Now that it has been nearly two months since my cardiac arrest and resuscitation, I have finally found the leisure and the motivation to put fingers to the keyboard to gather some thoughts and feelings about it. Of course these include at least in part the sort of changes in attitude and philosophy people are commonly supposed to experience, but for the most part, my own experience seems different.
In my particular case, the way it happened was not a bolt from the blue, but during a test specifically designed to provoke signs of cardiac ischemia. I knew I had mild coronary disease, but I was on lipid-lowering medication, had a good blood pressure, didn’t smoke, exercised regularly, wasn’t significantly overweight, and had passed two previous stress tests. On the other hand, I had just come to the emergency room with chest pain. But on the other hand, (I guess that’s the first hand), my EKG and cardiac enzymes had returned normal. So the event was a surprise, but not a huge surprise. Nonetheless, it’s a bit daunting to know that there but for fortune, the event could have occurred on the airplane I planned on boarding that evening.
First, lets attend to all the questions, truisms, and philosophic platitudes.
No, there is no white light. At least not in my case. Perhaps I wasn’t out long enough. (Although long enough to have a seizure and need CPR until the paddles were charged and shock administered. ) Or maybe I’m not headed in the “white light” direction anyway. On hearing of my failure to see a white light, a friend asked, “Well, how about a red one?” . Or maybe I just don’t believe in a benevolent God who watches over me. In any case, there was no white light and I did not witness the scene from above. I would love to have had that opportunity to watch it though. However, the experience was that one minute I was walking and talking on the treadmill and the next minute I was being rudely awakened from a sound sleep by a slap on the cheek and a bustle of frenetic activity. Nothing spiritual about it.
Next, that thing about “no longer sweating the small stuff”, “stopping to smell the flowers”, appreciating “the big picture”, etc. I wish I could say I have been changed by the experience but I really haven’t. I’m still compulsive. I’m still what they call “Type A”. I still sweat the details about patient care. I still worry about stupid stuff. The same minor irritations still annoy me; in fact, they annoy me even more sometimes because I feel I have less time to be bothered. Mind you, I do smell the flowers, but I don’t stop. Flowers are nice but I have other things I want to get done. And to illustrate how little I have changed, I will relate an incident that occurred walking our dog in a park where picking up after your pooch is the law. It took me only a minute to realize my foolishness, but I actually had the temerity to tell my wife she was going about picking up the dog poop the wrong way. (I won’t explain my logic, but I thought she should start with the small turds and work her way to the larger ones.) She reminded me that I was criticizing a woman with a bag of dog shit in her hand, standing within an easy hurling distance. So much for stopping to smell things.
Naturally, having turned 60 last year, I spent a lot of time contemplating my mortality for 6 months before and really ever since that birthday. I was even thinking, the day before my event as I was driving to work, how beautiful the nearly bare trees looked in a sunlit morning mist, and how I would miss that sort of beauty if I was told my life would be cut short.
But since the arrest, the notion of mortality has taken on a more immediate flavor. I have always had the sense that we spend our days skating on thin ice and not knowing it, never realizing how it all could fall apart without a moment’s warning. Lately, that sense is keener. I am reminded of a rented DVD that has skipped a few times, frozen, and been rescued by going back a scene. If you have had that happen, you know the feeling that it might freeze again and this time not allow you to finish it. So you watch every moment knowing it could be the last you see of the movie. I never really have been able to “live in the moment”, but I think I have gotten a bit better at it. The other observation I have come to is a firmer conviction that the thing we spend the most time worrying about is never the thing that gets us. It is always something from a completely unexpected angle.
The awareness that my span on this mortal coil is finite leaves me with less patience for people or things that waste my time. I am quicker to throw out some item on my desk that I would have previously contemplated making use of at a later date. I am less inclined to have my philanthropy dictated by letters with appeals from charities that happen to enter my mailbox or appeals to add a dollar that are made at the checkout counter; I am going to make my contribution how I want to, when I want to, and to whom I want to, of my own accord.
For better or worse, I am less inhibited about expressing my feelings, both benevolent or angry. On the streets of Manhattan, my wife and I were nearly struck by an aggressive driver in an SUV who was turning right onto a side street as we were crossing the same street with a walk sign in our favor. I turned and thrust an accusatory finger at him. He rolled down his window. I yelled, “I had the green, buddy! ” He yelled back, “So did I!” I responded, “Pedestrians have the right of way, Mister!” My wife, seeing he was half my age and fearing he might get out of the car to continue the discussion, tugged at me to continue walking (but only after she chimed in, “Yeah, read the book!”). As we walked on, I turned my head to look back and saw a crowd of pedestrians gathered around his vehicle scolding the man. I am not sure that before two months ago I would have confronted the guy. I guess I felt like, “I’ve been DEAD before, buddy, and you think YOU scare me?”
By the same token, I am much more liberal with my praise, generous with my smile, and generally more understanding of other people’s limitations and frustrations. I am nicer to everyone I encounter, even if they are dunderheads or nincompoops. After all, they are probably doing the best they can. I don’t hesitate any longer to say what I think, but I am quicker to forgive. (Exception: None of this applies to those jerks on the Merritt Parkway who think they will get there faster by first tailgating me in the left lane and then going around me on the right to cut in front when traffic is doing 65 in the passing lane, 60 in the right lane, and everyone is 3 car-lengths apart as far as the eye can see.)
I still think a lot about what it will be like when death does finally catch up with me. Will it be sudden, or will I be given a fatal diagnosis? Will I find that I have been obsessing about a healthy diet and exercise, only to learn I have pancreatic cancer next year? Or will something take me from completely out of left field? I know this much: I was looking back on my life this morning, waiting for some minor surgery with propofol sedation, wondering what I would choose to look back on. I found myself looking back on all the good times and not the bad ones. There have been many bad times, perhaps as many as good, but they seem to recede in my recollection. It is the joyful ones that stand out. Some people have criticized the effect that digital photography has had, allowing us to so easily edit out the bad images, unflattering takes, and blinked eyes. But memory does that too, and maybe that’s a good thing.
After my bypass surgery, and hospital discharge, I had the most uncanny sensation as I was being wheeled through the hospital lobby out to the car. Traversing the lobby was a crowd of people there, walking in all directions, most of them not looking down at the man in the wheelchair, each seemingly preoccupied with his or her concerns or plans. I was overcome with an acute awareness of each of them as a thinking, feeling individual with all of these cares and concerns, each with a life that was infinitely complicated with circumstances I would never know. It was reminiscent of that movie where the protagonist hears everyone’s thoughts, but for me like a world where I now almost expected I might hear them but knew fully I was deaf. That sensation has faded with time, but I think it can only be described as a heightened sense of empathy.
I guess one of the most positive consequences of having survived my experience is the feeling of gratitude that I have for my return to life, health, work, family, and all the joys of living. I am grateful to everyone who worked so hard to bring me back to health, people who number in the hundreds in one way or another. I am grateful to my good fortune, if not to a God who I have serious doubts about. I find it easier to believe I am incredibly lucky than to think that a supreme being should concern him or herself with the fate of one person on a planet of 7 billion souls among a galaxy with hundreds or thousands of planets occupied by millions or billions of equally sentient beings. It’s enough for me to thank my lucky stars.
Yes, you read that right. I nearly died a month ago on a treadmill halfway through a stress test. The short story is this: I had just gone to bed and was about to go to sleep when I started to have some chest pain that I told myself was just my usual heartburn, only worse. As a gastroenterologist, I knew better. It was bad enough that I couldn’t go to sleep. After two sleepless hours of denial and mounting pain, I conceded that it was time to get help. I woke my wife and called 911 for ambulance to the ER. I chose to go to my own community hospital even though I could have gone to an Ivy League “world-class” hospital that is equidistant; the staff at my own ER know me and they are family. One of my most trusted ER doctors saw me. But strangely, by the time I arrived, the pain was nearly gone. I proceeded to have a normal EKG. The cardiac enzyme levels in the blood returned negative. So, probably no heart attack. But was it angina? My cardiologist recommended a stress test immediately, since my wife and I had long-anticipated plans to get on a plane that afternoon and fly across the country to visit my kids.
Well, I failed my stress test. Big-time. Halfway through, just after I finished relating a humorous scene from a movie where a character drops dead, my heart stopped. They laid me on a stretcher, pounded my chest and performed CPR. I was brought back from ventricular fibrillation with a defibrillator and a single shock of 200 Joules (=watts of electricity). I was rushed to a tertiary care center where I underwent emergency angiography showing a high-grade narrowing at the origin of my largest artery. (Narrowing to that degree in that location is sometimes called a widow-maker.) I was placed on IV anti-platelet agents and other blood thinners while my doctors waited for me to decide between a bypass and having stents inserted. They recommended bypass surgery over stenting and I chose surgery. My operation was performed through an incision between two ribs, with my heart beating, by a surgeon using what is known as a robot. My cardiologist friend up the street tells me they aren’t even doing heart surgery that way yet in the Ivy League hospital in New Haven. Thanks to my surgeon’s talent and the efforts of everyone along my journey, I alive to write this entry, and I expect to write more on this topic. I walked out of the hospital three days after my surgery. I am indeed a very, very lucky man.
But one of the reasons I am telling this tale is to share what it was like from my viewpoint to experience waking up from cardiac arrest. Now I have participated in a few “codes”, as cardiopulmonary resuscitations are called in hospitals, as a witness, particularly when I was in training, and I have watched a few people wake up promptly. It is unforgettable experience. One that stands out in my mind took place when I was an intern in the emergency room at Lenox Hill Hospital in New York City. A man had arrived in chest pain and we were doing the usual EKG and blood testing when he suddenly lost consciousness. The cardiac monitor above his head revealed why: his heart was in ventricular fibrillation, the abnormal heart rhythm that can result from a heart attack among other things, and end in death if not corrected. I was told to start pumping on the chest as I had done so many other patients before, futilely, as the usual crowd of nurses and supervisors and anesthesiologist arrived. But this time the outcome was an exception. My resident charged the paddles, yelled, “Clear!” just the way you see do on TV, and administered the jolt. The man’s torso practically jumped 6 inches off the stretcher and he almost immediately sat up and asked, “Whats going on? What are all these people doing here? What happened?” My resident and mentor, before even turning to the patient with an explanation, announced to the assembled team, “See? Electricity is GOOD for you!” as if he did this stuff for fun. We, the house staff, celebrated the occasion in the retelling.
In my own case, in the role of patient, the experience was quite different altogether. I didn’t get to witness the event. One minute I was walking and asking the cardiologist what level of exercise I had achieved thus far. I was anxious to finish the test so my wife and I could make it to the airport in time. My main thoughts were on our trip to San Francisco for a wedding celebration with friends and a visit with our children. With my usual off-beat sense of humor I was asking him “How many mets, Mario?”. This puzzled him because his name is Bob. I explained, as the treadmill was gathering speed and I was already breathing hard, that there is an old movie called “Putney Swope” that features an opening scene of a corporate board meeting in which the chairman berates the members, gesticulates wildly, and abruptly clutches his chest, and the board members don’t get it that he is having a heart attack. One of them, clearly a bit senile, thinks he is playing Charades. He asks him repeatedly, “How many syllables, Mario?” until the man finally keels over dead. I had no idea how ironic I was being. The last thing I remember was the nurse saying, “Are you getting tired?” or something like that.
An unknown number of minutes later, I was awakened from a sound sleep by a hand slapping my cheek and the cardiologist’s voice saying “WAKE UP, DAVE”. My annoyance vanished in a millisecond when I opened my eye to see a roomful of people in great activity, a red cart to the right of the bed and a large hard square object between my legs that was clearly a defibrillator. When you’re a doctor and you awake to this scenery, you figure out pretty quickly what has happened to you. As if I needed to told, my friend and colleague told me from his supervisory perch at the foot of the stretcher, “Dave, you are NOT going to San Francisco today.”
Now let me say what else didn’t happen. Perhaps I was not in arrest for long enough, but I did not see any white light or view myself as if from above. They tell me they caught me promptly and lifted me down off the treadmill. I am told I had my chest thumped and then compressed until the defibrillator could be charged and I came right back after the first shock. They tell me I seized during the arrest. I later had proof of that when I realized that my tongue was severely lacerated by my teeth and my jeans were wet.
But what did I experience immediately was an overwhelming sense of gratitude. Gratitude that I was still alive. Gratitude to all the people in the room. And along with it, an immense feeling of being completely cared for in a way I don’t remember since childhood. All my life I have been caring for others in one way or another, even when I was a child. For the first time in as long as I can remember, I completely relinquished the imperative to make decisions. I placed myself completely in the hands of my colleagues and co-workers. And they came through for me in a big way.
My cardiologist probably had a far more traumatic day then I. I have been told that the incidence of sudden death during a stress test is 1 in 10,000. To have that happen to a colleague, referring doctor and a friend, on your watch, even if though it is an inherent risk that could happen to anyone, must have been very difficult emotionally. He was trying to keep his cool when he called my wife, who was across the street picking up some necessities for our flight. But she says his attempts at reassuring words were belied by his white complexion and shaking hands. In fact, I think I had an easier time of it than he did.
The strangest thoughts go through your mind sometimes. In all the commotion, I noticed that a nursing supervisor I have known for 25 years had highlighted her hair. And as they were wheeling me out of the room, I called out to her, “Nancy, I really like what you’ve done with your hair!” My journey from there to the Hartford Hospital cardiac cath lab to surgery was a whirlwind and a blur. And the road to recovery has been slower, but still seems to have proceeded at amazing speed. But more on these topics another time.
This one is for all you perplexed nutrition-conscious readers! You know who you are. You’ve had it with all that nutritional advice and diet plans; where has it gotten you? Weight control is a bore as well as an elusive and vain pursuit; just as all the studies attest, you’ve always gained back everything you lost after a year has elapsed. Are you any the better for it? It’s time to rethink your goals : the real reason we want to lose weight isn’t to live longer, it’s to live better. So why not keep your eyes on the prize and aim for the real goal: success and popularity!
How can a diet help you win friends and influence people? Over the past 30 years of intense research and testing, my partner (Mrs. Dr. Sack) and I have discovered the secrets of eating your way to success and popularity. In the next few paragraphs, we will share with you a synopsis of these valuable lessons. If you find them useful, you can send for the full text of our revolutionary new method at the ridiculously low price of only $15.99 plus postage.
Chapter 1. What not to eat at the cocktail party
Never mind what you should eat at the party. Just mind what you shouldn’t:
With your first drink: Avoid cheese and crackers. They always break and you will look foolish. Don’t eat the shrimp if it has tails you have to leave over. It looks bad on your plate. Stick to the hors d’oeuvres that pop in the mouth and leave little residue. And under no circumstances choose the pigs-in-blankets; it immediately marks you as low-class.
With your second drink, try to avoid things that will leave a stain when you spill them, or if you are wearing anything low-cut and pushed up, that might dribble in. Unless you are aiming to attract attention, in which case choose something creamy and not mustard or cocktail sauce.
With your third drink, be sure not to choose things that roll, such as olives. By now your balance is off and so will your game be if you are more focused on the orb on your plate than on gazing into those gorgeous orbs in front of you.
With the fourth drink, STAY AWAY from anything with toothpicks in it! We are serious. Toothpicks are one of the most frequently swallowed foreign objects we are called to remove from stomachs or even colons, and most often this occurs as a result of distracted deglutition (i.e., masticating while drunk). No joke.
With your fifth drink, the only caveat is to choose foods that will taste just as good going down as they will coming back in the other direction, since at the very least you will be experiencing some repeat tastes and at worst a recap of your evening’s alimentary activities.
Chapter 2. So-called “junk” food that will put a smile on your face and all those around you
We are constantly reminded that rapidly absorbed carbohydrates and fructose especially lead to fatty liver, obesity, diabetes, slovenliness, bad skin, sloth, torpor, flatulence and a propensity to gambling, as is well-known to anyone who has gone into the fast-mart for a Snickers while gassing up and then been tempted to buy a lottery ticket while at the counter. But why doesn’t anyone mention all the ways in which “junk” food can enhance your appearance and popularity? Here are some:
1. There is a reason people speak of a “sugar high”. It’s because sucrose lifts your mood. Any 5-year-old can tell you that. And when you are happy, those around you sense it and are attracted by your charisma. You will smile more and use far fewer of those horrid frown muscles everyone has cautioned you about exerting. Your good attitude will infuse your work. The alleged “low” that follows a burst of sugar is easily deferred by consuming more sugar, until you can safely remove your social persona for the evening.
2. Junk foods can improve your social acceptability. Got halitosis? Sure you can keep those nasty Listerine film strips on your person. But Thin Mints and Peppermint Patties are much more tasty and will give your breath the same freshness that you just can’t get from kale chips.
3. Payday Bars have peanuts. Nuts are good for you. The syllogism should be obvious. Ditto for peanut M&M’s, peanut clusters, and turtles (the chocolate kind, not the terrapins).
Chapter 3. Flatulence-free foods for small meeting rooms and intimate occasions
It should hardly need saying that nothing spoils a date like an unexpected announcement blaring from the hindquarters occurring in close quarters . Many a ride back from a nice first date at a tony restaurant with that hot guy/gal you met on match.com has come to grief when the vehicle’s operator failed his or her emissions test. Sometimes the standard dietary don’ts and “no, really don’t!”s are not enough. We all know about avoiding beans, onions, broccoli etc. You’ve already gone that route. And what can you do if you are already flatulent no matter what you eat? Here is where Dr. Mrs. and Dr. Sack can really help you avoid alienating those most important in your path to success and riches.
1. Feed a cold but starve a colon!: In the board room (or at the sales pitch): Your colon can’t make much gas if you don’t eat anything with metabolic value. If the occasion does not call for food, such as a business meeting, be continent! (behaviorally, of course.) But if you must eat, simply don’t consume anything organic from the time you awaken to the time of the meeting. And you don’t have to go hungry, either. Our recipes chapter teaches you how to create mouth-watering dishes such as our no-calorie omelet made using only methylcellulose (an inert product made by chemically treating wood pulp or such), Splenda, sliced dried mushrooms, a few spices, yellow dye #5, and Bacon Bits. Some substances, even coliforms won’t eat.
2. And for you organic types out there who insist on all natural ingredients, try our kale and sprout shake with a touch of agave nectar and liberally laced with Jagermeister. You might not like the first sip, but after a few it truly grows on you.
3. OK, so diet isn’t everything. Sometimes drugs are called for to keep your microbiota stymied! A good burst of non-absorbed antibiotics the night before your social plans can drastically cut down on the fermentation that normally occurs in your lower GI tract. We recommend two tablespoons of Pepto-Bismol with a capful of Miralax.
Chapter 4. Foods that say, “Come hither” you can dispense from your cubicle
Everybody loves a winner. And nothing says “winner!” better than the sight of smiling — and occasionally laughing — co-workers gathered around your desk from time to time. Others may assume you are entertaining them with your wit or that they are seeking your advice. Everyone knows the office colleague who keeps a bowl of M&M’s or mints by the desk. But if you can go one better, you can enhance your position in the office social order. Why not go all out?
A microwave under your desk can easily be used to keep a bowl of popcorn ready at a moment’s notice. But why stop there? You can find microwave cookies and even brownies; the recipes are readily available nowadays on the web. There was even a piece about it on NPR recently! They’ll be flocking to your desk like pigeons in St. Mark’s square to a tourist covered with birdseed.
Beverages, too, can gain you points at work. A bit of vodka will never be noticed in the thermos of coconut water you keep on your desk, but it will certainly improve your colleagues’ attitudes! Imagine the places you’ll go with a little creativity.
Chapter 5. Party-stimulating additives your guests will never guess
Whether it be a dinner party or a discussion group, your friends will leave with a positive attitude toward you if they leave having had a good time. While we heartily recommend alcohol as a social lubricant (see Chapter 4), not everyone wants or needs a drink to enjoy a party. Some people will enjoy themselves more if they feel charming, energetic, or less inhibited, and food can work the same magic:
1. Certain spices are known mental stimulants. Tea has long been popular in this regard. But if you frequent the natural medicine web sites, including Web MD, you will find scores of assuredly safe herbal products purported to increase energy and well-being by the thousands of clearly objective reviewers. Given their safety, what’s the harm in adding them to your cooking?
2. Use caffeine as an ingredient. Your guests may opt for decaf when it’s time to leave, but why not keep them lively during the soiree? Dark chocolate, rich in caffeine, may be used in your mole sauce, and instead of root beer in your brisket recipe, try using Coca-Cola with a touch of Red Bull. Did you know that manufacturers are adding caffeine to everything from waffles to jelly beans? Caffeine is an ingredient in many products nowadays, even an oatmeal. Imagine the lively conversation you could stimulate by starting your Scottish Food night with haggis made from caffeine-laced oatmeal! (Yes, it is really available.)
3. Good old-fashioned Alice B. Toklas brownies are legal in many states and have no more calories than conventional ones. Your guests will go home raving about the wonderful meal they had, and if not, at least raving in general. [BLACK BOX WARNING: Illegal in Many States and Unethical in All. Do NOT act on this advice. It is intended as SATIRE!]
Further chapters we have no room to summarize in this post that we will share in our book:
Chapter 6. Foods guaranteed to enlarge your male or female anatomy
In this chapter we will share nutritional strategies to spare you from replying to all those offers you get in your email for costly and artificial treatments. Here’s how to eat your way to success in bed (and not by reading fortune cookies!).
Chapter 7. When “empty” calories leave room for more
In this chapter, we expand on the notion that “there is always room for Jell-O”. We reveal the miracle foods with negative calories.
Chapter 8. Antidotes to food indiscretions
Who hasn’t committed a food mistake at one time or another? In this chapter we reveal our nutritional “morning-after pill”.
Chapter 9. Secrets we can’t even share in this post
You’ll just have to buy the book.
It has been creeping up on me for the past year or so, but I think it really hit me today. I am a senior (doctor).
I don’t mean to say that I am old. If anything, I feel younger than I did a year ago, having had a rejuvenating surgery for sciatica only this past April. What I mean to say is that I have achieved the status of venerable, sometimes crotchety, and even “old-fashioned”.
The evidence has been accumulating but today was the tipping point.
It was a simple terms of address . We doctors often address each other as Doctor, especially if we are strangers, out of respect. But after having worked with a colleague more than a few times, I usually say, “Please, call me David.” But lately, the new hospitalists are addressing me as “Dr. Sack”, and when it happened today, I found myself free of the urge to correct her. It has become apparent to me, astonishingly, that the junior staff really respect my wisdom.
And speaking of wisdom, that’s another thing. I have started to dispense it. And doctors and nurses have been actually listening lately. I’m not used to that. (My wife sees to it that I don’t get accustomed to it at home.)
I am even noticing that I am dressing old-fashioned. When I started out as a medical student, doctors wore ties. Some eccentrics sported bowties, but everyone put on a tie. This dress code was fairly well observed when I was an intern and resident. Most everyone I worked with after I became an attending maintained this practice . There was the occasional out-and-out rebel/weirdo that wore a bolo tie. (There was even for a time an ER director who wore a cowboy hat on the job.) Naturally, surgeons were permitted scrubs in their offices. But over the past ten years, I have noticed that the necktie is becoming an endangered species among my colleagues. Most of my gastroenterologist colleagues are either wearing their shirts open or are wearing surgical scrubs. Same for the hospitalists. Some specialties at my hospital seem to be holding the line: our nephrologists, oncologists and cardiologists. (All serious specialties.) Perhaps dealing in serious illness demands dress standards as serious as one’s demeanor. Yet here I am, knotting a tie most mornings. Lately, I must admit, I have been dispensing with the necktie on days that I will be doing procedures all morning. The patients are all too anxious beforehand or dopey afterwards to notice.
And recently I realized that my attitude about how a history and physical exam should be written, and how to interpret it, is utterly antiquated. I was taught in medical school to follow a certain order for recording the H&P. With the advent of the EMR (electronic medical record), I now note that the traditional order has been ceded to the province of computer programmers instead of doctors and is now completely and, for all appearances, arbitrarily scrambled. It has seemed to me an abomination but today I realized that the traditional order is really only arbitrary. Why should I be bothered if the chief complaint and present illness appear on page 5 after a listing of patient’s habits, prior surgeries, native language, and whether they wear seat belts? I’ll find the information I want sooner or later if I just keep looking. I’m just being a curmudgeon, right?
For that matter, the physical exam itself reveals itself as a telltale about my antediluvian attitude. And this particular item is really what originally inspired me to write this post.
Up until this month, I have been locked in combat with the “Physical Exam” section of the progress note in my EMR, which is so unwieldy to alter from the default normal that I end up swearing at times. I find myself spending precious time tailoring an organ system’s examination in the note, only to find all my free text gets erased when I try to amend it further. The menu tree is a shriveled excuse for a multiple choice device and takes more effort to enter the pitiful data that it does accept than it does to just free-text it. My EMR doesn’t even allow me to copy the previous visit’s exam components that are unchanged. Even my primitive ”non-qualified”, “non-meaningful” EMR I installed in 2002 had that feature! Don’t I sound like an old curmudgeon complaining about these “new-fangled contraptions”.?
So I have sometimes taken to simply opening a text box at the bottom saying: “EXCEPTIONS”, by which I mean “ignore all the useless drivel above!”. After all, it was only put there to satisfy the bullet points required to code for the visit at a level appropriate to my effort and time. No one reads these exams; not referring doctors, not doctors who I send patients to, not patients themselves, not, God forbid, insurance company auditors, who might count bullets. The sole exception is me, doing my proofreading. So why bother? I have come to the realization that most of my colleagues have long since recognized that this is nothing but a charade. If I spend my time perfecting a note in an EMR, I will have no time left to treat the patient. Anyway, most of the visit is always spent in counseling and coordination of care anyway, and I code it so. But it really would be easier to just click the box that says everything is normal. I know many doctors that rely on their memory for the real exam and do just that for the note. As Julia Child famously asked, “Who’s to know?”
Remember the movie Fail-Safe? The subtitle, as I recall, was “or how I learned to stop worrying and love the bomb.” It was about simply surrendering to the absurdity of the doctrine of “Mutual Assured Destruction”, or MAD, as it was referred to. Yes, I am old enough to remember the Cold War, and believe me, that notion was the foundation of our strategy for keeping the peace by nuclear deterrence.
At least I am trying to stay current in my medical knowledge and continuing education. So far at least this habit has not gone out of style.!
This post may be in the nature of a rant. It may not even be entirely a medical topic, but it touches on my medical practice and one of its constant frustrations: communication between us physicians and between us and our patients, and the tools we use. In this case, I mean the telephone.
It’s a shame we still need to use telephones. Using the phone used to be easy, but now its more of an inconvenience and a frustration for all concerned. The days of a simple phone call to the doctor being promptly and courteously answered by a receptionist and a simple message taken are bygone. Now we are usually greeted by the “automated attendant”. What an abominable excuse for communication that has become. The patients think the process has become frustrating and sometimes infuriating, but it has become that way for me as a physician as well.
Here are just a few irritants I would like to know who devised so I can post their names on the internet.
1. “Your call is very important to us.” A doubtful proposition to begin with when it’s the same greeting everyone receives while waiting. But can they really expect us to be even more convinced of our importance after hearing it repeated for the fourth time?
2. “If this is a true medical emergency, hang up and call 911 immediately.” Only a moron or someone living in a cave the past 30 years would wait to listen to that advice from a recorded menu while they or their loved one is gasping for breath!
3. “Please listen carefully to the following options.” Of course I am listening to the options carefully! You had me at “You have reached the office of…”. God forbid I choose the wrong one and wind up in automated limbo. But do you need 9 different options? I might listen patiently to 3, but can I be forgiven if my attention wanders after #8? And just in case you think you already know the options, you may be told that “our menu has changed”. I sometimes wonder what item on the menu is the special of the day!
4. A human being answers , and the first words out of (usually) her mouth are, “Dr. Smith’s office, please hold.” followed by hold music. And don’t get me started about hold music consisting of advertisements for whoever you are holding for. My hospital is a notable offender there.
5. The person answering actually gives me what would seem to be an option: “Can you hold?” If I am in a good mood and my hands otherwise occupied, I say “Certainly, I’m very good at it.” If the matter is more pressing I say, “No I can’t. This is Dr. Sack and I need to speak with Dr. X right away.” Amazing how quickly I get results. If I am in a foul mood, I am sorely tempted to answer “Can you hold?” with “Hold what?”
6. I get a human being but one who was never taught old-fashioned telephone etiquette. The person answering the phone doesn’t identify him/her self. Sometimes it doesn’t matter. But often it helps to know who took the message and if they are someone I can expect knows who I am. I called the ICU last week and the person at the desk answered “Hello?”. I said “This is Dr. Sack. Who is this?” She replied “the ICU”. To which I responded, “I know that. I called you! :”(I am thinking, “you ninny!”). What’s so hard about answering ”ICU, Betty.”?
7. The interminable human recitation. This corporate “Professional Greeting” is infecting more an more doctor’s offices now that more an more of my colleagues are working for Big Brother (did I say that?) – I mean the hospital. I used to get “Surgical Specialists, Jasmine speaking.” Now I am greeted with “Big Hospital Surgical Specialists, an affiliate of Big Hospital Medical Group, with affiliates in Gotham and Podunk, Jasmine speaking. How may I assist you?”. And the poor receptionist has to repeat this oration several dozen times a day! A wonder she has time to do anything else!
8. And my personal bugaboo: the emergency room page. I receive a summons on my pager(actually a text to my phone from my service) to call the ER. The secretary answers and says, “Yes, Dr. Jones needs to speak with you about a GI bleeder. I’ll get him.” Then 3 minutes go by. Now I am tethered to the line. I wonder if I should just pitch a tent. Then someone picks up and asks who I am holding for. Then, apologies. Or after several minutes I get tired of waiting, hang up and call again. “Oh, he didn’t pick up? I’ll try again.” Sometimes I get paged as I am putting on clothes in the morning. Have you ever tried buttoning a shirt with a phone in your hand? Thank goodness for the speaker phone!
9. The patient whose phone line is busy when you return their call. Sometimes it is because they are summoning the ambulance. Most of the time it’s just thoughtlessness.
10. My receptionist buzzes me: “Dr. Sack, doctor So-and-So is on line 4.” My receptionist sometimes fails to mention that it isn’t “Dr. So-and-So”, it’s her secretary. There’s little that makes me feel as foolish as having offered an enthusiastic greeting to my colleague only to hear, “Just a minute, I’ll put her on.” I suppose my staff probably perpetrate the same thing on other doctors when I call them. But lately they have been learning to tell me, “It’s Dr. Jones’ office on the phone. Pick up on 4, they are getting him.”
All these nuisances and inconveniences are the reason why I think we doctors are entering a new era. The landline has been obsolete among the youth of our nation for over a decade. Soon it will be a thing of the past for us doctors as well. Now if I want to call my friend Doctor X, and I have his cell phone number, I dial that myself. It’s amazing how well that works and how much it frees up our receptionists for more important tasks, like answering the patient calls and actually speaking with them immediately!
This post is inspired by the show Kids Say the Darnedest Things,an American comedy show hosted by Bill Cosby on television, although it was actually inspired by Art Linkletter’s radio show that aired until 1969. (see Wikipedia article). I wish I could claim originality, but there have already been several books entitled Patients Say the Darnedest Things. In fact, I even came across a fellow blogger, Dr. Bill, who blogs on (where else?) Blogger, and his latest entry dated only the day before I started writing this one was on the same subject. So the idea for the post is by no means original, but my patients certainly are, or at least think they are. The intentional jests are fairly predictable. Just as there no truly new ideas, there don’t seem to be any truly original jokes. But some of the unintended humor is always the best.
Thus, in no particular order, I thought I would set down some of the better statements or questions I have encountered lately. This is often in the context of a gastroenterology visit or exam, so be prepared. And by the way, even if some of this stuff seems predictable, I couldn’t have made it up if I tried.
1. Me: “I need to do a rectal exam.” Patient: “Do you want me to take off my underwear?” (This happens often enough that I have a stock response: “No, not if you prefer; I can make a small hole with my scissors.”
2. Me: “Do you smoke cigarettes?” Patient “No, I quit.” Me: “Congratulations! When did you quit?” Patient: “This morning before I left for your office.”
3. Me: “It looks like you have gained 8 pounds since your last visit.” Patient: “Your scale is wrong; my scale read 8 pounds less this morning at home.” Me: “Perhaps my scale is off, but it is probably off by the same amount each time we put you on it.” Patient: “But I am wearing shoes and keys this time”. Me: “Weren’t you wearing shoes and keys last time we weighed you?” Patient: “Those were different shoes!”
4. Me: “You will need to be on a clear liquid diet the day before your colonoscopy.” Patient #1: “Doc, is beer a clear liquid?” – obviously joking. Patient #2: “So I can eat as usual but all my liquids have to be clear?” - not joking!
5. Endoscopy Nurse: “I am going to push on your abdomen to help the colonoscope pass.” Patient: “Sweetheart, you can sit on my abdomen if you want!”
6. Medical Assistant: “Please take off everything but your underwear and put this gown on.” 10 minutes later: Me: “I see you have a gown on over your T-shirt.” Patient (usually over 70) “Yes. She said I could leave my underwear on.” (Lesson: patients over 70 consider T-shirts as underwear.)
7. Me: “My nurse wasn’t able to put your medicines into the computer. Did you remember to bring your medication list with you?” “Yes, it’s in the car.”
8. Endoscopy Nurse: “Your instructions said no liquids within two hours of your procedure. You stopped at McDonald’s on the way here?” Patient: ”But I didn’t have anything to drink with my meal!”
9. I keep bottles of antique medicines and remedies on display in my exam rooms for the amusement of my patients. I see on entering the exam room that my patient is eying them. Me:”I see you are admiring those patent medicine bottles.” Patient: “Don’t you think it’s time to get rid of those samples? They must be expired by now.” (Some patient humor is intentional.)
10. A seemingly demure 69 year old woman on the procedure table about to undergo colonoscopy is asked our usual pre-procedural questions. The nurse asks if she would please state her name, birthday and the name of the procedure she is having. Her reply: “No.” (joking). The nurse says, “I get it, I might be a bit ornery too if I hadn’t eaten for a day.” Patient: “Eaten? Eaten?? Never mind that, I haven’t had sex for a day!“
I planned to add more such pearls but memory failed me after only these few. The draft having languished these past several months, I decided to post now and add later. I only wish I had made these quotes up. Some are to laugh. Some are to cry. Most of them I will hear again.
Al Franken, the humorist-turned-senator once published a book that was titled something like “Oh, the Things I Know!”. Indeed, by the time we reach parenthood, it is truly amazing what we keep up there in that attic of a brain. Here is a brief selection of things about the practice of medicine that I have had to discover for myself or never quite figured out, including clinical pearls, aphorisms, dictums, platitudes, mysteries and conundrums that have somehow found their way into my own cranium and are constantly trying to escape.
If you are called for a consult, don’t accept the ostensible reason as it comes from the student, nurse or P.A. I have learned that rarely when I arrive is the problem what it was purported to be. As in everything else in life, “Nothing is as easy as it seems or as simple as it sounds.”
Once you are out of your training, you no longer find yourself an object in the chain of blame. You have reached the pinnacle. But if you are not at a teaching hospital, you must devise a new paradigm. My own goes as follows: ”If anything goes wrong, first blame the patient. Then blame the equipment. If that doesn’t work, blame the anesthetist, and if that doesn’t fly, blame the nurse. And only if all else fails, yourself.
I have observed that “All patients, even if moribund, look improved sitting up in a chair if the last time you saw them they were in bed.”
How come they never teach you how to pronounce someone dead? My first day on the job as an intern, when I was called at 1 AM to do so, I had to improvise. After entering the vacated room (aside from the dead body) and certifying for myself that the patient had no pulse or respiration, I proceeded to pronounce: “By the authority vested in me by the Johns Hopkins School of Medicine and the New York State Board of Medical Examiners, I hereby pronounce you dead.” I immediately heard raucous laughter from the nurses in the hallway, who informed me that pronouncement only required my filling out a form.
If you become a consultant, always remember what is expected of you: “Consults are requested for two reasons only: ‘Please make this patient’s problem go away”‘or ‘Please make this patient go away’.
Why did they never teach you how to open one of those Johnson & Johnson band-aids with the red string? I always end up pulling it out.
Regarding the standard recitation of the physical exam, some things they teach you are just plain useless. If you ever see an adult patient in your office for a scheduled visit who isn’t “normocephalic and atraumatic”, go immediately and buy a lottery ticket.” Such occasions are unprecedented and augur momentous events.
What in the world is “walking pneumonia”? I can’t find it in my Principles and Practice of Medicine text and it doesn’t seem to have an ICD-9 code. Maybe they’ll put it in ICD-10. For that matter, I have never made a diagnosis of a “nervous breakdown” or “exhaustion)”either.
“Never ask a patient if he is feeling better before finding out if he has actually obtained and taken the medicine you prescribed.” Otherwise you might say “I’m glad to hear the medicine is working” and receive the reply “Oh, I never filled the prescription.” or “I filled it but I was afraid to take it until I saw you again after I read the warnings.”
The topic of how to charm a patient could occupy an entire post in and of itself. Here’s one dictum I have developed. “Humor always breaks the ice. If you are a male physician seeing a married man, make jokes at the expense of your wife. If the patient is a woman, make yourself the object of the joke, especially if you can quote your wife. If both husband and wife are present in the exam room, make fun of husbands if you know what is good for you.” Female physicians have to write their own rules, but Borsht-belt style humor is not generally required of them. As a matter of fact, I haven’t any idea what women patients talk about with their female doctors, but I suspect the topic of husbands doesn’t come up unless they are a problem.
If you are a specialist, when providing all hospital consults, visit radiology before you see the patient, not afterwards. You’ll look smarter, do a better note, and you’re going to have to go there anyway. I have learned over the years through great inconvenience not to follow the usual sequence of history, physical and laboratory data in gathering evidence that I was taught in school. As I tell my students, “Always visit the radiology department before seeing the patient in consultation. There is much that doesn’t get into radiology reports. That way you won’t have to change your opinion to accord with the facts after rendering it.”
Not a hard and fast rule, but patients over 60 can be addressed as Bob and those under 50 as Rob. Unless they go by their nickname, which is usually their middle name. If so, enter that in your chart. It impresses patients if you know their nickname.
For further wit and wisdom, a great compendium of advice and humor that I wish to credit for inspiration, although I don’t agree with all its advice, is entitled “Kill as Few Patients as Possible (and fifty-six other essays on how to be the World’s Best Doctor by Oscar London, MD, WBD” , published in 1987 by Ten Speed Press and excerpted in Medical Economics Magazine. Perhaps you can find a copy on Amazon or eBay.