Category: Medicine

Posts that are specifically tailored around the practice of medicine.

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Being human Medicine Reflections on Life, Being Human, and Medicine Reflections on the Christian Life

Dependency

He has a terminal diagnosis. It is taking him slowly. No one can know how long he will last. It is weakening him and that is hard for him.

It was a routine clinic day for me. I was bopping from room to room working through my day trying to keep on time. I hate being behind in clinic. I keep pushing to get my notes done between patients. I rapidly scan the chart for the next patient. I see that he was recently hospitalized. In the hospital he didn’t respond very well to the treatment. He is home now but it doesn’t look very good for him.

When I enter the exam room seeing his face “clicks” something in my mind. I am a visual learner. Seeing him and his wife helps me remember a lot about him. He is a big and muscular man. He is the type that has always been strong in both body but also spirit. He is the type of person that you could rely on to always be there and to always get everything done.

He looks different now. He is clearly being weakened by his disease. His color is not good. It is still him, but it is as though the battery has been partly drained. The strong muscles are not getting the energy they need. This is going in the wrong direction. As his doctor, I do not have a thing that I can do to alter that.

I tried to engage him in a goals of care discussion. I don’t think that the hospital will ever be a good place for him. It won’t help him. It will likely just weaken him even more. If we are smart, we would keep him in his home. I honestly think he will live longer if we don’t ever put him in the hospital again. 

If we don’t talk about this proactively the hospital is where he is going to end up. That is the default and easy pathway in the U.S. It amazes me how it is always so much hard work to fight against that. Every time it is heavy lifting. I think – for him – this may be the most important thing that I can do today.

What does he want? What are his goals? What are his fears? What would be an unacceptable outcome for him?

He doesn’t want to be a burden on his family. He will want to be hospitalized purely so that they don’t have to take care of him. His wife was shaking her head firmly. She has no problem taking care of him. I know that we can get hospice or other home care resources to him. Even so he doesn’t like the dependent role that he was been forced into.

It has become clear that this is about so much more than just whether or not he wants to be hospitalized again. It is about how to accept and handle dependency on others. He is not wanting to talk about it, but he needs to. His wife knows it. I know it. And deep down he knows it.

I cross the line and start talking about my cancer journey. They knew I was off on a medical leave. They didn’t know why. I explain it to them. I then take it further and talk about some of the lessons. I talk about what it meant to me to be a man. I had strength. I had stamina. I could push myself. And then I could push myself more. I could work late. If I couldn’t get things done at night, I would secretly set my alarm earlier. It could even be extreme if need be to get the job done. I could and I would shoulder the responsibility for whatever I needed to get done. Sleep was good but I could sacrifice it at will to meet the needs of my work, my family, and my life. Sleep was the margin that I could and would sacrifice.

I told him that this was who I was. He nodded and tears formed in the corner of his eyes as I could tell that we were connecting. This was who he had been. 

But no longer.

Shortly before my surgery I lost my stamina. Perhaps it was the tumor. Perhaps it was the stress. I couldn’t keep up the pace anymore. The surgery was staggering to me.  It was enough to roll over in bed, let alone do anything physical. Radiation continued the story. Chemo turned it from a short story to a novel. 

I told him how my wife insisted on driving me to my radiation appointments. I thought I could go alone. She insisted that I not.

He and his wife started nodding. I had struck another point of agreement and understanding.

I told them how we are in this life together. As much as I wish I could be the man that I was before it was not intended to be. I told them that I believed my Lord had forced me into dependency. Sarah and my family and friends and colleagues needed to take care of me. I needed to accept having others do things. I had to accept the role of dependency.

I told him it was ok. His years of strength and serving and supporting his family were wonderful. In this chapter if he needed to have the roles reversed it was ok. He didn’t have to like it. But his wife and his children needed to take on supporting him. 

JJ and Sarah trying to cut the Christmas tree for me while I was recovering from surgery. So maybe they were not very good at it!

I told him that his wife and children too were being traumatized by his illness. They have been forced into a feeling of helplessness as they watched him fading. They were desperate to do something to help. In their grief they needed something physical that they could do. The energy that they exerted helping him was the only tangible means that they would have to fight. His willingness to let them come and help him was a gift. He needed to understand that as the leader of his family he needed to help them to be able to grieve. His illness was calling him to do something hard.  

He had to let others serve him. He had to accept dependency.

It was ok.

By now, the tears were evident in his eyes. He understood. I understood. We didn’t have to like it. But as strong men, we can and would do whatever was best for our family.

The doors were now open. We talked about home care services. We talked about hospice. We talked about continuing to endure – to work to stay alive – for now – if that is what was best. We talked about the inevitability of death for every one of us. “A recent study has shown that human mortality is close to 100%” We laughed. Then we talked more.  In his case now, we talked about the important questions of “how” and “where” rather than “if” or “when”.

I didn’t really change much in terms of his medicines. But I like to think I was a good doctor. I provided the treatment that he desperately needed. 

Thank you, Lord, for letting me be your servant in the exam room this last week. Thank you for letting my cancer journey be used for good. It makes it just a little bit better if it could do some good. It is not that I wanted the cancer. But at least, in that moment, it was good.

Categories
Being human Medicine Reflections on Life, Being Human, and Medicine

Wisely Managing Life’s Problems or How to Drive an Old Truck Down the Road


I learned to drive on the farm. First on tractors. Most of them were quite a bit older than me. One forklift was a tractor configured with a seat facing backwards. That way the forklift portion would be on what was the back of the tractor to better bear the weight. But in order to drive it at speed, it wouldn’t handle well unless you drove it backwards (what would normally be forwards). It surprised me how you could get pretty used to that, however.

The trucks and the tractors seemed to wander a bit as you went down the road. Perhaps it was some looseness in steering linkage? But for whatever reason the steering was never “tight”. That also took some time learn. The key was to look further down the road and avoid trying to overcorrect. If you stared at the road in front of you, you would get into a pattern of turning the wheel too far. You would then have to correct by turning the wheel the other way and you would turn it too far the other way. You would then have to correct that, and the cycle would continue. Left on this cycle you would run off of the road. Or at least panic and have to slow down and stop.

The key was to look far down the road and pick where you were planning to drive.

By focusing farther down the road, you could see that the minor wandering of the tractor or truck was indeed minor in the grand scheme of things. You would then be less prone to overcorrect. Your wild side to side steering would turn into calm and controlled driving to your goal. With experience there was no problem driving the old tractors and big trucks.

I discovered that there is a term for this during my flight training in the Navy. It is called, “pilot induced oscillation.” It is based on the understanding that human beings have a tendency to overcorrect. In aviation they would tell you to take how much correction you thought you should put in and then only do about 1/3 of it. As I went through my career as a flight surgeon, I had the privilege of flying some really nice helicopters. The HH60H Sea Hawk was amazing. It, like most of the larger helicopters, had an automatic flight control system (AFCS). One of the big functions of the AFCS was to dampen out the normal human tendency to overcorrect. I was surprised how easy and how fun it was to fly the helicopter with all of these “gadgets” turned on.

To be honest, when I tried practicing hovering in “the box” I needed some help. The idea was to hover over a large square and then in a controlled manner to move the helicopter horizontally to each corner of the box. With this there were a couple of times when I would fall back into “pilot induced oscillation.” The experienced pilot I was flying with would skillfully take the controls and correct the chaos that I was causing. With practice I got better. The pilot then turned off the AFCS and it got harder. A lot harder.

We all tend to overcorrect.

When we do, we create real problems for ourselves. We go from one problem to a bigger problem to an even bigger problem. Left uninterrupted we end up crashing.

I was treating a patient for hypertension. I was eager to get his blood pressure into control. I started an ACE-inhibitor. He called me a week later with his blood pressures and they were still elevated. I increased the dose. I kept doing this every week pushing to get his blood pressure into control. He ended up 6 weeks later with dizziness and with a dangerously low blood pressure. I learned an important lesson. I should have been a lot more patient. The peak effect of an ACE-inhibitor, in my experience, seems to come on a few weeks later. I needed to calm down and slow my control inputs. I needed an AFCS to override my tendency to overcorrect. Or in the absence of that I needed the maturity to be patient and make intentional changes looking at the long term. I needed to look far down the road and not just at the ground in front of me.

I work in a large health system. It can be frustrating how slowly things change. We can have the world’s greatest idea, but it seems like nothing is happening. It can take months to implement a change. “Patience, young grasshopper.” The change comes but you must wait for it. You must look farther down the road. You must not whip back and forth from one solution to the next.

I suspect by now you are already starting to see the life lesson.

You must not look at the ground or just the immediate problems that are in front of you. You must look farther down the road. You must be calm and wise. If you fail to do so you will flail back and forth. You will look foolish. You might even harm yourself.

Here is some more from Kung Fu:

Master Po: Close your eyes. What do you hear?
Young Caine: I hear the water, I hear the birds.
Po: Do you hear your own heartbeat?
Caine: No.
Po: Do you hear the grasshopper which is at your feet?
Caine: Old man, how is it that you hear these things?
Po: Young man, how is it that you do not?

This quote may seem a bit off from what I have said so far, but it is not. In youth we lack the ability to calm ourselves and truly hear and see our universe. We see and hear only the obvious. We look and react only to the problem that is immediately in front of us. In so doing we miss so much of what is truly important.

Today may bring many worries and issues to your life. Some you will need to address immediately. But do not be pulled into a caffeine crazed manic effort to fix all of them. Be calm. Be mature. Reflect. Listen. Look farther down the road. What is the big picture? Where are you going? Only then can you make the intentional clear actions that you should.

Patience, young grasshopper.

Can you test it now?

What is there that worries you today? Can you stop and sit and close your eyes? Listen to your world. Refocus. Look far down the road. If the worry is personal this may be an issue of faith. You may need to look very far down the road. If the worry is about work, you may need to refocus on what the long terms goals really are. Only until you have your eyes fixed far down the road should you then go back to the problem. Is it truly a crisis? Or is it a minor wandering on a long road to your goals? Once you have done these steps, only then can you act wisely.

I am perhaps a little bit proud that I still remember how to drive an old truck down the road and not lose control.

I just wish that I was always wise enough to apply the same wisdom to my life.