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What I love in medicine
Written by Ed Leap   
Friday, 02 January 2009

Consider what you love

 

             

            I love the skin of babies, because it is soft, and because it bears none of the scars that time, sickness, injury and heart-ache will leave.  It is a canvas waiting to be filled with kisses, touches and embraces   But I love the skin of the elderly because it is textured with time and stories, like imprints on a vinyl record.  Wrinkles simply represent long life, stored in the many hills and valleys of a body that has seen much, and endured much.  Touching the skin of our patients is such a rare delight.

            I love, in an odd way, the sound of patients crying.  Not because I want anyone to suffer.  I love crying because I have cried.  Falling tears and heaving sobs are signs that we are all equally vulnerable.  They mean that we have in common our frustration with this life, and our desire for help, healing or simply comfort.  Sometimes, when a patient is crying, I want to hold them close.  I’m not there yet, but maybe I will be one day. 

            The sound of breath, smooth and clear or sonorous and rattling, is fascinating to me.  I think I love knowing the difference between good breaths and bad.  It is magnificent to have listened to that sound thousands upon thousands of times.  They say that with every breath, we inhale a molecule of air that Julius Caesar exhaled on the Ides of March.  By now, I can almost hear him say ‘Et tu, Brute?’  It is a gift, an amazing gift, to have heard life move in and out so many times. 

            Equally fantastic is the sound of the heart.  I am fascinated every time that I hear its amazing twisting movement and contraction, its mysterious expulsion and reception of blood that occurs over and over again until one day, with similar mystery, it ceases.  The heart is special because as I listen, I may put my hand on the wrist or neck of the patient, and feel the pulsations travel down the highway of arteries, feel it beat against my nerve endings and travel back up all the long distance to brain where I sense it.  And across infinity to my mind, where I perceive it.  The heart gets inside my head, you might say, and its beating can thrill as much as its cessation terrifies. 

            I am enamored of examining the abdomen, wherein lie so many organs, so many blood vessels, babies in the process of becoming, tumors in the process of destroying.  To examine the abdomen is to shake a Christmas package, wondering what might be inside.  I love the feel of appendicitis, though I am sorry for those who endure it.  There is such joy in seeing the wisdom of our teachers made manifest in our hands, and confirmed in the truth of our suspicions when the diagnosis is made.

            The smooth symmetry of intact limbs is artistic, but equally wonderful is the way I can know, frequently without any test, that a limb is broken.  The many shades of blue and gray that surround fractures are testament to the underlying dysfunction.  There is an awful artistry to the jagged, disordered, fractal geometry of broken bones.

            Wounds of all sorts are oddly amazing, and I have touched so many that I almost enjoy the reproducible warmth of blood, and its smell, as it pours across my gloved hand and I admire its lovely scarlet shades, my delight nearly vampiric.  Holes and slashes from weapons are unfortunate portals into the mysteries of the living, and sometimes the dead, human body.  I hate to see such suffering; but I am a voyeur of the flesh, having spent so many years hovering over it and touching it. 

            And death, death!  The lessons it has taught me over the years! It is sudden and slow, painful and painless.  It is tragedy and loss, hope and opportunity.  And it is a thing unlike any other.  I have seen life depart in young and old alike.  I know, through death, that there is something indescribably holy that enlivens us all before that moment and that leaves with breath and heartbeat.  I sense, in that fact, indescribable hope.

            We humans are such pieces of wonder.  Every year that I have the privilege of practicing medicine, I realize that what I’m actually practicing is far more.  Medicine is the word for the study of the soul and flesh that dwell together in humans, and by which we physicians seek (in our limited ways) to put it right while it walks the earth; and before it is lain to rest in the earth.

            Spend a day, now and then, in amazement.  Love the broken, touch the sick, caress the dying, shake hands with the scandalous and wicked, embrace the mad.  Learn the feel of their heartbeats and the sound of their breaths, the color of their eyes and the textures of their hair.  Each of them is a wonder no less than the stars. 

            Learn to see your career that way, and you’ll be able to keep going from body to body, wonder to wonder, without misery.  Let this be the year you fall back in love with your career by falling back in love with humanity, with the amazing structure and function of each human, and with the eternal worth of each and every life entrusted to your hands. 

            . 

 
Medblogs Grand Round!
Written by Ed Leap   
Friday, 02 January 2009

Greetings all!  I'm hosting Grand Rounds for January 6.  I want to tell you about the theme.

Profit in health-care.

What do I mean?  Well, lots of things are driving my thinking here.  The Obama administration may create long-lasting changes in the reimbursement of health-care, up to and including a single-payer system.  To increase the numbers of primary care physicians, there's talk of paying for the medical education of those students interested in primary care, so that they won't have a burden of debt and feel compelled to enter high-paying specialties.  (The tacit assumption reasonably being that their primary-jobs won't be very lucrative.)  All over the house of medicine, we find invective against the pharmaceutical industry; for manipulating data and (let's be honest) because they seek to make hefty profits.

And if we, as physicians, want to make plenty of cash, are we hypocritical when we come down on big Pharma?  I mean, is everything we do, and recommend, really evidence-based and in the best interest of our patients?  I don't know all the answers...I'm just posing the question.
So, as physicians and others in the greater health-care world, what do we really think about profit?  We're taking care of people in need, many of whom have limited incomes and no insurance.  Humans don't always choose their illnesses (though they often do).  Many really need medical care; some just desire it.

As health-care providers, we're often working in dangerous environments, subjecting ourselves to the risks of infection, physical harm, lawsuits, exhaustion, relationship troubles and burn-out.

In light of all that, should we be turning a profit?  Should we feel entitled to lots of money?  Are we any different from other necessary professions?  Should your contractor build houses at minimal profit, since people need shelter? Should auto-makers sell cars without much profit, since people need transportation?  It's an interesting question.

Will young people endure medical education and practice without the promise of significant profit?  Will the young physicians now in practice continue?  Or, if we decided to pay less, would they simply become clock-in, clock-out factor workers?

Does the promise of financial gain make us better providers or worse?

Does profit compromise our morality, our compassion for those in need, or even our faith (to those so disposed)?

OK, hit me!  Send links and responses to my e-mail at:

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As before, you don't have to follow this theme.  But if you do, I'll be interested to see what you have to say.  I'll tell you my thoughts on January 6.

If you don't blog, and want to add your thoughts, send me an e-mail.  I'll make a place to post your opinion.  If you don't want your name attached, just say the word.

Have a great day, and a blessed, Happy New Year!

Edwin

 
A gift of truth
Written by Ed Leap   
Saturday, 13 December 2008

A stocking full of truth!

 

 

Merry Christmas to all! 

 

I was trying to think of what I could give you, as a kind of gift for the season.  I love getting gifts and I sure love giving them.  But the readership of EMN is pretty large and with four children of my own, it would be a financial stretch for me to send you a stuffed animal, toy soldier, book or pocket-knife; a bracelet, pen or watch or any of the things I enjoy giving.  So I was thinking between patients the other day about the things I can give you.  And I figured it out.  I can give you some truth.

 

One of the things I have always loved is truth.  I love absorbing it in books, in quotes, in lectures and sermons.  I love passing it on to my children.  I love hearing learning the truth in tiny snippets; the sorts of things I scribble into my notebooks, or write in the margin of a book.  I love the way it leaps out at me in interactions with doctors and patients; and the way novelists and poets can ambush me with it while I’m skipping innocently through a book.  The truth is a gift that’s hard as steel, sharp as a razor and absolutely critical; at this point in history perhaps more than at any other.

 

I enjoy writing for you because I enjoy writing the truth.  I have tried to convey it over the years, and you have all responded wonderfully.  We share a passion, you and I, for the unspoken, the obvious but neglected, the ‘great purple elephant’ in the room that no one wants to mention for fear it may get its feelings hurt.

 

So, fifteen years into my practice, and 8 years into my writing career with EMN,  I think I have some collected truth and a few ‘rules of thumb.’ I hope you enjoy.  Don’t expect anything under the tree…I’m working Christmas Eve!

 

1)  The key to competence is compassion.  If we don’t truly care for the well-being of our patients, no double-blinded, placebo-controlled, randomized study will make us better.  And no system of time-outs, prompts or algorithms will substitute for our developing genuine love for the people entrusted to our care.

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