One Day, Two Deaths

He was alive on Thursday. By Friday afternoon he was gone.

What caught me off guard was not the fact that he had succumbed to his cancer, but how rapidly he had passed. When I visited his home on Thursday he was fully alive. He was completely aware of his illness and his prognosis, and how both of these impacted his function and his family who was caring for him. We talked about this, about the natural course of his cancer, and about the coming decline it would bring. We talked about the help that he would need in the coming days and made arrangements for the hospice agency to provide it.

He was worried he might be developing bedsore, so I walked him into his bedroom so I could examine him in private. I took his arm as we walked, but it did not seem he needed my help. He was out of breath from the effort, but he was not unstable or unsteady. He did not need help getting undressed, and he was able to lie down and get up without assistance. He was a sick, but he did not appear to be dying.

Appearances can be deceiving. He died 30 hours later, in his home with his daughters at his side. He was a man of strong faith, and he died at peace with himself and with his destiny. When the moment came, he was ready.

Not everyone who is dying is ready. The morning of his passing I met with other doctors to discuss the care of another dying patient, a cancer stricken man 30 years younger than my patient whose wife was not at all ready for his passing. While my patient and his family had accepted his diagnosis and the reality of his dying, acceptance was elusive for the family of the younger patient.

At the moment my patient was passing away in his home, the second patient was in the intensive care unit, unable to breath on his own, septic, and had cancer all through his body. He was comatose, malnourished and weighed only 100 pounds. He had been bedridden for months and bedsores all the way down to the bone. He was a shell of the man he had once been. All of the doctors agreed: there was no chance of survival, no chance that the patient would ever leave the hospital.

In spite of this medical certainty, the family wanted the doctors to do everything they could to keep the man alive. They wanted him resuscitated if his heart stopped, maintained on a breathing machine, and his infections treated aggressively.  My meeting with the doctors was about how we could do what the family could not, allow him to die in comfort and dignity. As it against hospital policy to provide futile care, we informed the man’s wife that we would be transitioning him to comfort care (removing life support) within the next few days.

Both cases took a toll on me. I grieved the passing of my patient. He was a kind and gracious man, and I had grown to respect him and care about him. His death left me with a deep sense of loss. I also grieved with the wife of the second patient. She had never planned on losing her husband in his fifties and the idea of losing him was something she could not process. Her pain was real. I was moved to pray for her and with her, and found myself fighting back tears as we spoke. The knowledge that we had made the right decision did little to blunt the pain. Her loss was profound.

Both cases reminded me of important truths. I can’t save everybody, and when it comes to death, there is a point when I cannot save anybody. In cases like these, the most important things I do are not  medical, they are personal. As a fellow human being, I can love people, be there when they need me, be kind, and speak truth.

When a Patient Thinks I'm an Idiot

For all intents and purposes the visit was over in about 30 seconds. Our conversation continued for another 15 minutes after that, but nothing I said after the first half-minute mattered. He did not like me.

Being disliked by patients is a part of a doctor’s life. As hard as we try there are people we cannot please. Typically, it is because they want something we cannot give (such as antibiotics for a cold) or when we fail to meet expectations (such as running late or explaining things poorly). This was not the first time I had been disliked by a patient, but this happened quickly. It usually takes me longer to get on someone’s bad side.

He had not been to a doctor in many years, and probably would not have come this time if it had not been for the fact that his wife and some friends had been recently diagnosed with cancer. He was 49 years old, and he was worried that he had missed essential screening tests that were important for cancer detection.

“I know I am terrible for not coming in for physical exams,” he said.

In an effort to ease his guilt and calm his fears I said, “It’s not a big deal, physical exams are pretty useless. We almost never find anything.” I explained that in people who feel healthy, head to toe exams seldom uncover anything abnormal. I went on to explain that cancer screening starts at age 50 and that he had not missed anything.

He thought I was a fool and proceeded to tell my why. His friend was in his 30’s when he was diagnosed with prostate cancer. He believed that earlier screening would have saved his life. He told me of his wife’s breast cancer and how her doctor had missed the diagnosis. She should have been screened earlier as well. Based on their experiences he had a list of tests he wanted me to order.

I shared with him the reasoning behind cancer screening guidelines, how the harm of false positives was real and why we waited to screen until the benefits of screening outweighed potential harms. I went into specific detail about the screening guidelines for colon, prostate and breast cancer.

He interrupted me, saying, “So you are not going to give me what I want?” I replied that I would give him everything he needed. This answer was not good enough for him, and he started telling me of all the things he had read on the internet about detecting cancer. It was clear that he felt I needed to educated, and that he was just the person to do it.

I finally said, “Since it is clear that you think you know more about this than I do, I am not sure how I can respond.”

He said he didn’t think he knew more, but then proceeded to continue questioning my opinion. I finally said to him, “I do not think this is going to work. Maybe you should find a different doctor who you can trust.” He responded by telling me all of the ways he thought I did not know what I was talking about.

Exasperated, I said, “I have had hundreds of conversations with people about cancer and have said the exact same words that I have said to you. This is the first time it has blown up in my face. I am sitting here trying to figure out what the heck went wrong!” My implication that perhaps the problem was with him and not me did not register at all. I decided giving up was the better part of valor.

I said, “Let me buy you a cup of coffee and send you on your way.” I went and got a Starbucks gift card and handed it to him. “I wish you the best.”

I did not (and still don’t) feel good about the interaction. For days after I asked myself what I could have done differently. Absent a fit of clairvoyance, I did not see any way I could have prevented the conflict. The chip that he had on his shoulder when he came in was not visible to the naked eye.

As my attempts at self-blame proved pointless, I turned my reflections to his lack of trust in the medical profession. Since my comments and answers are shared by the vast majority of physicians, it was clear that his problem was not specifically with me. He did not trust any doctors.

I think his mistrust came from many places. The first is the elevation of self that has infected our society. For many, personal experience and google searches are perceived as the great elevator and the great equalizer. Instead of coming to my office seeking answers and asking informed questions, many patients now come certain in their knowledge and challenging mine.

It is easy to ridicule this mistrust but it is not unfounded. It is fed by doctors. There are some physicians who have gaps in their knowledge and who are not interested in investing the time required to fill those gaps. I have encountered these doctors both as a patient and as a primary care physician. I am not a specialist, but my basic knowledge of medicine combined with internet searches corrects specialist errors several times a year. As a patient, questioning my physicians has prevented unnecessary surgery, corrected erroneous diagnoses, and changed treatment plans.

I am not alone in my experiences. Also thanks to the internet, stories of medical errors and missed diagnoses are known to everyone. When combined with the mistrust brought by the advent of HMO medicine, the stories of price gouging by pharmaceutical companies and the loss of long term physician/patient relationships, blindly trusting physicians makes no sense.

Blind trust may be foolish, but not trusting at all is worse. Doctors cannot get through their days if they have to explain every single thing they do. Simple diagnoses and common recommendations cannot require detailed explanations. If they do, there will not be time to explain complicated conditions when they arise. Our experience and expertise needs to count for something.

My approach is simple. I have worked to develop a high level of self-awareness. I work hard to be expert in my field, but at the same time work to recognize the limits of my knowledge. I am willing to double check myself, and to answer all honest questions. For the occasional needy patient, I try to make time to calm their fears and go into greater detail. Fortunately for me, this approach meets the needs of the vast majority of patients. When it doesn’t, as it did with this patient, I reluctantly move on.

I take a similar approach as a patient. I seek out doctors I can trust. When in doubt, I ask honest and non-threatening questions. There are times when I do my own research, but I do not present it in an adversarial fashion. My relationships with my doctors are partnerships, and I try to work together with them. When we do work together, good care, and good relationships, happen.

Bart

Men Need Men

We meet every Wednesday morning. We are of different ages, different backgrounds and different socioeconomic classes. Some of us are devout, others are still unsure about their faith. We are a diverse group, not all of us are married and our ages range from 28 to 64. We do not have much in common yet we come together each week with a shared agenda. We want to be better men.

We want to be better because we know we can be and we know we should be. We recognize that we are all messed up, all have problems, all have hang ups and issues. Most importantly we understand that we cannot become the men we need to be on our own. We have blind spots, prejudices and preconceptions, broken thinking that gets in the way, and keeps us from being the men we want to be. We need other men to help us.

We rise early once a week, drink coffee and discuss the struggles common to all men. We spent a month discussing anger, why we get mad, when we get mad and how we can learn to control our tempers. We have talked about women, but not in the way men often do. We talk about how we can be the type of men who respect women in our personal and professional lives. We talk about morality, honesty and integrity, and all of the barriers that make it hard to be good.

We laugh together, tease each other, challenge each other and encourage each other, week after week. As we do, a remarkable thing is happening. We are changing. Tempers are coming under control, goals are being adjusted, and definitions of manhood are changing. Friendships have developed and are growing. 

Also growing is the realization of how much men need other men. Many of us did not have strong fathers, most of us have not had many deep male friendships. All of us are seeing that we need each other and that we are better because we meet.

It is one of the most significant things I have ever done. I have been a doctor for 28 years and been actively involved in church ministry for nearly as long. I cannot think of a single thing I have done that has been as consistently powerful and meaningful. Men need men, and it is a privilege to bring men together.

Bart

If you are a man interested in meeting with other men, send me a message. If you know a man who might be interested, send them a message. We weren't meant to fight these battles alone.

Bad Dads, Good Dad?

I have always wanted to be a good dad, the type of father my kids could admire and praise. Unfortunately for me my desire was not combined with knowledge, for I did not have a father growing up. There were two men who shared the title of “dad” in my life, but neither of them was committed to the role. My step-father was an abusive alcoholic who believed that children were supposed to quietly serve their parents. He took no delight in me and showered me with curses instead of praises. He was a man to be avoided, not admired. My own father, a bitter, angry man, only saw us at holidays and for a few weeks in the summer. The rare moments spent with him were opportunities for him to criticize and correct us. I was told that I used too small a spoon to eat my cereal, did not know the correct way to take off a shirt or put on socks, and was clumsy. I was never told that I was loved.

By the time I reached high school it was clear to me that I would have to figure out fatherhood on my own. I looked for role models, typically to male leaders in the churches I attended, but those men were always too busy to invest time in me. My training was limited to an occasional Bible lesson or sermon.

Those sermons, as limited as they were in number, were not without impact. They gave me the principles upon which I could try to build the character traits I desired, an idea of the type of person I wanted to be. I learned the values that characterized a good man and father.

I learned from the book of Ephesians that husbands were to love their wives. From this I realized that the most important thing I could do for my children was to love their mother. I could not be a great father without being a great husband. A man’s highest calling is to be a husband, and I needed to model this for my kids. In sickness and in health, for rich or for poor, come hell or high water, in the way I loved and served my wife I could teach my kids what it meant to be a man.

I learned from Deuteronomy 6 that it was my job to teach my children about God.  Moses’ words to the nation of Israel were a solemn charge to intentionally teach children about the nature of God, His words, and how to follow Him. With this in mind, from the age of 16 I worked to study the Bible and apply it to my life, to live consistent with the teachings of Scripture so I could be a role model for my children. When our children came along I worked to share God’s words with them. In conversations at the dinner table, in the car and at every opportunity I worked to teach my kids how Biblical truth applied to every area of life.

I learned from 1 John that in spite of my best efforts I would sometimes fail to be the man I was called to be. While sin was inevitable, through my faults I taught my children how to fail. From my father I inherited a bad temper and controlling it was a constant struggle. On those occasions when my anger got the best of me I showed my kids how to apologize, without excuse or justification. I am at times fearful and anxious, and my children heard me ask God for wisdom and help. I taught them what it meant for a broken person to love a perfect God.

I could have done better. Not a day goes by that I do not wish that I had been a better man, that I had listened more, been more patient, more attentive, or more kind. It is easy to look back over 28 years of fathering and think of all of the ways I could have done better.

It would be easy to let regret at my failures overwhelm me, to tell myself that I was a bad dad, but when I look at my children it is hard to accept such a conclusion. My son is singularly committed to the only girl he has ever loved and devoted to my grandson. While other men his age are out seeking pleasure and parties, my son wants only to be with his family. My son wants to be a great husband and father, and he is working hard towards that goal.

My daughter, who is engaged to be married this October, wants me to officiate her ceremony, because she believes that her dad is the best man for the job. She tells me she wants us to dance to “My Girl” and “That’s What Makes You Beautiful” because those are songs I sang to her and with her when she was a little girl. She is proud to be my daughter.

Father’s Day has always been a strange day for me. It brings with it sadness as I reflect on the men who raised me and the pain they caused, pain that lingers to this day, pain I will never fully escape. It also brings me joy, for I have children that love me, children that can see past my faults to the man I want to be and am striving to become.

Bart

Miss America isn't the Problem, America is

This last week the press was abuzz with the news that the Miss America pageant was no longer going to be a beauty contest. The pageant announced it was doing away with both the swimsuit and evening gown portions of the competition.  Gretchen Carlson, the Chairman of the Board of Directors made it clear that women who wished to compete for the title of Miss America would no longer be scored on their appearance. “We’re not going to judge you on your appearance because we are interested in what makes you you," Carlson said.

The move was hailed as part of the positive cultural change brought about by the #metoo movement, the widespread uprising against the harassment and abuse of women. Ms. Carlson referenced this when she said, “Miss America is proud to evolve as an organization and join this empowerment movement.” Commentators called the changes long overdue, with the Dallas News going so far as to say, “As long as Miss America requires contestants to look good in an evening gown while strutting in high-heeled dress shoes, it’s unlikely women in the United States will achieve gender equity.”

The reports were characterized by a sense of celebration, recognition of a positive societal evolution. There was a sense that the days of women being objectified were numbered, that women were now going to define for themselves feminine ideals. Miss America was showing the way, first by getting rid of misogynistic leaders and filling the organization's board with female leaders, and now by making sure that contestants would not be subjected to body shaming or leering audiences.

The changes in Miss America dominated the news this week were significant, but were not the most important story impacting the rights of women in America. The biggest news came from a minimally reported public opinion poll. The Gallup organization this week announced survey results that should give pause to all who think our nation is making progress in its attitudes about women.

Gallup asked respondents a simple question, “Is pornography morally acceptable?” The findings were devastating. 67% of men between the ages of 18-49 and 43% of all respondents said, “Yes.” This was not “yes” to bikinis or “yes” to nudity of the type seen in Game of Thrones. This was not “Yes” to the Sports Illustrated swimsuit edition or airbrushed poses for Playboy. This is “yes” to explicit sex acts, the most degrading material possible.

It is important to note that the question was not about legality, Gallup did not ask about what should be allowable or tolerated in a free society. They specifically used the word "moral." Morality refers to the rightness of a thing, or to put it another way, to the absence of wrongness in a thing. We have reached the point where two-thirds of young to middle-aged men believe there is nothing at all wrong with them gaining pleasure by watching women perform sexual acts with other men.

What does it say about a nation that celebrates banning modest swimwear on television while at  the same time finds it acceptable to broadcast graphic sexual acts over the internet for everyone to see?

It says that America has no sense of morality at all.