On Foppery

Our personal style of dressing broadcasts to others how we see ourselves and how we would like to be seen by them.  It's quite amazing how effective the strategy is. 


For example, wearing striped ties to class from middle school through college might accomplish your longstanding desire to become president of the local golf club. Wear three piece pin striped suits in your law practice and clients just might begin to believe you are actually worth eight hundred dollars per hour.  After all, clothes, as it is said, makes the man - and woman.

Without saying so we want people to know if we are gentle or rough,  liberal or conservative, heterosexual or homosexual, playful or serious.  Our clothes billboard the answers with laser accuracy.


Clothing also permits us to indulge ourselves in various fantasies.   That's why we drive our Ford pick-up wearing leather racing gloves or take to coming to the office decked out in a Stetson hat.    


Even the survival of the species benefits from a Darwinian fashion show of clothing.  While other animals attract each other and preserve their species utilizing color markings, we depend heavily on clothing to propagate ours.


So it was a big shock to me when I commenced my internship and discovered that my wardrobe was to go in storage and be replaced by a uniform which would do very little to either preserve the species or promote the persona I hoped to cultivate.


The uniform consisted of a short white jacket, white pants and white shirt.  They were all starched to a point that one had more of a  feeling of breaking into them rather than putting them on.  This cold, stiff, white landscape was relieved only by our neckties.  While it was mandatory to wear them, we were given free rein in buying them, leading to a cacophony of colors and patterns, which gave us a modicum of individual expression.


So we held on to our neckties as if they were lifeboats.  Most of us packed as much individuality as we could into our very limited haberdashery.  I favored ties with interesting color combinations hoping, I suppose, to be seen as 
artistic and sensitive. 


But selecting my own ties did not dispel for me the feeling of anonymity and enforced conformity.


So why were we exiled to this fashion Siberia?  What message was our hospital attire supposed to convey?   


The relentless white was possibly to project a pure and sanitary image despite our regular tramping around in gobs of purulence.  


It was widely believed at the time that germs (any bacteria, almost all friendly) were public enemy number one and television ads were awash in pitches for toilet bowl cleaners (Mr. Clean was an icon) and kitchen sanitizers.  The sparkling white color of our hospital clothes must have, as a result, been very reassuring.


The stiffness of our outfits might have subconsciously suggested moral rectitude though it is equally possible that the hospital laundry got a sweet deal on starch and felt free to starch the daylights out of our uniforms.  Which ever the case, my cohort  and I had, by common consensus, more starch than rectitude.


So when I finally entered practice, escaping three years of a deflating dress code (and two years in the army where I came to detest the color olive nearly as much as white), I vowed to never wear anything white.  This included white shirts and lab coats, long or short.  It surprised me how commonplace it was for practitioners to wear long white lab coats and I was grateful that the group I joined did not.


Long white lab coats on internists seems to  me like over - egging the omelet.  They give the impression of  a doctor who not only talks to you and takes your blood pressure, but also conducts animal studies in the basement and is regularly splashed with blood and an assortment of nasty discharges.  In fact, these contingencies are pretty far-fetched.


Moreover, the lab coats suggest priestly robes, giving them an air of authority which is disturbing.  While studies have shown that a majority of patients find doctors who wear the lab coats more professional and trustworthy, donning of the robes can create a divide which does not accommodate  open discussion.  After all, who will challenge or question a man or woman wearing priestly robes?


There are of course many internists in lab coats who encourage and successfully create open dialogues with their patients, but the coats are in many ways institutional props that, under the radar, stifle communication, and thereby deserve to be mothballed.


My second vow on entering practice was to not wear neckties.  In part I saw them as superfluous and uncomfortable and in part I admit to playing the gadfly.  But my chief aim was to cultivate a persona that painted me as open, flexible and somewhat unconventional.  Tossing off my ties was a metaphor for these qualities.


My seniors were scandalized by my open collar look which they regarded as subversive and unprofessional.  On the other hand, my  patients barely noticed and I doubt that I lost any patients as a result.


Today, at least thirty-five years later, the open collar is the rage among politicians, celebrities,  doctors, pundits, even lawyers. 


Furthermore, the tie is now regarded as a pariah in the medical world by some researchers who have shown them to be a breeding ground for pathogens and a rich source of hospital acquired infections.  Some hospitals in the UK have banned them and many others, here and abroad, discourage them.  


In some ways then, clothes indeed can make the man or woman.  At the very least, their presence or absence (my long gone ties) are vehicles for how we see ourselves and hope to be seen by others.  Whichever style we might adopt, it should feel natural or else it flops. Otherwise, most fashion sorties hit the target as long as there is not even a hint of sloppiness. 

Perhaps the best advice  I ever received about clothing was from my father who exhorted my brother and I to dress British and think Yiddish.  Its pretty good advice for anyone: create an image but remember where you come from.

Dress British, think Indian; dress British, think Polish; dress British, think Mexican and so on works equally well.

--




  











        

Pack Your Bag

The blog that follows is based on my actual experiences but the names are fictionalized.


Dr. Gregory Tuddle, Chief of Medicine at a teaching hospital where I trained, taught me one of the most important and enduring lessons of my 
medical practice - all walls are to be breached.  This meant that knowledge and information that could benefit a patient need to be secured at all costs, whatever the obstacles.  

If walls blocked the way, the physician should climb over them, smash through them, dig under or sweep around them.  A trojan horse was fine by Tuddle too.

Dr. Tuddle never actually articulated this lesson.  It was his choreography of morning report (where students, interns and residents were required to present   the patients that they had admitted over the previous twenty-four hours, giving a critical analysis and defense of their management of the patients to him) that brought the lesson indelibly home to me.

Here is how the dance went.

One morning I presented a case to Dr. Tuddle regarding a very sick man with an infected heart valve. Tuddle listened intently before he went on a talmudic spree of the "on the one hand and on the other hand." That was his way: there were always more questions than answers.  One of his questions dealt with the wisdom of the particular antibiotic regimen I prescribed.  He challenged me to defend my choice, always preferring independent thinkers to parrots, even if it meant disagreeing with him.  (Tuddle loved when we disagreed with him.  While he insisted on politeness and fairness, he shaped us not to be intimidated by authority).


As we sparred (I hadn't landed a single punch), he asked an unusual question that flummoxed me - who knew more about infected heart valves than anyone else in the country?  I had no idea at first but then remembered an infectious disease super star from Boston, Dr. Lawrence Waldman, who had given a lecture at our hospital some years ago.


"Good, call him," Tuddle said.


I thought my  mentor had a flash of temporary insanity.   Afterall,  I had never heard of an anonymous resident calling a famous medical figure for advice.  The Chief of Medicine was asking me to break into the ivory tower and  provided no clues on how to do it.


I found Waldman's number and as the phone rang, prepared my introduction.  A woman answered, his secretary.  In just seconds, I realized that it was unlikely that  I was going to talk with the great man without her approval.  I imagined that her previous employment was in the secret service and that she must be a doyenne in the protection field.


But, after an immodest amount of groveling and flattery, I was put through to the doctor who, strangely enough, seemed thrilled to hear from me. Initially, I couldn't imagine why but the thought occurred to me that his secretarial protection was so thorough that he was essentially under house arrest in the ivory tower.  Even I was welcome.


He was very generous with his time and made many helpful suggestions that improved my patient's care.  He advised on at least two more cases  and was always welcoming when I called. While we were not equals, he made me feel that we were colleagues.  I hoped I could be as magnanimous as him one day.


So lesson learned - connect with anyone who can help a patient no matter how far away or exalted they may be - and a wall was breached.


Subsequently, my report on another case  at morning sessions resulted in Tuddle sending me on a fantastic journey that would leave many walls in ruins.  


The case involved a middle aged man with what appeared to be terminal liver failure of uncertain cause.  I was hoping Tuddle could pull the rabbit out of the hat but he was stymied too.   The only hope might be a liver transplant, but he seemed too far gone for that.


"So who knows more about liver transplantation than anyone in the country," Tuddle asked me.  This time I was ready.  " Dr. Sundale in Denver," I quickly replied.  "Good, call him, "he replied, true to form.


Emboldened by my experiences in Boston, I made the call with a trace of  confidence.  Sundale picked up the phone on the first ring and like Waldman was gracious.  After hearing the patient's history, I asked him if he had any suggestions.  He did - bring the patient to Denver - today.


I couldn't imagine how we could do that with such a sick patient, in such a short time, but told him I'd relay his thoughts to Dr. Tuddle.


Upon hearing Sundale's advice Tuddle got very quiet and asked me to check back with him in twenty minutes.  When I did he told me,  "Pack your bag, you are going to Denver with your patient today."


Impossible.  He had somehow commandeered a regularly scheduled Boeing 707 jetliner (no security checks back then) to take us to Denver just three hours after he first went into action.


Our entourage consisted of the patient, myself and two nurses on loan from the intensive care unit.  The airline removed about twenty seats for us then placed a curtain around the area, our makeshift hospital.  When we entered the plane, the passengers seemed both curious and animated to be rubbing  shoulders with what appeared to be modern medicine at 34,000 feet.


While the passengers seemed fascinated, I was intimidated by the responsibility that had been given me in a singularly unconventional environment.  Much could go wrong.


But the experience was heady too.  The captain came to me in the makeshift hospital to ask if  everything was ok.  I said things were going just fine and thanked him for his concern.  He then asked if the cabin pressure was ok.  I didn't have a clue, so  I asked him what he thought.  He thought it seemed good and I, after pausing a few moments, as if in deep thought, agreed.


We landed in Denver, thankfully without incident, where a waiting ambulance took my patient to the medical center.  He, alas, did not live more than another week but the trip might have been his best chance.


Lesson learned again.  Doctors should go far and wide when necessary to get their patients the best information and treatments and never be intimidated by celebrity.  When walls interfere, as they did in these cases, they must be breached, brought down and left in ruins even if you have to hijack, so to speak,  an airliner, Tuddle style, to do it.


During my career I had the great fortune to work shoulder to shoulder with some outstanding doctors.  They were a rich source of advice and consultation and I often called on them.  But at times, when we were stumped, I would hear a faint but distinct echo of Tuddle's voice exhorting me to cast the net wider still. 

A Latin Beat

Over many years of medical practice this remains my most memorable case.  It demonstrates how knowing the patient well can be pivotal and it is a brilliant reminder that life is not always governed by reason.


My patient, in his early sixties, had an elevated PSA.  He saw a urologist who performed a prostate biopsy.  It was bad news with findings suggesting an aggressive tumor.

Within two days of the procedure, he became acutely ill with fevers and chills and all the markings of a serious infection.  The prostate was doubtless the source of the infection.  Powerful antibiotics were launched but he, nevertheless, worsened with rising temperatures and then very disturbing neck pain.  Even more alarming was the sudden loss of  strength in his arms and legs.          

Consultation with neurosurgery, along with imaging of the neck, indicated that he had a subdural abscess of the cervical spine.  The neurosurgeon performed immediate and urgent surgery hoping to head off permanent damage to the spinal cord by draining the abscess.

  

While the surgery eliminated the infection, within two days, he was fully paralyzed despite aggressive medical and physical therapies.

After two months, with no changes,  a fortress of immobility, the neurosurgeon and physiatrist (physical medicine doctor) were absolutely sure that he would never regain any independence.  Discussions with the patient and his family regarding institutional care commenced.  As expected he was crushed.

But that is not the end of the story. Against all odds, he actually regained function of his limbs and went on to an independent and fairly active life.   Mystery and magic were thick in the air during his long and  nearly complete recovery.

Here is what happened.


Both the patient and I were, after two months,  still unable to accept his prognosis.  I kept looking for a roadmap to reverse the injury to his spinal cord, but all efforts were to no avail.


With the science of medicine exhausted, it became clear that the last hope was to deploy the art of medicine.  This put us under the jurisdiction of mystery and magic where we would attempt what one of my friends and colleagues (a poet too) calls "leaping over the science."


Knowing "Carlos" for many years, I landed on the compelling idea that music just might be the vehicle to inaugurate the leap.  It made sense.  He was, after all,  a legendary musician in the local Latin jazz scene, and a venerable mentor to many young musicians. 


 Music was a calling for him and the key narrative of his life.   Just watching him walk and hearing him talk in his graceful latin rhythms marked him as a man crazy for music. 


So, I went to his bedside and told him I believed that music could very well improve his condition.  He looked dubious initially but then managed a smile which implied he was on board.  I asked him to tell me  his favorite albums and artists and had the family bring them to the hospital.


I then discussed my plan with the nursing and physical therapy teams who signed on despite some modest rolling of the eyes.


The plan was relatively simple.  Music would be administered at set times, just like medicines, and played for at least thirty minutes per dose, four times daily.


With the tunes of Machito and Paquito D' Rivera pulsing out of his room, the general mood on the ward elevated and some of us seemed to be walking with a subtle but noticeable swing.  Carlos, on the other hand, remained immobile, sleeping through most of the musical treatments.


Just forty-eight hours into  the experiment, however,  a nurse called - he moved.  Come and see.  Arriving at the bedside I saw his right foot sticking out of the sheets with his great toe moving slowly and sensuously to a latin beat.    


The physiatrist seemed to think we had whisked the patient off to Lourdes in the dark of night and considered the toe dancing miraculous.  With just this minimal improvement, he reversed his prognosis and thought that, with intensive and sustained physical therapy, this small sign could be the harbinger of major improvement .


One year later, he walked out of  a rehab center ready to resume his old life.  Do I believe the music cured him?  Of course I do. 


Can some people leap over the science?


You bet.


PS:  Carlos declined any further prostate investigations or treatments and eight years later, he leads an independent life and his prostate tumor remains asymptomatic. 




             

The List

Most appointments with physicians are either followups or relate to new concerns and, generally, run fifteen minutes.  

At the end of a session for, say, indigestion, the patient and doctor decide on a course of action.  Thinking the visit is over, the doctor moves towards the door, at which point the patient, with some panache and the dexterity of a Las Vegas black jack dealer, draws "The List," from their pocket along with an announcement that they have more questions.   


Already running late,  with many scheduled encounters ahead,  the physician suddenly experiences  a nascent desire for a career change, perhaps  lion taming. 

"The List" varies in style and form but aficionados have apparently agreed upon a number of, until now, unwritten rules.

1- There can be no fewer than five questions on any list.

2- Pencils are the writing tool of choice and the smaller the piece of paper the better.

3- The list must not be revealed at the beginning of the appointment.

4- Issues raised on the list must have been present for no less than five years.

5- It is required that the patient's major worry is placed last on the list.

The doctor who decides to extend the appointment to address the list faces the distinct possibility of mayhem in the waiting room from patients, who correctly believe their time is as important as the physicians,  protesting loudly.

What to do?  The key is to commandeer the list as quickly as possible to make sure there are no alarming elements that need immediate attention. 


Then, the practitioner needs to discern just how concerned the patient is about any of the listings. 


The first step, in my experience,  is to tell the patient that their appointment time is up.  This is hard to say but fair given that their stated reason for coming to the office was addressed in the scheduled time.  Additionally, it is unfair to delay subsequent patients short of an emergency or pressing contingency with the current patient.


Then, most tellingly, the patient is asked if they wished to make a special appointment to focus on the list.  If they said yes, then I knew the issues needed my undivided attention.  If no, they were probably mostly curious,  wanting to economize and get as much out of the appointment as possible.


Over many years,  very few of my patients accepted the invitation to set up a special visit to address the list.


With soaring health care costs and co-pays, it is a small wonder that some individuals might try to get as much into an appointment as possible.  However, in doing so, they do themselves a disservice.  A bloated agenda, conducted by a doctor now on the run,  will invariably not lend itself to thorough and responsive care.


Mission essentially accomplished.  With the element of surprise contained and a galloping list corralled, clinical balance is restored and a sensible and reasoned approach to the list emerges. 


Indeed, this problem can be headed off by a "List" savvy doctor asking at the beginning of an appointment if there will be other questions, some possibly more immediate than the declared reason for the visit.  


So, while "The List" presents a formidable challenge for the practitioner, it can be managed with candor and understanding.  Lion taming still remains a possibility but, for the foreseeable future, the notion can be stored away in a vault for safe-keeping and possible future deployment.




             

Let's Dance

Over the years of practicing medicine, patients taught me many lessons.


On one occasion, the lesson came from a couple whom I had never seen before. They were quite elderly and each looked frail, layered in ordinariness, dressed in non-descript clothes of a  distant era.


In contrast to their appearance was the husband's courtliness, helping his wife off with her coat and then getting her comfortably seated.  Their affection for each other was palpable and they unquestionably were still very much in love.


I sensed they had an interesting story to tell and was eager to discover it.


A fifteen minute appointment leaves you little time to really get to know your patients,  so  I utilized a favorite technique for connecting with patients when time is short.


Early in my practice I had discovered that even the most taciturn would open up and talk enthusiastically and appreciatively about their lives, revealing much in a very short time, when asked one of two questions: How did you and your spouse meet, or, where did you grow up and what was it like growing up there?


With this couple, there seemed most to be learned by asking how they had met.


They met in the early 1950s at the Eagle Ball Room where singles came to dance to big band music and perhaps even find romance.


He spotted her and asked her for the first dance of the evening.  After the music stopped, he asked her to marry him.  She accepted right on the spot.


Sixty-four years latter it was obviously a brilliant, if impulsive, decision.  "But how did you know that she was the one," I asked?


"Because we danced well together."  


Go figure.


So what did they teach me?  First, that the good life is not always governed by reason.  Second, that sometimes the heart is better than the head in navigating ones destiny.

Getting To Know You

The big prize for the primary care practitioner is regarded by many as the opportunity to know their patients well in sharp contrast to the generally fleeting relationship of sub-specialists and their patients.

This was certainly true when doctors regularly made house calls where there was much to learn: Hemingway dominating the book shelves; the lawn overgrown; a chessboard with a prominent place in the living room; pictures of the kids colonizing the front hall; the scent of cigarette smoke hanging furtively in the air despite numerous efforts to quit smoking.


So while we primarily knew about our patient's blood sugars in the office, the house call allowed us to see their humanity, their singularity.  These insights went far in caring for patients as they hoped we would, with our efforts anchored to their beliefs and values.


Moreover, the attentive and open-minded physician had much to learn from patients on their home courts as they not infrequently led very interesting and informative lives.

Nowadays, knowing one's patients well is really quite challenging.  For one thing, insurance coverage availability and cost of coverage, oftentimes results in a musical chair like coming and going of patients that is disorienting to both doctor and patient.  It barely allows familiarity let alone bonding.


Then there is the  matter of the computer in the exam room, the big gorilla. 


Patients regularly report that the doctor barely looks at them but gazes fixedly instead at the computer's screen, bringing to mind the the pop hit immortalized by Frankie Valli, "Can't Keep My Eyes Off of You."


With the computer, often large, planted on the desk squarely between physician and patient, the possibility of doctor and patient seeing each other becomes somewhat theoretical,  giving each the sense of being alone in the room.


While the computer is not without its virtues in patient care and might even be thought to be indispensable, it can make it quite hard for doctor and patient to connect.


Part of the problem is that the standard fifteen minute appointment is littered with clerical tasks that the clinician is personally required to do, leaving fewer opportunities to see or even talk to the patient.


The clerical mandates vary but partially include documenting on the computer that the diagnosis list has been reviewed, the problem list reviewed, the feet inspected, if a diabetic, and the medication list updated.  


There is nothing unsavory about data entry, it is honorable work, but when done by the doctor, valuable time is lost with the patient.  So by the conclusion of office hours many practitioners feel a murderous disdain for the computer along with the sense that the day had been bleached of value by the relentless stampede of computer clicks documenting this and that.  No wonder the computer is so well casted in the role of the endlessly hungry little furnace.


It should be said that there is nothing fundamentally wrong with documenting.  Indeed there are cases where it improves care.  But it is worthwhile to remember that not all information is knowledge and therefore might very well not deserve collection.   


In the early going of the computer age, we seem to gather data incontinently so we need to become much more thoughtful about what we collect.  Moreover, when we do document, we need to ask at what price we do so.  Surely not at the expense of time interacting with patients.


Answers to the computer and insurance issues that make it harder to know our patients remain for the software designers and health care reformers to solve respectively. Physicians also need to take an active role in solving these problems.


In the meantime, it would do us well to remember the author Evelyn Waugh's response when asked by a young man what was the key to becoming a good writer.


Waugh said, "Only connect."

              

On Language

Given the medical professions tradition of compassion it is indeed remarkable that some of our language regarding patients can be so adversarial and even brutal.

Looking at the words doctors use in their clinical notes makes the point.  

The patient is said to have "refused" the test, suggesting recalcitrance and an overall lack of cooperation.  Why not say instead that the patient declined the test,  a non-judgemental way of putting it, which allows the clinician, in an unloaded atmosphere,  to explore the reasons the test was declined?  

Perhaps a family member died from the very same test or procedure.  Perhaps they didn't have insurance.  Perhaps similar tests have led disastrously to false conclusions in the past.  These insights are not easily gained when words like "refused", charged with opinion and insensitivity, are deployed.

In the artillery of hostile language there is a special place for the word "denied".  Here patients are said to have denied, for example, chest pain rather than saying, non-judgementally, that they did not report any chest pain.  The typical office visit report is characteristically colonized with the word "denied".

Reading and creating such notes invariably conjures up images of the patient in an interrogation room,  replete with naked light bulb hanging from the ceiling and gray metal desks and chairs,  where trust, the coin of the realm,  runs low indeed.

The most egregious word usage is possibly saying that the patient "claimed" various things such as dizziness, headache, toe pain.  Why claimed?  Why not reported or indicated?

When medical records are reviewed and the word "claimed"is seen over and over, patients may be regarded more as liars than historians.  The results of this transformation can be calamitous as medical decisions are founded on mutual trust.

Words can not only be judgmental and insensitive but brutal too. For example, there is no convincing justification for telling someone they have heart failure.  Look someone in the eye and tell them they have heart failure or say kidney failure and you will invariably see all the air go out of their tires.  

It is not euphemistic to instead say they have cardiac or renal dysfunction.  One can even give an assessment of the degree of dysfunction, using words like significant or very significant.

Similarly, the tendency to tell patients they have dementia instead of memory loss is regrettable.  For many the word dementia is a biological hand grenade that evokes the terror of losing one's mind.   Softening the blow and holding out hope wherever possible is neither euphemistic or sugar coating.  It is humane.

So our words can tear apart or they can heal.   It remains unclear why the caring profession of medicine uses words  in ways that transforms patients into adversaries and sometimes uses words that terrorize.

The above practices suggest that for all of medicine's nobility, it has a tiny, but very significant flaw;  a concoction of arrogance and authoritarianism, rooted in a part of its history, still with enough force to make its way into modern medical care. 

It will not be easy to eradicate these practices. As physicians we are nursed on words like "claimed" and "denied",  but the job surely belongs to our medical schools where sensitivity to language and words can be taught as a way of discovering the best in our patients and ourselves, as well as a venerable tool to heal and comfort .  Encouraging literary pursuits and a fierce appreciation of language in medical training will assist future physicians to develop a vocabulary that is both caring and non-judgmental.