Anecdotally Speaking

It was a quintessential moment, fitting for a rural medical practice. I was on my hands and knees in the dark cramped kitchen of a patient's home. The patient was sprawled across the floor in front of me. CPR was in progress.

I looked down at her face. It was devoid of even a vestige of color. Thin electric wires fastened to her chest made their way to an automatic defibrillator. A disembodied robotic voice from the device intoned, "Continue CPR." I prepared to provide her with an airway.

Moments before I was in my clinic seeing routine patients when my typically busy Friday morning was interrupted by the urgent call, "Code blue, patient down." I answered the call.

It wasn't far; she lived only a few blocks from the clinic. But then, in a small town, everyone lives only a few blocks from the clinic. I arrived at her house with the airway equipment in less than a minute.

While she was being ventilated and chest compressions were being delivered, I calmly prepared for what I needed. I checked the laryngoscope, inserted the batteries, attached the curved blade and checked the light bulb. Fourteen years ago, I was an ER doctor and I did this all the time. I was very good at it and fancy that I still am, even though I don't do it that much anymore.

I selected an ET tube, inserted the stylet, adjusted the stylet and shaped the curve of the ET tube just right, attached a ten cc syringe, inflated the balloon, checked it and then I was all set; I was ready.

I gently extended her head and inserted the blade of the laryngoscope along the side of her tongue, pushing the tongue out of the way. I was nearly laying flat on the floor, my head lowered down as low as I could go, to be at the best angle to see into the larynx.

Redundant folds of oral and pharyngeal structures obscured my view. I pulled up on the scope with my left hand and angled it to try to expose even just the smallest glimpse of the arytenoids or the vocal cords. I craned my neck. It was an awkward angle.

My bifocals couldn't quite bring into focus the minute area I needed to see, that particular teensy tiny little spot just beyond the tip of the epiglottis that I had to visualize in order to place the ET tube properly. I had to see it. I repositioned the blade and probed with the tip of the ET tube. I jiggled my glasses up and down.

For a flash of a moment it crossed my mind that maybe I wouldn't be able to do it. That it would be just too hard for me, that it had been too long since I had done this sort of thing and my eyesight was not good enough anymore. As I struggled within the diminutive space of my patient's gullet, stretched out as I was across the floor, it flickered through my mind for only a brief half of an instant that I should let the other doctor have a go.

Then I recalled that I am good at this. Really good. I used to do this all the time. I worked once in a busy ER full-time. I intubated people in code situations nearly every day. I am the best person for the job, I reminded myself. This patient needs me and by golly I am not giving up, I am doing what it takes to get this done.

So I pulled a little harder, angled a little bit more, got down a little closer to the floor, then I slid the tip of the ET tube up under the epiglottis and directed it anterior into the trachea. I removed the laryngoscope, inflated the balloon, attached the amboo bag, gave some breaths, watched the chest rise, fall and listened for breath sounds. It was a successful intubation.

Later on, ensconced again in my ordinary busy Friday clinic, I was still feeling warm inside from the glow of accomplishing something truly remarkable. I imagined that it might be like the feeling one might get from catching a game-winning touchdown pass or from winning a $10,000 Lottery Prize.

I wanted to share the feeling, so I said to my staff, to no one in particular, "You know, intubating somebody is always tricky, but it really is something doing it when you're in a cramped dark space laying flat on the floor."

No one in particular, replied, "Huh, huh, that's nice."

Hmmm, what do I expect? Anyway, I think I'll make an appointment to get my eyes checked. Maybe they can do something about that.

He was bigger-than-life and big in true life with a loud Texas drawl that boomed in the distance before you even saw him. Ruddy, barrel-chested, thin greasy hair plastered carelessly across a mottled scalp, his face was adorned with a toothy grin spread perpetually wide from one haggard ear to the other.

His cylindrical girth was festooned with a long white lab coat embroidered with his name and title, and I dare say no one ever saw him bedecked in anything else. He was an icon at our institution, as close to god as anyone could be. He was Chief of Pediatrics of Children's Hospital, specialized as a Pediatric Pulmonologist. He was world famous as an authority on Cystic Fibrosis, making the hospital a foremost treatment facility for the disease.

He was an imposing figure, no he was an intimidating figure, no he was simply terrifying, at least from the perspective of a fledgling third year medical student. That is what I was when I encountered this paragon of a legend many moons ago.

I heard stories about him; everybody talked. I heard that he was brilliant and that he was awful, but I couldn't really tell in the end what to expect from him. Then, I didn't know what to expect from anything. I was fresh from two years in lecture halls, gross anatomy dissection labs, mountains of thick textbooks and all with never a patient in sight. Then finally, I was thrust onto the wards of the Pediatric Hospital and I didn't have the slightest clue as to what came next. I was overwhelmed.

It was the first assignment of my Pediatric rotation. I had morning rounds with the famous terrifying Pediatric Chief. Fortunately, I thought to myself, with some degree of comfort, the group making rounds that morning was big enough that I could fall back on the time tested strategy of making myself look real small, become invisible, blend in, disappear and survive by not being noticed.

The grand Pooh-Bah entered, his white coat flying, big belt buckle flashing, cowboy boots clomping, he swooped down on our ensemble, a huddled mass of unsuspecting learners waiting for his arrival. He wasted no time as he launched into a soliloquy, shooting questions right and left, attacking here, zinging there. There was no hiding; no one was safe, so much for my strategy. He was fast, loud; eyes darted everywhere and missed nothing. This was his turf, he was king and he relished asserting it. In a dervish, we were off, bed-by-bed, patient-by-patient, on "lightning" rounds.

I was a novice student, as green as they came, my first time in a hospital. At that stage of things I was prepared for doing little more than just tagging along. We came to the room of a mother tenderly holding a small, thin, almost emaciated child in her arms. She gently rocked him as the room filled from the onslaught of our Chief-following troupe. We crowded in until we surrounded the tiny patient and his mother. No one knew what the diagnosis was; we waited to hear the presentation.

The Chief boomed out, "Where's a student? You there!" He pointed directly at me and my eyes must have widened in response, I know my heart quickened. "Kiss that baby!" he commanded.

"Kiss the baby?" Nonplused, incredulous, I froze; I didn't move a muscle. "Am I missing something here? He can't really mean it, can he? 'Kiss the baby?' What part of Marcus Welby did I miss? Do doctors examine patients by kissing them? Is he making fun of me? Is this a joke? Am I going mad? Am I missing something here!"

During the brief moments that I hesitated, I noticed that no one in the group made a sound. This wasn't turning out to be a joke. The Chief persisted, this time more earnestly, "Come on, kiss the baby!" He was motioning me on. His imperative was not in my imagination.

I looked around. Everyone stared back at me. There were no smiles; no offers of any help. I looked at the mother. She looked like a normal everyday kind of mother. I looked at the baby. Nothing special there, just sleeping away. I looked back at the Chief. He didn't look happy. I shook my head. This just couldn't be right. I didn't want to kiss the baby. Right then, I wished that I was on another planet. I wished that a hole would open up in the floor and would just swallow me up. I didn't know what was going on and I didn't know what to do.

The Chief's face turned a scary red color. He jumped out, grabbed my arm, pulled me forward toward the patient and continued to insist that I "kiss the baby, kiss the baby!" Wanting to just end the disaster, I leaned over and quickly planted a peck on the child's arm, then returned to my place with the rest of the group. Seemingly satisfied, the Chief then turned to me triumphantly and asked, "Well, what did he taste like?"

"What did he taste like!!!? How the heck do I know what he tasted like!!? I didn't lickthe child!! What did he taste like!!? Is this guy stark raving mad!!? Does he think I French kissed the stupid baby's arm!!? What did he taste like!? Is this guy a moron!?"

Of coarse I didn't actually say any of this, instead, I just mumbled, "I don't know." With that response, thank God, in exasperation, he finally lost patience with me, gave up and moved on. It turns out that he never spoke another word to me again. Fine with me.

The point he was trying to make was that patients with Cystic Fibrosis have a genetic defect that prevents them from being able to keep salt out of their perspiration. Therefore, patients that have Cystic Fibrosis have salty tasting skin. It is so salty in fact, that it is virtually diagnostic for the disease.

There was a time once when physicians no doubt made the diagnosis of Cystic Fibrosis with their own tongues, but in our day, there is a lab test for measuring the amount of salt on a persons skin. Doctors do not have to go around licking their patients in order to make a diagnosis; we can save our tongues for other uses.

So, out of my fear and naiveté did I miss the chance of a lifetime to experience a great clinical teaching moment by not licking the child and actually tasting the salty skin of a Cystic Fibrosis patient?

Or, did my fear and naiveté lead me into being intimidated and browbeaten by a bully of a man who was ultimately just a poor teacher?

Something I do know. People like him do not scare me anymore and I don't let things like that day on rounds happen to me anymore.

I don't know where that unfortunate man is today, but I have to say, he sure was one strange cookie, ho boy. Sometimes I wonder -- if he had been a Pediatric Endocrinologist and if the patient had been a diabetic -- would I have been required to taste the patient's urine for sugar? Would I have done it? It boggles the mind.

Intrepid adventurers, experienced, seasoned, weary from explorations in the sultry depths of the Amazon jungles and atop the rarefied heights of the ancient Mayan ruins of Machu Picchu, six American travelers were finally heading for home. They were happy, satisfied, brimming with tales to tell kith and kin upon their return. It was a good trip.

I was among that cadre as we checked into our hotel in Lima on the last day we would be spending in Peru before flying back home to Omaha that evening. It was all but over. We had braved danger together, excitement, the unknown. Ours was a once in a lifetime experience of the exotic kind. Now there was nothing left of it but to rest for a while, board a plane and show up back home.

We gathered in the lobby, clustered together with our bags, our fearless leader hovering. We were getting good at working together as a single unit. Now we needed to move up the elevator to the third floor where two rooms and hot showers awaited us. One of us pulled open the hinged metal door of an unusual elevator. As the exterior door swung outward, a more typical inside door slid away sideways. We moved our bags and ourselves inside the elevator, until we were tucked away inside, comfortably snug.

The elevator door closed and the number three button was pushed. The elevator began its upward ascent. There was no thought in anyone's mind that this journey would be anything but a short one. However, that was not the case. Shortly before arriving at the third floor, there was a strange sound, a gentle shudder and the elevator came to a standstill. We were stuck between floors.

There was an odd moment of silence, an imperceptible instant of corporate disbelief, followed by realization. Then, of coarse, someone stated the obvious. "The elevator stopped." What followed then was a flurry of activity. This group is nothing if it is not industrious and innovative. Unfortunately, no one had any actual being-stuck-on-an-elevator experience. Nonetheless, there were all kinds of ideas and suggestions on what should be done.

We ruled out climbing through the hole in the ceiling. Likewise, jumping up and down to lighten the load was too screwy and too scary. The best idea was to press the button that made a distant bell ring. So, that is what we did. We could hear it ringing off somewhere in the distance, so we kept pushing it.

We were not quite sure what the best button pushing method was to use in a situation like this. Should we hold the button down continuously, do Morse code or do a kind of irregular pattern? We tried all of the methods. We pushed it for what seemed like a long time before we got any kind of a response at all. You would think that they would eventually miss their elevator and go looking for it.

In time, they did find us. We had a window in the door, something else that was a bit odd about this elevator. I was standing near the front of the elevator, pushing the button with a kind of irregular pattern, when I started to hear a commotion below us. Looking down through the window, I could see a human face peering back up at me from the floor below. Ah, good, I thought, the rescue has begun. Now we can all relax, help is on the way.

Spirits seem high, everyone was still in a good mood. They were kind of looking at this as a new experience and that is a good attitude to take. What a great bunch to be stuck on an elevator with, what sports. The commotion below us continues. There is lots of Spanish talking. They must be trying to decide what to do. That is when the lights go out.

It is now pitch black inside the elevator. It is now silent in the crowded little elevator. I offer a little joke. "It sure is a good thing that none of us has claustrophobia." There is dead silence. Then a little voice answers back. "I'll talk with you about that when this is over Dr. David." We start to speculate as to what might be going on when the elevator moves! Not much, just and inch, but it did move down one inch. We were all generally very encouraged by this progress.

There seemed to be a big pause, then we dropped another inch! Then another and another. We were stuttering and jerking our way down excruciating slow, as if someone was cranking us down by hand. Yes, soon, we could see an opening. There it was! The second floor was coming into view and, yes, we can see people there!

An inch at a time and the floor of the elevator finally came down level with the opening of the second floor. We started to grab our luggage and prepared to exit when the elevator did not stop, it kept dropping! The people on the outside said, "Hurry, you must get off, quickly!"

No one needed to be told twice. That elevator was evacuated posthaste. As I turned to look back, I noticed that it continued to drop down. Now that is just strange. I then turned to greet our rescuers. We were grateful indeed, joyful smiles all around.

There was the hotel staff, the manager, and then there was this older gentleman. He was obviously the one in charge. He seemed to be directing the rescue operation. I was thinking that he must be the engineer, the operations person or maybe even the guy from the elevator company, I don't know.

What a relief, we were all cheerfully saying thank-you to them all, when this older guy, he says, "A story to tell," and he walks down stairs and is gone. That's all he said, "A story to tell." I busted out laughing. "A story to tell? Yeah, it sure was that!" I expected an explanation as to what happened, what went wrong, or an apology, but no, just a statement of fact. "A story to tell." No harm, no foul, I guess. What a hoot.

So, we finished our grand exotic adventure stuck in an elevator. And that left us with "a story to tell." Priceless.

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.

It was one of those icy, wintry nights, when you can feel yourself being slowly petrified into a frozen block of ice by the unrelenting frostiness of the frigid air, as amazingly painful, intense jolts of the bitterly cold turbulence stabs into you, piercing you through to the very bone.

I was working my ER shift that night when the trauma nurse called me away from a routine case. She informed me that an ambulance had just arrived with the victim of a vehicle vs. pedestrian collision. Right away my brain is clicking away because these cases usually involve a lot of serious trauma. As we are hurrying toward the trauma room, she tells me that the case involves a young man who has been run over by a friend's pickup truck. Apparently, he has severe chest injuries.

When I burst into the trauma room, I am at first relieved to see that the patient is awake and sitting up and does not appear to be in any distress. Other than the fact that the whole room is a bustle with emergency personnel who are doing their thing, going about being all professional and all, me included, and no doubt frightening the bejezus out of the poor guy. He looks very anxious. If he didn't think he had anything to worry about before he came in, we sure did give him cause for concern now, if for no other reason than just because of how we were acting, so concerned ourselves!

I take a closer look at him and I see what some of the fuss is about. The paramedics and trauma nurses and everyone else have done their jobs. The patient, a young man of late teens to early twenties, has his oxygen on, his IVs going and his cloths have been removed, in order to make an appropriate assessment of his injuries.

When his shirt came off it was plain to see that diagonally across his chest, running from the lower right liver area up across his chest to his left shoulder area was the most clearly marked imprint of a pickup truck tire tread anyone would ever possibly imagine to see on a persons chest. I mean, a CSI detective could identify the make and model of the vehicle the tire was from, the details of the imprint were so remarkable.

So, OK, the guy was run over by his friend's pickup truck, we could sure see that. His chest should be all crushed, smashed, and squashed to heck, right? Tire treads marked up his chest in plain view. So how come he is sitting there, pretty as pink, watching us buzz around being all concerned, as if he wasn't having any trouble at all? So, I ask him, while I am checking him out, "Say, you got this interesting tire thing on your chest here, what happened?"

"Well," he says, in no distress, because according to my examination, there is absolutely nothing wrong with him. Except for the tire mark. X-rays, tests, observation, everything we did proved the same, no injuries, just the tire mark.

"Well," he says, "My buddies and I were out on the frozen lake with my friend's pickup truck, spinning around, doing donuts and things, you know, having fun." Yes, I do know about that; having fun. He went on, "Well, we found this old hood from an old car. So we thought we could make a sled out of it. We turned it upside down, got a rope and tied it to the back of the pickup truck. Then I got on the upside down hood tied to the truck and my friend and the guys got into the truck and then they started to pull me around on the frozen lake with the truck, you know, like a sled." Yes, unfortunately, I did know, and I knew where this one was going.

"Well, they started going faster and faster, then they started going around in circles. That's when it started to whip the sled around. Oh boy, did it really get going fast then! I could hardly hold on! But the rope was too long. The sled whipped around completely in front of the truck. On the ice, the truck couldn't stop and it couldn't turn. Everything was just sliding around and around and then, boom! The truck ran over me! They called the ambulance and brought me here." He seems disappointed.

I consider him for a moment and then think to myself, "Amazing, remarkable."

"Am I going to be all right, doc?" he asks.

"Yeah, you're going to be all right," I reassure him. "But you're one lucky young man." He nods, agreeing. I nod too. Yea, lucky guy. What else can you say?

Ain't it just heck, getting old? The perils.

I walk into X-ray and find a young man sprawled out on a chair with both of his feet bare, shoes, socks and coils of ace bandages pilled in a heap next to him on the floor. His father sits against the wall, arms folded across his chest. They both greet me with silence. I cross to the view box where I find a set of films hanging that demonstrate views of both the right and left ankles.

I linger over the images, concentrating intently. Then I brace myself with an intake of breath, peer sideways at the father, then at his son, then turn and look incredulously down at the teenage boy's feet. I stare for a few moments in consideration.

Then I pull up a rolling stool and sit directly in front of the lad, poised to perform my examination, when with rapt interest in his answer I ask, "So tell me, what happened. It looks from the x-rays like both of your ankles are broken." The boy and his father exchange glances.

"Not only that," I say as I look up at the father, "but the exact same bone is broken in the exact same place on both sides." I have not seen simultaneous bilateral distal fibular fractures before today; I am really curious to hear how an injury like this has occurred.

The father says, "He didn't break them at the same time, you know."

"Oh really?" I look back to the boy. He speaks up. "I was out sledding on the snow, when this kid with a great big inner tube runs me over. That's how my foot got hurt."

"He keeps on sledding after that," the father adds, exasperated. "My son, don't get me wrong now, but he's not the brightest star in the sky. He keeps on playing around until he gets the other foot busted up too."

"After that I couldn't walk," the boy finishes. He seems disappointed.

I examine his feet. He has the exact same fracture on each foot on the same day. Amazing, remarkable. I look up at him. "Bad luck, man." He nods, resigned. I nod too. Yea, bad luck. What else can you say?

"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."

The Chief speaks these words to Dr. Bailey in a moment of self-doubt. A life hangs in the balance and she is hesitant and unsure. Her voice wavers as she nervously implores her mentor to relieve her of the burden of responsibility, "You want to handle this Chief?"

He does not take the burden from her, "I'll be standing by to help but this is all yours." Faltering, Dr. Bailey mumbles orders, "Grey, let me have an 8-0 ET..." She is interrupted by the calm but firm voice of her attending, "Dr. Bailey, this is a patient like any other patient..."

The Chief looks her straight in the eye. This is a brief, focused moment in the midst of a crisis. An intimate moment when mentor wisdom is passed on, the essential stuff not found in textbooks. "Dr. Bailey, there is no room for error, which means there is no room for nerves, shake it off."

There is no incrimination or blame, no reasons or explanation. Just a calm, clear statement of the situation and what is expected. A moment passes as Dr. Bailey considers what the Chief has just said. Then, decision made, she steals her resolve, loosens up her neck and declares in a clear strong voice, "All right, let's do this!" and proceeds to accomplish a difficult intubation procedure.

I appreciate the show "Grey's Anatomy" because it has these moments when it captures pieces of medical practice with a touch of authenticity. I have written on the expectation of perfection before; this scene in the show, I think, dramatizes it poignantly.

There is an essence here, in my mind, about what it is at the heart of the matter that makes one a doctor, about what it means to be a doctor. Doctors are those who do what Bailey did; they step up. When a life hangs in the balance, someone has to step up; someone has to do the job. When she was unsure of herself, Bailey appealed to the Chief, and as the doctor, he could have, and would have, stepped up. However, she was the doctor too. The Chief wanted her to learn that she needed to step up too. So, he pushed her. And she did it. She acted as, and performed as, the doctor. She stepped up and did what needed to be done.

The problem is that the one who takes on the responsibility to step up when it is necessary, to do the job when it needs doing, to be the doctor, that person is just that, a person, human. As a human, that person is fallible, a human prone to error. A human prone to error taking on a job where, as the Chief said, "there is no room for error."

So, that is what being a doctor is. The requirements are clear. They were clear to the Chief; they were clear to Dr. Bailey. There is no room for error, but someone has to step up and do it anyway. The physicians among us say, "I will take on the burden of needing to be perfect in order to do the job that needs to be done." The buck always stops with the doctor.

After it was over, Dr. Bailey looked exhausted, perhaps as much emotionally as physically. The Chief asked her, "Dr. Bailey, are you all right?" She replied that she just needed a minute.

I wonder though, if the Chief's question might not still be a very good question to ask. Because, I posit, it has not been answered very well. With what we ask our doctors to bear, the inhumanity of it, are our doctors all right?

If anyone is looking for evidence that I am certifiable then let me oblige. I have incontrovertible proof that I am loosing it. Let me explain.

An ongoing effort of mine lately has been looking for a way to improve my life by becoming more organized. In evaluating the perpetual backlog of onerous paperwork I amass so easily about me, my personal coach pointed out that I tend to define the hideous paperwork in my life with negative terms. Am I that transparent?

The point being that people are more likely to do tasks that they see as positive and postpone tasks that they see as negative. It makes sense. He suggested that if I could frame ghastly paperwork in a more positive way, turn it around, say, and make it into an adventure, I would be less likely to procrastinate and more likely to get it done.

So, this past week I was looking for a way to put a positive spin on doing dreadful paperwork. A very interesting blog caught my eye. It is called Mindmap of "Getting Things Done" by David Allen, and it has this cool diagram created by some software by a kidney doctor and used by him to organize his thinking. This caught my eye, of coarse, because I am very visual, and I am thinking maybe I can make unbearable paperwork into an adventure with this kind of a visual Mindmap organizing tool thing.

This blog had a link to the book Getting Things Done: The Art of Stress-Free Productivity, by David Allen, which really looked like it was right up my ally, so much so that I ordered a copy.

Still on the lookout for ways to make repulsive paperwork appealing, I found another blog that caught my eye latter in the week. Dr. Maria on her blog "intueri: to contemplate" puts up a post where she mentions that she increased her productivity by shifting how she measures her tasks. Rather than looking at a task as a project and pursuing tasks by project, she now measures tasks in units of time. The switch is working very well for her. I am thinking that since I look at tasks as projects, maybe the switch would be just the thing I need too.

She refers to a thing called GTD, or G.etting T.hings D.one. I clicked the GTD link and it takes me to a wikipedia website that explains this really cool system of organizing things, taken from this book by David Allen which really looked like it was right up my ally, so much so that I ordered a copy!

But wait, you say, didn't I already order a copy of that book? You noticed, huh? Well, I didn't notice, not until both books, both identical books came in the mail, oops. Can you believe it? I guess I really do need to get organized. Absolutely amazing. Nothing to be said about it really. I started reading one of them. It really is pretty good and should be good for me, hmmm.

I certainly must be loosing it. If someone wants to call the guys from the loony bin to come haul me away, I would consider it an act of kindness. Thanks.

I sat at the small square desk in the corner of the exam room holding a crinkled plastic shopping bag stuffed with a variety of prescription medication containers. My new patient had just handed them over to me. I looked closely at the bag. This might take awhile, I thought.

I dumped the contents of the bag onto the desk and began to sort through the array of empty bottles, tubes of cream and hand-held inhalers. The labels disclosed that the prescriptions originated from various doctors and many different places. And they were all labeled with generic names. I soon realized that I was going to need a Physician Desk Reference to look up some of the generic names that were unknown to me.

"Metaproterenol sulfate inhalation aerosol, that would be your Alupent," I said, setting it aside as I started a list. He was nodding. "And this is pirbuterol acetate inhalation aerosol. I think that is a Maxair inhaler." He confirms, "That's right." So far so good. We go on.

"OK, this is a tube of ciclopiroxolomine and this one is desoximetasone and this one is fluocinonide. I'm going to have to look these up." I do. "OK, we have Loprox cream, Topicort and some Lidex. Pretty strong stuff." He is nodding, "Yes."

I pick up one of the bottles. "This one is triprolidine hydrochloride 2.5 mg and pseudophedrine hydrochloride 60 mg, I think that's Actifed. And this one is isometheptene mucate 65 mg, dichloraphenazone 100 mg and acetaminophen 325 mg, that would be Midrin. Do you get headaches?" He nods vigorously, "Oh yes, terrible headaches."

"Let's see, enalapril maleate-hydrochlorothiazide, that's Vaseretic. You have high blood pressure." Again he nods, "Yes, but I ran out of my medicines and I'm not taking anything now. I need to get back on something."

"This one is guanafacine hydrochloride, that's Tenex, for blood pressure, and indapamide, Lozol, also for blood pressure. And triamterene 75 mg/hydrochlorothiazide 50 mg, I think this is Maxide. It's for blood pressure too, and you say your not taking any of these medications right now?" Again nodding, "That's right, I need to get back on."

"Alright, acebutolol hydrochloride and amiloride hydrochloride-hydrochlorothiazide, I'm not sure what these are, I need to look these up." Thumbing through the massive PDR tome, I find what I am seeking. "OK, here it is, it's Sectrol, that's a beta-blocker, for blood pressure too, and the other one is Moduretic, for blood pressure as well. I'm not sure you're going to be needing all of these medicines for your blood pressure."

"Oh good," he replies. "I don't think I was on the right kinds of medicines. Besides, I don't like to take pills." I think to myself, "I can tell."

"And the last two, cyclobenzaprine hydrochloride and orphenadrine citrate. Do you know what they're for?" He takes the bottles and looks them over while I turn the pages in the PDR. "They're for my spasms, I think."

"Here we are, Flexaril and Norflex. You're right, they're muscle relaxers. Have you had back problems?" He nods vigorously again, "Oh yes, terrible backaches."

I finished writing the list of medications, then picked up the plastic grocery sack to replace the odd mixture of medication containers. "Whoops, looks like I missed one." I fished out the elusive, solitary, empty prescription bottle.

I read off the label to myself, "Perphenazine-amitriptyline hydrochloride, what is this? I know amitriptyline hydrochloride, that's Elavil, a tricyclic antidepressant, but perphenazine. It must be some kind of neuroleptic, a type of phenothiazine. What an interesting combination, there must be a lot of side effects with this medicine, how strange."

I ask, "What do you take this for?" He looks over the bottle. "Oh, them's for my nerves, the little blue pills." I look them up. "Oh, OK, this is Triavil, I've heard of this. The perphenazine is called Trilafon. I've never used it. Kind of an older drug."

The medication list was finished. I refilled his sack and handed it back to him. "Well, that's all of them." He speaks up, tentatively, trailing off, "Just one other thing doc." I hesitate, then, "Yes?"

He screws up his forehead, squints his eyes, purses his lips and with what seems like great effort tries to remember something. "There is this one other medicine that I need but I can't remember its name." I wait quietly, not moving.

He goes on. "I think it begins with pro something. It sounds like pro, pro, pro something. I can't remember." His shoulders sag in defeat.

I open the book and turn to the "pro" section. "Procan," I offer. "No, that's not it," he replies. "Wait," I say, "it would be labled with the generic name, not the brand name, silly me. How about procainamide hydrochloride." He shakes his head, "No."

"Prochlorperazine? No, that's Compazine. You wouldn't be on Compazine. Promethazine hydrochloride? No, that's Phenergan; you wouldn't be on that either. How about propafenome hydrochloride, which is Rythmol? That's for the heart." He is shaking his head, "No, no."

"Propoxyphene napsylate?" The name floats out into the air. His face relaxes, his eyes brighten, he slowly raises a finger, points to me, a smile breaks across his weathered face, "That's it doc, propoxyphene napsylate, that's what it is! Yes sir, propoxyphene napsylate. I need some of those." Of coarse you do, I think to myself.

Darvocet-N 100. I should have known. Patients never make me play the "guess what drug I'm thinking" game unless it's a controlled substance. Never for something as boring as Pen-V-K or Naprosyn. Generic names, I'm ready to pull out my hair or scream or something.

There is an urgent call from the hospital regarding a sick patient. I take the call and hear about a patient with congestive heart failure in volume overload. I order Lasix 20 mg IV push, then I hang up the phone and reflect.

I am not sure how long generic furosemide has been available, but it has been around for as long as I can remember. Yet, I always have and I am nearly certain that I always will, order furosemide by saying Lasix, even when furosemide will actually be what is given; I don't mind if it is substituted. So, I ask myself, "Why?

It is simple. Because no one will ever wonder what I mean if I say Lasix. However, if I order Lasix by its generic name furosemide, I can guarantee that the day will come when someone will wonder what it is that I am asking for.

I think that if drugs were always referred to by the brand names that they were given by their original patent holders that patients and practitioners would overall end up being considerably less frustrated, make less mistakes and waste less time. Medical care might be delivered more safely and the experience of its practice might be generally more satisfying.

What's in a name? A lot.

The patient is about my age. I do not know her well. She usually sees one of my partners, but on this day the pain was exceptionally bad so she came to the office to see me for some relief.

It is difficult for patients with chronic pain to see a new doctor for the first time. They have to start all over from scratch. Even with good medical records available they still have to explain everything all over again, answer the same questions again but worse, they must deal with the new physician's doubts and suspicions about the diagnosis, the treatment plan, even about their own veracity.

It is difficult for a physician to see another doctor's chronic pain patient. We all have our own problem patients and so we do not want to inherit another one. Besides, these patients tend to be complicated and time consuming and are often deceitful and manipulative. More often than not, most encounters end up with both parties being dissatisfied in one way or another.

This particular patient suffered from the condition of trigeminal neuralgia, sometimes still referred to by the classic moniker "tic douloureux." I was taught in medical school that this dreaded disorder was one of the most, if not the most, painful conditions known to man. Before effective treatments were available, patients apparently would frequently put themselves to death to escape the relentless agony that this disorder subjected them to.

I read this patient's record and listened to her story. She has been on every treatment possible in every combination imaginable. Most treatments at one time or another have helped to some extent. She has seen a neurosurgeon who thinks that surgery in the area of the nerve may be beneficial. She has a date scheduled for the operation and she is hopeful about the outcome.

She says something when she is telling me about the neurosurgeon that makes me think. She tells me that she can never really explain to people how bad this thing really hurts. Her family, her friends, every one she knows, they try to understand but she says no one seems to get it. It is as if they seem to think she is exaggerating it or making it up, and she feels hurt and cut off and lost.

It is not hard to know why this is the case. If this is indeed the most severe pain a human being can ever experience, then none of us has any frame of reference to relate to her experience. She is indeed alone in her experience. I am thinking what a difficult burden that would be to bear when she already carries an unimaginable one.

However, she told me that the neurosurgeon seemed to understand, that he "got it," and how that was such a comfort to her. I reflected on this. The neurosurgeon has never had trigeminal neuralgia, how could he communicate to my patient this sense of understanding of the unimaginable overwhelming pain she lives with day in and day out?

A quality that I think is essential to practice medicine as a physician is that of sympathy. Some may not agree, but I think to care effectively for a patient requires it. I am told that the term "patient" from the original Latin derives it's meaning from "the suffering one." Physicians help people, sympathy is essential.

However, not everyone possesses another quality. I do not know if it is rare or common, but some exercise it exceptionally well, and some not at all. It is the quality of empathy, to actually be able to understand another person's feelings or difficulties as if you were in their shoes. It is an ability to understand more completely, more thoroughly, more accurately, to identify and to relate.

I think that that is what the neurosurgeon accomplished. It is what I try to accomplish. To imagine what I myself will never experience so that I may understand my patient and thereby better serve them. I think empathy makes good physicians excellent physicians and I think patients are drawn to empathetic physicians.

My patient that day needed empathy, because without it she was alone and lost, oppressed with a horrible affliction. I did my best, I provided medical care for her.

When I interviewed medical schools for admission, they would ask, "Why do you want to be a doctor?" My answer of coarse was, "Because I want to help people." I certainly can elaborate on that answer, but very simply, it is what I do, I help people, and it is a great thing.

The last patient on a busy Friday was a friend of mine. He came in with his wife. We have very successfully treated the effects of his so-called metabolic syndrome. His blood pressure and cholesterol numbers have reached the established targets and he has recently shed ten pounds of extra weight.

He was there to discuss the results of a two-hour post-prandial glucose tolerance test. His fasting blood sugars have been normal, even his hemoglobin A1c has been normal, but the 2 hr pp result was 185. By definition, this would place him in the category of "impaired glucose tolerance," a common development in someone with metabolic syndrome. Some would say he was now a "borderline diabetic."

We spent forty-five minutes before going home for the weekend discussing the significance of the result for him. We talked about the physiology of insulin resistance, beta-cell function and the current theories related to the development of Type II Diabetes. I wanted him to make an intelligent choice out of the myriad of therapeutic options he faced.

The three of us settled on a therapeutic strategy that they were comfortable with and that I think makes sense. From my experience with these things, I expect to see impressive results. I expect to see his glucose metabolism normalize, at least in the short-term, staying normalized perhaps for many years to come.

I may have saved his life that day. Our work on that Friday afternoon may have started a chain of events that prevents diabetes, a stroke, a heart attack or at least postpones such things for years, perhaps decades. I may have given him a longer, healthier life. I will never know, but there is a chance that I might have.

It gives me considerable satisfaction to improve people's lives and health in this way. I expect to live, age, retire and die with these people. As we all grow old together I expect to see the fruits of my labors, the benefits that our current evidence based medical practice is achieving, reducing risk factors and managing chronic diseases effectively.

We are already beginning to see that people are living longer, healthier lives, living well into their nineties, healthy, strong, with their wits about them, enjoying life. This is a great gift to give people. That is what I like to think that I am doing, giving this gift of life and health.

It is always difficult when a patient dies, even more so when the patient is a baby. This is an account of the first time I lost an infant child entrusted to my care. It happened a year and a half after I finished medical school. Just a warning, this account runs a little long.

I was still asleep when I lifted the receiver from the ringing phone. "Hello," I mumbled. It was the operator from the hospital. One of my OB patients called to report that she was bleeding. I was waking up now. I took down the number and dialed.

My patient sounded worried. There had been a sudden large gush of water followed by a large amount of bright red blood. It was the breaking of her waters, a common occurrence at the end of some pregnancies. It usually signaled the start of labor. However, the bleeding signaled trouble.

I was very awake now. I told her to go to the hospital immediately. I would meet her there. As I quickly dressed, my mind ran through the possibilities. What causes hemorrhaging in the last three months of pregnancy?

One possibility is placenta previa, which is the dreaded complication of pregnancy where the placenta covers the opening out of the uterus and tears off when labor begins. Without quick action, this problem might not only kill the baby, but the mother as well. Then there is abruptio placenta, when the placenta detaches from the uterus before birth, again risking the life of both baby and mother. Quick action will be needed to save them. I hurried.

The night was quiet. There was very little traffic on the street. I lived only two miles from the hospital so I arrived quickly. I pulled into a parking space near the emergency room entrance. As soon as I stepped out of my car, my patient drove in and parked her car next to mine. She told me there had been no more bleeding as we walked up to the obstetrics floor together. I relaxed a bit and reassured her.

This particular patient was special to me for a couple of reasons. First, I was a new physician just starting out. I was a Family Practice Resident building a fledgling practice. I was personally responsible for the care of 30 or so pregnant women. She was one of the first patients I had the opportunity to care for from the beginning of the pregnancy all the way through and including the delivery and postpartum care, giving me a chance to get to know her and form a strong bond of trust.

However, there was another reason she was special. She became pregnant at the same time my wife did with our second child. At every stage of my patient's pregnancy, my wife and I were experiencing the same things in ours. My patient and I looked forward to the time when we would both be delivering. At every visit, she would ask how my wife was doing. We would compare notes. We shared together the joy and anticipation of the arrival of our new babies.

We arrived at the OB floor. The nurses went to work. My patient put on a hospital gown, got into the hospital bed, and the nurses hooked her to a fetal monitor. This machine measures the baby's wellbeing by graphing the heartbeat and graphing the uterine contractions. I stood outside the room, causally waiting for them to complete their ministrations before I would step in and do my examination.

They took a long time. They took more time. It was becoming obvious that something was wrong. I stepped to the doorway. The nurse was using a probe that amplifies the baby's heartbeat. The probe was slathered with the messy clear goop that they use to help find the internal sounds. The same goop covered my patient's distended swollen abdomen. The nurse searched from one side to the other, back and forth, up and down. Nothing. No sound. No one in the room said anything. The nurse looked up at me, and then gave up. Trying not to think of the incomprehensible I went to the bed and sat next to my patient. I took up the instrument and began to search for myself.

On every office visit since this baby was three months along, I listened for his heartbeat. On every office visit I heard the reassuring "whoosh, whoosh" sound calling out to me. It was as if the baby was speaking to me in the only way he could, connecting to me, saying, "Here I am, I'm doing OK." However, tonight there was no voice, no reassuring sound, no connection. Only silence.

I hesitated. Think! Think! My mind raced. Is there any explanation for this other than the obvious? Was I missing something? Was I doing something wrong? I had to be sure before I opened my mouth and made things true by speaking them. No, I told myself, there was no way out, no escape from the harsh reality. I would wish it away if I could, but I could not. I stopped my vain search. He was gone. The baby was dead.

The grief came, tears, shock, disbelief, the question how? Dazed, I offered sympathy, support, answered questions. Abruptio placenta? Placenta previa? Probably. We would find out. However, right now, we had another problem. The baby had to come out. I considered the implications. This young mother will have to struggle through who knows how many long hours of labor, enduring probably the most intense physical pain she will ever have, only to deliver a dead baby. There will be no great "prize" at the end of such an ordeal for her, no pink baby to cuddle and hold, just emptiness. It seemed too much to bear.

This was a tragedy of nightmarish proportions. I was reeling. There was an uneasy silence among the nursing staff. We went through the motions of our duties stiffly. I called an obstetrician as a consult. I gave him the details of the case over the phone. He said he would be right over. Bleeding was still a threat to the mother and an emergency c-section could be needed at anytime during the labor to save the mother.

When he arrived, he searched in vain for a heartbeat himself. He then began an examination of the birth canal. Then he became alarmed. The amount of blood and blood clots in the vaginal area seemed dangerously excessive. He called for an emergency c-section for presumed placenta previa, a life-saving procedure for the mother.

Now things really went flying. The healthcare providers had something to do. We had a life to save. We were like knights on white horses. We were eager to push aside the feelings of despair and helplessness that overwhelmed us after losing the life of the baby and replace them with the earnestness of our practiced effort to save the life of the mother.

The floor became a bustle of activity. Nurses, anesthetists, aides, scrub techs, a dozen professionals working in concert to deliver the baby and placenta as quickly as possible in order to save the mother. The obstetrician and I were scrubbed, masked, gowned and ready to start when my patient was positioned, prepped, draped and put to sleep. Deft hands made the incision. Down through the layers the surgeon progressed, quickly reaching the lifeless baby. The limp body was removed and handed off to a waiting nurse who placed it gently, almost reverently, on a newborn warmer that was not turned on.

Then the obstetrician reached in, probing with his fingers, working in an area he could not see as he gazed absently across the room. Satisfied that he had a good grip, he began to gently pull the placenta out through the wound. It all came out in one piece and he laid it out on the drapes next to the wound. We stared. The obstetrician reacted with disgust at himself as he realized that he just performed a c-section that was not necessary.

I looked with a mix of puzzlement, curiosity and disbelief. I did not immediately appreciate the significance of what I was seeing. The umbilical cord, the vital attachment of the infant to the placenta, did not insert securely to the center of the placenta, as it should. Instead, it incredibly attached to the thin filmy membranes that had enclosed the baby and his surrounding water during the nine months of pregnancy. The arteries and veins, which run protected inside the tough umbilical cord, emerged from the cord's point of attachment. They then ran unprotected and vulnerable along the surface of the fragile membranes over to the placenta, attaching there, as they have to, to receive nutrition and oxygen from the mother.

I had never seen anything like it. It was extraordinary, the blood vessels stretching out across the thin membranes toward the placenta. Large fat veins with their thin walls, tougher smaller arteries. It was now easy to see what had happened. When the membranes ruptured, the breaking of the waters, one of the delicate blood vessels was torn and the blood spilled out. However, this blood, this blood came from the baby. It was the baby's blood, the baby's precious blood. The blood came and came and came, until the baby had no more. Then the bleeding stopped. The baby bled to death inside his mother's womb as the result of a freak anomaly. The blood the mother watched pour out, and then stop, was her own baby's blood.

We finished the procedure. The obstetrician left the operating room. My patient was waking up, but was still very groggy. She would not be aware of what was happening for an hour or more. I went over to the still, silent figure laying in the cold warmer. I saw a perfectly formed beautiful newborn baby in every respect, except that the skin did not look quite right. It was grayish, and far too pale. I reached out and touched the baby, not to hold it, but more as if to examine it. It was as if I needed to verify that this was real, that a normal healthy baby with a future of promise and limitless possibilities could be suddenly and tragically lost. Here one moment and gone the next.

As I touched him and reflected, I decided that there is no sight more hideous than this, a dead baby. There is nothing more unfair; there is nothing more wrong. It was almost more than I could bear.

I went to the placenta where it was laying. I carefully spread it out so that the whole anomaly was visible. As I stared at the reality of what was before me, the physical presence of it, I took in the truth of how helpless and powerless I actually am. I took care of this baby and his mother during his entire short life. I was their doctor. They relied on me. I carried with me the whole weight of centuries of accumulated medical knowledge and technology to apply against any enemy or problem that might appear. I was ready, I was prepared, and I was there.

As I looked at this placenta before me, I knew the truth. Absolutely nothing could have saved this child, nothing that I could have done, nothing that anyone could have done. He was doomed and we were powerless. I had never felt so small in all of my experience as a physician and since starting medical school. My view of myself and of medicine itself reached a new level of humility at that moment, and the impression was indelible.

I took the Polaroid camera that was at the nurse's station and photographed the placenta. The placenta was destroyed, but the photograph remains to remind me of that night. I learned important lessons that have shaped me since then. I learned that no matter how certain things appear in life, we are never certain of anything. I learned to be grateful for the good things that happen in life. They may seem to come to me by my own efforts, but that is only an illusion. I learned as a physician that I should do the best job that I can, and then leave the results to God. The results are always in his hands from the start anyway. Finally, I learned that no matter how much I know, it is usually less than what I think I know.

All of the paperwork was done. My patient was tucked away to bed safely. The OB floor settled back to a normal routine. Everything went back to normal, the same as it was before, except for me. I would never be the same again. The pain in my heart would weigh me down for many years, and in fact, it still does today. I suppose it always will. I tucked the Polaroid into my pocket and headed home.

The streets were dead now. No one was out. It was very late. I arrived home and walked in quietly, not wanting to disturb my sleeping wife. I stopped to check on my one-year-old daughter, asleep in her crib. I said a prayer of gratitude for her and watched her for a long time. When I entered my bedroom and saw my wife lying there, I was overcome with a mixture of fear and love.

I woke her as I was putting my ear to her abdomen. I poked gently to wake him. I spoke to him. I listened to his heartbeat. His heartbeat spoke to me loud and clear. "Here I am, I'm doing OK." He moved. He poked me back. I wept. I wanted him to come out so badly, so I could hold him and protect him. I loved him so much. And I was so afraid.

He was born two weeks later and I really did not sleep very well until he was born. I listened to his heartbeat every chance I could get. I prayed and I thanked God for my blessings. When I finally held him in my arms I realized that I knew something that I may not have known before. My son was a gift. And my daughter was a gift. My desire to have them did not bring them to me or keep them with me. I have no power. What I have are extraordinary gifts. What I was then, and continue to be, is awed and grateful.

My patient came to see me in my office one more time after going home from the hospital. She was handling the grief process as well as might be expected. Physically she was recovering well. She asked about my baby. I felt embarrassed that I had one. Somehow, things just did not seem right. We should be comparing notes on how things were going as both of our babies were growing up together. Instead, she would leave, and I would never see her again.

I have often thought about her, and how that night ended up affecting her and her life. I hope she eventually was blessed with the joy of holding a pink, soft, warm newborn in her arms. Because, that is how I would like to have the story end.

It was Friday before the holiday weekend. The staff had been working hard to finish so that the office could close early enough to give everybody a chance to get out for last minute Christmas shopping.

My last patient of the day, my last patient of the week, turned out to be a kind, soft-spoken, elderly gentleman who had been my patient for many years. He waited patiently for me in the exam room.

I picked up his chart and looked at the nurse's notes. It read simply, "infected cyst." He lifted his shirt to reveal a nasty infected sebaceous cyst, fluctuant, tense, pointing, surrounded by cellulitis and painfully tender.

I sighed. I glanced at the clock and then at his chart. He is an insulin requiring Type II diabetic and is ninety-seven years old. Today is his birthday.

"Happy birthday Mr. Grey. How long have you had this?"

"When you get to be my age birthdays don't matter much anymore. I have been hoping it would get better on its own."

Mr. Grey's abscess was incised and drained of its foul putrid puss. The remnants of the sebaceous cyst were cleaned out. The empty cavity was loosely packed with iodoform gauze and an antibiotic and analgesic were prescribed for the cellulitis. Cultures were sent to the lab. Mr. Grey was sent on his way to salvage what was left of his ninety-seventh birthday. Arrangements were made for me to meet him at the office on Saturday to repack the cavity.

So began three brief encounters between four individuals over the coming three-day holiday weekend. My daughter, a third year Vet student, home for Christmas, was my companion and assistant for the dressing changes. Mr. Grey's out-of-town daughter was home for Christmas as well. She served as his chauffer and companion on their trips to the office.

For three days, including Christmas Day, the four of us met at the back door of my office at a predetermined time. I unlocked the door and we went inside to go through our little ritual of the abscess dressing change together.

We four got to know each other a little, to share each other's lives together a little and to just care for each other a little. It wasn't a big deal; it wasn't anything anyone planned. It just happened. It was just something that needed doing.

When Mr. Grey's daughter first met my daughter she asked, "Are you the nurse?" My daughter said, "No, I'm a Vet student." I said, "She's studying to be a doctor. Another doctor in the family." I guess I'm proud about that.

Driving home we had this great discussion about the inflammatory response, wound healing, healing by secondary intention and I'm thinking, "What a great conversation to be having with my daughter."

It was a great Christmas.

The relationship between physicians and pharmaceutical representatives is unique. I have worked in an office practice of one type or another for over 21 years in three states and during that time, I have always been called on by representatives of the major pharmaceutical manufacturing companies. I have come to admire and appreciate the general quality and caliber of the type of person that enters this profession. And I acknowledge that the job they have is more difficult than they are allowed to admit and than most people are aware of.

The unique relationship between physicians and pharmaceutical representatives sets us both up I think to exploit the human parts of us that tend to be less noble. Where this kind of thing plays out in obvious ways hardly needs mentioning since it has been discussed extensively. But the more subtle and less obvious influences are more pervasive and exert their effects day in and day out and the brunt of the burden is born by the reps and this is why I think their job is so hard. Let me explain.

The reps are trying to sell their product. They come to the physician as the customer of their product, the one who "buys" the product, the one who must be sold on the product. The physician sees the rep coming to him or her as someone who wants something from them, something of value, something of value that only they can give. They are instinctively defensive, skeptical, expecting to be sold on the product. The physician initially feels no obligation to give anything to the rep. The rep tries to create a desire in the physician to give something, ultimately to "buy" the product.

A crude overview granted, but the way I have seen this play out unfortunately many times is that reps have to be nice to doctors even if they get mistreated because they still have to sell their product to them. And doctors can mistreat reps and the reps will still be gracious and treat them with kindness. Sometimes it can be as small as making them wait more than an hour to talk with them for less than 15 seconds without even looking them in the eye. Or making them wait and then leaving the office forgetting that they are there and not seeing them at all. Or the offenses can be horribly cruel and vicious I am ashamed for my profession to say.

And in defense of the reps, the graciousness and consideration that many of them so munificently give is frequently not insincere, but genuine. A testament to the rich character many of these reps possess, which makes sense. It takes someone with character to accomplish difficult jobs and they have a difficult job.

I am always challenged. When someone treats me nice regardless of how I will treat him or her back, there is no accountability on my part. How I treat them depends solely on my own character. If I return their kindness with unkindness, what does that say about me? However, you could say that I am being manipulated, and that is true. But is trading unkindness for kindness the way to deal with manipulation? I think not.

Kudos reps. You are among the most bright, persistent, kind, interesting, compassionate, talented and tough people I know. And I say that not just because you like me. Because I don't really know if you like me, because even if you did not like me, how would I know?

You are always welcome in my office. And not just because you like me. But it doesn't hurt.

I was driving home one day when I spied black smoke crawling into the cold sky near where I live. It was a thick, heavy, dark smoke with an ominous and dangerous look to it. It curled in a way that looked as if the fire had just started. I was not very far away, so I turned down a nearby gravel road and went to investigate.

As I drew closer, the smoke became thicker, blacker, angrier, until I drove over a rise and could see that that the smoke emanated from a conflagration that completely engulfed an automobile angled into the ditch.

I pulled over and got out to see if I could help. We were on an isolated gravel road at the crest of a rise. Two vehicles traveling down the middle of the road toward each other apparently had collided head-on at the crest. One of those vehicles was now being completely consumed by flames in the ditch.

I was one of the first to arrive at the scene of the accident. There was a lone driver in the second vehicle, the one not burning. As I moved closer I saw a tall thin young girl, a high school student, standing alone, watching the burning wreck. She was in obvious distress. I went to help.

She had numerous small little cuts on her face, the kind that safety glass from broken automobile windshields make. I realize she must have been in the vehicle. She was crying loudly, nearly hysterical. It was difficult to tell what was wrong with her. I ask her if she is all right. She pointed at the inferno and wailed, "My sister is still in the car!"

Her voice was a mixture of anguish and pleading, disbelief and pain. I peered closely at the burning car for the first time and the fleeting idea of rescue flashed in my mind. My only thought however was, "If her sister is indeed in that car, then she is indeed lost." I have never seen an automobile so utterly devastated.

I did the only thing I could. I wrapped my arms around the tall thin young girl standing alone on the deserted gravel road, lost in the anguish of a witnessed horror almost too terrible to describe. Little comfort, I am afraid, when comfort is hardly enough.

Later, I assisted the volunteer firefighters in extracting the burnt remains of the young girl's sister from the wreckage. The collision had jammed the engine block backwards against her foot. We had a difficult time getting it free. Apparently, so did she. She succumbed to the heat of the flames, stretched out through the open door of her car, held back by her trapped foot. Her sister had to watch her burn to death, utterly and completely helpless, powerless to do anything to help her.

To live life on life's own terms is to somehow find a way to face and bear the devastating consequences loss and grief impose on us. That young girl went on to graduate High School, then Nursing School, and now works as a nurse and is raising her own family. We do not see each other much anymore and we do not talk about that day.

Grief and loss is a part of life, yes, but what I have never been able to understand or figure out, in a way that make sense to me, is how to live life with devastating loss waiting to pounce upon you at any moment, at any time, when you least expect it. You cannot live life as if tragedy is about to strike at any moment. Yet you also cannot live life as if there will never be any tragedy.

I guess what I would like to do as I struggle to live life on life's own terms, is to live in the moment enjoying the blessings of life without dragging along unnecessary baggage of dread to contaminate my joy. To quell the famous "Yea, but" response to, "Isn't this great?

We end up living life as if bad things are not going to happen, even though we know they will. It is because we do not know what bad thing is going to happen and when it will happen. It just seems twisted and hypocritical. It seems wrong.

I guess what I really want is heaven. Living life on life's own terms, for me, is putting in time, waiting for heaven.

We call unsolicited promotional material in our mailbox junk mail and in our email spam. What do we call this stuff when it gets to us by fax machine? These "junk" faxes come to my office all the time and are constantly cluttering up my in-box mixed up with my regular paperwork. As soon as I see that it is junk, I toss it.

However, I wanted to share one with you. It starts out at the top in big letters "$20 For Your Opinion."

$20 For Your Opinion

Dear Dr. David;

Please follow the link below to participate in our partner's short survey.
In return for your valuable time, they will provide you with a

$20 Amazon.com Gift Certificate.

START NOW, HERE'S HOW: - Blah, blah, blah...

And help shape better services and information for both patients and physicians!

The reason why I wanted to pause and think about this one for a second is that I was having a conversation with my son about how much money I make. He made the comment that I make a lot of money, which is true. That has not always been the case. Both my wife and I come from families that struggled to make ends meet, and in the early years of our family life, we had our own epochal moments of financial struggle.

Indeed, however, we now are very blessed financially. My son is entering that time in his life when he is getting a perspective on what impact income has on a person's life, lifestyle, their choices and ultimately their future. He is weighing his options and measuring his values, as well he should.

My conversation with him got me thinking when I saw this enticement "$20 For Your Opinion." I remembered a survey I read many years ago where patients were asked what they thought the income was of their own doctor. Invariably, across the board, the patients underestimated the actual income of their doctors. The reasons for this are fascinating and could be the topic another time, but the question in my mind was, "Is $20 a good price for my opinion or not?"

My first reaction would be that the value of my opinion for a "short survey" must be $20 because they say it is. It is in print, in big bold letters at the top of the page, where everyone can see it and read it. It is authoritative, therefore, it must be true, my opinion for a short survey must be worth $20.

However, I have been around for a while and I am a skeptic. Besides, I do not need $20 that bad, so I am going to do some figuring, just for laughs and giggles.

I have a good idea what my opinion is really worth on the open market. It is what I do. I sell my opinion. My value derives from an accumulation of knowledge, experience and skills, which I apply with a measure of sound judgment.

So, I took the survey and determined that to earn the $20 Gift Certificate from Amazon.com it required ten minutes of my time. This promotional company is offering me a $20 Gift Certificate for ten minutes of my time. Ten minutes for $20 dollars. OK, got it.

That is a lot, is it not? I mean, that works out to $120 an hour. $120 an hour is a lot. How many jobs are there where a person makes $120 an hour? Especially jobs that are that easy? Sitting on your butt, clicking on buttons on an Internet computer screen for $120 an hour. Wow, who would complain, sign me up.

Except for one, little, tiny, itty-bitty, teeny-weeny, little, problem. We have 1,000 patients coming to our office every month that pay more than three times that much money for ten minutes of a doctor's time. Now, not all of that money goes into the doctor's paycheck, obviously. There are all of the overhead expenses, and all of that stuff. Nevertheless, even after overhead expenses are paid, I make more money for my ten minutes with the patient than $20.

So you say, "Of coarse you should make more for ten minutes seeing a patient, doing doctor stuff is a lot harder and everything. Making $20 for clicking a few boxes in a multiple-choice survey on the Internet is not the same thing, and so it is OK to expect less money, it is just an easier job. What, you don't expect some outrageous dollar amount just for clicking some boxes on a web page, do you!? You rich doctors are all the same!!! Just because you ...blah ...blah ...blah ..."

Yes of coarse clicking a few boxes is a simple job that is hardly worth paying someone to do. That is not the issue. The issue is what is the value of the time of the person that you are asking to give you time. As I said, I know what my time is worth on the open market. One thousand people remind me what it is every month. If you want to purchase my time for an activity that is important to you, at what rate would I be willing to sell you my time? At one third of my going rate? I think not.

Then who would do this kind of survey you ask? Good question! Now we come to my point. I think that there are two reasons this kind of thing exists. The first is the physician whose income is not exposed to the forces of the market. Let me give you two examples of this kind of physician.

The first example would be a doctor who was not seeing very many patients. In order for the amount of money you earn per patient encounter to impact the amount you earn per hour worked, you have to be busy and have a close to full-time practice. The less busy you are, the less you make per hour, the more attractive a low payment for your time will appear. The second example would be a doctor paid by salary or on a guaranteed income. Then any time spent gaining any extra income would be seen as a bonus, not as time taking away from a more profitably spent activity.

The second reason this kind of thing exists I think is more sinister. It is a scam, a fraud, a swindle, a rip off and a con. There are plenty of doctors out there that do not know what their time is actually worth. When they see "$20 For Your Opinion," they think either that their opinion is actually only worth $20, or there is an appeal to a part of them that actually feels guilty for making a lot of money. Yes, it seems ironic, I know, but if a doctor grew up in a poor family, as I did, then being offered $120 an hour for easy work might seem to them like stealing. It would not cross their mind that they were the one being ripped off by being offered only 1/3 of their going rate. This same type of doctor tends to undercharge patients too, and has a hard time making a go at it in private practice.

Do you know what the worst part of this is? This is why I know it really is a scam in sheep's clothing. This is what is at the end of the short survey:

"In order to send your voucher, we need some basic information. Please fill out the fields below, (mandatory fields are marked with an asterisk), and click on the "Submit" button."

Basic information, hah! Right! This is a list selling company. Fill this out, and you will get so many headaches, you will wish you had been paid way more than $20.

Pitch it. There is no easy way to make money. I like to make money the old fashioned way. I earn it. It is more fun that way anyway.