Friday, April 17, 2015

The Ironic Illness of Izzy

     When I first met Izzy (name changed) he was a portly elderly gentlemen with an effervescent and jolly personality that lit up the clinic every time he visited. His most recognizable feature was his voice. His lifelong hobby was singing opera, as a tenor. The first time I discovered this, he belted out a few lines that echoed through our entire clinic. It was marvelous and since that moment, I always made sure my medical students and residents not just saw him, but heard him as well. He was a spectacular patient and person.
    A few years from our initial encounter, I found myself wandering the halls of the hospital with 2 medical students. They were 2nd year students looking for patients to practice taking histories and doing physical exams. Earlier that day, I received word that Izzy was admitted. Though this was unfortunate for Izzy, it was fortuitous for my fledgling doctors that such a great patient was available to talk to. And not surprisingly, despite feeling unwell, Izzy with his wife by his side, welcomed my students openly.
     I stood off to the side of the room, while my students peppered him with questions for over an hour as they tried to piece together his medical history without much experience and medical expertise to fallback on. They learned about his vocal talents and though he wasn't well enough to sing on that day, Izzy was quick to point out how his voice swept his wife off her feet when they were in college. I thought I knew everything about Izzy from our several appointments together, but these medical students were able to illicit a entirely new story from him that even I was unaware of.
    My intrepid students were taking a travel history when they discovered his wife was originally from  South America. He reminisced about the last time they went to visit her family which was about 4 to 5 years prior. He fondly recalled staying near a seaside town, enjoying the fresh ocean air and wonderful local cuisine. The only thing he didn't enjoy about this trip was going further inland to visit in-laws living in more mountainous areas. He recalled getting sick during that part of the trip, blaming it on some bad food and lack of sleep. His wife reminded him that he almost passed out a few times that week from feeling so unwell.
     After almost 90 minutes of questioning, doing a physical exam and sharing lots of laughs, my students and I left Izzy to go debrief on everything we had talked about. There was just an incredible amount of things to learn from Izzy. We were able to weave together his history, his physical exam, basic pulmonary physiology, and pathology to explain what had happened. I described to the students that Izzy was suffering from pulmonary fibrosis and explained some of general facets of this illness including impaired gas (oxygen) exchange and just the progressive reduction in his lungs' abilities to perform . We reviewed oxygen disassociation curves and the effects of altitude and oxygen saturation. In light of his diagnosis, it became clear why with his reduced lung function and thinner mountain air, Izzy felt so ill on his vacation. This was probably one of the first signs of his illness until later when it became sadly obvious his opera singing days were coming to an end.
     With every patient, there's always something to learn and Izzy's story was no exception. For me, when I look back at his story, I began to appreciate medicine as something more than doctors treating individuals with specific diseases affecting affecting well defined anatomy through different but predictable mechanisms. Medicine, as a science has surprisingly very abstract human qualities. At times, it can be funny, or sad, thrilling, uplifting, unpredictable and often dramatic. When an opera singer that relied on powerful lungs got a relatively uncommon condition affecting those same lungs, medicine got my attention that it also has a knack for irony.


Wednesday, April 15, 2015

OMG, you're alive!

     As a  physician, it's great to revisit the medical miracles you've played a hand in. In the monotony of the common every day events, a visit from that one patient who you brought back from the brink, can really lift the spirit. These moments are rare, especially if they happen while you're a medical student or resident that is destined for a short stay in the community, never to see that one incredible patient again. Even if you stay in one place for a few years, many patients get lost to follow up (for a variety of reasons) and the curiosities for whatever happened to Mr. or Mrs. X  can fade over time.
     As a 3rd year surgical med student, I remember attending trauma clinic and following around a weary 5th year senior resident (Dr. HC) as he lurched from room to room in his scrubs and clogs doing post op checks and removing stitches with little enthusiasm but great urgency. Clinic was a chore, an obstruction from the operating room or his call room bed. One day he picked up a chart of a gentlemen Mr. D (name changed) who presented with stitches that were surfacing from his abdomen from a trauma surgery a few years prior. He knocked on the door while reading the chart, entered the room head down while still reading and introduced himself... while still reading. When he finally looked up, he stopped suddenly, grabbed his mouth and mumbled "Oh my God!"
     3 to 4 years prior, when Dr. HC was a lowly surgical intern on trauma call, he assisted on a lengthy operation on a young Rastafarian gentlemen that suffered multiple knife wounds to his abdomen. I don't recall the details of the surgery but Dr. HC made it clear to me, that he didn't expect this patient to survive once he was patched up and shifted to the intensive care unit. The patient had a lengthy stay in the hospital and despite the visceral experience of doing surgery on him, Dr. HC's gypsy, sleep deprived surgical life turned Mr. D into simply another case to log and a patient unwillingly forgotten.
    After a few more seconds of disbelief, Dr. HC was finally able to drop his hands from his mouth and give Mr. D a  handshake. Mr. D's chief complaint  were put on hold while I was told about the circumstances of how they 1st met. Mr. D actually didn't even know who his doctors were on that terrible day but was pleasantly surprised to hear that this random resident sent to remove some stitches today, helped save his life. But Mr. D's enthusiasm was tempered, probably due to the discomfort he was feeling that day,the difficult post op course, rehabilitation and numerous nutritional issues he'd been battling ever since his abdominal trauma. But nothing could temper Dr. HC's smile as he grinned from ear to ear, repeating several times " Man, I can't believe it's you. "
    Dr. HC was a battle weary 5th year surgical resident, in a bleak inner city hospital. During my 12 weeks as a surgical med student, he was generally pleasant but had always had a morose aura. His chance encounter with Mr. D was the first time, he looked genuinely happy. In one of those very important "teachable moments" that med students crave, Dr. HC emphasized that it's cases like Mr. D that keep you going. It was a valuable lesson and although I didn't become surgeon, I did become a much better doctor that day.

Monday, March 30, 2015

Going back to where it all started

When I look back at my career, there are many different important moments that led me this point. One that really stands out was my decision to attend St. George's University (SGU), in Grenada West Indies.
It was 2001, a time of great personal doubt and uncertainty in my life. Despite that, my dream to become a physician persisted and SGU gave me the opportunity that I knew I deserved. Since then, it's been an incredible fulfilling journey that keeps getting better every day.

I have incredibly fond memories of my time at SGU and despite how busy life can get, I've been meaning to try to give a little back to my alma mata. And with that, I'm really excited to have the opportunity of going back so to speak, to where it all started.

On April 21st, I'll be attending the SGU information session in Fort Worth, Texas. This will be the first SGU event I'll be attending in many years. As an alumni, I'm really looking forward to meeting the next generation of bright minds looking for that same opportunity. I look forward to catching up with SGU people, answering questions and sharing my story with everyone there. 

Hope to see many of you there!

4/21/15 Tuesday
Ft. Worth, TX, USA
Courtyard Ft. Worth Downtown
601 Main St.
Ft. Worth, TX, USA

Monday, March 16, 2015

Learning, food and great memories

I had a few minutes so I thought I'd try and collect some of the many pictures taken at my last job that capture the spirit of learning combined with the fun and joy of eating together like a family.

At least a couple of times a month, we would hold pot lucks at our clinic while we did our Friday afternoon outpatient noon conference. They often a had a theme such as "Pi day"where we all made/bought some form of a pie.

The work we did in that clinic was often quite difficult but small events like these really made the work and learning process so wonderful!

Lot's of great memories and I miss all of you!

Tuesday, February 17, 2015

The eager Salesman and the stubborn Doctor.

     I really don't enjoy going into a store with a planned purchase only to get hassled and cajoled into purchasing something different. The fact is, with so much information at our fingertips, I decide ahead of time what I want and the price I'm willing to pay.

     Recently, I dropped my smart phone in the toilet bowl.

(Take 1 minute to laugh at me.)

     This event forced me to run to my wireless store and purchase a new smart phone. Despite having done my research, my anticipated 10 minute purchase turned into a 45 minute battle of wills between an eager salesman and my practical sensibilities.

     He couldn't have been a nicer guy. In his mid twenties, he had energy and enthusiasm for his job that likely made him very successful. His great attitude won me over and I let him do his sales pitch despite fully knowing I only came in for 1 specific purpose that I wouldn't veer from. He used numbers, diagrams, compliments, (even mild insults!), jokes, clever colloquial lines all to convince me I was making a huge mistake not heeding his advice. In the end, he relented, went to the back of the store and came back with my phone.

     As he was ringing up my purchase on his tablet,  he made one last ditch effort to win me over. In the process, he asked me what I do for a living. I told him I was a physician and suddenly, the entire tone of our conversation changed.

He paused, gave me a forced smile as I watched the wheels spin in his eyes. For the 1st time I sensed the smallest hesitation in his sales pitch and instead of talking about his product, he came back with this:

"How do you treat vertigo?" 

     I felt bad that I made him expend a lot of energy  knowing he'd fail. I humored him and we switched roles. Standing in a quiet corner of the store, I began asking him all the questions I normally would. After a few minutes of trouble shooting, we changed the symptom description to "disequilibrium" instead of vertigo and I reassured him while encouraging further evaluation with his primary care doctor. He seemed grateful but I couldn't help notice a morose coming over him.

     He explained to me he always worries about something terrible happening to him just like his sister. I delved further to find out several years prior, his 16 year old sister died of a pulmonary embolism. His voice lost clarity as he fumbled around his tablet muttering how all the bad doctors ( pediatricians, ER etc)  missed the diagnosis. He chuckled recalling how an x-ray went missing but was subsequently found and clearly had abnormal findings. Although I didn't ask, I presumed the x-ray was later found as part of some litigation process.

     I couldn't imagine how it must have felt to lose a sister when you are a child yourself. I could understand the frustration and anger under his breath that probably took years to soothe. An unexpected death of a loved one is always a tragedy especially when it seems the answers are so obvious and in the hands of the physicians entrusted to figure it out. I felt terrible for him, as he pulled out his own smart phone to show me an old picture of her,

     As objective physicians we always contemplate alternatives. I didn't know the physicians that treated his sister, but I empathized with them a little bit We are taught very early on in our education that pulmonary embolism is one of the trickiest diagnosis and easy to miss. We are taught about pre-test probabilities and chest pain in a teenager is statistically much less likely to be a life threatening condition. I imagined that could have easily been me, a well meaning physician doing their due diligence and something terrible like this still happening. As a physician, we never get comfortable dealing with the death of a patient. It's even more difficult when there's an unexpected death and you're left wondering what else you could have done. These very personal emotions are occasionally twisted, tossed and turned through malpractice litigation ; a process after which physicians are left confused, numb and questioning their purpose. This is a burden many physicians carry to their own grave, quietly without any expectation of assistance or pity.

     As he finalized my purchase, I completed my thoughts coming to the conclusion that no matter what the circumstances were, he went through a tragic experience and nothing can change that. I was happy to see he survived  and had become a very good salesman with a good attitude and great smile. But on this day he didn't get the sale he wanted. I regained my connection to the digital world with a new smart phone. I'm hoping he regained the tiniest bit of faith that doctors despite being fallible, listen and care.

Sunday, February 15, 2015

Health Insurance ; A prerequisite to the American Dream

The American dream is alive and well. We still live in the land opportunity where hard work is the ticket to endless opportunities. On the contrary, bad health poses a major impediment towards fulfilling that dream. Besides the physical toll of an illness, the financial cost of an illness can make the American dream impossible to achieve. Millions of people without health insurance everyday face the spectre of their dream becoming a health care nightmare. Recently I got some great news about a family member who immigrated to the U.S a few years ago. A middle aged man with a wife and 2 kids, he came ready to do whatever it takes to secure a future for his family. An educated man, he struggled to find employment. He latched on to several different jobs that helped continue to build his skills but was given no health care benefits. He didn't qualify for Medicaid and couldn't afford private health insurance. Just like many Americans in this situation, his health took a backseat. But recently, he was finally able to secure a job that offered benefits including health insurance. He now had the security that seemed like a natural prerequisite towards pursuing his own American Dream. He took this opportunity to finally seek out world class healthcare. From a distance, I began to get caught up with what was happening with his health. Fortunately, he didn't have too many medical problems besides benign prostatic hyperplasia (BPH). It was significant enough that he was referred to a urologist. He felt lucky to find a local well renowned urologist with many positive reviews (both online and word of mouth) that also took his excellent new health insurance. After 1 visit, it seemed like he was appropriately placed on some medications to try to alleviate his symptoms. What was surprising is that he was also placed on brand name testosterone replacement. Immediately, skepticism towards testosterone replacement therapy began to engulf my thoughts. I began to wonder if my family member was another victim of the "Low T" marketing campaign. Furthermore, I was shocked to find out that within weeks of seeing this doctor, he was being offered greenlight laser prostatectomy. Granted I am looking at this case as an outsider. But without trying various types of medical therapy at optimal doses and for significant periods of time, the recommendation for surgery seemed very premature. Since then, my family member has been directed to a second opinion.
Health insurance is an extremely high priority issue for most Americans. It is the sensible thing to attain, whether it is to ensure wellness or treat illness that might otherwise derail a lifetime of hard work. But my family member's reward for obtaining health insurance wasn't good health but rather a glut of potentially wasteful and dangerous medical care. As we continue to expand health insurance in an attempt to cover all Americans and provide them access to care, we have to continue efforts towards curtailing health care that is not evidence based, wasteful and only serves to fulfill the American dream of providers and drug companies while taking advantage of hard working naive citizens. 

Monday, February 9, 2015

Don't hate the Anti-Vaxxer

     It's easy and convenient nowadays to take a few minutes to rally against the "Anti-Vaxxer" movement. With the recent measles outbreaks, there's no shortage of articles, memes, jokes and cartoons to share on blogs, Facebook, Twitter etc. But I'm going to throw a very small teeny tiny microscopic bone to the Anti-Vaxxer camp. I will do so with the disclaimer that as a primary care physician I think vaccines are an extremely important part of good health. Anyone that doesn't see their value, is misguided and perhaps misinformed.
    Having said that, there's no denying that the Anti-Vaxxer  movement  is real and unfortunately seems to be growing. They have quietly become a significant part of the general population. The reason for their growth is multifactorial, but the easiest targets are probably defrauded scientists, celebrities and politicians with dubious opinions. But the target that's probably hardest to identify is the one looking right back at us in the mirror.  When a problem afflicts society, the easiest thing to do is blame others. The introspective route asks us to look within to identify causes and offer solutions.
     How did we let this happen? The Anti-vaxxer movement is just another example of the growing mistrust and lack of faith in our doctors and healthcare system. There are many reasons for this. When it comes to vaccines, why aren't we, the trusted physicians able to educate and change their minds? Perhaps we are not living up to the true latin meaning of the word "Doctor" which is "to teach." Perhaps the modern doctor,  gathered and taught in traditional (antiquated?) methods are struggling with modern informed patients who challenge and question rather than accept paternalistic physician decision making. Perhaps we simply just don't have time to have a decent conversation with our patients about the importance of vaccines.
    Whatever the reasons, we need to figure out better ways to connect with this subset of our patients whose beliefs about vaccines post significant individual and community health risks. What we don't need to do is further alienate this population by kicking the proverbial horse while it's down. The amount of  seemingly joyous vitriol pouring from the medical community against anti-vaxxers is disappointing and at times bordering on classless. Social media is teeming with derogatory descriptions of this population.  I think this only furthers many people's views of rampant intellectual elitism in our doctors. The most disappointing stance on this issue is when doctors proclaim they will refuse to see patients who don't believe in vaccines. Hey genius, if you don't see that patient, then they definitely don't stand a chance of getting a vaccine!
   The anti-vaxxer type of population is something that has always existed in most medical practices. They represent a group of people who don't believe in the gospel you are preaching. I have patients who don't believe in cancer screenings, statins and a whole host of other great evidence based ideas. They can be frustrating and time consuming.  But they are still my patients and I will continue to respect them and care for them with the confidence to know I will eventually change some of their minds.

Thursday, December 4, 2014

Endings and Beginnings

It's been a while since my last post. I've been busy and life has been changing.

For one, we had our third baby! She's beautiful and certainly takes up a significant amount of our time (disproportionately at night!)

I'm also moving. After a lifetime of calling myself a New Yorker, we're packing up and moving to Dallas, Texas.
I will always be a New Yorker and the emotions regarding this change are far too complex to discuss on this post.

But with this move ends a tremendous chapter of my medical life. Much of my posts on this blog were based on stories and experiences from these past 5 years.

We go into medicine because of the patients. The patients and their stories will always be the crux of my existence in medicine. I will always find inspiration to write and keep practicing medicine because of them.

But these past 5 years have been about more than just patients. I got to take care of a different group of people. I got to be a caretaker of some pretty incredible internal medicine and med-peds residents.

They inspired me, taught me, challenged me, tested  me, made me laugh but most importantly made me feel proud to be a medical educator.

As doctors we love making patients better. As medical educators we love making patients better and making doctors better. It's an incredibly fun and gratifying career path.

So with that, a sincere thank you and good bye to my trainees past and present. I hope your interactions with me were as meaningful to you as it was for me. I can't wait for our paths to cross again as professional colleagues.

To my new patients, I can' t wait to meet you all and take care of you!

To my new trainees, I can't wait to meet you all!. Let's get to work to make healthcare better and change medicine forever!

Tuesday, August 12, 2014

Tribute to Robin Williams and Patch Adams

In honor of one of our favorite "Doctor" movies, we turned our brunch into a Patch Adams/Robin Williams tribute!

U treat a disease, u win, u lose. U treat a person, I guarantee u, you'll win, no matter what the outcome." -

Monday, August 11, 2014

Picking up the pieces

At home I'm usually surrounded by a mess of toys. With 2 toddlers running around, the floor is littered with knick knacks and my evenings are spent picking it all up. It's challenging, sometimes frustrating but I know with time and education, they will learn and it will change.

I'm often doing the same thing at work. Patients come with their internal home littered with problems that my residents are constantly trying to correct and pick up after. In this era of chronic illness, this is a challenging and sometimes frustrating endeavor. But with medical expertise and a partnership with the patient, many of these problems can be fixed.

But there are some things in medicine that are extremely difficult to "pick up" after. The most difficult one is the chronic pain, opiate dependent patient. This group of patients has become an albatross for too many primary care physicians. There are many unfortunate reasons for this.

Like most problems in our healthcare system, it begins with the system itself. Simply put, when you don't have insurance and access to healthcare, it's very difficult to get well. With chronic illnesses like diabetes, high blood pressure and obesity, they can be managed (albeit sub-optimally) without insurance. We can see these patients every few months and work around the limitations of insurance. We can easily switch medicines to more cost effective ones. Patients are usually pretty adaptable to medication changes with these conditions.

When a chronic pain opiate dependent patient doesn't have insurance, it's a real quagmire. First, they need to come monthly for assessments and refills. With such potent potentially addictive medicines, monthly visits are appropriate and the standard of care I advocate in our resident training clinic. Without insurance, monthly appointments become expensive and patients get frustrated. Secondly, changing or even stopping the medicines is extremely challenging. This drug class creates a level of dependency similar to how Frodo Baggins felt towards the one ring of power in Lord of the Rings. It is impossibly hard to change or let go.Thirdly, without insurance its very difficult to do urine drug screens  (expensive!) which is rapidly becoming the standard of care in managing this group of patients.

The insurance problem also highlights an issue with accountability with chronic pain opiate dependent patients. I'm constantly seeing patients who've recently lost their insurance or their doctors stopped taking whatever insurance they have. This is not unusual these days. If they were on a brand name drug for cholesterol, I can easily switch to a generic. If they were on a medication that I thought was unnecessary, I can easily stop it. But when a doctor creates an opiate dependent patient then essentially dumps them because of their insurance, I have serious issues with this. It's just wrong. The ethics and morality issues in this scenario are honestly better explained by Mary Shelley's Frankenstein than my little blog.

Besides the insurance angle to this problem, I won't even get into misguided guidelines created in the 1990's by specialists and drug companies that touted the safety of opiate medications for non-cancer pain.

When you combine such realities together, you get patients with many chronic illnesses without proper access to care, hopelessly dependent on dubious medications, nowhere to go except the overwhelmed safety net that is primary care.

A litany of toys in my living room is just not acceptable. I pick it up, optimistic that eventually it won't be a mess anymore. And with that same smile and vigor, I (we) pick up the pieces of our patients, working and waiting for the system and our patients to get healthier.