In Lehman's Terms

So there are just times when it’s crazy to be a doctor.  Not crazy cool, like when your little cousins are looking up to you, and not crazy awesome, like when you’re trying to impress a girl’s mom.  Sometimes, it’s just plain crazy.  I just intubated (put a breathing tube into) a patient who had part of their brain coming out.  It looks like a sea urchin, or like fish eggs when you clean a fish–very slick and soft and shiny, like maybe all of the information in there makes it sleek (a modern mind?).

Naturally, I was trying to avoid getting any on my scrubs.  Does that stuff come out in the laundry?

Crazier is that this stuff just gets scraped away because there’s no way to put it back!  Whoa!  Dude!  What if you just took something important:  Like how to find my keys, or my hidden jewelry, or what order to poop-wipe-flush (or was it wipe-flush-poop…).?  Or how not to fart in a quiet meeting?  The possibilities are endless, but no matter what got scraped off, it makes you think that something is definitely going to be out of sorts when this person wakes up…

Like I said, sometimes it’s just kind of crazy.  I hope they didn’t need that!

Chaz on the prowl.  No one is cute on call nights.  Where are all the ladies in the House of God?  This is no Grey’s Anatomy.

“Physician, heal thyself”

-Luke 4:23

I’m sick.  My throat had the tiniest of tickles on Saturday night.  By 3am Sunday morning I was experiencing chills, fever, joint aches, terrible sore throat, and your run-of-the-mill malaise (said like you’re savoring the word…it’s a great one).  I spent all of Sunday morning and afternoon taking my concoction of meds, sleeping, shaking, sweating, and praying for a quick release.  Today was round two, but with baby steps in the right direction.

Wait, you mean doctors get sick?  Um, yeah!  Even ones that exercise, eat well, and avoid most major pitfalls still succumb to the reality of being human: frail chinks in the immune system’s armor.  In this case, I’m suspecting allergies or makeout poisoning (strep throat).

What’s it like for a doctor to be sick?  I’ll share my experience.

1) I wake up kind of freaking out.  I’m shocked that something penetrated the immune system that’s been slapping away all of the hospital creepies I deal with every day.  Then I run through all of the terrible possibilities that I know of thanks to my profession.  I spend time wondering if I’m overreacting–which is not so bad–but then wonder if I’m under-reacting–which would be really bad.

2) I start doing things to take care of myself.  Maybe I’m embarrassed to ask for help.  I really want to be taken care of: my mom would be great right now, my ex-girlfriend, my double ex-girlfriend, or anyone else I can think of who knew me well enough that I would let them see me like the mess I am right now.  I’m a mess, and I shouldn’t be.  I should shrug this off, but instead my despair gets an added dose of guilt (this is pathetic for a doctor).  And I feel worse because the exes aren’t around because they left; maybe because I was pathetic.  This is a downward spiral…so I’m back on the internet confirming my differential diagnosis and deciding on a treatment course.

3) I meet Centor criteria for strep throat (this is a clinical list of things that if filled makes it more likely that you have a bacterial source of infection–which makes you inclined to use antibiotics), plus fast onset.  I start with treat the symptoms: Tylenol 1000mg plus Aleve 600mg every 6 hours.  They work through different channels, so it’s good to use both (isn’t it interesting what doctors do differently?).  Plus I sleep as much as I can.  I also start on some augmentin.

4) I finally feel crappy enough to call Jordan because my doctor friend David made fun of me and called me a wuss.  Isn’t empathy nice?  No wonder doctors are such douche bags sometimes; it’s only funny if its not you that’s sick, and I’m sure he didn’t “mean it.”  Jordan brings Gatorade and a Tylenol refill.  Lifesaver!

5) Finally the fever breaks.  I haven’t left my house all day.  Still depressed and miserable.  I could cry and really want a hug.  It’s a lonely place in the ivory tower.  I feel like I’m wasting the vacation days I took this weekend, but I can hardly move and swallowing is like being stabbed in the neck.  All I can think about is getting better because I’m not getting anything done that has to be done outside of work–and this is the only time I have to do it!

6) It’s now Monday.  I thought I was getting better, but I’m not.  The exudates are nasty on my tonsils; even that word is gross.  I give myself an IM shot of Decadron (a steroid).  Being a doctor is great for having good access to medicine.  I’ll give myself that.  Not that I’m necessarily managing it well, but it’s also a good experiment–if it works, it’s a nice thing to know.  What better way than to test it on myself!  I’ve also gone through my customary pity thoughts: wishing the mom/exes were here, wondering if I’ve gotten something horrible, under-treating myself, or going to stay sick and have to be on call (Wednesday) like this (and no, there is no calling in sick, it would be a step short of sacrilege–even if I risk exposing others to what hit me; stupid logic I know).  What if I never get better, or have mono?  And I start cardiac anesthesia in a month.  Oh man.

7)  To make things worse, I feel like the “Physician, heal thyself” (A biblical “I told you so” if you read the scripture) is on its way somehow.  And yes, lo-and-behold, it popped up on my facebook comments when I was looking for sympathy.  Thanks for making me feel awesome.  Everyone else gets sympathy, I get a why-don’t-you-just-take-of-it-yourself.  Well, for one, I am.  But that’s not the issue.  I think it’s in times of weakness when love is a powerful source of healing.  Not for just the body, but for the emotionally vulnerable mind.  Hugs don’t cure fevers, but they can cure doubt, and they can give peace of mind.

I know being sick isn’t fun for anyone.  These times remind me that I’m a patient, too, even if the rest of the world doesn’t think so.  I certainly hope that the experience is less needy, overwhelming, and/or less full of worry (ignorance is bliss?) for others, but I know it’s some combination of all these things for each of us.  I’m also thankful, because thanks to my good habits, this is the first time I’ve been sick like this in 2 or 3 years!  But regardless, it’s not fun, and it isn’t any easier just because it’s part of the job.

…Off to salt-water gargleglglglglglgllglelelglelgllserglesglglg…and pray for an end to being/feeling pathetic and lonely.  Oh, and why not see a doctor?  Because I don’t have a primary care doctor.  Yes, I know; another hippocratic hypocrite.

“I bet for an Indian, shooting an old fat pioneer woman in the back with an arrow, and she fires her shotgun into the ground as she falls over, is like the top thing you can do.”

-Jack Handy

Hey guys, it’s Dr. Roddy here.  Drs. Marcus and Chaz have their niche, so I’m throwing my ring into this hat (lol, I’m on call, this is what happens when you go without sleep!).

Anyway, today I worked with three patients all of whom were so large they almost didn’t survive their surgery!  Certainly their size also contributed to why they were there in the first place, but every step of the way for them has been more dangerous, costly, and stressful for everyone involved.  One lady was so big we thought gravy was going to come out when they made incision!

Alright, bad joke…but not really (cuz it’s funny AND tasteless).  You can’t take this topic too seriously, because too serious means you don’t talk about it.  Seriously!  You’re my patient, you’ve crept up in weight to the point that people wonder how you put clothes on!  Dang!  Let’s talk about it!  Addressing the health consequences without discussing the cause is just sweeping it under the rug…and that’s not cool in the long run.  Embarrassment is not a good enough reason to ignore this!

What can we do to reverse someone who’s gone so far down that path?  Truthfully, I don’t know the answer to that.  It takes a lot to stop years of putting on weight.

But as a doc who’s a jock and loves to rock hard abs, I think the solution starts with prevention.  Don’t GET that way.  Learn early what the good choices are, and do whatever you can to make them every day!  It isn’t easy for me, but it’s no harder than anyone else.  I have my advantages and disadvantages.  That’s the gift basket I was born with, and we each have one.

Alright, dude, how do I turn the early tide, or keep myself from “bigness.”

Step one: Figure out where you stand.

It all starts by asking the tough questions and answering them honestly…How would you rate your health?  What would a doctor say about your health?  What does he or she know about health and what does he or she see in you that explains his or her thoughts?

If you can answer these three questions, it will go a long way to keeping you where you need to be.  Education and determination are the anti-obesity drug.

Let me be the Guinea pig.  How do I rate my health?  Well, I think my health is pretty good.  I’m not as strong or in as good of cardio shape as I used to be, but I did finish a half marathon on Sunday, and I can still get through my lifting and core (yoga) workouts pretty consistently.  I eat well most days a week, including fruits and vegetables.  I splurge on bad food weekly, but try and limit the amounts.  I don’t sleep as much as I’d like.  I have a good support system at home.  In general, I’m doing pretty good.

My doctor…wait, I don’t have one!  (Strike one) I am a doctor, though.  My, this is awkward…self-prostate exams are the worst!  A doctor would say my health is excellent in terms of risk avoidance and general nutrition/exercises.  Sleep is poor, and stress is high.  Drinking alcohol and meeting ladies are risks.  Accidents are risks, too.  Seeing a doctor for a yearly check up is a must at 30 years old.  Overall, though, doing okay.  Room to improve, and things to watch out for duly noted…

What does the doc know that makes him say that?  Well, he knows my behavior, and he knows what risks are most dangerous for someone in my age range and for one who has the daily demands I have.  But the positive assessment comes from the avoidance of major risks and embracing good choices that bode well for health down the road.  I’m making educated decisions because as a physician there is no “ping” or disconnect between my choices and my knowledge of where to expend my efforts on behalf of my health.  Where are you spending your efforts?  Are they spent in the best place for your age, obligations, and goals?

No one is perfect, but hopefully I can share some thoughts that will help everyone get closer to good health now, and avoid those bigger problems (pun intended) down the road!  Take the time to answer your Step One questions and you’ll know what’s missing for you…
“A recent police study found that you’re much more likely to get shot by a fat cop if you run.” -Dennis Miller

Ladies.  That’s right.  It’s on my my mind.  It’s how I roll.

There is something about the so-called ‘fairer sex’ that seems to occupy a good 17-120% of my brain, depending on the situation, the amount of mind-altering substances I’ve consumed, and my last self-love.  It’s amazing how girls can be all-consuming.  Even in some of the most stressful times, I’m still aware of how not hot many of my colleagues are; it’s like they’re a background program running on your computer.  Omni-freaking-present.

This annoys me greatly.  Girls, you are such a pain in my proverbial pain in my a$$, an Achilles heal—so intrinsically a part of me, yet such a weakness.  You take an accomplished, intelligent, good looking, cultured guy like me and ruin me.  I get built up to think that if I am all these awesome things that give me some sort of clout or respectability.  I should have a full dance card.  I will get my groove on.   Don’t come knockin’ because I’m always gonna be rockin’.

Nay, friends.

I still have to beg, borrow, steal, pay for $#!+, call more than I’d like, and everything else on the planet in spite of the fact that most ladies would be lucky to end up with such quality gentlemen as we.  In fact, just the fact that I’m half the things I am makes me think I did it for them in the first place.  Now that really pisses me off.

This is a mystery I’m committed to exploring.   An obligation to mankind, blind squirrels just trying to get a nut.  Or two.

Men, I’ve decided it’s like herding cats.  In fact, cats and girls share a lot of remarkable similarities, body hair, sandpaper tongue, and allergenicity aside.  My life with cats summarizes my dating experience pretty well.

I’m convinced, infact, that ‘they’ may descend from some common ancestor, perhaps.  I mean, cats are so cute.  Little fluffy muffin kitties that do the funniest things, are soft, graceful, and sleek.  But then again, they have teeth, make people sneeze, and kill baby birds.   There’s a love-hate thing going on here.

Cats aren’t exactly the best pets, but it’s so annoying when they don’t want to hang out with you.  It makes you want to be near the cat more.  Cat, I think to myself, You would fulfill me if I could just pet you and hear you purr in appreciation. The cat is sitting there, looking at me, ready.  Or better yet, begging for a pet: the cat walks up to me and rubs my leg, purring it’s little kitty a$$ off.   So close to completion, I reach down to pet cat.   It backs away.  Sudden ire wells up within me.  WTF, cat?  Are you high on cat nip?  Did you NOT just come up to me, all cute and furry-fluffy, jonesing for some scratchies?  Now you back away like I just did a gloveless prostate exam on a rhino.

So then I try and coax the cat with all sorts of treats and sticks with a feather on it and little toys just for the “privilege” of scratching its neck—forget about my needs completely.  “Here, kitty!” No response.  Now I have to embarrass myself.  I get down on the cats level, start making cooing noises I’m somehow programmed to think will be effective (where did I learn this?).  Cat looks nonchalant, unconvinced, maybe even dismissive.

Now I’m annoyed.  You little piece of…fed up, I take one step toward this cat.  Cat takes off like a—wait for it—cat-out-of-hell.  It hisses at me like I’m the devil, jukes me out of my shoes, and bobs/weaves its way under some couch.  I was trying to be nice, KITTY. Now, in your little cat brain, I’m the bad guy, and aren’t going to come near me for a week.  Trying to avoid this, I’m down on my knees trying to get you out from under the couch.  I’m apologizing to A COUCH; for twenty minutes—that is before you decide to run out the other end of the couch and into another room just to prove your point.  You know what? Eff you, cat.

The problem is, at some point a bit later, the cat comes back.  She’s really hungry and needs me to feed her.  Suddenly, the cat is really nice and things go smoothly.  And I, gullible me, I hook it up.  Because for those few, precious moments I feel like I’m special.  I catch a glimpse of the way I wish it always was, or could be.  Everything makes sense.  It makes me want to pet you…

See why I’m annoyed?  I think I’m running things, but I’m not at all! That’s kind of a summary of my dating life, both the brief episodes (a.k.a hooking up) and the lengthy relationships (a.k.a. disasterville).  Why should a bad$$ Dr. Chaz have to deal with this $#!+? It’s time to figure out how to deal with the cats who just don’t “get it.”  It’s my mission to expose the way it is in my search for the way it ought to be.  Where will this all lead?

Why here, kitty-kitty…

“Honk if you love Jesus!”

Just this evening, I informed a nurse that we would be delaying a case for 45 minutes due to a patient’s recent ingestion of liquids.  Nil per os or “NPO” guidelines are logically and somewhat evidence based, and quite traditional in surgery.  The allotted time made us consistent with the recommendations, but the nurse’s immediate response was rude and cantankerous because in her view of things it went against her expectations.  She started a scene in front of several other staff, used provocative phrases like “you people,” and confrontational judgments like “ridiculous.”  Ultimately, my attending made the decision, so all of her commentary did nothing more than insult me and create a negative scenario in front of others.  She has yet to apologize.

I recently had a co-resident go downstairs to check on a patient scheduled to eventually go up to surgery.  Upon seeing an anesthesia person, the attending surgeon immediately started gathering his things to go to the surgery.  She informed him that she was not there to pick up the patient, but to prepare them, and suddenly found herself in the middle of what can only be described as a “hissy fit” or “temper tantrum” to anyone who witnessed it.   In an inappropriate tone of voice, he began criticizing her, the anesthesia staff, the hospital, his breakfast, and anything else he could think of that could be included in his lambasting reverie.

How did the message relayed to the nurse create such negative energy?  What did it accomplish, especially if wasn’t even in the patient’s best interest?  Why did this bit of information, relayed to a surgical attending—a head surgeon and leader—create such havoc?  What’s more, how did it further the patient’s needs?

Medicine boils down to empathy toward a suffering human that creates a blind sense of self-righteousness in the empathizer and gives them a sarcastic and critical tone towards the rest of humanity.

A nurse attempted to burden me with her indignation because of her perception that she was the only advocate for this patient.  On the floor, my fellow resident went from a functioning cog in the machine to a frustrated, unfocused, and emotionally hurt unit for the same reason.  What makes this issue become a real problem is the after-effect.  Our frustration at being attacked spread to everyone we told.  It made us less effective and distracted.  It made us shorter with others.   Thus, each interaction afterward created more insult, negative feelings, and slower action.

Stressed out and anxious to accomplish their goal for the patient, the nurse and attending physician took out their frustration without thinking.  Both reacted immediately, and directed their disagreement at whomever they saw before them.  Then, as the thinking began to expand beyond the current circumstances, they started to incorporate all the other groups (“you people,” “the hospital”) that might be involved in creating a situation outside of his and her expectations.

Had their thinking been broad in the first place, they would have seen that we are all advocating for the current patient, as well as the others we must take care of.  Then their expanded thoughts produce camaraderie, not criticism.

This phenomenon of verbally massacaring the “offending” messenger occurs constantly in the medical profession.  I believe that it occurs as a result of the human stress or fight/flight response.   In a life-threatening situation, our danger alarms are triggered.  We immediately trigger defenses and strategies to repel the threat.  We hone in on the present conflict with all of our senses.  Our body and mind tenses and prepares for a battle!

These things are vital in a life-threatening situation, but certainly not in a hospital setting!  Focusing on one situation creates danger for the patient, and the other patients who are neglected.  It ignores information, a doctor’s most valuable asset.  It predisposes us to repel help, other ideas.  It sets us up for conflict, eliminating teamwork.  All of these issues are terrible risks!

One might think that nothing threatens medical professionals, in other words nothing triggers the fight/flight response.  But our mind’s other pathways—those that process anger, bad news, frustration—overlap with the stress response.  Moreover, our tired and over-worked baseline pre-disposes us to feeling easily threatened.  Medical education and the medical/legal institution teaches through pressure, criticism, and judgment.  The stress response becomes increasingly sensitive under these circumstances.

When someone honks at us at an intersection, if we’re honest with ourselves, our first reaction usually involves berating the individual honking at us.  Usually, we have a few fleeting thoughts of that person’s car having a piano fall on it, our some other horrible-yet-deserved tragedy.  Only after a moment do the other factors working their way into our head to help us “see the light.”  Not just the one that has been green for 10 seconds but we missed because we’ve been texting.  Instead, it’s the light shed on us and the situation: the horn isn’t necessarily a threat!  Maybe our behavior caused the problem (it did in this case–text later!), perhaps that person has a pressing place to be (like the hospital?) or is simply being polite to let us know.  Maybe they want us to realize we are discourteously wasting others time and providing a hazard on the road.  Maybe we have a bumper sticker that says, “Honk if you love Cheez-its!”

No one honks at a PJ

The messenger behind us was right to honk, we conclude, but only after we overcome our stress response—and hopefully before we lashed out!

So why do medical professionals seem to have such a poor ability to overcome that stress response?  I suspect it has to do with the nature of medicine I noted above, and perhaps some ego sprinkled in.  The risks of treating other humans, the pace, the workload, the poor personal health habits, the legal and economic pressure, and everything else involved in creating the frenetic pace and the lifestyle of working in medicine all contribute.  That horn’s message grates on our psyche way more when we’re leaving a long day at the office than when we just got out of a massage after a restful weekend.  Under constant, intense pressure our behavior becomes reactive and instinctual.  We lose our ability to contextualize our circumstances and lose perspective.

What would happen if the stress level diminished and medical pros could react effectively?  With perspective, the nurse who inquired about my patient realizes that I am acting in the patient’s best interest and becomes a part of the team.  If she feels a disagreement, she knows that my attending is the one in charge and discusses the issue with her.  The surgeon realizes that my fellow resident is there to prepare the patient for surgery.  He reminds himself that we are all dedicated to a patient’s well being, but that includes all the patients in the hospital, some of whom unfortunately have more pressing needs.  He reflects upon his experience with emergencies of his own and his knowledge of the limited manpower available after peak operating room hours.  He considers the hierarchy of the hospital before deciding where his concerns will be most usefully voiced.  In all, he appreciates the process, finds something else to do while he waits, and later contacts the appropriate channels to see what can be done to improve the system.  My fellow resident continues functioning effectively.

Where does ego come in to play?  Many people in the medical profession thrive off the concept that their work validates their existence.  Other work takes on a less relevant feel.  Others over commit to this one thing—perhaps because they must to keep up intellectually, or because they choose to for its reward in gratitude and stature, or because that’s their personality—and so their value becomes related to their position.  Sadly, bad news really does become a threat to them on a certain level.

The pugilistic verbal confrontations that occur with information exchange call to mind “anger management” issues.  I’m mad my case isn’t going right now, and I’m too stressed to realize it’s the nature of the situation, so I’ll take it out on whoever is around.  This is immature, does nothing to alleviate the problem, and in the end usually creates a few—and the patient and other patients all lose.  Instead of driving forward with the green light and committing ourselves to pay better attention, it’s like we get out of the car and start a fight about getting honked at.  There is no justification.

Not everyone will agree with this perspective.

Some people make a living off of the system’s brokenness.  Others use the system and ignore the broken parts.   The latter have convinced themselves that some people don’t act appropriately, or are lazy or less motivated.  But they are working hard toward their personal goal, wrapped in the sheep’s skin of patient care.  In fact, they might not see everyone else working hard, and in the right direction. One truly seeking to make medicine work—and therefore last—needs to focus on the really obvious broken parts.  The fundamentals of why medicine feels wrong right now.

And in general, next time we hear bad news or out hackles get raised by someone clueing us in to something we weren’t expecting, we should take a minute to consider things a bit further.  First, to whom will voicing our concerns be most effectively done?  Second, what about the situation might we be missing?  Third, what issues in our lives might be limiting our ability to step back and see the forest instead of just this single tree?  And finally, what good will it do to massacre the messenger?

“In purity and holiness I will guard my life and my art.”

-original Oath of Hippocrates

“I will prevent disease whenever I can, for prevention is preferable to cure.”

-modified version, Dr. Luis Lasagna

As I go through my day, the consummate physician-observer in me sees the people around me as potential patients.  It’s nothing special; every doctor–and I’m sure any profession that works with people—barbers, personal trainers, etc—will admit that they all assess strangers in terms of their profession all day long.  Just think, every one one pass by is thinking, “This guy could use a haircut,” or “that lady needs to work on strengthening her core.”  I look at peoples’ veins and think “that one would have great I.V. access.”
I’m more than just an anesthesiology resident, though, so I see the rest of the patient, too: their weight, limps, lesions, weaknesses, skin issues, and on and on.

It won’t surprise you that the most shocking ‘patients’ I see walking around these days are in the hospital.  But would you guess I’m talking about the medical staff? That’s right!  I’m most surprised at the state of health I see most doctors and nurses living in as they do their work!

I notice the doctors most.  There he or she is, leading a pack of wild-eyed, disheveled residents down the hallway.  See them there, squinting over a chart, yelling at the residents or nurse condescendingly, wearing loose-fitting clothing over their pudge?   “Teaching” completed, catch them ponderously passing the stairs as they labor toward the elevator, then complain that it’s taking forever.   When it finally arrives, they crowd in with the other medical staff, and press the button to go up.   One floor.
Doctor of Medicine, expert in health, wellness, disease, healing and—get ready for it—disease prevention.  There they stand, huffing and puffing their way through the day; out of shape, clueless about their own health status, and with health habits they shake their had at with each patient that passes them by.   Now tell me, what is this Doctor–head of a pack of future doctors–bestowing upon them? What do these doctors show us while they are preaching the merits of diet, exercise, and taking care to avoid the pitfalls of life?  He who is without sin cast the first stone…

I’m winding up, bitches.

As a doctor myself, I shake my head at the example I see us presenting to the mass of patients we are simultaneously trying to save.  How does a doctor who is out of shape, overweight, not seeing a primary care physician regularly, and not eating well going to be able to counsel someone effectively in these vital aspects of healing and health prevention?  Where is our credibility?  Where is our understanding of the struggles to do this, if we have no experience struggling to do this?

“Hold the phone, doc!  Who are you to judge?”  Well sir, at least I take the stairs in the hospital unless I’m carrying my emergency tools to a code which are on wheels, can run at least 5 miles whenever, plan and cook a healthy diet, exercise daily, and pay attention to my diet and habits, including sleep, fun, stress, and recereational activities and beverages.  I’m not perfect, but I’m elbow deep in the struggle.

“But sir, we are so busy taking care of people!”  Yet, how much of what we do is directly related to preventable issues? If doctors practiced what they preached, one has to think that patients would take notice.  Healthier patients means less work, right?  And what, you don’t think your patients aren’t busy?

We could enter the chicken or the egg debate above, but the bottom line is that if Michael Jordan and Fat Albert where both showing you how to dribble, who would you listen to? (alright smarta$$, be serious for a second)  About the only thing Fat Albert can dribble is gravy onto his mashed potatoes.  Frankly, we doctors are like Michael Jordans dressed up as Fat Albert–it’s hard to take us seriously.
But we doctors are dressed up in white coats, symbols of our expertise, and trying to be taken seriously!   We are trying to sell you on the fact that if you take our advice, you will reduce your suffering, increase the quality of your days, and lengthen your time doing the things you love with those you love.  But we aren’t selling it with our example, leading the way.

‘Understand this,’ we say, ‘you will get sick, you will get hurt, and you will eventually die. However, you have a choice as to how much and how often and how soon those things happen.’

It’s no wonder that diseases controlled with good health practices such as diabetes, obesity, high blood pressure, and heart disease still top the leading causes of death and morbidity in the US.
Attitude reflects leadership. Our leadership currently avoids the stairs, remains overweight because they are “too busy” to plan healthy meals and exercise, and generally chooses to ignore the evidence in their own field of expertise.

I have to wonder: could this be the ultimate example of the holier-than-thou stigma doctors have often been given? Maybe it’s a manifestation of the God-complex I hate to hear associated with doctors. But I can’t help admit that giving patients a hard time for their excuses to not change their bad habits while justifying our own has little defense.  Just because we take care of other people doesn’t absolve us from having to take care of ourselves.  Helping others doesn’t make our ‘busy’ a justifiable excuse compared to a patient’s ‘busy.’
Here’s my logic.  We invest time studying, practicing techniques, and learning our profession well to help people.  But we’re failing in our ability to execute our plan effectively.  We are led to believe that the former will make us better doctors.  So why not take care of ourselves.  If anything I’ve written above makes sense, we will practice longer, empathize better, and be more effective in each interaction, not to mention be more believable!  If we aren’t too busy to dedicate ourselves to learning medicine, we should be  too busy to run, sleep right, and eat well.  Hippocrates would be proud.

I don’t say this to sell out the medical profession or to justify behavior. The kid that goes out and shoots someone because his hero football player or older brother did it, or the patient that doesn’t exercise and ends up with diabetes still has consequences to face that ultimately are their responsibility. However, it seems reasonable that doctors should choose to and their ranks chosen from people ready to be an example of their knowledge applied. That being accomplished, the example goes a long way in the right direction.

One way to look at it...

“And there is a Catskill eagle in some souls, that can alike dive down into the blackest gorges, and soar out of them again and become invisible in the sunny spaces.  And even if he forever flies within the gorge, that gorge is in the mountains; so that even in his lowest swoop the mountain eagle is still higher than the other birds upon the plain, even though they soar.“

-Herman Melville, Moby Dick

It’s normal to be bummed out on Christmas–right?

I don’t truly believe that normal exists.  As black-and-white as many people have told me I tend to be (or wish I could be?), I believe truly that gray is the color of life.  Normal is the gray that most people would fall into when the obviously white and obviously black parts of whatever we’re discussing are thrown out.

In this case, I awoke asking myself this on Christmas morning, and the day after.  I asked myself this because of the feelings that surprised me each of the last few mornings.

For me, Christmas has never been the most ideal time of year: my parents didn’t exactly get along, which made the “cheer” of the season seem more of a fascade than a deeply-felt sentiment.  Now, there’s no more nuclear family like before.  Nor is my sister alive, nor is there anyone to walk the road with in my life at this time.  When I awoke each of these past mornings, the Christmases where not all of this was true come back to me, and those memories left more of an ache than a nostalgic warmth.  My Christmas memories are like a cold cup of coffee.

As a resident, I also had the honor of back up call on Christmas.  It’s like being assigned to a purgatory.  I couldn’t go be with family (my mom lives an hour away) because I needed to be near the hospital.  But if I’m not needed I won’t get called.  At least the in-hospital call person is busy and thus preoccupied with surgery.  For me, it was a long day of doing random chores in a quiet house with a pager.  Have you ever walked around the house with a pager attached to the elastic of your boxer briefs?

So all day, the curse of too much time kidnapped me into my melancholy world of Christmas relationships past.  Bound to the house by the electronics on my underwear elastic, the memories I have of the things I no longer have became my constant companions.  As their “plus ones” they brought pessimism, mourning, regret, loneliness, self-doubt, and the fear of all these things being permanent.   These guests have been the feelings that commanded my attention this Christmas.

Is that normal?  Is the self-analysis that now stems from experiencing these feelings normal?

Then there’s also shame.  I’m constantly told how worth it, talented, of valuable I should consider myself, how successful or positive my life’s direction has and will be.  It was a shocking place to find myself on the day when one should expect differently in such a desolate place.  But how dare I feel this way with “so much going for me?”   Regrettably, it felt like a familiar place, making me feel worse.  What, do I like spending time bummed out about what most people probably think of as nothing?  I find myself thinking, ‘I’m just acting like a spoiled kid who has almost everything but wants even more.’

I don’t want to be here, though, so why am I?  I don’t want to blame myself for complaining and feeling down.  Maybe it was my upbringing?  Maybe all of the things that people value about me are the result of me trying to do things to get myself out of here?

In some ways, the positive affirmation about my “resume” person makes it worse.  How is it that I could be and do all these things everyone says are good and would satisfy and bring fulfillment–do and be more than most–and yet not find the “normal” fulfillment and satisfaction?  It’s like doing a calculation in your math homework over and over.  You know you’re doing every step correctly, yet the result is not what it should be.  You’re even being extra neat!  Is it something you’re forgetting?  Is it some mis-written number you’re over-looking?  Or is the answer itself actually wrong?  Or are you just dumber than you thought?

The scariest part is that if it’s the last question, how can you ever fix it to get to where you want to be (the right answer)?

It shames me more that people with “less to be happy about” are not in this lonely place. That’s when you really start to ask yourself what’s up.  I know I can be wrong, but I’m not in their heads, and everyone seems to be happy or engrossed in the season.  Most people have the joy of Christmas all over their face, most people have the people with whom they share their memories close by and doing things to make new memories–the positive ones that out-weight the tougher ones.  Most people aren’t struggling to justify their worth, either.  (I can’t believe I’m saying this) And in particular some people have a lot more reason to feel the way I do–but they don’t!  So why do I?

But maybe if they were stuck in the house alone, in my current job, and having been given the same blessings and challenges I have been given, maybe they, too, would question and suffer a bit.  Maybe it’s not normal to be in the situation, but it’s normal to react as I did.  But maybe not.

But regardless of that answer, I have to wonder, how do I go beyond the bounds of these feelings?  How do I find joy, assurance, optimism, self-forgiveness, self-confidence, and hope that good will be again?  I don’t know the answer, because I look at what I’ve tried: doing things, being distracted, meeting new people, etc., and these are the components of a house of cards that often falls when it is leaned upon most.  It’s what I am now and none of these things are keeping me out of the hole.

Maybe something internal must be found within during the suffering times.  Perhaps it is a choice to forgive myself, a choice to admit defeat and stick with that decision to let failure be, a choice to focus on the present good, and a decision to remind myself of the times before that I felt in the gorge but flew out again.  And maybe even forgive myself for feeling bleak when I have so few basic obstacles in my life.  Perhaps that is the greatest challenge to the cycle: being angry about feeling low.  So I’m sorry I feel low, I’m sorry if I shouldn’t compared to someone else suffering more than I.  I feel bad about that, but I want to say that I’m trying.  I don’t like not feeling great about how many things go well in my life most of the time.  This Christmas, I’m trying to appreciate the gifts and the joys that I’ve had, even if I’m feeling stuck on the few things I didn’t get for Christmas.  Maybe it’s not normal to feel this way, but it’s how it’s been and I’m just saying I’m working on it.

One of the things that I do a lot of in my work is make notes.  Okay, I take that back: it’s the majority of what I do.  Throughout a doctor’s day, almost 50% of their time is spent documenting their decision making and doing related paperwork.  Considering we divide the rest of our day into reviewing charts, prescribing medicine, and seeing patients that’s why I say it’s most of what I do!  In anesthesia, we have to document everything from the medicines I give, to the fact that I taped the patient’s eyes to protect them, to the time I went in the operating room and left it!  During surgery, I’m constantly updating the “anesthetic record:” blood pressure, temperature, patient’s position, ECG rhythm, and much, much more.

Documentation serves its purpose, and it demonstrates yet another example of shifting perspectives to learn about oneself and one’s work.  Unfortunately, these shifts can lead to misunderstanding,

Medical record keeping at its finest...

misinterpretation, and misuse of the data that such documentation provides.  The end result?  It’s another way that we fall short of our possibilities.  Instead of making us better, it threatens us.  We have then have to spend our energy on the document, or protecting ourselves from the document, becoming a slave to it and being less able to focus on the care of the patient!

Let’s imagine why all of this exists.  I suspect that very early on in the process of learning to do something well, people figured out that recording their actions in a systematic way would help them go back and improve their performance.  DaVinci and others like him come to mind here, but obviously it started far before that.  Surely, no one knew immediately what to record and how often to record it.  So some times there was too much recording–maybe it got distracting, or the work itself suffered.  At other times, too little was recorded and those looking back wondered what happened.  Through a process of trail and error, though, a pattern of record keeping emerged intended to create an insightful and useful history of an event.  As people sought to emulate those before them, it became clear that an efficient way to pursue knowledge included documentation.

I imagine some other point people started to look at the documents as an entity in and of themselves.  Instead of just having a record, people started to see that other things could be gleaned.  For instance, documenting something every few minutes served as a reminder to check on that parameter consistently.  Also, some data helped corroborate a story when someone tried to piece together what went wrong in a bad out come.  Even more, certain information could show patterns, a forest view of individual experiments.

Suddenly, documentation became a tool with its own life; instead of using it to simply record things with their own goal, it started to have its own goals!  The conclusions derived from this outside-the-box or forest view of data helped streamline the work process itself.   In a sense, instead of just a one-way historical record, data became a conversational historical record.  Actions create documentation, but now documentation also created action.

To an extent, this was great because it helped us improve systems.  But in our current health care system, things can go too far.
As I mentioned, now the record takes up the majority of the day.  Because of the expectations that the record creates, I have seen people “fudge” the anesthesia record, surgical record, or whatever records are being made.  Is that really the time the antibiotics were given, or is that the time documented because a policy was created based on the data pool and we need to meet that policy’s obligation and avoid chastisement?  When things go to the point that the record is no longer accurate, certainly we need to re-evaluate our situation–conclusions based on false data are dangerous!

How did this happen?  I suspect that when we started looking at the data outside the context of the work we do that division created unnatural pressures.  We looked at goals within the work process instead of the overall goal.  While it helps to improve the parts we look at, it also makes us focus on those trees too much–sometimes to the point of creating issues.  For instance, surgeons don’t like to have high blood loss because it’s a data point associated with criticism when taken out of context.  But instead of facing the music, they will bicker over blood loss so the document shows less. This leads to inaccurate assessment of blood loss.  If you’re underestimating how much blood your patient lost, don’t you think that’s dangerous for the patient?  And yet…

JCAHO is an entire governemental overseer for hospitals largely based on documentation.  Where do you think all of our legal issues in health care come from?  Lack of documentation is a key component of malpractice.  Does the pressure of meeting the demands of these overseers and legal threats cause us to change our records, or pressure us to focus more on the record than necessary?  See the example above…(and note, is it just the surgeon’s fault?  They get credit for not having antibiotics in time, but if the anesthesia team forgets to put them in, the surgeon still gets blamed…)

I think the pressures of the record are causing problems.  In addition to the examples above, I’ve seen records improperly done, I’ve felt or been the pressured to curve numbers in the better direction, I’ve been told time and time again about documenting lots of random facts for legal reasons.  The document that began as a helpful adjunct to becoming a better physician or doing work better (or scientist or whatever) now demands its own respect.  When something gets to the point that it leads to inaccurate documentation to avoid repercussion, it is also likely taking time away from patient care–wasn’t that the point of this health care in the first place?  It’s a tragedy to  think of the inefficiency that develops from the pendulum swinging in the direction of the document.

Then there’s the legal aspect: a concept that if it’s not written down it didn’t happen.  It is ridiculous.  Not only is that simply not the case, but I’ve just mentioned above the worst flaw: I can write down things that didn’t happen.  Then where do we go?  Back to our oral tradition?

Can we stop the documentation from getting out of hand?  It’s probably too late.  Too many people’s jobs depend on documentation now.  It would take someone to remember what we originally did this for, and then to realize the negative impact that this entity brings to a system.  Seeing this disparity, that leader would then have to find a way to turn all those people currently using documentation improperly into people who turn the system around in a positive direction.  Not likely to happen with the unrealistic expectations that are out there.  Change the expectations?  Sorry, they come from people analyzing data points on a record that is becoming less-than-accurate as we know.  Many times those people have a business or legal background; people without the background of the context in which the documentation was meant to be interpreted might have unique insights but they can also have uniquely wrong opinions about what they see.

Forgetting the context (the forest) of documentation is the culprit, so naturally remembering the context is the solution.  I can use the patient’s old operating record to know if there were problems with their last surgery and be aware of those for this one.  I can use an old record to analyze with one of my elders and learn how to do things better.  I can see trends in the patient that I couldn’t otherwise see that help me make decisions during a surgery.  Finally, I can take data like surgery times, etc, to make my practice better.  However, all of these things are within the forest I’m looking for: how to take my patient through the surgery more safely and use our resources effectively.  It’s here–where the document’s goals and my work’s goals are juxtaposed with an overarching goal in mind–that we will see, hear, and do what really matters.

So what a better way to spend the weekend than at the World’s Largest Outdoor Cocktail Party?  That’s right, Florida plays Georgia in a yearly battle of the rivals.  This neutral field has finally become a weekend of frivolity and partying that reaches epic proportions.  This year, Florida turned up the heat on Georgia (literally, it was as hot as it’s ever been for the game), and put the Dawgs back on the bus to Athens with their tail between their legs.  Go Gators!

In between strong drinks, cornhole games, and wiping the sweat off my brow, one of the funny things about being a doctor at the game is that all of your friends start asking you medical questions related to their game day decisions.  That, or they start apologizing to me for what they are currently doing (smoking, funnels of beer, etc.).

These interruptions from my own ridiculous antics got me wondering about health and perspective on a day like game day.  Tailgating is ridiculous, and usually involves excesses so absurd even the most hedonistic fan has to sometimes shake their head.

One theme emerges from all the questions and apologies: the sense that “I destroying my health by doing this.”  In question form, is there some way of making up for the behavior?

The short answer is “yes,” but as usual, it’s a bit more complicated than that.  Actually, not complicated.  It’s just that the answer isn’t a specific change so much as a change in attitude.

Look at the fundamentals.  There is no activity that we do that isn’t a balance of good and bad.  Even “healthy” things like exercising have risks and rewards.  If I fall or get hit by a car jogging down the block, then I’m definitely setting back my health–even if I was doing something healthy.  Conversely, all of my friends are questioning their decision to drink or smoke, but they are socializing, seeing old friends, and enjoying an emotional and joyful day.  Well, if you’re a Gator, that is.

Now obviously, drinking yourself into oblivion is more likely to set you back physically than a run, but like my last post, that’s only seeing one tree in the forest!

If everything has good and bad to it, then each experience is a combination of those things.  Florida-Georgia, football games or tailgating in general, provides the chance to celebrate, enjoy psychologically and emotionally healthy social interaction, but also punishes your system with excess food, beverage, weather exposure, and risky behavior.

What’s the moral of the story?  The Gators are awesome.  The other moral, though, is that we have to balance out our choices to get the most out of our experiences.  Want to enjoy your run?  Don’t jump out in front of that truck that’s cruising by, or go around the pothole.   The more you think about it, though, if you get some sleep the night before, don’t eat a pack of hotdogs right before your run, warm up properly, stretch before and after, and wear appropriate gear you’ll also get more of the good stuff from your run.  In a sense, this is what we get with experience: the ability to manage more and more of the subtleties that maximize the good and minimize the bad.

So how do you do this with a tailgate?  It’s a personal choice, of course, as some people consider the ability to just let it go and do the gluttony of the day as the prime goal.  Those usually aren’t the people asking me the guilty questions, though.  Even more, sometimes the obvious road of just rocking it out isn’t as satisfying as a little planning—after all you have to plan the tailgate itself, so why not this?  For me, it starts with a few less drinks the night before.  I also worked out—a short run—in the morning, and cooked a good healthy breakfast.  The other decision I made was what to enjoy.  I chose not to pig out on grub, but relish the bacchanalian offerings instead.  I also stuck to a couple of drink types, instead of drinking whatever was handed to me.  I made all of my drinks with diet or zero calorie drinks.  Had I actually remembered the fruit I packed, that would have been another way to enjoy the day, but take the edge off of the unhealthy potentials of the day.  I put on sunscreen.  Finally, I also took a drinking break during the game itself a.k.a. pacing myself.

The end result?  I had a blast, let loose and partied, and don’t feel so horrible today that I won’t be able to function.  I also kept pace with my long term goals (exercising) and  not being so far gone helped me interact more effectively socially (interpret this as you will, of course)…and I’m don’t look like an over-boiled lobster.  What was the cost?  Well, I probably missed a couple of opportunities, and maybe didn’t titillate my brain to euphoric levels as often.  But maybe I did more because I could keep going when other people couldn’t?

For the record, it’s not perfect…my chest is congested and I didn’t feel well most of this week.  But my roommate was out of work, while I still managed to work and exercise!

I don’t have the answers to every question, but I love epic weekends, and this has been yet another one with people that makes my world great.  Hopefully, the approach I’m taking will keep my weekends epic for a long time to come…

You know you love them

“Lord grant me the serenity to accept the things I cannot change,
the courage to change the things I can, and
the wisdom to know the difference”                                       -St. Francis of Assissi

So this is the way the world works according to what I’ve seen…

I often get called Dr. Marcus or Dr. Marc, which is sort of what prompted this whole whole thing.  However, along the way it’s been Sucram, Dr. Roddy, roddylaves, Survivor Marcus, Tata McShibby, Marc, Guy LeDouche, jerk, genius, idiot, Neji, arrogant a–hole, Cosmo’s Georgia Bachelor of the Year ‘06 (holla!), Marcus Aurelius, Macho man, etc.  It short, you name it, I’ve been called it.  And in the spirit of calling things like they are, ought to be, could be, should be, would be and might even be, I’ll lay it out just as plain, from my brain to the pixel pages you’re absorbing through those optic tracts of yours…

Thanks, Noah–former college roommate, current internet guru and long distance event master.  He intended for this to be a site specifically directed at health and wellness through personal responsibility and self-awareness.  He wants me to harness my continual attempts to inspire and direct us toward the real solution to the “healthcare crisis” into something that people can get to easily.  It’s all in the hope that pushing for wise decisions reduces the fear, pain, and hurt–the things I see on the faces of those who suffer setbacks in their health.  May we find a way to harness our innate power to know and improve our own health.

We will ever see how much we can do to be healthy?  Do we as individuals have the ability to maximize the genetic and environmental “gift basket” that has us wherever we are in this moment?  Whether I’m six feet tall, with a lean figure, or five feet five inches tall and “pudged out,” am I doing what I can to maximize my health?

I may be skinny, but it doesn’t necessarily make me healthy.  I may may on the chunk, but it doesn’t make me necessarily unhealthy, either.  Starting from this point, it’s my decisions that mold my raw materials into the best that they can be.

What does it matter?

Well, as the anthropology-major-turned-MD, observation is key.  I think the scope of one’s observations can make something seem healthy, and occasionally vice versa.  For example, if I consider just the next 30 minutes, a double cheeseburger is delightful in my belly and easy on my budget this month,  but pan out to 20 years…how much is that heart attack costing me in hospital bills and early retirement?  With a short term scope it makes sense, while in the long term one the same reasons in made sense in the short term no longer hold.

Then again, what if I’ve spent the entire week training for a half-Ironman and this cheeseburger is to celebrate my best friend’s birthday and get some well earned emotional and psychological fulfillment?  Overall, it may seem like a confusing picture, but it’s not.  It’s a mixed bag of positives and negatives as we can see, but if I know myself and this latter circumstance is the case, then I can say that I’m trying to seek the balance between my emotional and psychological health and my physical health.  I’m more likely to get there by considering my decisions along these lines.

Now pan out from me, the individual, to society.  Assuming I don’t take the time to think through my daily decisions, I just rock the DC’s whenever the mood strikes.  I start having health consequences.  It requires that I consume healthcare: doctor’s time, tests, medicines, etc.  The health care delivered to me because of my genetics-turned-ugly-thanks-to-Mickey-D’s-double-squeezers doesn’t go to other people that might have benefited: a kid who needs a vaccine, or a car accident victim who needs emergency surgery.  (Naturally, we’re assuming a limited resource.  Do you know of anything that exists in infinite quantities?)

So if we change the scope of time, we see different characteristics of my decisions.  Now, having changed the scope from personal focus to society we see different implications for my decisions.  Not only does my decision to maximize or minimize my health affect me, it affects others!

Let focus in on ourselves again, since that’s human nature when things go wrong.  If I’m maximizing my health potential, everything in my life runs more smoothly–fewer things go wrong with my health.  When something does go wrong, it’s because it’s something beyond my reasonable control. Even then my decisions pay off though, because whatever it is I need is less risky, stressful, and more likely to be effective when the rest of me is being taken care of well. 

To me, the person looking at their decisions through these scopes, and following through with them is doing something to fix things.  And this individual is experiencing all of these benefits and even more themselves!

This isn’t a health care specific observation.  The world seems to run in patterns.  It’s either because the world works in patterns or because our brains all work on the same basic principles so we can’t help but repeat things.  The pattern here is that there is an element of individual focus that can have enormous impact on any system.  Have you noticed this about personal finances?  About upkeep with your car?  About playing a sport?  About saving our natural resources? In any of these situations, paying attention to daily decisions to maximize your potential consistently improves your circumstances, and in most cases also inevitably improves other peoples’.

The hardest thing us to face is that inevitably there will still be failure, and end of sorts.  Inevitable failure is the best excuse for not trying in the first place.   Not to be morose, but the healthiest decisions will still end in death.  People love to talk about the marathon runner who died of a heart attack as proof that you should do whatever you want.  This is an unfortunately narrow-sighted, or short-term perspective.  I consider that that same runner would have had that heart attack along with other issues years before had he or she not made good decisions.  I also consider that perhaps this was a marathon runner with a cocaine habit–we’re not perfect.   Think of the argument against running in this case as a scope to closely focused on one aspect of a person, in other words. It’s definitely not proof that ignoring your daily decisions to take responsibility and improve your circumstances will lead to failure.  It’s also ignoring all the before-mentioned benefits to self and others of taking care of oneself.  Seeing the flaws in these scopes makes the inevitability of the runner’s demise a matter of perspective (to narrow), and suggests that applying this in our own lives is similarly narrow.

I’m not sure why people conclude this.  Maybe it’s our instinct to see cause and effect because two things are closely associated somehow?  Perhaps it involves the fact that some people love to see the underdog win, or the claims refuted–like not wanting to do something when you’re a kid.  There’s a part of us that wants to give in and do nothing, so we narrow our view to conclusions like the one above.  But had I told you a cocaine addict had a heart attack and died, the same people would also nod as say, “I told you so.”  But as above, what if they are the same person?  Now what do people say?

So I’ll generalize this scope discussion to a familiar pattern.  Cocaine is a “tree” and marathon running is a “tree” in the “forest” that is (was) our deceased runner.  The greater your ability to keep the forest in mind when making conclusions, the more likely you are to make good ones, and see the flaws in narrow-sighted conclusions.  I suspect laziness or inability or ignorance might all lead us to make narrow conclusions.  I don’t know exactly what convinces some people to broaden their scope, while others stay irretrievably tunneled.  However, I do know that I’m convinced it’s worth stepping back and keeping at least part of yourself looking at the forest.

Hopefully we see that the forest includes the caveats.  The more we think about everything all at once as best we can, the closer we get to taking care of ourselves and through that others.  That’s were the “middle ground” people talk about it: a place where your pendulum swings in the middle of everything, thus maximizing the joys of life for everyone in the limited world we live in.

As for the Assissi quote, I’ll make one more reflection.  The more I’ve stopped to consider all of the scopes of my decisions, the more I’ve managed to broaden my view to keep the forest in mind as well as the trees, the better I’ve gotten at seeing what I can change and that which I cannot.  It’s a peaceful place to be when you know that beyond a certain limit you cannot change things, nor should you.  In a sense, this pattern of thinking gives you the wisdom to know the difference.

Hope this “Doctorine” of sorts helps you find that peace of mind from this piece of a Doctor’s Mind…