I only live here sometimes...

At four in the morning, they are surprised to see me. 

The halls are dimly lit, about half of the big overheads turned off; the nurses' station is white and gleaming and bright, busy with a sort of unhurried business.   There's no rush at four in the morning.  There are no orders being phoned in and no tests being run.  There's time to sit and chat and stock carts.  I am somewhat of an anomaly in their world, a doctor in the night world of nurses, but they make room for me in the little cubicle in the corner, find me vital signs and updates, glad to have something to do. 

It's a far cry from the bustle at six-thirty, when the shift changes and the day nurses come on and the lights flicker into a facsimile of daylight.  When I come at six-thirty or seven, I meet the morning labs coming off the printer and the fresh new sheets of overnight vitals, step into a bustle and chaos of phone calls and notifications and getting things done.  They know to expect me early; I like my cubicle and its three walls of privacy right next to the intermittent beeping alarms of the remote telemetry, and so do all of the other doctors.  First come, first served.

It's easy to lose time inside a hospital: patient rooms have windows but the curtains are usually drawn, and the hallways exist in a perennial brightness of linoleum tiles and flickering lights.  Morning looks like afternoon looks like evening looks like midnight.  There are always nurses -- more in the daytime, but there are always nurses.  When I come down at four in the morning, euphoric from a delivery or half-awake while awaiting one, there are nurses who know my name and greet me by it, and more often than not the people I am there to see are as awake as I am. 

Visitors move around the hospital in elevators with wood panel walls and bright signs advertising hospital events.  I move in stairwells with unsealed concrete steps and railings that are nothing more than pipes and joins, where the lights are never the same color as anywhere else and the sound of my footsteps echoes eerily while I climb.  I walk through wooden doors marked "Authorized Personnel Only," knowing that my authorization is that I know what's behind them, cutting through back hallways with faded paint and abandoned clinic rooms, passing from hustle to bustle and back.  I have a tiny grey circle on my keychain that makes black boxes go "beep" and magnetic locks click open.  I have a list of codes for keypads that don't beep.  I know which doors are locked at night.

When I am attending a delivery I live in a sort of temporary camp: I put fresh folded pillowcases on plastic pillows and unfold the pale beige blankets around myself when there is no work to keep me awake, sleeping fitfully in the folded-up futons in the call rooms on Labor and Delivery, with the door half-cracked and my socks still on, my glasses lying beside my outstretched hand.  Time doesn't matter: there is food in the little glass-fronted refrigerator in the doctor's lounge, sandwiches and hard-boiled eggs and fruit and yogurt; there are chips and peanut butter and granola bars and bouillon packets stashed in the kitchenette on Labor and Delivery, the one with the sign on the door reading "Patient Use Only".  I eat when I am hungry, whatever I can scavenge.  I sleep when I do not have work to do. 

And at four in the morning, if I am awake and have patients to see, I go downstairs to greet the nurses in the half-twilight of the hospital night.

God Within

One late post-call morning when I was a family medicine resident I went to make sure all was well with a patient I’d admitted early that morning.  I don’t remember the details of her diagnosis or the reason I felt like I had to check on her, but I do remember that as I took my stethoscope out of my ears she smiled at me and said “Are you a Christian?”

This is not a question that I am frequently asked, and to be honest hearing it always makes me a bit uneasy.  It’s not the answer that concerns me: I know the answer.  It’s the followup questions that always seem to delve into deep theological issues best not discussed with strangers when you are going into thirty hours without sleep.  But I said that yes, I was, and quietly, fervently prayed that she would leave it at that.

“I knew it,” she said triumphantly.  “You have something about you.  I can always tell.” 

What do you say to a statement like that?  I said “Thank you,” and finished my exam, and told her I thought she’d feel better soon, and left. 

But things that people say to you when you're going on thirty hours without sleep sometimes have a direct line into your subconscious – and here I am, five or six years later, telling you about a momentary encounter when what I’m supposed to be doing is talking about finding God in other people.

Except that’s what I do every day.

Every time I walk into an exam room, or sit down at a hospital bedside, or huddle tightly with family members to speak in low tones, I am facing God in every person.  It’s not always an easy thing to remember – people get drunk, or angry, or belligerent, or apathetic; they drink too much and they don’t take their medications and they can’t figure out why they’re always so short of breath, but it can’t be those two packs of Marlboros I smoke a day, I smoke Lites. 

It’s easy to see God in newborn babies and happy parents.  It’s easy to see God in the toothless and gap-faced smiles of children.  It’s easy to see God in the cancer patient who comes in with a brave smile and a chemotherapy update, filled with prayers and hope. 

It’s hard to see God in the diabetic who doesn’t show up for appointments until  I see her in the hospital on an insulin drip.  It’s hard to see God in the fifth admission in six months for alcoholic pancreatitis when he promised me the last four times that it wasn’t going to happen again.  It’s hard to see God in the frequent flyers, in the patients who make your heart drop when they’re on your schedule in the morning, in the angry and resentful and combative and uncaring.

Sometimes, I have to look really hard.  But it’s in the looking – in the moments when I’m standing outside an exam room taking a slow deep breath and reminding myself that even this woman is a child of God, and is created in the image of God, and is a reflection of God – it’s then that I find God most certainly in me.

Last Rites

My mother is amazed that I'm a doctor. She is amazed at the things that doctors go through. It's a charming sort of attitude that manifests itself in comments like "You're so young to be dealing with all this heavy stuff."

She's right, in a way: I'm thirty-three going on a hundred some days.  Those are the days when I tuck my kids into bed, or bring them to the hospital with me, and I sit down and talk seriously with family members. The days when my spouse hears "I'll be there inside of twenty minutes" and sets his expectations that he'll be going to bed alone. The days where I dine with death, and walk the halls with death, and sit vigil waiting for death to come. Those are the days when I only know that I don't know what it's supposed to be like to be thirty-something, but I'm pretty certain it doesn't involve asking someone's sons and daughters how hard I am supposed to be trying to save a life.

The easy nights, when I have come so far as to ask that question, are the ones with tears and tissues and hugs and half-formed sentences.   Those are the nights where I know that I may not be able to cure what's wrong, but I can still heal something. I can do what is in my power to ease pain, and answer questions honestly, and I can be the one to say the things that I can see in everyone's eyes. Those are the easy nights, when death is quiet, and sits by the bedside holding someone's hand, and waits.

I have had this conversation before: by now I have had it a hundred times. I still tear up, and reach for my own tissue from the communal box. I still mourn. I hope I always do. It is hard to let go of someone -- it is hard to step away from your own self and grant another person the freedom to die if they choose, without trying to nail them to life.

Sometimes, there are hard nights. Those are the nights when decisions come too hard, and there are codes and chemicals and pressors and antibiotics and machines: we set great store by our machines, we doctors. We have machines to breathe for you and machines to pump your blood for you and machines that take the place of hearts and kidneys and lungs and stomachs.

But we have no machines to replace the soul.

Call it what you will: a life force, the essential energy of being, the will to live, the soul, the animus, God within. By any name, it is the thing that animates us, that makes a pile of blood and bone and flesh and synapses a person. It is the thing that makes us be, and it is the thing that leaves when we stop being. And I have seen its struggles, like a butterfly on a pin, on the altar of technology, vivisected by the hands of medicine.

Just because we can does not mean we should. There are some things that are universal: when the thing within desires to live, then we should support it: that is the time for machines, and for technology, and for the doing of heroic deeds. That is the time for the saving of lives. But when it is finished, then we should let it go. We should let it slip as gracefully away as we can; we should practice the art of medicine and the art of healing -- which is not the same as the art of fixing things. And we should look for peace, where we can.

When we have reached the point of this conversation, it is rarely a surprise to anyone that it is occurring. I can see it in the eyes, and the crumpled tissues, and the lingering touches. But it is not my doing that will decide whether a person lives or dies, and that seems sometimes to come as a surprise. I tell families that I can start pressors to raise the blood pressure, and ventilators to keep the air moving, and I can call the big city doctors at their big city hospitals and I can find an ICU bed, and we can keep the body alive, but that does not decide when a person dies. Only the person -- only that animate thing within them -- knows when it is ready to go. And without it, a body is nothing but a body.

Sometimes, I have this conversation, and there is agreement, and then people get better. They go home. They see their families again, and they stretch out their lives another week, or month, or year, or decade. Sometimes, they don't. There's no science that I can divine that says that this woman will recover from the point of death, while this man will not. I tell families that, too. I tell them I don't know what's going to happen. But I tell them if I think something will happen soon.

That's the best I can do.

Two Hats

Cap’n has a history of atypical febrile seizures (we have Valium in our house for these because his first one lasted over 20 minutes), with 102.5 axillary (about 103.5 oral) being the danger zone for this.  He's been as high as 105, but that was with the first one.

We’ve been to the neurologist after the first twenty-minute-plus ordeal (I drove him to the ED, still in status epilepticus, because he was breathing fine and I didn’t want to call an ambulance; he wound up getting IV valium and spending the night), on the recommendation of any number of pediatric specialists that I’ve had casual contact with.  His EEG is normal.   There’s a strong family history on both sides and so she felt that this was just a case of bad genes. 

We now take fevers very seriously. 

He had an ear infection with the first seizure, and since then he’s had three more ear infections and one more febrile seizure, so we went to see the ENT doctor of my choice to talk about getting tubes put in.  

Cap’n has flat tympanograms: his eardrums don’t move much because there’s fluid behind them.  They didn’t even do a hearing test, and it took the ENT doctor about ten seconds to agree with my assessment.  He also suggested I consider getting Cap’n’s adenoids out.   “Does he snore or mouth breathe?” 

“Oh, not really.  Only when he has a cold.” 

I hadn’t thought about the adenoids.  I went home and did some research, and read up on them.   And then I started paying attention to the symptoms.  That was when I started noticing how much mouth breathing and snoring took place in our household.  And also how many colds he really had.  It’s one of those things that makes you feel a metric load of retrospective parent-guilt, for not noticing. 

Surgery is scheduled for tomorrow and I have been a nervous wreck for a week already.  Then I got the call from daycare.  “Just letting you know he’s running a little fever, just 100.1.”  They gave him Tylenol.   An hour later it was 102.  We went and got him and I gave him the rest of the Tylenol dose for his weight and set to watching him and worrying.

He didn’t eat much dinner (although he liked the apples in the pork chop sauce) and whined more than usual (although he liked being pushed around on the tricycle), and then two hours after the Tylenol he started getting warm again.   My preoperative instructions said no NSAIDs for 2 weeks before the surgery, so I went to the other homegrown remedies and put him in the bath.

After 30 minutes in the tub, he was starting to shiver, and I couldn’t tell whether he was just cold or whether he was starting to get the tremors that presaged another seizure, so I took him out and checked his temperature, and he was 100.4 axillary still.  He was also still having tremors, so  in flagrant defiance of my preoperative instructions I gave him ibuprofen. Then I called and had the ENT paged at 8 PM so I could talk about whether we needed to cancel. 

There are some privileges that come with being a doctor.   Sometimes I use them.  I try not to abuse them.

He called me back and gave me his cell number.  "Call me any time."  I went over the physical exam with him (ears still dull and a little red, not acutely infected; snotty nose; lungs are clear) and asked if we needed to reschedule.  He said "maybe not."

We are tentatively still on for tomorrow morning, but it will be Anesthesia's call ultimately.   I want this done.  I want my son to be able to hear more clearly and sleep more soundly.  But I don't want to put him in danger to do it.

He’s cooler now; sleeping soundly in the middle of our bed where I can keep an eye on him as I type.  He’s allowed clear liquids until 4 AM so I will be making sure he gets his ibuprofen at about 3:45. 

I spent today reassuring parents and seeing patients.  Today, I was an efficient and effective family physician.  Tonight, I am a worried mother. 

It’s hard to wear both hats. 

Match Day

Today is Match Day.

Seven years ago today I was sitting in the big open central hallway of my medical school, next to my spouse, forgetting repeatedly to breathe.
At my school, they call you up one at a time and tear open the envelope and tell you where you're going to spend the next years of your life in front of the entire school. Until Match Day, your fourth year of medical school ends in a great gaping chasm; you don't know where you're going to live, who you're going to spend your time with, who's going to teach you.
You make plans, of course: everyone told me that in Family Medicine you get your first choice. You only rank the places you want to go. You know that if you didn't get called by the office in the days leading up to Match Day that at least you'll be going somewhere.


We'd gone house hunting in the city where my first choice was, and I had my eye on a pretty yellow dollhouse with crown molding and an airy feel. I knew the residents there, and the city, and it had the opportunities my spouse needed as well, to further his career.
But there's a giant computer somewhere that makes these decisions: it takes in rank lists from medical students and rank lists from residency programs, and it shakes them all up and it spits out the future.

And they called my name, and they read my program match, and I forgot to breathe. It was my second choice. Nobody gets their second choice in Family Medicine. Nobody but me. And in that moment, everything changed. We were going to a different part of the state, to a place where I didn't know what kind of house I was going to like, to a program that had been, dizzyingly, one of the first I'd interviewed at. For a moment I thought I'd heard it wrong. But I walked up and I took my envelope and I read it again and I sat down and I looked at my spouse and he smiled.

"It's got a great school for me to study at. And they have a rural track."

I don't know what would have happened at my first choice program. No one is ever told what would have happened, to cite C.S. Lewis, but I know what did happen. What did happen is that I was pushed, and pushed harder. I was given opportunities and training and encouragement, and I was left just enough on my own.
I have not looked back with regret on the decision the computer made for me, not even once, since the first day I started at the residency it chose. And I know that it made me what I am today, and I'm glad.

Accidents happen. Work goes on.

It was misting - one of those grey and sulky mornings where everything is glistening and dull with rain; where fast-intermittent is too slow on the wipers and constant-slow is too fast, so driving becomes a battle between vision and the incessant squeak of dry blades on dry glass.  The mist had cleared, but there was no sign of dawn in the dawn hours: it was a cold morning in shades of muted grey.
A flash in peripheral vision -- not even fully processed before the flash became a shape in brilliant beige no more than twenty feet ahead, an obstacle at high speed.  I saw it turn its head and shoulders away in the split second before impact, as if trying to dodge, but twenty feet at almost sixty miles an hour is about a quarter of a second.  It is long enough to move from the gas to the brakes; to register legs-body-head and for the brain to finish its previous task: "Deer! That is a deer!" moving between nouns from jubilation to terror.  I am reasonably certain I had time to scream.
And then the dull thud of collision; the body suddenly airborne and vanishing over the top of the car while my mind spun desperately, ludicrously: How much does a deer weigh?  I just had this car fixed.  Holy fuck I just hit a deer.  And then, sickeningly: Did I kill it?  And all the while the thrum and vibration of the antilock brakes under my foot; the car skidding to a halt, somehow reflexively guiding it to the side of the road where I stopped, gasping for breath and swearing in panic.

I did not, in fact, kill the deer. And this is where the story gets progressively more like a nightmare in my mind, so if you are of the softhearted variety you may not want to continue reading.

I got out of the car and looked at the damage before calling emergency services.  The 911 operator was very nice and promised she would send someone out immediately.  She asked two important questions for which I had answers: Are you hurt? No.  Is the car drive-able? No.  I was reasonably certain of both, having examined both myself and the car for serious wounds and found one of us more or less intact.  She did not ask about the deer.
I called and made sure someone would be able to see my hospital patients: these are things you think about when you are a physician.  It came immediately after Call 911 and before I got around to the serious business of adrenaline shock.  I packed the whole car into two shopping bags that were sitting in my front seat while trying to stay out of the rain and not think about the deer.   Finally I peered back along the road.
If there had been skid marks, the rain had erased them, and it was still dull grey and hazy.  For a while, nothing moved, and I started breathing again.
Then there was a dull brown shift in the dark green shoulder -- farm shoulders, a solid drainage area falling away from the road -- and something lifted its head.  And moved.  Laboriously -- painfully, I could tell even from twenty yards off -- the deer heaved itself to its feet.  Its back legs weren't working right, but it could prop itself up on them.  It was bleeding, but not much: just enough that I could see the flash of red on the soft pastel brown and white belly.
It worked its way up the shoulder and back into the road, heading back the way it had come.  Halfway through the first lane, it collapsed and lay there, now in the middle of the road on the downslope of the sort of gentle country hill that serves only to obscure oncoming traffic's view of the road ahead.  I braced myself for someone else to come over the hill at almost-sixty, and tried to stop my mind from wondering what, exactly, would happen then -- and then it got back up and lurched across to the double yellow lines in the middle before falling down again.
The traffic headed that direction stopped for it.  Someone rolled down his window and yelled across the road to make sure I was all right. I told him I was.  Shaken, not stirred, added my brain, and inside my head I dissolved in hysterical giggles.   He asked if I'd called anyone.  I told him my ride and the police were on their way.  I couldn't stop watching the deer.  There was nothing I could do -- nothing to do -- but wait.
Eventually, the deer managed to get across the road and traffic resumed.  I couldn't see it any more -- brown in the brown stalks of the harvested cornfield across the road -- and there were flashing lights red and blue and welcome in my eyes, so I stopped looking then.  It was city police: come to make sure the deer and the car were both out of the road; there to be certain I was unharmed as had been previously reported.  "Just shaken."  He nodded.  Not stirred! added my brain and something inside me began to giggle hysterically once more.  County was not far behind.
I had everything from the car packed; I had my license-registration-insurance card in my pocket.  The officer asked me about the deer.  I pointed to the field.  I went back to looking at my car until I heard someone say something about a camera and then I looked up.
They had found the deer.  It had lifted its head and was watching the lights.  I watched city raise his revolver -- firing-range grip, two hands, steady as she goes -- and fire.  The shot echoed as the deer's head slumped down, and something inside me relaxed a bit.  And then it lifted its head up again.  Five measured shots later, it had stopped looking at us, and the hysterical thing inside my head was no longer alternately screaming and giggling.  "Looks like a buck," someone said, and the giggling started back up again.

A little bit later, while I was waiting for my license-and-registration back, someone else in brown went out into the field and shot the deer again, this time from close range.  Then he came over to me, smelling faintly of gunpowder and death.  There was a patch on his sleeve that said "Conservation", and my brain spent a while trying to figure out what he was conserving before realizing that he was there about the deer.
"Did you want the deer, ma'am?"  he asked me.   It took fully a minute for me to understand what he was saying.  "Because if not, I have a needy family who can make good use of it."  I told him to give it to the needy family.  The thing in my head giggled and screamed that this was some sort of superdeer, which had taken a compact car and seven bullets to kill, so if I took the meat  it might just rise up out of my freezer and eat me.  The Conservation officer tried to smile at me -- I am sure my face looked ghost-pale and haunted.  "At least something good will come of this."
Silently, inside my head, something untied itself.  Something good.  Someone would eat well on venison, at least. The screaming thing hiccuped, giggled, and crawled back away to huddle in a corner, in case later I might need it again.

They loaded my car onto the tow truck.  They loaded the deer into the Conservation truck.  They loaded me into the County SUV and I tried to call my ride, but our cell phone carrier had apparently chosen this morning of all mornings to decide that nobody got to make outbound calls unless it felt like it, and I couldn't get hold of him, so we lurked in a parking lot until he drove by and then stalked him until he pulled over.
I was at work 30 minutes before my first patient failed to show up; I have spent the morning in all the mundane activities of medicine.
I am a family physician: my patients ask me how I am, how the children are.   I have been telling them about the deer.  I practice in a small town: some of them heard it on the police scanner -- "oh, that was you?"  Some of them were stuck in the traffic and are glad to know what happened.  Some of them have their own deer stories.  Everyone asks if I'm all right.  And I finally said "Shaken, not stirred," and someone laughed with me.

Family Practice

I’m at the annual meeting of my state family medicine association this weekend, sitting in the business sessions; I see a lot of women and there are some medical students and residents and that is a great thing to me.   I’m catching up with some residency friends, some of whom are a lot more involved in my Academy than I am, and some of whom are budding members of the Old White Guys Club™ coming in hung over after a night of drinking and smoking cigars and eating Denny’s.  I am not a budding member of the Old White Guys Club™, and I never will be.  I will one day, if I let myself, be old.  I will always be white.  But I will never be a guy.

In my row, there are two Old White Guys™ and me; our president-elect is a woman who used to be my advisor in medical school.  I’m looking around the room at all the white hair and at all of the newer people around me, in between exchanging hugs with men and women alike, thinking about drinking single-malt bourbon and smoking cigars and how that is the kind of party I will not be invited to any time soon, but they are all so glad to see me and when I was a medical student, I was the only one who came sometimes, and maybe it’s familiarity alone that makes them glad.  I’m thinking about how when you do a search on my state Academy’s home page for “GLBT” or any other permutation, or “gay”, that there are no results, but the AAFP Advocacy committee is considering resolutions with titles such as “Healthy benefits of Same Gender Marriage – Not Just a Social Issue” and wondering if maybe I should have brought a resolution to the table this year, in this state, on the issue.  After all, we are family practitioners.  And for the first time I’m putting something on my CME needs assessment, when they ask what you feel like you need more education on.
But all of that is inside my head, and outside I’m making small talk with the Old White Guys™ in my row and taking a good-natured ribbing from the other doc in my town for seating with a different district (I have privileges in two counties, which are in two separate districts).  I’m renewing some old acquaintances with people who would never invite me to drink single-malt liquor and smoke cigars but who are happy to have me on their commissions.  Among all of this I’m bustling out between sessions now and again to feed the Cap’n, since we didn’t think to ask if we could have a fridge in our room so we have no stored milk, and the topic turns at one point to women in medicine.
“We have a PA in our office, has school-aged kids, and all the dance recitals and things are at like 3:30.  So we try to accommodate her, but…”  And he’s talking about how the men in the office never take time off to go to their kids’ things; how it seems like they’re put-upon sometimes to accommodate this woman’s needs.  I’m cringing inside, already, and I know I have to say something – because this is the secret core of the Old White Guys Club™ in medicine: we can’t let women in because they won’t put the work first.   So I make my opening gambit. 
“But they ought to.  They ought to be as much a part of their children’s lives as the mothers are.”  I believe this; I believe that children need all of their parents to be involved with them.  And I believe that this is part of feminism, that if we are only going to argue that women ought to be able to work just like men that we are not making the argument that all people are created equal.  Men ought to be able to work just like women too.  And I’m ready to argue this one against him but he makes a surprising turn right about then, and breaks ranks with the Club™.
“I think that’s part of what’s happening in medicine – you have 50% of medical school graduates being women, and it’s changing the face of it.  There’s more focus on family.  I don’t have kids, but I bet if you asked a lot of the kids in my generation, they wouldn’t say they had a bad father – because it was mostly fathers, then – but they’d say he was never there.  I think we need to find some balance.  I think men should be able to take a few weeks off when their wife has a baby.” 


Balance.  There’s the word that defines my entire struggle with family medicine; the complex and delicate dance between personal concerns and patient care.  It’s something I’ve felt acutely through two pregnancies, through struggling with breastfeeding and pumping and working, doing midnight deliveries and coming home to a husband who’s just finished feeding the baby a bottle because he didn’t know when I would be back.  It’s sending my nurse over with a note to pick up my daughter from daycare because at 5 PM I still have patients to see.  It’s children who know where the crayons and the snacks are on the OB unit and Saturday mornings spent watching DVD’s in the doctor’s lounge.  It’s something every female physician with children I know struggles with. 
We spent some time talking about it, he and I – a childless Old White Guy™ and a young woman with two kids and a husband with his own professional aspirations.  The culture is changing, but slowly, and I’m afraid it’s only changing for some of us.  I hear physicians bragging on forums about only taking two weeks of maternity leave; of coming back after surgery before they would ever release a patient; of missing their children’s activities and family vacations and all the wonder of growing up.  They veil this under the guise of it’s for the patients but I wonder sometimes if it’s really hubris; if we as a profession have become convinced that the sun can neither rise nor set without our surgical intervention. 

I disagree.  I think we have forgotten Luke’s admonition of “Doctor, cure yourself!”  There is a need for balance.  There is a need for us to be models – not only in our professional lives, but in our personal lives.  How can we talk to people about their children when we do not even know our own?  There is value in school plays, in sports events, in dance recitals and taking your children to the museum.  There is just as much value for men as for women, and perhaps even more when your child has all of his or her parents there.

I do primary care.  I do preventative maintenance.  I spend hours every day talking with patients about taking care of themselves, about balancing their lifestyles, about making choices that make them healthier.  It makes you a better person, taking care of yourself.  It makes you a better doctor, taking care of your personal life.  And if it takes an influx of women into medicine to make that change then so be it. 

But I don’t understand why it has to.