone. Those heady days are long gone!

Hospital patients are much sicker nowadays. Many of the conditions that previously resulted in hospital admissions are now managed as outpatients. Skin infections, kidney infections and even new onset atrial fibrillation, conditions once thought to be serious, now do not even merit a visit to the emergency room. Those patients sick enough to be hospitalized are now beyond my knowledge and expertise.

For 12 of my early years in practice I provided maternity care and delivered babies. I was perpetually on call, only unavailable when I was out of town. It was demanding and challenging but I loved it. Welcoming new life into the world was one of my great joys, and it is what I miss most about those days. I delivered my last baby in 2007.

My office practice has changed as well. The era of “one problem per visit” is long past. Every visit to my office is now an opportunity to address multiple health concerns. Patients who come in for respiratory illnesses may find themselves leaving with orders for cancer screenings and routine blood work. Other routine visits evolve into impromptu counseling sessions. The result is fewer patient visits per day, but more care per visit. Where once I saw as many as 35 patients a day, my Physician Assistant and I seldom see that many patients between us.

The business of medicine had changed for me as well. In 1994 I was part of a multi-specialty group of over 30 doctors. Neurologists, cardiologists, obstetricians, internists, surgeons and family doctors, we were all in the same building with shared management. The business styles of the doctors proved to be as diverse as our specialties, and there was frequent conflict. The three physicians with whom I shared a suite joined together with me to leave and found our own Family Practice, Beach Family Doctors, I’m 1995. I managed that practice for 7 years.

By 2002 the practice had grown to 5 doctors and I had grown weary of managing it. In February of that year I went on my own, moving into a small suite across the hall from my former partners. Ours was an amicable parting, and we remain friends to this day.

Two years later, when driving back to my office one afternoon I passed a small house on Beach Boulevard. The “For Sale” sign caught my eye and two days later I was standing in the doorway of the home, imagining where I could put up and tear down walls to convert it into a medical office. Escrow closed in February 2004 and I moved into the office November 1st. It has been my medical home ever since.

Much has changed in the last 25 years but the most important thing hasn’t. I wake up every day knowing I will have the opportunity to make a difference in the lives of the patients who come to see me. This knowledge still brings me joy, and it is that joy that will sustain me in the years to come.

Bart

A special thanks to the many patients who have entrusted me with their health over the years. It has been a blessing, a privilege and an honor.  

Surprised by Cancer

The patient’s symptoms defied explanation. He wasn’t sleeping, felt as if breathing was a chore, and had persistent pain in his abdomen that wrapped around into his back. He had been suffering for weeks and was at the end of both his physical and emotional ropes. Multiple physicians had already been consulted, dozens of lab tests had been ordered, and a stomach specialist had even put a camera down his throat to check out his stomach and esophagus. No answer could be found.

I was not hopeful. His symptoms were unusual individually, together they were beyond confusing. As intense as the symptoms were, they did not fit any diagnosis with which I was familiar. After hearing his story and performing a brief exam I sat quietly and thought, completely dumbfounded. Other doctors, similarly perplexed, had told him that he was having anxiety. While this was a possible explanation (and an easy one at that), it didn’t make sense to me. I had seen hundreds of anxious patients over the years, many with physical symptoms, but none whose complaints matched his.

I went over his labs again, looking to see if anything had been missed. His potassium had been off, and I remembered that abnormalities of cortisol production were often associated with changes in potassium levels. It was a diagnosis I had seen only once, and that was over 20 years ago, but I went ahead and ordered the test.

That night I sat at my computer and searched for other possible causes. I read about rare conditions I had never seen before and vaguely remembered from medical school. Nothing fit. I decided that if the cortisol was normal I would blindly look everywhere I could. I knew I would probably not find an answer, but I was determined to be thorough in my search.

The cortisol test was normal, so I decided to order imaging tests. Deciding which tests to order was also a challenge. His symptoms were nonspecific so I was not sure where to start, what body part to image first. Frustrated and uncertain, I decided to order CT scan images from his neck to his waist. I doubted I would find anything but I could at least tell the patient I had tried.

He went in for the scans the next day. The phone call from the radiologist came the day after. “I am not sure why you decided to include the abdomen in your order, but it is good you did,” he said, “he has a 5 centimeter mass on his right kidney.”

I felt the color drain for my face. “Oh crap,” the words came out of my mouth involuntarily. 5 centimeter kidney masses are always cancer. I did not know whether it was dumb luck or divine intervention, but I realized that my decision to take pictures of everything may have just saved his life. Importantly, the scans showed no signs of spread, suggesting we may have caught the cancer in time. I could not explain how or if the cancer was related to his symptoms, but I had found it!

I spent the next few days reflecting on the near miss, on how easy it would have been to not order the tests, to refer him elsewhere or blame anxiety. I realized that I had found the cancer not because I knew what I was looking for or because I understood his presenting symptoms. I found the cancer because a patient was worried that something was wrong and I believed him. 

My reflections included memories of times when I did not believe worried patients as I should have, of concerns I may have dismissed and diagnoses I may have missed. I promised myself to be better in the future. I cannot always know, but I can always listen and I can always care. 

- Bart

Can a Christian be Anxious?

Words are dangerous things. As with a knife in the hands of a surgeon or the grasp of an assassin, whether they heal or harm depends on the manner in which they are wielded. The words of Scripture are no different in this regard. Divinely inspired and intended to further the purposes of the Loving God, when used incorrectly they can wound the soul.

In my experience, some of the most dangerous words in the Bible can be found in Paul’s letter to the church at Philippi-

“Do not be anxious about anything, but in everything by prayer and supplication with thanksgiving let your requests be made known to God.”

Written to encourage believers to focus their hope on God and his eternal purposes, they are at times transformed into a cudgel of discouragement, ignorantly wielded in a manner that bruises the hearts and minds of emotionally struggling Christians. “Do not be anxious,” wrongly elevated to the status of commandment, becomes a measure of faithfulness such that the presence of anxiety is interpreted as a sign of mistrust in God, spiritual immaturity and sin.

For Christians stricken with anxiety disorder, these words can be devastating. Feelings of guilt and inadequacy, already the daily companions of anxiety sufferers, grow in power and intensity at the implication that one’s feelings of anxiousness are a sinful choice.

I have been on both the giving and receiving end of these misspoken words. In the formative years of my Christian faith I attended a church with a Pentecostal bent, a place where faith was more emotional than intellectual, a place where hurting people were “encouraged” to simply “let go and let God.” Prayers for the struggling often included asking God to help them “trust God more” or to be “set free” from sin. I joined in these prayers, ignorant of the impact of my words.

My perspective changed a little over 10 years ago. I was preparing to enter an exam room one day when I felt a sense of dread come over me. Uneasiness and fear took hold. For no reason at all I felt as if something bad was about to happen. These feelings were soon joined by pressure in my chest, lightheadedness and a sense of detachment. My mind began to race and I felt as if my emotions were about to spin out of control.

“What is happening to me?” I thought. I answered my own question as quickly as I had asked it. “I am having a panic attack!”

The intellectual awareness of what was happening gave me the strength to stall the downward spiral. I was able to calm myself partially, enough to allow myself to call my wife and ask her to bring some medication from home. I had the presence of mind to tell my staff what was going on, and to ask them to reschedule some of my patients. It took a while, but with great effort and the calming presence of my wife I was able to finish my work day.

In the weeks that followed additional attacks came. I found myself in fear of the next attack and what it would do to me. I developed other fears as well, including intense self-doubt in personal and professional interactions. With the fears came increased irritability as I struggled to regain a sense of control over my life and thoughts. I saw a doctor, and with the help of counseling and medications learned to deal with a new reality.

I have not been the same since. While debilitating moments of panic have been rare, fear and anxious feelings now greet me every morning. Their voices are quieter some days than others, at times easily drowned out by the clamor of the day, but they are always present. Countless hours in prayer and Bible study have made one thing certain. Telling myself, or being told by others, “Don’t be anxious”, does not help.

It does not help, because the words of Paul (and Jesus in the Sermon on the Mount), were not meant to be used in this fashion. New Testament teaching about anxiety is never directed at the generalized sense of unease associated with a serotonin imbalance, it is directed at the human tendency to obsess and focus on earthly needs in a way that is contrary to a life of faith.

When Paul wrote to the church at Philippi, he was in prison, awaiting a possible death sentence. The church was being persecuted and many believers were suffering for their faith. It would have been easy for them to out of fear turn away from God. To these people, in these circumstances, Paul said, “Do not be anxious… but make your requests known to God.” Similarly, in the sermon on the mount Jesus reminded people not to focus on material needs, but to instead trust in God’s eternal purposes.

Paul was not saying that all anxiety was sin, or that Christians should never be anxious. He was acknowledging the danger that in focusing on the sufferings of this present life Christians can become discouraged. He therefore reminded them of the alternative, to focus on God and his promises.

I do not believe feelings of anxiety are a measure of anyone’s faith. Faith is displayed not in the absence of doubt or fear, but in the choice to trust God and his purposes in their presence. I do not say to myself, “Stop being anxious and trust God.” I instead say, “Yes, you are anxious, trust God anyway.”

These words do not take my anxious feelings away, but they do put the feelings in context. I am reminded that I will not be anxious forever. Eternity awaits, free from both emotional and physical pain. In that hope I find hope, peace, confidence and strength. I also find, strangely, a sustaining sense of joy.

Bart

While the focus of this post has been on Christian perceptions of anxiety it is worth noting that bad counsel is not limited to people of faith. Patients often tell me about family and friends not understanding their struggles, of being told that there is no reason for them to be anxious. I typically smile as I point out that this is why it is called an anxiety disorder. Normal people worry for a reason, people with anxiety disorder are often anxious for no reason at all. 

All patients with anxiety, regardless of faith, should be encouraged to get help. Counseling, in particular Cognitive Behavioral Therapy, is extremely beneficial. Medications, especially selective serotonin reuptake inhibitors, can also be tremendously helpful tools.