Anecdotally Speaking

Reducing my office schedule to two days a week, because of my new medical director responsibilities, is creating problems from a sometimes-overbooked appointment list. I am finding that I need to adapt to time pressures I have not experienced before during the coarse of a busy session. Regardless, the problems people are presenting to me are not correspondingly less complex or less time-consuming.

On a recent day, a full schedule revealed the name of an established 12-year-old male patient in a ten-minute appointment slot with a reason for the visit noted as "knee pain - track starting." I had four other patients scheduled that same hour and five in the next with a cornucopia of ailments, but this patient's visit did not look threatening, at least it did not as it was booked on the schedule.

The visit began to take on a different flavor when I picked up the chart from the chart holder outside the room and looked at the patient sign-in slip clipped to the front of the chart. Scrawled out by the patient's own hand next to the question "reason for visit" were the words "complete check over."

I entered the room and found the 12-year-old boy sitting in the patient throne at the end of the exam table and his mother sitting in a side chair next to my little writing desk. I assume my position on the circular rolling stool, that object of great fun and delight for many youngsters that visit my domain, until I arrive and wrest it from them and claim it for myself.

I know this boy's mother well. We go back many years. Though I do not know him as well, I have known him since he was an infant and we have meet on several occasions for minor problems and the occasional ubiquitous sports physical.

I will not go through the entire history and details of the medical problems. Suffice it to say, there turned out to be a significant interplay between subtle, but real pathophysiology, and profound psychosocial overtones, not the least of which was this families strong evangelical religious beliefs.

The precipitating event that ultimately leads to this appointment, it appears, was a well-intentioned lecture at school, followed by intense Internet browsing, on the subject of testicular cancer. My poor fearful young patient was terrified of dying from cancer, thus the reason for "complete check over."

As our encounter progressed, I became aware of four things. One, his exaggerated fearful anxiety over having cancer was appearing to be the tip of the iceberg. I was discovering an underlying pathology, perhaps an affective disorder, anxiety or depression, or a mood disorder, these were common enough but other possibilities could be explored as well, this being a complex and convoluted area of medicine. Any approach in this direction needs extremely careful and skillful handling, considering this young man's fearful and impressionable nature and the family's faith beliefs, which can sometimes affect attitudes towards mental health issues in challenging ways.

Second, I was soon aware that a quick word of reassurance on my part would be inadequate to set my patient's mind at ease, maybe because he did not trust me sufficiently, yet. Maybe because he did not trust the word of a doctor alone, but needed something else besides, something more thorough, some type of evaluation or work-up that would go far enough to suitably satisfy his sense of certainty, maybe then he would be reassured. However, I sensed that not even that would do. I sensed that I could do nothing that would set his mind at ease completely. I thought, "He's bright." I must keep that in mind.

Third, I was aware that everything that was said or was done during our encounter had potentially profound significance, the slightest gesture, a raised eyebrow, a hesitation when answering a question, a frown. These things could be interpreted by the anxious and fearful to represent dire portent. Therefore, I was aware, careful and deliberate in everything I said and did, because I was aware how much it all mattered. This might be just another visit in the day for me, but for my patient, this is a significant moment in his life. He will remember details of this visit for many years to come.

And finally, I realize that to do what I need to help my patient I need to summon all of my skill to understand how this family views health in the context of their overall worldview, so that I can then help them integrate my scientific medical model in a way that they can embrace with integrity. I will fail if I just throw a solution at them that is the antithesis of their faith system. However, if I can help them learn how to incorporate a scientific solution into their belief system, then we will both succeed.

This visit required subtlety and poise and I pulled it off very well but it took longer than the ten minutes that was allotted to it. But hey, that's the nature of Family Practice. Incidentally, he still had track coming up and had a problem with his knees hurting. Hah! Did I think I'd get out of that one? Ha, Ha, Ha! It's Family Practice, no way.

Yesterday I get up early to head off to my new job in the city. I have an appointment at 8:45 AM to sit in on a treatment session of an outpatient group that is scheduled to begin at 9:00 AM. This is an early start, even for me, because I need to go to the far side of town and in the best of weather, it will take me 45 minutes to get there. So I figure I need to leave by 8:00 AM, but I don't get off until 8:15 AM, so I'm stressed. Typical.

Worse, there is a snowstorm going on and it is in the middle of dropping, oh, I don't know, four, maybe, six inches, who knows, maybe even eight inches of snow, all over my world. I fret over the clock the whole way as I drive in, as if that will make any difference. At least I have the 4 x 4 Trailblazer; it handles the roads just fine. I only get slippery sloppy just once or twice. I arrive at 9:02 AM and I figure that will probably do just fine. I compose a passable "oh the roads were terrible" excuse as I go in.

Then I find out that the group actually starts at 10:00 AM, not at 9:00 AM. Typical. So I make it to group on time and I am sitting in group, doing my doctor thing, when my leg starts buzzing. Dutifully I have remembered to turn my cell phone to the vibrate mode before group started. I had slipped it into my front trouser pocket so that if someone called me during group, it wouldn't disrupt the session, but I would still know if someone was calling.

I realize now, too late, that I have underestimated how loud a buzzing cell phone can be. I try to act nonchalant as at least two people in the group are checking their own cell phones, no doubt thinking the ambient buzzing might be their own phones. I can't help it, but I feel like I just did the silent fart in a crowded elevator; nothing to do but just act natural, hum a few bars, whistle a little. Mental note: turn off cell phone in group, check voice mail after.

So, I check my voice mail after group is over and find out that Cindie called. I give her a ring back. Apparently, her Buick is high-centered in the driveway at home and is totally stuck in the snow; she is not going anywhere. I have the 4 x 4 and she is supposed to be at the hospital to take out a gall bladder at 1:00 PM can I go over and do that for her? Sure, yeah, why not, what choice do I have? I cancel out the rest of my schedule and head over to the hospital to take out the gall bladder. I do make it to a board meeting that I was scheduled to attend at 4:00 PM though.

Latter, after the meeting is over, I'm sitting at a drive-through waiting to get a burrito to eat on the drive home, when Cindie calls me and says that she has a pregnant patient down at the hospital who is now in labor. A friend has picked Cindie up from home and has driven her to the city and now Cindie wants to meet me, take my 4 x 4 and then let me catch a ride back home with her friend. So, that is what we do.

I have a dozen red roses with me in the car that I had picked up for Valentines Day tomorrow. I could have surprised Cindie with them if I had gotten them home without her knowing I had them. But switching the cars and all, it sort of let the cat out of the bag, so we had our Valentines gift exchange in the parking lot of the Ralph's supermarket. I could say, typical, but no, it's rather just, strange maybe. It works for us though, in a funny romantic sort of way.

Cindie's friend drops me off at home and as I walk down the driveway I see that Cindie's car is not only stuck in the snow, it is now somewhat buried. It seems as if the elements have decided that her Buick is an object that must be claimed, absorbed and incorporated, as if it is something that no longer belongs to the humans.

My task the following morning is to recover the lost Buick. I trek to the barn to retrieve the long unused skid loader. This is the first time this winter it has been needed. The first thing I am aware of is that despite the pleasant and cheerful greeting of a bright sun, it is frightfully, frigidly cold. I check the thermometer; fifteen degrees below zero! After tossing hay to the donkeys, I turn around, head back to the house, and layer on more cloths, whew!

Back in the barn, I brush the frozen bird droppings off the seat of the skid loader. I climb up; strap myself in, first the belt, then the roll bar cage, clanking into place. I pull the choke, set the throttle, turn the key and hear the sad sound of errr, errr, errr, errr, then silence. Dead battery. How anticlimactic. I extricate myself and climb down. I stand and perform the requisite "stare at the thing when it doesn't work" pose and notice that one of the tires is flat. Typical.

I put the battery charger on it, grab the snow shovel and walk out to the Buick's final resting place. I look the problem over. I cannot stand the idea of walking away from this, thwarted. And don't forget, I'm male, and I'm not yet ready to ask for help; I still have a desire to solve this problem on my own. So, I get down on my hands and knees and start digging. I would not have done this unless I thought it looked somewhat simple and easy. And it would have been, if I had gotten it unstuck on the first rock-it-back-and-forth effort. But no, instead, every time I dug the blasted car out, it would go one or two feet, then get stuck again. I like literally dug the stupid car out ten times before it finally came loose.

And it's a crazy thing, because if I had known that it would have been such an ordeal, I never would have started off doing it that way in the first place. But the longer I worked at it, the less likely I was to quit, because I had already put so much work into it; come hell or high water, damn it, it's coming out or I'll die first! Argh! It's OK; I'm fine now.

After Cindie's car is out, the driveway looks like a war zone. Well good, it should. I feel like I've been in a war. The neighbor has left her car in the driveway. She couldn't get it in because Cindie's car was blocking the way. She asked me to bring it in after I finished getting Cindie's car unstuck. So I walk down to where it sits, get in and find the keys. I put the key in the ignition, turn it and hear the sad sound, click, click, click, click, then silence. Dead battery. Typical.

Fifteen degrees below zero?

One week from Saturday I will be in the jungles of the tropical rain forests of the Amazon, enduring instead sweltering heat.

Hmmm, now that is juxtaposition.

Nothing typical about that.

"The ceramics teacher announced on opening day that he was dividing the class into two groups. All those on the left side of the studio, he said, would be graded solely on the quantity of work they produced, all those on the right solely on its quality. His procedure was simple: on the final day of class he would bring his bathroom scales and weigh the work of the "quantity" group: fifty pounds of pots rated an "A", forty pounds a "B", and so on. Those being graded on "quality", however, needed to produce only one pot -- albeit a perfect one -- to get an "A". Well, came grading time and a curious fact emerged: the works of highest quality were all produced by the group being graded for quantity. It seems that while the "quantity" group was busily churning out piles of work -- learning from their mistakes -- the "quality" group had sat theorizing about perfection, and in the end had little more to show for their efforts than grandiose theories and a pile of dead clay. --David Bayles & Ted Orland, from "Art & Fear, Observations On The Perils (and Rewards) of Artmaking"

I love this story, not just because of what it has to say about art, but because of what it has to say about perfection and the pursuit of perfection, a subject germane to medical practice. I have written on the subject as it relates to expectations for flawlessness and it speaks to Voltaire's famous statement, "the best is the enemy of the good," on which I have also written.

In my opinion, medicine it is no different than the ceramics class. "Quality" medical care emerges when dedicated physicians are "churning out piles of work -- learning from their mistakes." Ironically, it is from the fruitful ground of error, that physicians produce their best, highest "quality" work, getting better and better as they learn more and more, refining and revising, modifying, changing and adapting. So then, I think, physicians must be free to make mistakes; they must be, in the words of Bayles & Orland, free to tap into their "ordinary (and universal) humanity."

Current trends in health care, however, tend to advocate just the opposite. They tend to overly focus on the elusive goal of the perfect outcome, error free, faultless, exact, precise and flawless in everyway. This would be the job of the right side of the ceramic class whose task was only to produce the perfect pot. However, what happens when you demand perfection as the only acceptable result? You get no result. Worse, as is the case in health care, you can actually get a decrease in "quality."

So, I say, let physicians be physicians. Let physicians "practice" medicine. Let physicians refine their "art," the "art" of medicine. It has been done so traditionally. Then, I say, you will see "quality," just as they did with the pot makers, free to be who and what they are, pot makers. Or with doctors, doing what it is they do and doing it well, getting better and better.

Why does this work? Why can it be trusted? From Bayles & Orland: "For you, the seed for your next art work lies embedded in the imperfections of your current piece. Such imperfections (or mistakes) are your guides -- valuable, reliable, objective, non-judgmental guides -- to matters you need to consider or develop further. It is precisely this interaction between the ideal and the real that locks your art into the real world, and gives meaning to both."

Therefore, this is what it means for me. I will never be perfect or practice perfect medicine and I will never try to. I will never expect to never make another error again (hah!). But I will continue to do what I have always done, and incidentally, it isn't what I was always taught or trained to do, and that is to take each "error" or "mistake" or "undesired outcome" as they occur and learn from them. I take them as the "seeds" and as the "guides," and next time I do better. In this way, I improve, I get good and I end up making really good pots.

"To demand perfection is to deny your ordinary (and universal) humanity, as though you would be better off without it." --David Bayles & Ted Orland, from Art & Fear, Observations On The Perils (and Rewards) of Artmaking"

With this quote in mind, I want to revisit the mantra expressed by the Chief to his Surgical Resident, Dr. Bailey, in the drama "Grey's Anatomy."

"Dr. Bailey, this is a patient like any other patient, there is no room for error, which means there is no room for nerves, shake it off."

Elsewhere, writing on perfection, Bayles & Orland state: "If you think your work is somehow synonymous with perfect work, you are headed for big trouble. Error is human. Inevitably, your work will be flawed. Why? Because you're a human being."

There are two aspects of her basic humanity that the Chief is asking Dr. Bailey to set aside. One is the tendency toward error; the other is the capacity for experiencing emotion and the implication that this emotion can increase the likelihood for error to occur. As a doctor, she is being asked not to make a mistake and not to let her emotions cause her to make a mistake.

How can a human being perform work error free and unaffected by emotion? Dr. Bailey's mentor advises her to "shake it off." My experience in medical education and training has been that there has not been any advice in this regard any more explicit than this. Nevertheless, the implicit and tacit pressure to demand of ourselves perfection, and indeed thereby to deny our ordinary humanity, has, in my experience, been the way we were shaped into physicians.

To what end? To make good doctors? Maybe. To make good people? No. Wounded people, certainly. You cannot deny your true humanity, your true self, who you are, and emerge unscathed, no matter how noble the cause.

However, maybe there is something even more insidious at work, something ultimately more harmful in the end, than the injury to the healers themselves. Trading their humanity for perfection may be more than a bad bargain for the doctors, but may be a bad deal for their patients as well.

Bayles & Orland: "Your perfectionism denies you the very thing you need to get your work done (it denies you your humanity). Getting on with your work requires a recognition that perfection itself is (paradoxically) a flawed concept."

On reflection, I wonder if it has always been this way. Terms such as "the art of medicine" and "medical practice" harken to a time when there was no expectation that a physician always had the necessary or typical characteristics required for any given situation, complete, lacking nothing essential, without errors, flaws or faults.

Does practice make perfect? Twenty-nine years of practicing and I haven't made it yet, to perfection that is. Please don't let that secret out though. It raises another interesting question, however, how does one define a "good doctor?" Is it one who does not make mistakes? Save that question for another time, perhaps. Anyway, must get to the office, back to my practice. More practice; practice makes perfect, you know.

This morning, as I started down my driveway toward the highway, I spied my next-door neighbor moving down the drive ahead of me. The frozen gravel and snow crunched beneath our tires as we moved in tandem down the drive toward the road. Her car reached the end ahead of me, hesitated, then pulled out onto the highway and moved off toward the west.

I reached the end of the drive and paused as well. Another neighbor approached from the west driving his pickup truck, towing a hayrack. We waved at each other with a friendly wag of our index fingers as he passed by in front of me. I then pulled out and headed off down the highway myself, thinking, "Boy, a lot of traffic today."

There wasn't much else to see on the rest of my trip, except maybe for a triad of ring-necked pheasants, standing in a field, straight up, frozen at attention, eying me intently as I passed by. Standing ablaze in brilliant color, flooded by the dazzling morning sunlight and set against the luminous white canvas of the pure winter snow, as if waiting for me to go, so that they could carry on with some unrevealed interrupted activity.

And then there was the red-tailed hawk, perched atop a fence post, standing so still, and so regal, so as to seem to be part of the post itself. I hardly would have noticed him if I was not looking carefully. If all goes as he expects, some rodents in the grass will fail to notice him, much to their regret.

Oh, and the flock of small birds that traced out an invisible wave in the sky as they passed by, beating up in unison, coasting down, beating up again, coasting down. Individuals acting together in harmony, unified as if one, coming from somewhere, going to who knows where.

One stop sign slowed me down on my trip. I hate delays. However, I figure that you must be philosophical about these things. You know, take the good with the bad and all of that. I should not complain, but it is annoying, nonetheless. There should be no stop signs in life, right?

Oh, I almost forgot. There was also this magnificent bald eagle, soaring with his wings outstretched, tilting and turning, twisting and spinning, without once breaking his wings for a beat the whole time I could see him as I drove by. What a way to fly! What a way to take a trip.