Wednesday, July 26, 2017

Last Night on Call

July is the beginning of the new academic medical year and the end of my neurology group's nighttime emergency room contract. We had previously turned over the daytime responsibilities to the full time neurohospitalists.  For months I have been ruminating on what is likely my last working venture. There is not a simple fork in the proverbial road, more like a traffic circle, with several exits not reading "Physicians This Way". I could work in the outpatient clinic, continue to teach the first and second year med student's basic science courses, or both. I also know I would be entirely content as a full time gardener, stone mason or bike bum. On my recent cycling trip to Spain I felt confident I would make great progress on this dilemma, having a perspective set by the distance in both miles and duties. Also I was surrounded by lifelong friends who would be happy to listen and opine. At the end of my vacation I was no closer to the solution than I was two weeks earlier.

Almost everyone hates call. I cannot remember if this was always the case. When our new washer and dryer were delivered, the owner of the appliance store proudly told me his daughter was in training for ENT surgery at a prestigious university program and she was loving the entire experience with the exception of "call" which she hated. I guess it starts early. Our neurology group had shared this "on call" responsibility for decades but had notified the Med Center we were no longer interested in continuing this duty. Recently it was my turn for the "last night".

At 11:30 PM the ER called about a patient with some unusual "jerking" movements. This did not seem to be a critical problem but I was clueless by the phone description and preliminary test results. It is fairly easy to go back to sleep in a non life threatening situation, as long as there is a definite explanation. Since there was not, I felt I needed to take a look. Did I like driving there? No. At least there was little traffic. The Rolling Stones song What a Drag It Is Getting Older wafted through my mind. Once arriving and going over the patient I confirmed she was not too sick; she needed a brain wave test (EEG) in the morning and a medication change. It could have waited. Oh well.

While there I received calls regarding three more patients.  One was easily handled by phone, another had to be sent from a distant hospital where I gave routine instructions on a straightforward case, and lastly a patient in our ER. This one was a puzzle. An elderly women with known multiple medical problems came to us by ambulance complaining of recent onset generalized weakness. The ER doc determined she had severe anemia secondary to GI bleeding, proven by finding old blood in her stool sample. She received several units of blood, then had a procedure in the GI lab under light sedation to find the source of the bleeding and to coagulate it, all performed without incident. She returned to her ER room awake and alert.

She then had sudden neurological change becoming less responsive and unable to speak. The treating physicians felt she was having a stroke and perhaps needed the clot buster, risky in a patient with a bleed even if allegedly fixed. It took me awhile to do the examination, always a challenge in the poorly responsive patient. When completed I was certain she was not having a stroke and she did not need the risky medication. The change in her status was due to a combination of medical issues likely to be corrected with time and support. The CAT scan of the brain was of no help.

While doing the neurological exam on this sick person, I realized how much I enjoyed doing it and how confident I was in my assessment once done. I forgot the unpleasant wake up, the drive to the ER and even the Rolling Stones.

The ER and inpatient duty is a complicated ride. It is analogous to going down a steep hill on the bicycle. When I was young and on a soaring mountain descent I was absolutely confident nothing could go wrong and what a thrill it was. I have always been intrigued by the medical puzzles the hospital provides, the more bewildering the better. Early in my medical  career I had the same confidence and thrill as on the bike over equivalent treacherous terrain. Young riders and young doctors are naturally fearless and this likely works both for them and against them.

I have had seriously crashes on both venues. On the bike I am now very cautious and the downhills are not nearly as thrilling. In the hospital there has been a parallel evolution but more complex than simply being cautious. I have put hubris aside and uncertainty has become my constant companion.
Maybe it was the drama of the "last night"  on call or perhaps I would have had this insight on another occasion, but I so clearly realized that evening how gratifying it is to have the confidence of a young doctor entirely generated by the ability to do an accurate bedside examination. "Putting the hands on" is the old description. This is rapidly becoming a lost art.

The Indigo Girls song comes to mind,

     " I got to get out of bed and get a hammer and a nail
       Learn how to use my hands not just my head"

There is something beautiful about building a stone wall yourself instead of using a contractor, pedaling the bike into the breeze verses sitting in a closed moving car, and solving the medical problem by the bedside physical examination rather than ordering a number of tests which are always expensive, sometimes risky and occasionally misleading. I am not sure what part of the brain these activities stimulate, but I am certain everyone has it.

I am now in an ideal position to pass this on. With very short notice I was able to set up an inpatient Neurology service with every third year med student required to participate. An all day one on one relationship for a week where they learn to properly perform both the physical and the neurological exam on a real patient with immediate feedback from me.

I hope I can convince them what I know to be true. I hope at some point they will regularly experience the rejuvenating feeling I had in the ER that evening. I hope I can continue to handle the patient care uncertainties and the inevitable occasional bad outcome.

Sunday, June 4, 2017


This year has been a series of catastrophes.

 Adversity #1. I am riding my bike alone, deep in thought, working on a talk, then I regain awareness to find myself in the ER. I recall the bike ride but not the fall, not the kind strangers who found me, not the ambulance ride nor the first twenty minutes of the ER evaluation. I was awake and talking the entire time and as I later heard, only mildly misbehaving. There were a few broken bones, sprained knee ligaments, a cracked helmet and a small amount of blood around the brain. The last of these resulted in two days observation in the Neuro ICU, one day on the Neuro floor and then home. The difference between a small bleed and a fatal one is likely only a couple of miles per hour. This was only slightly more unsettling than not knowing cause of the crash. A hole in the road with leaves found by my brother-in-law and patched before I was able to investigate was more likely than a crossing animal or foul play from an aggressive driver. In the hospital I knew everyone from receptionist to nurse to doc involved in my case and was impressed by their kindness. I surmised I had not previously pissed off any of them.

Adversity # 2. Two weeks later in a Neurology tutorial group with eight first year med students I get a call from my wife Charlotte. Defying company rules I take the call and learn the house is on fire and the big trucks are there. I further defy the the rules by leaving an on going class remarking over my departing shoulder the old cliche of teaching instruction, "House on fire, talk among yourselves."
It was a distressing drive. I had been too stunned to ask Charlotte for any details. I assumed the worst as any respectable Irishman would-total loss and my fault. Did I leave the stove on or power equipment running on the porch?

When I arrived 15 minutes later, the fireman had blocked traffic both ways so I had to park on a side street. As I approached, the full standing house progressively and gloriously came into view. The fireman in full regalia, the fire inspector and eventually  the sheriff, plumbers, gas people and electricians were all there. Only the clergy were missing.

How did the fire start? The dishwasher motor ignited and the fire spread laterally in both directions about six feet. The stone counter tops prevented any vertical extension of the flames saving the house. The dishwasher on fire? That seemed as likely as the sink burning or the pizza oven flooding!

Unfortunately the house and the panicked pets, freed as Charlotte entered the front door, were choked by a massive amount of black smoke, a consequence of the rubber/tar insulation all dishwashers apparently have. The kitchen was a total loss, including all appliances and the adjoining great room as well- walls, ceilings and floors. In addition all carpets and bedding throughout the house were pronounced dead.  Every single piece of clothing we own was removed, counted and taken to an industrial cleaner. Some of them including My Beautiful Jacket from Florence did not survive.

Faced with a half year of homelessness we decided to camp out in one of the properties out buildings This was our best option to stay with the animals and gardens, as well as supervise the construction. We have a barn, painting studio, spring house, and tenant shack. The insurance company offered a hotel down the street which was too depressing to consider. At this point I am feeling like a tragic character in a Tennessee Williams play.

We chose the painting studio, built in 1987 by us, almost 100 years after the house. It was designed by our old friend Robin from med school days, a brilliant architect who now lives in Boston. It is a 50 by 22 foot single room with twelve foot ceiling, eight mostly glass very old French double doors, each with transoms lining the two long sides of the building. Up front there is bay window with eight one by four foot windows, also antique, meaning the glass was poured, not pressed, with uneven thickness projecting a slightly distorted image.

It took two weeks to clear out the painting paraphernalia and to bring in the living necessities- bed, table, chairs, hot plate, toaster oven, microwave and sound system. TV did not make the cut. The refrigerator, the sink within a substantial island, and full bathroom were already here, a last minute thought when the building was conceived, in case one of our parents had to join us in their December years. Well it's November for us and here we are!

Despite the official entry into the English language of  the word "glamping" in 2005, a portmanteau of glamour and camping, I never recall hearing the word nor did I grasp what it implied until I was thrown into it full throttle by the above events. Cooking here is as fun as it is around the campfire except way easier, not to mention the comforts of shower, bed and  A/C.

Over the last twenty years I had spent only brief moments in this room, as opposed to Charlotte who had come here to paint for hours most days. Once cleared it took no time to appreciate the full panorama of stunning sites in constant view. The wavy images through some of the antique glass makes me smile every time I notice To the south there is a four acre pecan orchard with a thriving camellia garden at the distant border under giant pines blocking the road 75 yards away. There is one mature loquat tree just outside the bay windows and for the past three weeks I have frequently opened one of the windows to grab a few to eat.  On the east, a near contiguous citrus stand with lemons. limes and kumquats leading into an old forest with many trees several feet in diameter and over 100 feet tall. On the west, twenty feet away is the fifty foot long three foot high native stone wall which took three years of most of  my spare time to build. The house is on the far side another fifty feet up the slight hill.

The furnishings are the ultimate step back into time. After our wedding in 1972, we rented a room in a large old Gainesville, Florida house. It was the grandest room on the corner with large windows and great view of the hip Duck Pond area speckled by old growth trees. We had a bed in the middle of the room, just as we do now, a red table and four old bentwood dining chairs- the exact same table and chairs we just pulled out of the barn.Total value 1972 -$150. Was I happy then? Yes. I had a beautiful wife who liked her job as a designer at the best ad agency in town, more than enough money to live as a student, attending med school which was half as hard as Georgia Tech and the information so much more cleverly presented. It was a great joy to live there and learn .Glamping in this room has so many similarities to those happy times in Gainesville.

Adversity #3. At the end of the first week we are victims of an insect swarm.  A quick check on Google confirms our fears-termites. A thorough review of the choices to combat these pests suggested a complicated system involving the drilling of twelve inch holes every ten feet, around both the house and the new digs, formerly known as " the studio" and inserting a plastic toxic bait apparatus. We called the utility people who assured us they would be here to mark all gas, electric and phone lines, three days max. A week later the drillers came and of course the markers had been a no show. The guy decides to drill anyway assuring me he can tell if there is an obstacle before any damage can occur. I was as skeptical as he was confident. On hole number ten, he hits the incoming gas line at 30 psi which spews out enough stinky natural gas in one minute to alarm the neighbors and precipitates a call to the fire department who, for the second time in one month, bring the big trucks and block traffic both ways. This delays the gas guy who alone has the expertise to shut down the calamity.

The Adversity #4 Once the gas line was repaired and a few electrical problems from turning the circuit breakers off and on with the gas leak were solved, we had no problems for two weeks and perceived a gradual improvement in our "glamping" skills. Then one day the lights would not come on and the electricians came for the 5th time in 6 weeks. Peeling off the panel case we found a pile of mouse dung which had shorted it out. Nice work cats.

A decorator consult suggested curtains everywhere. Denied. To disturb the view would be a sacrilege. Are we worried about people driving by, seeing the lights, parking and then walking 75 yards to see us in our underwear? If they do take the walk and the peek, let them have it. As the trees leafed out, the flowers bloomed and the grass greened we became progressively enthralled with the entire spectacle. We miss the modern cooking devices but have become proficient with the toaster oven and magnetic hot plate. We generally send the laundry out. Occasionally we wash items in the sink with a washboard I bought off Amazon, then hang them on the clothes line which took five minutes to install between the barn and a maple tree 25 feet away. I love the nostalgic act of putting the clothes on the line.

This room is so much better than any room in the house or anybody else's house for that matter.
Epiphany-You can only be in one room at a time!

I am not sure what makes me happier-the living quarters or the fact we are able to be satisfied with so little after so much adversity. Streetcar Named Desire comes to mind. At first it appeared we would be a Blanche Dubois (played by Vivian Leigh in the iconic 1950's movie version) "depending on the kindness of strangers" - friends bringing us food or eating at their house while doing laundry and lending us some clothes to wear, But no. The play is correct but the right character for us is Stanley Kowalski (played by Marlin Brando who I love to emulate, we look so much alike). Blanche becomes the metaphor for our adversities as she was for his shortcomings, and as he so passionately cried out to her at his victory and her last tragic turn,
        " Ha Blanche, do you hear me? Ha ha ha."

Friday, May 5, 2017

Graduation Keynote Speech at Hooding Ceremony Class of 2017 Mercer Medical School

Thank you for asking me to be here.  I have really enjoyed this event over each of the last several years but only as a spectator. It is a honor to speak. I have debated whether to highlight your accomplishments (or perhaps tribulations) over the past four years, there being an "awards ceremony" later, or take this last opportunity to tell you something constructive about preparing for next year and perhaps your whole career. I'll attempt both but I want to make sure you take home four recommendations. I will contrast my experience with your previous and likely future experiences. I will also  speculate on how the differences or similarities might relate.

The difficult role in education is in primary and secondary school where some students do not want to learn or even be there. The real heroes are at this level. These teachers can take a young student, maybe it was one of you, and perhaps against all odds, turn him or her in the right direction for the rest of their lives. In contrast, med school is where everyone is smart and accomplished as well as eager to learn. What a joy it is to teach here. I am amazed so many doctors can pass on the opportunity to be in my shoes. Especially when one gets a little older. At this point I am- desperate- to pass on everything I know. It took awhile and a lot of effort to obtain the knowledge. Why would I selfishly want to take it to the grave. Teaching you guys is like handing out money, except when I go to the bank it's still there.

It is imperative to discuss your impending metamorphosis from medical student to house officer.  I have firsthand experience with this years ago, and the unfortunate talent of remembering every painful  professional situation I have ever encumbered.  "Back in the day" as I like to say, (when I was student/intern/resident) there could not have been a more monumental transition as this one.  In preparation for this talk I spent a lot of time reminiscing on how difficult it was and why. I reread the novel House of God, an accurate and scathing indictment of an internal medicine residency program at a prestigious university hospital at exactly the time I was doing an internal medicine internship at a similar place. Almost everyone in my day read it.  Some of you have also and others have asked about it. After a great deal of contemplation, I concluded things have changed so much over the thirty years between my previous transition and your eminent one, the book is no longer relevant and accounts from my personal experience would not be enlightening. The details of this change however are worth mentioning for a historical perspective.

First of all, for me, medical school was all fun and no pressure whatsoever. Everyone in my class passed every test and most of us just showed up for the Step Exams and I think everyone passed those also. The results did not even go on our residency applications. There were more House Staff slots than American graduates and if one were low on the class rank, he or she usually received whatever residency field they wanted,  but perhaps at an undesirable location such as Detroit versus San Francisco.  I'm so sorry you did not have an identical experience, though it did appear to be somewhat fun for many of you.  The MDE tests here were significantly more difficult than any test I ever took in med school. You had to study full time- 6 weeks for each Step Test as well as part-time for Step during the rest of the curriculum.  You had shelf exams for each rotation. These toils were all outside of my experience. Then Step 2 CS. What is that? How can you fail someone for misdiagnosing a fake patient. Just another layer of worry for you. Finally there was a real chance you could have not matched for residency at all.  All adding up to much so more stress for you relative to my puny stress during med school. There is nothing unique about this here at Mercer. All medical students today are likewise inflicted.

On the brighter side, being house officer is not like it was back in the day.  I worked forty straight hours, from 8 AM one day to 10 PM the next, every fourth day for the entire year and rarely got home before 8:00 PM on the nights I was not on call. There were no electives or ER rotations where you did your shift and went home without more patients on your list like chain around your neck.  I did not see one attending during a several month rotation at a big county hospital and some of the senior residents were not too helpful. I think they were resting up for their moonlighting jobs. In the surgical fields the hours were even worse, though they did do a much better job of spreading the blame if things did not go well. This predicament was almost insurmountable.  Jumping off the top of the building, like Potts, a major character in House of God was not rare.  As sorry as I am about medical school not being all fun for you as it was for me, I'm delighted you do not have to go through the pain I had to as an intern. It was a sophisticated and dangerous form of hazing.  You will likely find residency more fun than medical school.  Since the four years in med school were so much more demanding for you than me, I believe you are better prepared than I was. Likely you will see your attending every day and receive some meaningful input.

One the changes you will enjoy is more of a team approach.  It is my understanding after night call these days, around noon, interns pass the patients to their fellow house officers and no more 40 hour shifts.  You will need to have a great working relationship with whomever you pass the patients. Lives will hinge on that relationship. I repeat-lives will hinge on that relationship. Mercer grads have an advantage as house officers. From the first year here in "group" you were forced for long hours to interact  constructively with students you did not choose. Next year you will be better prepared to work with your fellow house officers with whom you also did not choose. One of our previous students now in her first year internal medicine at Emory told me recently she can pick out the former Mercer students in the hospital (where there are apparently enough to notice) as they are the ones who rally their fellow house officers when a patient unexpectedly crashes. Recommendation #1: Don't ever pass on an opportunity help to your new colleagues next year even if it is not your duty.  Your patients will benefit when your colleagues are eager to reciprocate .

There has likely been little change from my time to yours on just how different it is to be the one 'in charge' of the patient as you will be this July, opposed to the more or less observant role we both had as med students. You would have to be in bubble not to know this. This is not simply a different level of stress which, as previously implied, will not be such an increment for you as it was for me. The experience of being in charge of patients' lives is-life altering- simultaneously uplifting and frightening.  The closest generally well known phenomenon I can think of, is having a child. For the few of you who have, you know what I mean. It's difficult tell you how to balance this feeling. Like parenting, there is no consensus prescription. I have no concrete advice. All I can say is to be ready. Hopefully it will be more uplifting for you than it was frightening for me. With the changes over the last few decades, I think it probably will be.

Now for the one which will take some time to defend and also the one you might not want to hear. Money.  The older and very accomplished jazz singer Tony Bennett told Amy Winehouse " life teaches you a lot if you live long enough",  which I have and unfortunately she did not.  What I have learned, among other things, is the human species does change much, that's biology, and if so, only a minutely so over millenniums but culture can change and dramatically so in short order.  Also, it is easy to go along with that which is culturally the norm and difficult  to go against  it.  How is this relevant? When I finished my residency I moved to Macon and within a short period of time was joined by four other Neurologists  from my generation to start a practice.  We all had some debt  but nothing like the magnitude you are facing.  Despite very diverse backgrounds: small town versus large town origin, one immigrant, one from New Jersey, one local, some with parents who had money, some not, we all had the same "cultural" approach to debt.

Baby boomers like myself are very conservative financially. Brain washed by our parents who all went through the great depression of the late 20's and 30's as youngsters, it was inconceivable  we would sign on to additional unnecessary debt when starting in practice. The five of us lived exactly as we did as residents until all debts were paid. It was easy. It was the culture. Everyone did it this way. Now I see young doctors, just out of residency, the same "people", genetically speaking as my colleagues and me, in  a different culture, owing a sizable amount of money for undergraduate and med school, with a different plan. Recommendation #2: Even if the bank says it is OK at that time to buy a big house and even if many of your colleagues are doing so, it is not OK.

And why not? Two reasons:

First, from the beginning of your career you will likely be negotiating your salaries with a hospital or health network or your fees with an insurance company, hospital or health network on a frequent basis, maybe yearly.  To be effective negotiator you need to be in a position to walk.  If you have a $3000/month student loan obligation, $5000 on your mortgage plus other fixed expenses you will take what they offer even if it is a significant cut from one year to the next. You won' be able to miss a payment. You want to be in the position my niece is in now, who finished a family residency nine months ago.  She lives in a small rental, identical to her situation as a resident and has saved a good portion of her salary already. She works for a prominent health network and a couple of months ago asked about a specific time off this summer for a vacation and could not get answer, likely benign bureaucratic indifference.  Frustrated, but  confident of her financial situation, she went to management recently and said "you are telling me when I can take my vacation tomorrow or I am resigning.” They did. And I am sure when it comes to next year salary offer, if not pleased, she has enough  money to live at her current level while she takes months to look for something else.

Secondly : "Time is money" is the old saying and perhaps there is truth to this but what is more relevant  is no money (or negative money-debt) means no time and no time in the medicine game is agony. After three years of practice I owed only a doable mortgage.  I always set my schedule at a pace I could do comfortably. Of course there were few difficult patients  but for the most part I enjoyed every day. I also enjoyed call at the hospital most of the time on my call days but having no control over the number of consults, occasionally they were excessive, and on those days, instead of being OK for most of day and a little tired at the end, I was miserable all day.  To avoid this I have recently move to night call only. Years ago older docs would say to me "better to be too busy than not busy enough". From day one I muttered under my breath "I don't think so".  Nothing is more disturbing to a doctor in charge of patients than to have too many to deal with safely. I am aware of some Neurologists, and I am certain this would be true of other fields, who set their schedule every day to see the number of patients that would be a misery for me to see, as I know it must  be for them, but they feel they need to, to cover their debt. Medical school is expensive and it fine to borrow and unreasonable to expect your parents to cover it. But I plead with you to go against the current culture of assuming more debt once you have finished training.

When you are not in hurry you will have time not just to be a better doctor but a better person. There are several things that make me happy as a doctor. Atul Gwande a surgeon and prolific writer says "you become a doctor because you feel you will enjoy the work and what you find out is, you enjoy doing the work- competently." I can attest to that. I was tormented my first several month of internship because I assessed -my- competence as "suspect" (at best) despite never receiving any bad feedback. I don't think anyone cared. Of course you will take your training seriously and get competent as soon as possible as I eventually did. But other than competence, which is absolutely essential, what does it take for a doc to be happy? Do I like it when I am consulted on a case and no one has a clue and I solve the riddle?  Yes I do. I am that shallow. It turns out this is not a true joy, and just a brief thrill. That's my job, and it is not as much a thrill now as it was when my partners and I were long ago trying to establish credibility for the field of Neurology in its infancy here in middle Georgia.

Which leads me to-Recommendation # 3 Have the right patient attitude and that will make you happy. What gives me the greatest and longest lasting satisfaction begins with having  extra -time- on a difficult case. Sometimes this occurs when circumstances are beyond my control such as finishing up with one patient in the ER and waiting for another on the way. This happened three evenings ago. Sometimes it's when I have to go in the middle of night.  Once there, what's the hurry?  It's nice to go back to the patient's room, spend some extra time and perhaps address his or hers fears. But most importantly, it is an opportunity for me now and you later to be genuinely kind to someone desperately in need. This takes time. Usually no one but the patient notices and it is unlikely you will ever receive any kudos and certainly no extra money. But I know, just as I knew my competence was suspect early in internship,  and you will too when one of these many opportunities arises. Being kind to a distressed sick patient when I don't have to is my greatest and most enduring satisfaction. I hope it will be for you.

I am sure when you have your own practice your patients will all be compliant with their meds, never smoke or overeat and their definition of needing a drink is a glass of water after their daily jog you suggested. But next year in many of the hospitals I've noted you will be working, some, if not many of those patients will be there as a result of bad behavior-not taking meds, smoking, overeating, gun and knife club, driving while intoxicated. It's a mistake to be judgmental and angry. Just do your job. I wouldn't make a point of thanking them, but their poor choices likely led to an excellent training opportunity for you.

Recommendation # 4 Always, and I mean after residency, be a student. No profession lends itself to this concept more than medicine. Every field is in constant evolution. Our team has PhDs and MDs working a gazillion hours coming up with new approaches and treatment and making their results available to those who are curious. There is a fork in the road and of course you can go one of two ways: the wrong way- head buried in the sand, annoyed, bored and indifferent, or the right way- stimulated and energized by the new concepts. I see both groups of travelers and the latter are not only much better physicians but much happier people.

So in summary, in case you drifted off, the four recommendations are 1) Be  generous to your fellow house officers. 2) Don't buy that big house too soon, being overly financially responsible will buy you time every day. 3) Attitude: in addition to being the most competent you can, be kind your patients and non judgmental. 4)make a vow to be a permanent student which will best insure your satisfaction throughout your career.

In closing I would like to add something on another level altogether. For decades I was only peripherally involved  with the Medical School  having an occasional 4th year elective rotation. My main responsibilities were  my practice, the hospital and the Internal Med residency program. With the exception of the few med students who wound up staying here for Internal Medicine, like Dr. Sumner (to this day still the best resident ever) I did not have the chance to really know anyone. Of all my work over four decades, teaching you and the others classes over the last five years has been my favorite. The contact starting with the basic sciences in the first two years and through the clinical portion of your training in your last two years has provided me with the opportunity to not only to teach but to know many of you in some depth. I will always cherish these relationships. The best to each and every one of you. Thank you for the opportunity to be part of your training and thank you for asking me to speak tonight and to be part of the hooding process.

Wednesday, December 30, 2015

War(d) Buddies

I love movies and have always been inspired by the stories and characters. I should claim to be more guided by the great works of literature and religion, but that would not be true. War buddy movies have been a popular genre for decades and I was always drawn to the emotional bonding between the characters, especially when the bullets were flying and the situation seemed hopeless. The emerging friendships always seemed to transcend the predicament. Despite the dangers, I usually felt a desire to be embroiled in the same trenched warfare.

Many years ago, after a tumultuous year as an intern in Internal Medicine, where I had no help, few friends and many bad outcomes, I traveled from New York back to Florida to begin my Neurology residency. The transition from being an intern in one discipline, where I eventually gained some level of competency, to a resident in another, where I had forgotten the little I had learned as a med student, was a point of great concern. To make this monumental move from a Friday in New York to the following Monday in Florida was an additional challenge. The two hour plane ticket and the twenty four hour train ticket were identical in price. I chose the latter, feeling the geographic perspective would some how mitigate the professional chasm. With nothing to do on the train and no one to talk to, I manage to read the entire textbook Stupor and Coma by the famous Cornell neurologists Plum and Poser. This was somewhat helpful, but I still had a long way to go. I felt like one of our soldiers must have felt on the eve of D-Day heading towards Normandy. When the residency started, no one was actually shooting, but there were many potential causalities and metaphoric mine fields to negotiate. I needed a buddy.

Each in-patient Neurology Service in Gainesville was set up with two residents. The attending physicians provided some help at one of the hospitals and very little help at the other. Each resident rotated the duties of speaking to the referring physicians and arranging admissions, which generally involved arduous follow up care on these complicated patients. There was a finite amount of  work and the split was somewhat arbitrary. We had very little exposure to benign outpatient cases. We dealt almost exclusively with the very sick. Several residents in my program were famous for shirking their responsibilities and adding to their partner's workload.

I got along fairly well with everyone and even tolerated the few who did not pull their share of the weight. I did developed a very special relationship with a fellow resident named Ed, who started the same year as I did. We had completed our Internal Medicine training at separate locations and had never met, but found ourselves thrown together for the three year stint. We worked together on the wards many months throughout our stay in Gainesville. When this occurred, each of us tried to do 55% of the work. I always had the feeling, (as I expect he did) we had each other's back. We rounded together every morning on all the patients and took great care to go over each patient's physical findings and imaging studies, consistently providing constructive advice to one another. Though appreciative of specific advice he gave me, the fact I knew he was also " on the case" was critically important as it ameliorated the lonely, scary feeling of accepting total responsibility. I loved him for that. This was my first real 'Ward' buddy.

Now, thirty five years later, in my medical school faculty teaching duties with the first and second year students in basic sciences, I am encouraged to introduce some clinical issues to help the students grasp the subject matter. Often I find myself saying:
          "My friend the Eye doctor says.." or
          " My friend, the Sleep doctor says..".
Not surprisingly, these two guys are my main cycling partners. When not in the office and on our long rides we have plenty of time to share ideas and stories. Though neither has taught at our medical school, both are now well known there. The Sleep doc, Chuck, is also my 'sous chef ' when cooking pizza in the backyard. Since leaving our Neurology group ten years ago, he has built a very successful Sleep practice. I wish him continued professional success of course, but if at some point in the future there was a major technology breakthrough obviating the need for docs in the sleep world, I would not be too disappointed. I am confident I could talk him into joining me at the hospital. He always did like the intense stuff. We could then finish it out as we started, making rounds every morning with a good friend we totally trust, going over each other's cases in a meaningful and constructive manner, then off to do the individual consults. Just like in the movies.

I have come to see life as a set of concentric circles. The outside circle is the classic dust to dust for which I am prepared. Within that circle is the fetal position as an infant to the fetal position as a demented old person, which we all fear, Within that circle, potentially another, just as natural and for me, most desirable: 'Ward' buddies working together on intense cases at the beginning of our residencies, to 'War(d)' buddies decades later. In the same war. Just old soldiers.

Monday, December 14, 2015

Who Stole My Beautiful Jacket

I am aware of just how shallow it is to admit I love parts of my wardrobe, but I do. I love my Steve Jobs St. Croix black mock turtle neck shirts so much, I have five of them. I love my extensive eye glass collection and I suspect no one other than Elton John has invested in eye wear more recklessly. I love my sock collection which can't be equaled. But most of all I love my Florentine leather jacket.

My unique enthusiasm for this garment is easy to understand. Most importantly, it was a gift from my wife, Charlotte, who purchased it on our fortieth anniversary trip to Florence, where our relationship arguably began. Many years ago she did her Junior year abroad with a hundred or so Florida State students, one of whom was my brother Joe. Subsequently she returned to the USA, graduated and moved to Atlanta where I was on cruise control in my final years at Ga Tech. She gave me a call at my brothers suggestion. I "didn't get out much" so the rest  was predictable. It was a no brainer to pick ''Firenze'' for the major anniversary trip.

Florence has a lot to offer and it is easy to be entertained by it's treasures. Our personal favorite was Michelangelo's eighteen foot marble statue The David which we went to see every day even though we had to buy tickets each time. I concluded (and am not willing to take any other suggestions) it is the single greatest accomplishment of western civilization. One day upon exiting 'The Academy' where The David is housed, we went by a leather store featuring only Florentine jackets. Charlotte offered to buy me one to celebrate the trip. There were five or six different styles, in multiple colors and five different types of leather: cow, sheep, goat, deer and antelope. That translated to almost a hundred choices and after three hours of trying on almost all of them, I settled on a dark teal, doubled zippered, high collared, antelope jacket. Coincidentally it was the most expensive one in the shop.

I chose antelope because it was the lightest weight. A heavier jacket here in the deep South, where thermostats during the cool months are usually set quite high, typically needs to be removed once indoors. I have had an embarrassing history of losing a number of coats and sweaters while going floor to floor on hospital rounds, so I vowed not to take my Florentine, dark teal, doubled zippered, high collared, antelope jacket to the hospital. Never.

Recently I had the late call duty which usually involves a phone consult or two. Perhaps one in four nights I have to actually see a patient. Many of those are before midnight. We occasionally "take a direct hit" like a shot from a German U boat, and have to go into the hospital in the wee hours. Such was the case this particular evening. A nurse from the Neuro ICU called me about a problem she was having with a patient I had not previously seen.

She told me everything she knew about the case. The patient was a 34 year old man transferred from an outlying hospital five days earlier for sudden onset of confusion with a headache. He was not known to have any prior medical problems, was on no medications, had a negative drug screen, and only mild kidney damage demonstrated on his blood lab values. He had had several very high blood pressure readings at initial presentation which was surmised to be possible recording errors, because it dropped significantly with moderate doses of medication. He had an abnormal brain scan showing severe edema (swelling/fluid) throughout deep areas in the brain, including the brain stem, sparing only the surface grey matter. He was under close observation in the Neuro ICU and was back to baseline normal mental status for the last three days, without any change in the brain scan abnormalities. The radiologist's official interpretation of the scans listed a number of possibilities, but nothing definite. The nurse also informed me that during the prior the morning he become confused, but by the time he was seen by the daytime neurohospitalist, the patient was back to normal.

An unwitnessed seizure was felt to the most plausible explanation for the event on the previous day and he was placed on anticonvulsants. He was maintained on several blood pressure medications. At 2:00 AM the following morning, during my duty, he again became confused with trouble speaking and seeing. I was called when the difficulty persisted almost an hour. The nurse, who was at the bedside the entire time, was confident he had not had any type of seizure nor did he have any disturbingly high blood pressure readings. After listening to her story, I pulled up the chart on line with the feint hope of solving the problem without getting out of bed. I read all the notes by the multiple doctors who were on the case. I carefully looked at each of the CT and MRI brain scans, and reviewed all the blood tests as well as the spinal fluid results. I was stumped.

I quickly dressed and just before leaving, reached into the closet to grab what I thought was an old leather jacket of no real or sentimental value. While driving in and focused on solving the clinical mystery, I suddenly noticed I was wearing my prized Florentine dark teal, double zippered, high collared, antelope jacket. With just a flicker of attention, I decided to leave it in the car upon arrival. But distracted as I was by the details of the case, there was not a thought of the jacket for another six hours.

When I got to the bed side I found the patient to be awake and alert but definitely confused. He had no weakness or sensation loss. He had some difficulty comprehending what I was saying. He had partial visual loss on one side. I then looked into the back of his eyes with my trusty ophthalmoscope. This is always a challenge in an uncooperative patient with pupils not dilated by the drops which the ophthalmologists routinely use in their offices. We in Neurology, never dilate the eyes of a sick patient with possible increased intracranial pressure because to do so, would make the patient appear to be squeezing the brain from one compartment to another, necessitating emergent decompressive surgery.

Many years ago when I was an internal medicine intern, knowing I was going to later become a neurologist, I decided I needed to develop some "skill" which would later serve me well. This was decades before the movie Napoleon Dynamite conclusively settled the question on the importance of "skills". I vowed to make sure I got a good look at every single patient's fundus (the back of the eye one sees through the ophthalmoscope), without dilating the pupil, even if I had to wrestle with the patient for ten minutes to do so. Frequently it took that long and more often than not, it added little to the assessment. But by the end of my internship year I had acquired the "skill".

With some difficultly I was able to visualize his fundus, From what I read in the chart, no one else had been able to do so. The patient's fundus demonstrated classic finding of "hypertensive emergency" (formerly known as malignant hypertension), a condition where fluid leaks into the walls of all the small arteries (arterioles) in the brain causing a variety of neurological problems, including the ones he had experienced at the onset of this saga. Commonly on brain CT and MRI scans, fluid is seen only in the back of the brain, but not always. I concluded the man likely had had very high blood pressure for years (probably had not seen a doctor) and just before his admission, because of progressive kidney damage (admission labs) caused by the high blood pressure, he developed a sudden increase in blood pressure into the hypertensive emergency range which precipitated the clinical presentation and abnormal brain scans.

In regard to the immediate problem, I suspected with the appropriate anti-hypertensive treatment he was receiving, there was intermittently too much of a drop in his blood pressure. This often is poorly tolerated in a patient with longstanding high blood pressure. I had the nurse find the exact time earlier in the previous day when he was confused. We went over all the vital signs and discovered one hour before that episode, and one hour before the second episode after which I was called, he had a low but not critically low blood pressure reading. There is a beautiful physiology curve in standard textbooks demonstrating the relationship between blood pressure and cerebral blood flow (blood flow to the brain). The blood flow is constant even if the BP is very low or very high, with decreased cerebral blood flow occurring only if the blood pressure is extremely low.  When one suddenly stands up after lying down all night the blood pressure will drop but blood flow to the brain does not change and it would be unusual to have any trouble. On the other hand if one is severely dehydrated, the same maneuver may cause an otherwise normal person to be lightheaded or even faint from too little blood flow to the brain. When a patient has chronic severe high blood pressure, the curve "shifts to the right" and what appears to be normal blood pressure can actually result in very low blood flow to brain, causing the clinical picture he exhibited.

I told the nurse to lower the head of the bed, which increases blood flow to the brain and to give him extra intravenous fluid, which would increase the blood pressure and blood flow. I predicted he would likely come around and I drove home. When I called at 5:00 AM the patient was almost back to normal. I slept from 5:00 to 7:00 AM and when I awoke, I thought of the jacket and panicked. I quickly surveyed the closet, most of the house and finally the car. I knew once again I had left a nice piece of clothing at the hospital.

Fortunately I had been only to one unit and not much time had elapsed since my departure. I remained calm, phoned the hospital and asked the new shift, which started at 7:00 AM, to look for my beloved Florentine dark teal, double zippered, high collared, antelope jacket, stating I would call back in ten minutes. Another search through house and car was fruitless. I called back and was informed it was not in the unit. I then had a major temper tantrum, with loud cursing while throwing magazines, books and shoes at the front door, careful to miss the glass part. Without any warm up the activity was violent enough for me to pull one of my butt muscles (gluteus maximus). Barely able to make it back to the phone. I called the unit and told the new nurse I was coming in. I wanted him to contact the hospital police, the Macon police, the GBI, and have them meet me there. In my mind this was a crime requiring a well coordinated law enforcement effort.

To my amazement no one was dusting for finger prints when I arrived twenty minutes later. In fact there were no law enforcement agents present. They must have felt I was joking which was not the case. I looked all over the unit for the jacket in vain. I surmised it was gone for good and I was particularly irritated by the likelihood it was stolen by someone working the night shift, who had to have known it was mine.

I was heartbroken at the loss and annoyed at myself for having mistakenly worn my beautiful jacket to the hospital. To salvage some good feeling I went to the patient's bedside to confirm he was doing well. He was alert, completely oriented, able to understand everything I said and had no visual impairment. He claimed he had never seen me and had no recollection of our encounter hours before. What he did have to my complete amazement and delight was my Florentine, dark teal, double zippered, high collared, antelope jacket, which I had probably left on the chair next to the bed. Likely he had used it for additional warmth after my departure.

He surrendered it without argument. I walked, well, limped off, with a smile proudly wearing my absolutely favorite piece of clothing, vowing to risk freezing to death before making the same mistake again.

Sunday, January 4, 2015

Right Between the Eyes

Day one, case one, a shot right between the eyes, and in more ways than one. It was several days before the official start of my new duties as a neuro-hospitalist, but I had the solo weekend call, all new consults, at the level one medical center from Friday at 7:00 PM to Monday at 8:00 AM. The third year students had just started their twelve week Internal Medicine rotation and two were available each day to work with me. My main goal, my raison d'tre actually, to convince these students how taking a thorough patient history and doing a complete physical examination will determine the problem, would likely be apparent by the end of the first day.

There always has been a potential problem on these full 'call' days of getting too many serious cases. For years there has been one neurologist assigned to take all new consults in the hospital, the ER and surrounding ERs that have no neurology coverage. Often the weekdays numbers are overwhelmingly  "difficult".  The case load on the weekend is generally lighter, the main problem being the sixty consecutive hours of availability.

The day started well because I had not received a single call from 8:00 PM Friday through the graveyard shift early Saturday, and therefore experienced no sleep interruption. I went on my traditional short "loops"" cycling ride, staying close to home in the event I was called. Before the house was out of sight, the cell phone rang and within fifteen minutes I was on the way in.

The patient was in his fourth day of recovery after an elective knee procedure. For three days he had been complaining of a headache, which is usually nothing, but that morning he was noted to be confused, which is always something. The combination is additionally alarming.

The patient's CT brain scan, ordered by the attending physician, showed a small benign pituitary tumor. This is not a rare occurrence and if small, very unlikely to cause any difficulty.  The Neurosurgery team, who deal with tumors, had been consulted and had reassured the attending physician the tumor was  too small to be of any concern. I had been able to glance at the scan on line while getting dressed and agreed with their opinion. An MRI had been attempted but was not completed  because of the patient's claustrophobia.

When I arrived with my student in tow, we did a detailed examination confirming a mild state of confusion, an elevated temperature and a stiff neck in the forward direction, all suggesting meningitis. (Stiffness in all directions indicates other disorders). The detailed neurological exam showed no asymmetrical strength, sensation, tone or reflexes to suggest a stroke, and no visual abnormalities to implicate the pituitary tumor. A normal pituitary gland sits below the crossing of both optic nerves at the bottom of the brain, just behind the eyes and above the nasal structures and sinuses. If significantly enlarged by a tumor it will press on the optic nerves resulting in loss of vision.

The chart indicated the patient had received a spinal anaesthetic at the time of his orthopedic procedure four days earlier, which means the numbing medication was injected directly into the spinal canal. There is always a rare chance of introducing bacteria which days later could turn into meningitis. The onset of his meningitis symptoms, the headache he complained about within 24 hours of the injection, seemed a bit early, so I assumed he had some type of sterile irritation from the injection, a self limiting chemical meningitis, which we occasionally see after someone has a myelogram (dye study into the spinal canal to image the spine in conjunction with a CT scan). He had already been started on the appropriate antibiotics to cover the usual bacteria, so there was no rush to prove it with a spinal tap.

I planned to research the time sequence for bacterial meningitis after a spinal injection when I had a break during the day. Unfortunately the new patient requests were coming in at an all time thirty year record high pace, and it was 2:30 AM the next morning before I could get to my computer search. This research was done in "my office" also known as "the bed", which includes the computer, a pile of books and journals scattered on the floor creating quite an unattractive mess and a major bone of contention with my wife.  I was surprised to learn it was possible to get meningitis within 24 hours of a spinal injection. My patient therefore needed a spinal tap to exclude unusual pathogens. I was too tired to hold the needle much less point it in the right direction, not to mention I was already horizontal and down for the count. I slept four hours and returned early to reassess.

The spinal  tap was easier than I anticipated confirming  meningitis with a profile of cells, protein and glucose indicative of a bacterial infection, rather than a viral, fungal or chemical meningitis. No bacterial organisms were seen on microscopic examination of the spinal fluid sediment suggesting successful eradication with the antibiotics he was receiving. By the end of the day he had no temperature elevation and he was clearing up mentally. By the following  morning he was back to baseline with no complaints, up walking with the physical therapist and back on course to do the rehabilitation from his knee operation. I apologized profusely for taking so long to identify the problem while keeping his very nice wife in an uncomfortable state of anxiety. We said goodbye and I was off to work on the other patients.

Having spent an inordinate amount of time on the case, I  was a bit behind in addressing the needs of my other patients. I also had to drive over to the medical school for a three hour teaching stint and then drive back to my office to clear up some issues there as well as see a few scheduled  'out' patients. When I finally returned to the hospital I had quite a large number of patients on my list. I assumed my "meningitis" patient would no problem whatsoever as he was obviously on the road to recovery when last seen. I had officially signed off the case with the intention of stopping by as he was finishing his ten days of antibiotics recommended by the infectious disease team. Once stable he was moved to a room next to another person I was seeing and just by chance I saw the two of them, patient and wife, comfortably chatting as I was walking past their room. I stuck my head through the door and asked if all was OK. His wife replied he was doing fine except he had earlier in the day noted a new problem of blurred vision. This couple was the type who would have never complained to the staff much less demanded I be called to reevaluate . I thanked my guardian angel for steering me their way.

I was stunned by this compliant and knew it meant a time consuming complete reassessment. Mentally he was fine. All eye, face, throat and limb movements were normal and he had no abnormal reflexes. When testing his vision, however, I noted a subtle problem with his ability to see laterally (away from the nose) in each eye. This means one thing only: pressure from pituitary mass on the optic nerves, which cross about one to two cm above the normal pituitary gland. This impingement seemed impossible given the small size of the tumor. An urgent MRI was ordered and performed, this time with a pep talk backed up with an intravenous sedative as he was going into the machine. Sedatives administered this way carry a small risk of breathing difficulty, and I was therefore required to accompany him to the scanner, which takes forever!

This turn of events was a two edge sword. First, given the unanticipated time it was taking to do an urgent evaluation, there was only a slim chance of finishing my appointed rounds for hours. Secondly, it appeared my initial assessment was probably incorrect, likely with serious consequence. As the latter realization bounced around my tired brain, I started to get that sick feeling I have unfortunately suffered in the past,  and more than a few times. It starts as a nauseating burn in the gut which migrates up and down. As it reaches my head the demons pour out, clearly reminding me this feeling is here to stay awhile and good luck sleeping.

I started to pray, well, more accurately, I brought up the lyrics of  The Killers song: All These Things I've  Done  
         "You know you got to help me out, yeah
         Oh don't you put me on the back burner
         You know you got to help me out, yeah
          Your going to bring yourself down, yeah."

This seemed to work, because I soon received a text from the night time ''on call'' medical student who had finished her regular duties. She asked to accompany me on my rounds. I had some research to do on this particular patient in order to possibly solve the dilemma of what at first appeared to be an unrelated spurious sequence of events.  I knew the student to be very quick on the small computer she carried with her and we could research the complicated array of issues as we were rounding on the other patients. The MRI demonstrated the pituitary tumor was more than twice as high as it was wide, which is very unusual, and, as I had only recently suspected, was putting a significant amount of pressure on the optic nerves.

It was impossible for me to combine all the findings and complaints under one entity, which is my usual modus operandi when analyzing difficult cases, a variant of Oscam's razor ( i.e. entities are not to be multiplied beyond necessity).  First I re-consulted neurosurgery who recommended medical treatment with steroids, Then we did the research, or I should say, the medical student did, as I was writing notes. Fortunately, there were no unexpected problems with the other patients to distract us, at least for the moment. Initial research data confirmed my belief that if a patient with a pituitary tumor suddenly develops visual and other symptoms, a scenario labeled ''pituitary apoplexy'', there is always a bleed into the tumor. Bleeding shows up nicely on CT and MRI scans and he clearly did not have a bleed.

But when we put in a search "pituitary apoplexy" and "meningitis" we found two cases identical to mine. Both cases had a pituitary tumor, a picture suggestive of bacterial meningitis, and eventually other neurological problem including visual impairment. The spinal fluid cells, protein and sugar readings were also typical for bacterial meningitis, and not the other infectious and chemical entities mentioned earlier. The hypothesis, suggested by one of the authors, is the tumor has some type of insult, leaks protein like material into the spinal fluid, causing a chemical meningitis which for unclear reasons, mimics bacteria.  The pituitary gland then swells up and pushes on the optic nerves, which are notorious for not being able to take much pressure without permanent damage.

The next day he was significantly worse. Yuk. Looks like an error on my part was going to result in an incapacitating visual loss, likely both eyes, and in a patient I was supposed to be helping. Worse, the disabling problem, the visual loss, occurred after I was on the case,  With no response to the steroid medication, he underwent an emergent neurosurgical procedure which involves going through the nose and sinuses, drilling a small hole through the bone just beneath the brain and then removal of the tumor, which relieves the pressure on the optic nerves. If the pressure on the nerves is quickly recognized and the surgery is done in a timely, skillful manner, there is usually little permanent damage to the vision.

After this surgery, however, the patient's vision deteriorated further. I guessed this had something to do with all the inflammation from the chemical meningitis.  I last saw him at a rehab hospital two weeks later on my way home from work, with severe visual impairment in all fields of gaze, and in my opinion, unlikely to change significantly. His job required he drive all over the state and clearly he could not. This was no different than a gunshot right between the eyes, and as alluded to initially, I felt we both had received.

I was able to do my work over the next few weeks but not a day passed when I didn't think about the pituitary disaster. I vacillated between a feeling of incompetence to one of frustration over the bad luck of having too many cases to properly handle the one that mattered most. This was hardly my first bad outcome and I wondered how many more bad outcomes I could  take. Maybe it is just time to quit.

Back to The Killers:

               "I got soul but I'm not a soldier
                 I got soul but I'm not a soldier"

I have come to know the medical student who helped me on this case quite well over the last two years. She has successfully endured a tragic set of events in her own life which makes my tribulations seem trivial. She has been a great inspiration to my whining side. One night, weeks later, I was coincidentally rounding with this same student. We were at the hospital, well into the evening, looking at MRI scans on the computer after seeing all of that day's patients. My phone pinged a text from a number I did not recognized. When the message started:

                " We saw the Neuro Ophthalmologist earlier today....",

I immediately knew it was from the wife of the patient I had failed. Wincing with a sudden jolt of intense anxiety and a rekindling of that sick feeling in the gut, I squinted and grimaced as I let my eyes role to the bottom of screen to see the rest of the message. The wife was writing to tell me her husband had somehow made a late, near miraculous improvement in his vision and had been cleared to drive and work. She wanted me to know. I blinked, took a deep breath, and passed the phone to the student. She read the message, looked at me, smiled, and handed back the phone. I sent the wife a short reply:

                               "Thanks for letting me know".

Soon I was driving home in a quiet car with no music which is unusual. Convinced everything has meaning beyond the superficial, I tried to make sense of this last lightning bolt. Initially I could not get anywhere. There are equal merits to the argument I should quit now, to the one I should never quit. Then I asked myself:  "What do I do when I go to a bike race and suck?"  I always come up with a elaborate plan to get better and sometimes it is actually effective. When I run out of ideas to get better as a Neurologist, I'll know it is time to quit.

Sunday, November 9, 2014

Into the Burning Building

I am starting this piece 48 hours before beginning my new career as an inpatient Neuro Hospitalist at our 700 bed hospital. On one hand I am as excited as a kid heading to camp, on the other, as nervous as a fireman ordered into a burning building. Everything I have done professionally to this point has not only prepared me to possibly succeed. but in retrospect has been a clear pathway to what I assume will be my swan song. Several years ago I signed up to tutor a few courses for the preclinical medical students at the local med school . The decision to teach was supposed to be a logical segue into full retirement, but here I am, driving to work in combat boots (recently purchased for the event), ready for the front lines of battle in a level one trauma center.

A confluence of factors has brought me here. The first factor was 'need'. Currently there is only one neurologist at the hospital during the day, slugging it out, heroically doing all the work, seeing up to ten new sick patients a day and continuing to follow them through their stay. The Hospital has unsuccessfully spent a year trying to hire a second full time neurologist. Allocating 60 to 90 minutes to each new patient, this one neurologist has been understandably overwhelmed.

The second factor was my experience teaching at the local medical school. These young doctors-to-be simply do not know how to examine a patient in an acceptable manner, resulting in an inability on their part to determine if the patients are sick, 'why' they are sick and, most importantly, 'how' seriously sick. This disturbing fact is a national epidemic colorfully commented upon by the Stanford University Professor of Internal Medicine and writer (Cutting for Stone), Abraham Verghese, both in print and as a periodic contributor on public radio. Our local medical students are no exception. Ironically the primary reason for this lack of proper training is advancements in medical technology, most particularly diagnostic imaging, which has greatly improved our ability to evaluate patient problems since my days of training, and I am very happy it has. A physician can now frequently (not always) get away with assessing the medical problem merely by ordering an large number of imaging studies and later checking the results. But there are many instances where an intelligent and well trained hands-on  assessment will quickly lead to a more accurate assessment with no radiation exposure and with considerable less expense.

The third factor occurred when I applied for and was hired as the second inpatient Neuro Hospitalist allowing me  to see and follow a finite number of sick inpatients each day with two third year medical students. Now every single student will have the opportunity to see a dozen or so patients, complete a comprehensive physical and neuro exam under my direct supervision with no time constraints.

It is my view we are in the midst of a national cultural war on how to most accurately and cost effectively assess a patient. Though no one in an official capacity likely ever claims to forgo a detailed physical exam, somehow this time honored medical tradition has become a lost art. The echo cardiogram with  CAT and/or MRI scans of the entire body are too often these days accepted as the new standard of care. A while ago while on call, I was asked by a cardiologist to see a patient who was repeatedly fainting. The doctor had done a heart catherization and a long EKG reading both negative. He was concerned the patient might be having some type of seizure. After doing a complete exam, I told the cardiologist the patient did not have epilepsy, but merely a profound drop in blood pressure when she stood up, as a result of one of her medications. The cardiologist thanked me, adding:

               "It is easier for me to do a heart cath than to check the blood pressure".

This incident has become for me a perfect metaphor for what is missing in preparing future generations of young physicians. I have been teaching basic science courses over the last few years to first and second year med students. Teaching these four main disciplines heart, lung, kidney and brain has been one of the more rejuvenating experiences of my life. I have learned ten times what I felt possible for a number of reasons, mostly new developments in physiology since my time in medical school and residency. Besides being highly entertaining which is obnoxiously self indulgent, I have gotten to know almost everyone of the students. I am confident when we meet in their third year, they will accept my viewpoint about the other more traditional way to practice medicine: Doing an intensely detailed and informative physical examination is the hard way, but it is the right way, and the medical students as well as their patients will be the better for it.

I have fired a few volleys in the battle for awhile, running a third year ' selective' on the twelve week internal medicine mandatory rotation and a fourth year elective, both in my office. Like trench warfare in WWI, I have gained very little significant ground. In the office there are time constraints and the patients would be somewhat uncomfortable with even one, much less two, detailed multi-system physical examinations. Also, if they walk into the office, they are not likely too sick.

Is there a down side to what I have decided to do? Yes. My neurology group, myself included, spent more than five years weaseling out of inpatient duty, negotiating with the Medical Center, and encouraging management to hire three full time neurologists to handle the overwhelming number of sick patients being referred to this tertiary hospital. We felt the pay was lousy, the intensity of the problems were exhausting  and the patient/family disappointments, if things did not go well for the patient, were psychologically draining  and occasionally threatening. Our group's view was, ''the house is burning, run for your life''.To get back on the front lines will require a new level of energy and more importantly, a touch of invincibility, which may difficult for me to summon.

So how does an old guy prepare for this undertaking. Cycling, of course which has been my salvation for decades. This time however, it will require more than just being on the bike. I'll need to take my physical intensity to a philosophical level, to something more profound and relevant, namely The Rules, a popular unofficial manifesto of bicycle racing/training etiquette, well known by most cycling aficionados. There are 80 or so, covering all aspects of the sport, including grooming, attire, tucking on downhills, holding your line etc. But the most important and most relevant from my current position is, Rule 5:
                                   "Toughen the fuck up"