Doctor On Call — Past/Present/Future

This will be a short version of the story, of an aspect of being a physician that most readers are aware of but which has an enormous impact on their own health care, the personal lives of their own doctors and the future of health care in this country.

Being “on call” begins with a young physician’s first clinical experience as an intern/resident and ends when their either retire or arrange for another physician to assume that responsibility.  It reflects the 24/7 nature of what we do.  As I begin to wind down my medical practice, the first element to jettison is, you guessed it, the on call.

I cannot enumerate the numerous times that I would be awakened by a blaring phone call at 3AM, or a vibrating smart phone in later years to bring my attention from some deep, undisturbed REM state to immediate awareness. The “Service” would be calling. The adrenaline rush became instantaneous and that mili second a barage of thoughts filled my sleep deprived brain.  As a gastroenterologist I knew that the problem I would be facing as I responded would center around a few specific disease states. Had they swallowed a piece of meat, now lodged in their esophagus. Or was it a relatively minor issue– Mrs Jones was ‘bloated’ or called at 3 AM to report her two week history of diarrhea.  Even those minor calls were quite frankly major to me.  I had to shake loose the cobwebs of my cognitive self and make a decision– to come in to the hospital, to defer for a few hours or have the patient call the office in the AM.  At least these calls and decisions could be made over the phone.  I could be half-asleep, grubby and disheveled.  I could be wearing pjs or nothing at all. The consequence of such a call is the inability to quickly fall back to sleep.  The adrenaline is still flowing.  The self-questioning begins.  Did I make the correct decision? Should I call back and change my opinion?

But it is 2015 and it is the dawn of a new era in medicine–Telemedicine.  We are told that the future is rushing up to great us regardless of how we feel. The future will mandate a visual exchange between physician and ER, physician and patient. Telemedicine will require a Skype kind of communication.  After all it will be far cheaper to connect patient with physician this way. And it won’t just be for the emergency on call interaction. Why go to the trouble of having a “hands on” visit when it is so much more convenient to do it via a computer screen.

 So I do not envy my younger colleagues one bit.  They will not have to sound competent at 3 AM, they may have to look the part as well.

YOUR DOCTOR, THE AMBIVERT

Now don’t be alarmed by the title of this piece. The term ambivert is not in anyway connected with the term pervert.

In fact I first became aware of the term via The Wall Street Journal article on the subject by Elizabeth Bernstein. It described a combination of personality traits that did not fit the definition of either an extrovert nor an introvert but something of a hybrid.  

In truth this description sounds very much like me.  Like most of us I often embarked on the journey towards self-discovery.  Who am I, really? How do I relate to the world, really? I have come to the conclusion that I am not a “people person”.  On occasion, when the discussion arises, I will confess this quality to others.  Those who have witnessed me in the course of performing my professional duties as a physician/gastroenterologist are often baffled by my confession.  “No way” they might state.” You can be charming and warm with your patients, particularly the nervous ones.” Of course I thank them for that assessment but admit that this is an act I put on.

 I am always been around extroverts.  My Father was comfortable speaking with anyone and everyone. My wife and daughter-in-law are very comfortable engaging in conversation with total strangers. My Mother was quieter.  I must have inherited her genetic makeup when it comes to speaking with strangers. 

I have always wondered if my approach to dealing with patients is an act, a bit of a charade.  Am I just faking my outward persona?  I know many of my patients would be shocked by my admission.  I often observe myself in the role I play.  But am I being inauthentic? I don’t think so.  I believe we are all capable of being different people under different circumstances.  Years ago I learned the behavior that allowed me to relate better to my patients, to win their trust and to maximize the therapeutic encounter I have with them. I am now comfortable in that role.  I don the white coat of the physician and become that doctor. I believe it contributes to the healing process itself.

 I have observed that I do actually relate well to one individual at a time.  I value time spent with one person in which I can cut through the superficial banter that passes for being “social”.   I am comfortable discussing the deepest metaphysical issues with anyone.  I find those topics holds my interest and I lose any sense of being self-conscious.  I find that actually quite rewarding.  On the other hand, I find “small talk” about personal preferences, other people’s families whom I don’t actually know, rather boring.

 But at least I now know what I am— an ambivert.  I just need to explain the term to anyone who hears it for the first time.

WISDOM FROM THE SAGES — “This Too Shall Pass”

The origin of the phrase “this too shall pass” is clouded in antquity. Whether the pronouncement of a Sufi mystic or derived from the wisdom of King Solomon is frankly irrelevant.  The term resonates with meaning to anyone who seriously considers it.  It is essentially life’s great equalizer.  

It was utilized to make sense of the challenge given to a wise man– derive an expression which will bring joy to those who suffer and sadness to those who are experiencing life’s bounty.

Those who are joyful will acknowledge the transient nature of life’s positive experiences.  Likewise those in the midst of unbearable suffering would be wise to remember it as well.

It can function as an amendment to the Serenity Prayer which prays for the acceptance of that which we cannot change, the courage to chagne what  can be changed and the wisdom to know the difference.

This phrase parallels the Buddhist notion of “nonattachment”.  This does not compel us to distance ourselves from all emotional connection, or to avoid loving relationships.  It merely reminds us of the transient nature of physical existence. By recognizing that “this too shall pass” we are mentally and emotionally better prepared for what comes our way.

“This too shall pass”. Meditate on its meaning and find a path for healing.

CHRISTMAS 2014 — Why This Year is Different for Me

To me Christmas was always the “other” holiday of winter. As a Jew we celebrated Hanukah. But I knew that Christmas was an extremely important holiday for Christians for many reasons. Certainly there were the theological implications of the Messiah becoming fully human as well as divine. That was always a mystery for me as well as devout Christians as well. Then, of course, there were the commercial aspects, Christmas music and time off from school.  All good. We celebrated the gift giving and the beauty of the Christmas tree with our friends and neighbors. But it was always someone else’s holiday.

While becoming officially less observant of Jewish religious traditions, my identity as a Jew is indeliable since being Jewish transcends religion.  It is a cultural, historical as well as genetic (as can be determined by testing) tradition.

The past year 2014 has witnesssed an alarming upswell of anti-semitism in the world, now fostered by radical Islam. This has been deeply painful to the Jewish community. We cannot help but feel its chill in the deepest recesses of our souls.  It rekindles age old fears. The Shoah was only the most horrific and most devastating of a several thousand years tradition.  Now it appears once again.

 That contrast between what is happening around the world  and what I have seen in my personal life is particularly striking. My friends and patients have wished me a joyous Hanukah from the bottom of their heart.  Their sincerity is palpable.  And I am deeply grateful for it.

 It brings home the power and beauty of this great country of ours.  America may stand alone in the world as the bastion of tolerance for diversity.  Tolerance was once understood as the basis of who we are as a nation.  It still remains.  I have been deeply touched by its presence.  

Christmas 2014 is different for me because I will never again take this country for granted.

May we continue to be a light to the nations.  Merry Christmas and my hopes for a peaceful and happy New Year for those of good will.

WHY THIS LIFE ? — It’s a Novel with Many Chapters

I hope what I’m about to write resonates with some of you.

 Most of us look at our own lives as some unexplained mystery.  Why do we experience what we do? Why do we encounter people who seem either loving or toxic to us? Why do some individuals seemed bound to us by proximity or kinship and seem to different from us?  Why is life just so impossible to figure out?

Perhaps we need to enlarge our perspective on life itself.  Let me offer a few thoughts and see if they even remotely make sense.

 Let us suppose, for the point of this exercise, that reincarnation is a real force in the universe.  If that is so then certain aspects of our life here begin to make some sense.  If our true nature is that of a spiritual being having a human experience, then we return to each lifetime with a mission, or at least a goal.  Overcoming adversity, embracing relationships, working on our faults, connecting to the planet, encouraging other beings to become their best selves, etc. etc.

 In the context of rebirth, each lifetime could be regarded as one chapter in our soul’s journey, the ultimate novel.  If our soul, the immortal self, requires multiple lifetimes to evolve, and that we forget the details of our last one, we find ourselves living this life confused and bewildered.  The analogy would hold because if we came upon a novel we have never read, picked one chapter in the middle and begin reading, we would most likely remain confused.  Who are these characters? Where did they come from? Why they interacting with each other? Where are they all going anyway?

 I suspect that our soul’s journey is like that.  If we had the benefit of a greater perspective, many of life’s mysteries and conundrums might make sense.  Since we don’t, this is all mere speculation.  But if reincarnation is real…..it might just make sense.

Stay tuned.

ALTERNATIVE MEDICINE BREAKTHROUGH–acknowledgement of its Influence

The highly regarded American Journal of Gastroenterology (aka Red Journal) published an article in November’s issue Volume 109 Number 11 pp1705-1711 regarding the use of CAM (complementary and alternative) treatments by US adults with gastrointestinal conditions from 2012 interview of over 13000 individuals. Nearly 42% utilizes CAM modalities.  

This is an impressive number. Even more impressive is the attention from one of the most widely read and respected traditional GI journals. Recognition of the appeal and effectiveness of some of these treatments.  

This is a welcome trend. We need the scientific establishment to be open to these approaches and to apply their analytic skills to their study.

JOAN RIVERS– Revisited

The latest revelations from the Joan Rivers tragedy seems to indict her treatment at the Yorkville Endoscopy clinic.  The importance of these latest findings which appeared in the NYTimes and are based upon a “federal report” seems to point to a variety of avoidable errors and omissions.

The importance to me on a personal level  ( in addition to the Ms Rivers tragic death) is that I participate in an ambulatory surgicenter where upper endoscopies are performed on a daily basis.

I do hear from some of my patients who have expressed concern regarding their own fate. 

To summarize:  there seems to have been a failure to notice her deteriorating vital signs.  To me this points to a dereliction of duties by the anesthesiologist involved in the case.  Their job is to administer the drugs and closely monitor the patient’s vital signs.  That is their responsibility.  The anesthesiologists I work for are compulsively monitoring our patients on a continuous basis.

Again there was notation of the unauthorized ENT doctor Korovin who performed two laryngoscopies.  Even without performing a biopsy, this procedure is known to potentially result in spasm of the larynx and trachea, the result leading to bronchospasm and inability to oxygenate the patient.  This was clearly an inappropriate procedure for an ambulatory surgicenter and may have directly led to the anoxia (lack of oxygen) that resulted in “brain death”.

 The taking of “selfies” was an act of poor judgment and unprofessionalism but not directly contributory to Ms.River’s death.

So in summary, her death was most likely avoidable.  Poor medical judgment and perhaps an anesthesiologists lack of attention contributed to it. 

Obviously I am not responding to sworn testimony for this assessment, merely the NY Times article. But at least I can offer my own patients some assurance that their experience will be much different at our center.

BRITTANY MAYNARD DIDN’T DIE TODAY — But She Is Planning for It When She Chooses

It is highly unlikely that 29 year old Brittany Maynard would choose to become famous because of her choice to end her life prematurely.

The cover article in PEOPLE Magazine October 27 th edition outlines her struggle with a fatal brain cancer and her decision to choose physician assisted death on November 1. She has chosen to postpone that decision because she still has a reasonable quality of life. Apparently she has not decided to change her mind about her ultimate choice.

She is the poster person for a powerful movement to bring personal choice to the issue of death. It is about dying with whatever grace and dignity one can possess in the face of life’s inevitable end. It is about choosing to avoid the loss of control, degradation of the body and suffering for oneself and one’s loved-ones.

Of course controversy surrounds these issues. The role of physicians in the process is equally charged.  I for one believe we need to air this debate openly and bring it to the public forum.  I regard it as an area of bioethics, the law and spirituality intersect.

Oregon remains one of five states with Death-with-dignity laws on the books. Other states including New Jersey have begun the legislative process. Organizations such as Compassion & Choices are strong advocates for legislative action as well as personal support for patients and families battling these issues.

All of us need to think seriously about how we want to end our lives. Death being what it is, many will not have the opportunity to choose how and  under what circumstances it will occur.

The aftermath of Oregon’s experience in the 14 + years since the law was enacted should alleviate some of the fears of its opponents. Massive numbers of people did not move to the state in order to facilitate their own death.  The law is restrictive in many ways.  It insists that depression and psychological issues not be the diagnosis. A prognosis of six months or less must be documented by more than one physician. The patient must be physically and mentally capable of ingesting the lethal dose of barbiturates.  In practice nearly one third of patients who qualify for the law and have the drugs DO NOT use them.  But they feel empowered that they have the choice to do so. And fears that Hospice or palliative care options would be abandoned have proven false.  In fact their utilization has increased. Patients are more apt to make use of all available support because of the increased public awareness of end of life choices.

So let us appreciate the courage of Ms Maynard to share her public tragedy which will ultimately be for the benefit of us all.

PHYSICIAN ASSISTED DEATH ? — How’s “Termination of Suffering”

The debate over physician assisted suicide (PAS) is hampered by its terminology.  For some, suicide is always an evil.  

I personally don’t have a problem with the term but other’s prefer physician assisted death (PAD)_.  There is legal precedence now accepted in four states.  It began in Oregon and is making its way through the NJ legislature. (not sure where at present).  Criteria are extremely strict and the process is highly regulated.  Physicians who sign on to the program can prescribe a lethal dose of  medication.  The patient must be physically and mentally capable of ingesting the drugs.  There must be no clinical evidence of depression.  

The Oregon experience seems to contradict the fears of many who oppose such legislation.  Massive numbers of individuals did NOT sign up for the program.  Only about 10% of those who qualified and received the drugs actually took their own lives with them.  Palliative care and Hospice use actually increased in Oregon (as opposed to opponent’s beliefs) and there was no deterioration in the patient-doctor relationship.

Kevorkian exhibited the right intentions but his efforts were not well thought out.  He was actively challenging the law and forced the country to take notice.  His active euthanasia was too provocative for the population to accept.  He was not particularly careful about screening out those who were severely depressed and not truly terminal.

 Perhaps there would be even more acceptance if our labelling of the program would change.  Termination of Suffering says it all.   Perhaps we should change the term to PATS (physician assisted termination of suffering).  I hope no one truly believes that hopeless suffering servers some higher spiritual purpose?

Who in their right mind would object to that?  How naive of me.   There are those who will.

THE BLACK JEWELRY BOX — Unexplainable Experiences

A devout skeptic, my metaphysical journey was first triggered by hearing first hand the personal experiences of ordinary individuals who had unexplained experiences.

 What was so compelling was the context of these experiences.  They were told to me in deepest confidence.  The experiencers were rather reluctant to share what had occurred for fear of appearing strange or foolish.  Yet I knew many of these individuals for years.  I knew they had nothing to gain by fabricating these stories.  They were compelling yet unexplainable. There was a level of credibility to them that drew me in.

 I still find them compelling and worthy of investigation.  Although they remain unexplainable, they point ever so subtly to a level of reality which transcends every day awareness.  Do they “prove” survial of consciousness after physical death.  Hardly. Yet taken as a whole they cannot be easily dismissed.

 The following was told to me by a patient and acquaintance of many years.  His credibility is without question.  I have altered the names and details of the story but the core of it remains intact.

 I was cleaning out my Mother’s house prior to the official closing.  After she died we tried to empty it of all its objects.      First we held a garage sale.  They we donated what was left to a local church.  Some of it became garbage.  We went through her possessions is great detail, many times, as did the numerous visitors.  We were particularly seeking to find her black jewelry box which she claimed had become lost.  She had suffered from some dementia before she passed.  She cherished the modest jewelry she kept inside and my family had bought it for her.  It was essentially gone and we began to believe it would never be found.  Now I was the last one to visit the home.  I walked through the rooms one last time.  I removed the mezzuzahs from the door posts.  I spoke out loud to my Mother thanking her for all she did for us and that now she was moving on as were we.  There was a deep silence that followed.  For some reason I glanced one last time into the empty living room.  The jewelry box was there!  It was literally impossible for that to be so.  Dozens of people had marched through the home.  Our family checked every square inch of it for that box.  But there is was.  Here’s the photo of it.  We have it securely with us  now.  I thought you would find this interesting.

   To say the least.