| 3 April 2015
Dear Interested Readers,
Inside This Week’s Letter
I had a wonderful surprise awaiting me in San Francisco this week. The first part of this week’s letter is my report of that experience at San Francisco General Hospital. The introduction to the story is a review of “Lean language” with some speculation about why accepting Lean as an effective tool may be problematic for some healthcare professionals. I am sure the whole story is much more complex than my musings.
The letter is long because it includes Part 3 of the four-part serialization of a piece of almost truth and some fiction from my experience as an intern about 44 years ago. Some of the fiction is just a function of failing memory.
Please check out the postings on strategyhealthcare.com if you have not done so already. If you have been there before I hope that you will return time after time and let friends and colleagues know of its existence. The Strategy Healthcare site is also where anyone can sign up to receive these weekly letters.
The Gemba By The Bay
Like the old joke that says you can divide the world into two groups, those that do not want to be taught and those that do not need to be, the “Lean world” can probably be divided into two groups many ways. For example there is one group that likes the exotic Japanese lingo and uses it all the time and the other part of the Lean world would translate everything into verbiage that is pure English and can sound boringly technical. There are those of us who are fascinated by the opportunities Lean offers to improve care and speed our way toward a world that looks and feels more like what we dream of when we think of the Triple Aim; and then there are those who shudder and become inexplicably angry when they hear the word Lean. For them Lean is a new term in the world and is a “mot d’ordre”. Mot d’ordre translates from the French as “watchword” or “password” but Jonathan Cray, Professor of Modern Art and Theory at Columbia University, defines “mot d’ordre” in his book 24/7 in the context of more complex meaning of nuanced language described by Deleuze and Guattari, as “…a command, as an instrumentalization of language that aims either to preserve or to create social reality, and whose effect, finally, is to create fear”.
Said simply the word “Lean” may have created yet another division in healthcare. Many of our colleagues who feel oppressed by a variety of other “negative externalities” like electronic medical records, ICD 10, new regulations promoting transparency, continuously declining revenues and other obstructions to professional life as they would like to live it, have added Lean to their growing list of concerns and bedevilments. They do not see Lean as a philosophy and “operating system” that can create a new symphonic masterpiece out of the cacophony that has replaced what they remember as the harmony of their lives “back before all this began to happen”. They see Lean as another challenge to the world as they have known it and want it to be again or at best an unnecessary learning curve and challenge to the reestablishment of the stable world they think that they once had. Lean epitomizes the worst concerns they have. The very word may remind them that they are trapped in an aforementioned “new social reality” and as such the presence of the “new social realities” are associated with words and terms like Lean, ACO, Obamacare, and value based reimbursement. For some it may be that the word Lean is a local enhancement of their fear and sense of loss of control. For them it could really be a “mot d’ordre”
Many who believe in the ability of Lean to improve care and perhaps offer some relief to that increasing number of physicians who are succumbing to “burnout” and who are using Lean tools to move toward the new and challenging goals of healthcare reform have wisely learned to avoid conflict by using euphemisms or more ecumenical terms like “continuous improvement” rather than dare say Lean. Even within the “Lean world” there are those who never use the Japanese phrases that provide for me much deeper meaning, but prefer instead to opt for English translations. As an example, a “kaizan” event becomes a “rapid improvement event”. I have spoken both ways but have come to love the phrases like “Hansei” which means deep reflection. Kaizan, Hansei, gemba, muda, Hoshin Kanri and all the other terms provide me with a sense of color and deeper meaning. As I have sought to become familiar with them and what they mean I find the necessity to pause and think about them for a moment to be an exercise that adds to my own understanding of the deeper principles.
I think that “respect for the hearer” may determine usage. If your are trying to help someone then forcing them to listen to you use a word that causes concern, anger or diverts attention away from the critical issue of the moment just so that you can be a purist or exercise a personal indulgence, may not promote learning, be respectful, or be a tactic that will advance understand or the desired outcome. I have taken the middle road of mixing in a few Japanese Lean terms with audiences that I do know because the words seem to promote understanding or because there is not just one equivalent English word. I do it rarely with people or audiences that I do not know and with caution with people that I do not know well because experience has taught me that just the mention of Lean and its “language” with Japanese words like “gemba” can cause some to bristle.
I am not apologetic about Lean because I see Lean as an excellent approach to the problems that face organizations at this moment of transition in healthcare and not as an aggravator that disrupts professional lives or as a threat to “clinical values” or to anyone’s legitimate degrees of freedom in practice that we so fondly refer to as our “practice autonomy”. “Gemba” is one of the first terms that I use when I want to speak about where the power of Lean comes from or discuss how Lean leaders function. Gemba means “where it is happening” or “where the work is being done” and that is where I want to be.
This week I had the opportunity to go to the “gemba” at San Francisco General Hospital where I was part of a group hosted by Dr. Alice Chen and Dr. Delphine Tuot. Dr. Chen and Dr. Tuot were supported during the presentation by other associates as they walked our visiting group through their work to improve the referral process for the outpatients who get care through SFGH and its network of neighborhood clinics. Neither their presentation nor our visit was scheduled as a Lean event, although the concern on both sides was better clinical access and improved utilization of specialty appointments and expertise.
It did not take me long to remember Dr. Chen who trained and worked at the Brigham from 1996 to 2001. Since leaving the Brigham she has been on the faculty at UCSF and most recently she has been leading the ambulatory teaching practice at SFGH where she lead the work on the referral process. She has recently accepted the position as the CMO of the affiliated San Francisco Healthnet (the clinic system in neighborhoods, schools, and jails) that provides care to the underserved populations of that great city.
I was also delighted with the bonus opportunity to learn about “Healthy San Francisco”, which since 2007, much like Chapter 58 in Massachusetts, has provided coverage for all the uninsured of San Francisco. Quite unlike Chapter 58 that coverage is also extended to undocumented patients who now even after the ACA would not otherwise have coverage. Healthy San Francisco also provides coverage for those who fall through the cracks between the Medi-Cal Expansion of Medicaid through the ACA and the subsidized coverage of the “Cover California” state insurance exchange created after passage of the ACA that which is the equivalent of the Connector in Massachusetts.
If you are interested and want to learn more about Healthy San Francisco and San Francisco Healthnet just click on the links below.
http://healthysanfrancisco.org/
http://en.wikipedia.org/wiki/Healthy_San_Francisco
https://www.healthnet.com
As Dr. Tuot, who will now lead the work as Dr. Chen assumes her new responsibilities, got into the meat of the presentation, I was thinking that the work of the referral process was a “value stream”. She never used any Lean language but she described the reason for action. The referral process had become cumbersome and overloaded, as more and more patients need the help of a specialist. There was also the opportunity to use eConsults as alternative touches if the problem and the patient were appropriate for that kind of support for the referring PCP.
As Dr. Tuot, a UCSF trained nephrologist with an academic interest in practice improvement, presented data about the size of the problem, the SFGH patient population, and the mechanics of the referral process before the new work routines were instituted, I realized that she was giving us a glimpse of what the current state had been back in 2010-2011 when the work was conceptualized. At that time it took up to eleven months to get an appointment with a specialist in medicine or with any of the surgical specialties. If a PCP wanted a patient seen urgently they needed to be ready to invest in some time consuming political maneuvering, be good at cajoling and be ready to bargain. There was no semblance of the right care, in the right place, at the right time by the right provider. Dr. Tuot used a phrase from Dr. Tom Bodenheimer, professor of family and community medicine at UCSF, to describe the previous referral mess, “…a perilous journey through the healthcare system.” The referral process was a problem that was only going to get worse given the fact that their population was aging and that the average patient over 65 needed more than two referrals to a specialist every year.
When the work began the SFGH associated practices served almost 125,000 patients with 70,000 getting their care in the network of community clinics. Thirty seven percent were uninsured (now post ACA that number is 15% which is why the city sponsored San Francisco Healthnet remains important). Medicare and Medicaid covered most of the others except for a small population covered by commercial insurance that is now somewhat larger with the subsidies to the insurance exchange created by the ACA. The population is diverse with 23% Caucasian, 16% African American, 30% Hispanic and 28% Asian.
As they imagined an ideal state they realized the possibility of transforming the journey described as perilous by Bodenheimer to a process that was patient centered and much closer to the ideal state of the “right care, at the right time, in the right place by the right provider”. Their objectives also included creating a process that respected and improved the work experience of the people who did the work. They wanted the process to be easier and more efficient for PCPs and much less stressful for the staff that supported the PCPs and specialists. They also wanted the process to yield more appropriate referrals and with less hassle gathering the appropriate data for the consultation. A key goal was a system that enabled everyone to work at the top of his or her license. Another goal was aligned with the educational mission of SFGH. The process was seen as a way to provide educational support to PCPs since many of them were either students or house staff working in the clinic environment (much as I have described in “Elizabeth McCarthy” part three, later in this letter). A final objective was the exploration of the innovative use of eConsults.
I must assume that whether or not the team used A3 language, talked about a SWAT analysis or were thinking PDSA, the end result was a process that they “tested”. They began with a pilot in GI as their experiment. The new process is triggered by a PCP’s desire to schedule a referral. That referral process is designed to make sure that there is clarity about the question that is being asked and clarity about how care will occur and who will be responsible after the referral. All the appropriate EMR data is flagged and the appropriate testing data is gathered. An experienced consultant reviews each request. The job of the reviewing specialist is to “triage” the requested referral to his or her specialty, to make sure the referral is appropriate, that the referral is appropriate, that the question is clearly stated and the information necessary to have an effective consultation is available to the consultant. For these senior consultants working as reviewers, the review work is part of their “standard work” and they are appropriately compensated.
Getting agreement on the basic design of the process “required a lot of meetings and negotiations”. When I heard that I just chuckled to myself and began to look at Dr. Chen and Dr. Tuot to see if they had any scars or missing body parts. Perhaps time and success heals the wounds of battle because both of them seemed to be healthy and happy on the other side of fostering change.
The basic flow pattern used by the reviewers was to first divide the requests into urgent and non-urgent consults. Urgent consults were booked even if they required forcing a place on a schedule by overbooking. Non-urgent consults were given “next available “ appointments. If the reviewer thought that the referral question was unclear, the PCP was informed and a didactic interaction with the reviewer began that could have several cycles of back and forth before there was complete clarification of the concerns. This process was performed electronically and in essence was both an educational experience and an eConsult. The outcome was assured within an appropriate time frame and obviously the attitude was one of teaching and fostering greater clarity of the clinical problem. It was respectful for all and of benefit to patients because a referral that leads to no answer is a waste of the patient’s time as well as a waste of a scarce appointment slot in a crowded specialty schedule.
Metrics are a part of all good processes of continuous improvement and innovation. After a successful pilot with GI, the process has been implemented across the system with high satisfaction from all involved. There have been more than 70,000 referrals through the system every year for the past three years; and 50% end up scheduled as non-urgent within two months in all specialties; . 10% are truly urgent and are seen in time frames measured in hours if appropriate or in days when that is the correct interval; 20% of the initial referrals go back to the PCP for more information before being scheduled after the questions and data are eventually appropriately assembled. Finally, 20% become eConsults because the exchange with the reviewing consultant yields the clinical guidance requested by the PCP.
The collected data shows that both PCPs and specialists like the process because they recognize that they are more collaborative and are delivering better care with shorter waiting times. PCPs like the quick access to specialists and specialists like the fact that their time is more appropriately used. Some PCPs think of the process almost like “care based CME”. The eConsults or “virtual consults” keep the patient in the PCMH and decompress the specialty schedules of appointments that were unnecessary. The specialists see a higher “case mix index” of problems when in their offices and are more comfortable with thinking of the eConsults as more formalized “curbside” consults that are a better teaching tool.
The work of the reviewing consultants has become more standardized in time. Their work is reviewed for appropriateness and quality. In many of the specialties the waiting time for a new appointments has been reduced by more than 80% and is well below two months and sometimes less than a month. Within SFGH 79 PCPs say that the eReferrals have improved the experience of care for their patients, 16 say there is no change and only 4 think that care is worse. Very similar results come from the external affiliated clinics. As part of the discovery process of the experiment, the work has identified what makes a good reviewer.
- Enjoys educating colleagues
- Understands value and waste reduction
- Attuned to overall responsibilities of specialty service in context of larger system
If you know me, you know that I pestered the team with questions throughout their presentation. I kept saying to myself this is a beautiful Value Stream. There is A3 thinking here. These people are Lean leaders creating a culture of respect for patients, providers, and support personnel. They are good stewards. They are increasing value for the customer and eliminating waste while teaching all of this to the next generation of providers and improving the PCMH model and collaboration with specialists. This is fabulous!
After two hours, as we were leaving I just had to ask Drs. Chen and Tuot if I could write about what I had heard. They were delighted and said sure. I then asked Dr. Chen if she had done any reading about Lean or had any experience with Lean. She smiled and said that she had been to ThedaCare. She has been getting some advice from John Toussaint and others at the ThedaCare Institute.
I had the good fortune to spend a little more time over dinner with the two Lean leaders and had the added good fortune to attend another meeting the next day with Dr. Chen. We talked about Lean and our shared belief that it represents an institutional manifestation of the Scientific Method. Dr. Chen told me that she thought that to be most effective she believed that Lean must be the operating system of the management team and the foundation of the culture of the practice and not a set of tools for one-off projects. That statement alone is proof that she has been to Appleton, Wisconsin.
We talked about ThedaCare and John Toussaint. We talked about the importance of C suite and Board level support and leadership if Lean is to thrive. We talked about Dr. Patty Gabow’s inspirational work at Denver Health with a very similar underserved population and we chatted about Marshall Wolfe, a wonderful mentor for both of us at the Brigham. Marshall sent me to Harvard Community Health Plan and he was equally directive in Alice’s career decisions. I left San Francisco with my own sense that Lean is making a difference in San Francisco and that young leaders like Dr. Tuot and Dr. Chen are using the principles of Lean thinking and culture to advance the Triple Aim in San Francisco. I was inspired.
Introduction to Elizabeth McCarthy’s Story, Part 3
This is the third segment of four in the serialization of a story that is true in principle and in its presentation of the experience and stresses of training in not totally factual. Is I said a few weeks ago paraphrasing Kris Kristofferson, it is “partly truth and partly fiction”. Misquoting Joe Friday from Dragnet, most of the “The names have been changed to protect the innocent”. In the first episode we meet Elizabeth McCarthy as she presents to the Peter Bent Brigham Hospital in the early morning hours after an episode of “flash” pulmonary edema. The second part is a rehash of her experience on the old “ward service” where she serves as the subject of teaching as she recovers. In the segment this week she returns to see me in the outpatient clinic for follow-up.
After the final segment next week the entire piece will be available in the archives of the letter where you can now find Parts 1 and 2 if you missed them.
http://app.getresponse.com/click.html?x=a62b&lc=9DFL5&mc=Iy&s=Gxi6Lx&u=VZl2&y=q&
Elizabeth McCarthy’s Story, Part 3
She was discharged on Friday evening. My clinic was on Thursday afternoons. Clinic days were always a stress. Clinic started at 1:30. If you had been on call the night before it was quite possible that your last hour of sleep had been between five and six AM the previous day, thirty plus hours earlier. When you finished clinic three or four hours later, there was still the usual ward work that needed to be done before you “signed out” to the intern who would “cover” your patients for the night. If clinic fell on a day when you were on call, work was accumulating on the ward while you were seeing your six to eight outpatients. Either way, “clinic day” loomed as a distortion in the seemingly endless cycle of days on call and a few hours off.
Despite the stress I always looked forward to my clinic. It was a window to the future for me. Hospital work is episodic. If your practice is limited to the hospital, you see a patient for a few days in the middle of an ongoing process and then return them to the community, hoping that they will remain well and never need return again. If they do return, there is no certainty they will come back to you. I do not pick up a novel and read a random chapter and then return it to the shelf never to look at it again. Even as I began my career in medicine, I intuitively knew that I wanted to be someone’s doctor for the long term. If you become my patient, I’m your doctor until you leave the relationship.
Part of the joy of practice is the diversity of patients. It is exciting and challenging to try to understand and help people from all races, all educational backgrounds, all age group, all cultures, all sexual preferences, and all social situations. I am fascinated by the lives of people. I draw inspiration from the privilege of observing their lives as life goes on day after day and year after year. Years ago I saw the play, “Same Time Next Year” which followed a couple as they conducted an affair seeing each other for a weekend once a year over decades. Practice can be like that. The doctor and the patient become part of each other’s lives and go forward together often not seeing each other for a year or so but immediately renewing the relationship on the next encounter.
Well, it had only been six days and I was eager to see Mrs. McCarthy. Four months into my internship I had admitted dozens of patients but there was something that seemed especially interesting about her. What was it? Was it that I was the first doctor she had seen in many years and was therefore a different, “fresh” patient, “untainted” by the work of others? She was not like so many of the other patients who seemed to be professional actors who let us “play doctor” with them in exchange for the care they so desperately needed. They would put up with the endless stream of medical students, interns, residents and “attendings” all asking the same questions, doing the same exams. We would argue the findings and observations seeking to demonstrate superior knowledge and insight. We often had our debates at their bedside as if the patient were in a coma or totally uninterested in what seemed to the medical personnel to be so fascinating a problem. In the tradition of the medical wards of city “teaching” hospitals they bartered their “teaching value” for their health care. This transaction had been the backbone of medical education in Europe and America for over two hundred years. It was not immoral; it was perhaps insensitive and impolite. We thought we were benevolent with the patient’s best interest as our motivation. It was the way we trained doctors. Mrs. McCarthy was new to this transaction and I was the only “young doctor” she had experienced. Maybe there was some other explanation. Perhaps I just really was interested in knowing how she was doing. I wanted to read the next chapter in her story.
I had thought about her frequently during the six days since she had gone home. I was worried that I had increased her diuretic too much as she left and as a result her potassium could be dangerously low. If I over diuresed her, perhaps her renal function had deteriorated and now she would not “clear” her digoxin and would be poisoned by excessive accumulation of the drug in her blood. I was sure she would have difficulty following a low salt diet. Perhaps she would have retained fluid. There were a thousand things that could have gone wrong. Seeing her was the treatment for my anxiety. What if she did not keep the appointment? I could have called her but that would have exposed my uncertainty. I was just as sure that she would be well as I was sure that something bad had happened.
The clinic was housed in a wing of the old student nurses’ residence at the opposite end of the hospital from F2. Sometimes when I walked the quarter of a mile to the clinic I would revel in the thought that I was walking the same path of many famous Brigham doctors. As I walked past the door to the operating room, I knew Harvey Cushing, a pioneer of neurosurgery, walked this same hall on the way to remove a pituitary adenoma that was causing Cushing’s disease. Joseph Murray walked into the same OR to transplant the first kidney. Just above me Sam Levine, one of the greatest of all clinical cardiologists was brave enough to get people with heart attacks out of bed and up in a chair when common wisdom kept them in bed for weeks. Soma Weiss the brilliant young physician whose last diagnosis was his own exploding aneurysm must have walked this hall on the last day of his life. George Thorn, who was retiring as chief of medicine this very year and a pioneer in endocrinology, speed up and down this route everyday checking out research on E Main that was supported by his famous patient, Howard Hughes.
The Peter Bent Brigham Hospital was built in 1913 (the year we invented income tax, a death and taxes connection?) behind the new (1903) site of Harvard Medical School. It is a perfect example of how the solutions to today’s problems are tomorrow’s problems. The Brigham was built before the era of antibiotics when infectious disease was the most dreaded enemy. The new hospital won architectural awards for its revolutionary design. It was a campus. There was a central administrative building with Grecian columns at the end of a park like drive that passed through decorative iron gates leading to Brigham Circle and Huntington Avenue. On the right side of the drive parallel to Huntington Avenue which flowed from Richardson’s Emerald Necklace toward the Museum of Fine Arts and Brahmin Boston’s Symphony Hall were the nurses’ building and the clinic. To the left was the “A” building for private patients. The other buildings spread over the acres to the west. They were lettered “B”, “C”, and so on down to “F”. Over the years other buildings appeared like metastases between letters and along Shattuck Street, the alley way between the hospital and the Medical School, the Harvard School of Public Health and Children’s Hospital.
The original idea was that disease would be confined to a single building and the doctors would have to walk through fresh air and sunlight as they went from one building to the next. I do not think it took many Boston winters before the buildings were connected by a covered walkway, which became “the pike” and below that ran the subterranean tunnel through which I rolled Mrs. McCarthy on the night she was admitted.
I liked the “pike”. Running to a “code” or walking fast to get to clinic on time was the best exercise I got in the five years of my training. On this day I was hurrying to clinic not wanting to be late and in a state of great fear and anticipation of what might await me. I ran up the stairs to the second floor and there she was sitting on a metal folding chair along the wall of the corridor that served as a waiting room. She looked like a well person. She was dressed in a simple cotton print dress with blue and pink flowers and wore a slate gray cable sweater that looked hand made. It had pockets that looked useful. She wore laced black two-inch heeled shoes which as a child I had called “old lady” shoes. My grandmothers and all the older women at church wore them. I noted little mother of pearl earrings and she looked like her hair had an added wave. It had a faint blue tint.
I sang out to her, “Hello Mrs. McCarthy, how are you doing? You certainly look nice today.” I was delighted with her answer; “I’m very well and thank you Dr. Lindsey”. I collected her record from the clinic office and escorted her into my “office”. I spent the next thirty minutes asking her all the right questions. I reviewed her physical exam. I talked with her about her diet. I was pleased with my management of her congestive heart failure. She was doing well. I asked her to wait for a few minutes while I walked down the hall to review my plans with the clinic “attending” who was hanging around chatting with the clinic secretary and drinking coffee. He seemed a little annoyed with my intrusion and quickly signed off on my assessment and treatment plans.
When I walked back into the room she was staring out the window at Huntington Avenue and the people waiting for the trolley. She looked a little sad. I had not seen the look before. I asked her if she was feeling well. She quickly composed herself and said that she was fine. “I was just thinking about the trip home. I hope it doesn’t rain.” I asked her where she lived and did she ride the Green Line. “I used to have a nice apartment of my own in a “three family” just up the hill. She pointed to Mission Hill, which rose out of the eastern side of Brigham Circle. The Robert Breck Brigham Hospital sat on the crest of the hill like a medieval castle, which looks down on the peasants in the town below. “Now I have a room in my daughter’s home in Jamaica Plain.” Her tone and inflection communicated loss and an unwelcomed transition. It sounded lonely and isolated. I had a “nice apartment” contrasted with “Now…a room in my daughter’s home.”
I asked if she still visited friends on Mission Hill or went to the Mission Church. “Most of my friends are gone and I just don’t get out much.” I remembered the hill she had to walk up to her daughter’s house and now to her “room”. I started making clumsy suggestions about meeting new friends and finding a senior center. She listened politely. I eventually talked long enough to bore myself and recognize the futility of the situation and finished with the thought that maybe before long she would feel well enough to ride the trolley all the way into Filene’s Basement and would not that be great? I guess that my thought was that Filene’s Basement must be every woman’s idea of a great day out. She told me that she did not get much Social Security and that was why she lived with her daughter. I got the message. If you do not have any money to spend, why would you want to go downtown?
“Well now, let’s figure out when you should come back”. I suggested a month would be about right and then realized that would be Thanksgiving Day. “Well why don’t I see you the first Thursday in December.”
Her response surprised me, “Shouldn’t I come back sooner?” We settled on the Thursday before Thanksgiving. She left for the lab to have the EKG and blood tests that I had ordered. After she was gone I sat at my desk trying to write my note about the visit into her chart. I felt a little sad and unsure about what had happened. I was reassured that her condition was stable but somehow I was not at all sure she was well.
There was a time when I would say that I was not drawn to medicine because I was fascinated by the study of diseases. I did not become a doctor to advance the science of medicine. It is was not the challenge of promoting health to people by trying to teach, cajole, or convince them to make healthy choices in their lives that called me to medicine. I am committed to using any tool, including fear-inducing projections of disasters to come, to promote health, but I didn’t become a doctor just to be an evangelist for health. After the list of why “I didn’t become a doctor to…” I would facetiously say, “I became a doctor to be a voyeur, a peeping Tom through the windows in the lives of people”. I never believed it. I just thought it sounded interesting. It was sort of an explanation for my atypical orientation toward clinical practice in such a specialty and research-oriented environment as Harvard Medical School and the Brigham. I was a student of sick people, an observer who was passive and maybe a little titillated by the excitement and drama of medicine. Sitting there after she left I felt strangely vulnerable. It was not sure on which side of the window I stood.
The next three weeks passed quickly because I was finishing my time on the women’s ward and looking forward to my vacation on the “TCC”. There were a few easy “rotations” during the internship. When you finished the wards you were given R&R on E Main, which was the previously mentioned research unit of Dr. Thorn that was officially called “The Clinical Center”. It was an endocrine metabolic unit. There were also a few cardiac research patients. Sometimes patients were even paid to be there participating in research.
I remember almost nothing about the TCC except meeting a very shy young man with a brain affliction that drove him to eat. He weighed almost 700 pounds. I think I slept for most of the month. Mrs. McCarthy was on my mind for the first few days after her visit but then life on the ward and things away from the hospital filled most of my consciousness and Mrs. McCarthy’s face popped up in front of my mind’s eye only from time to time. I would quickly flip through her problem list in my mind and set myself at ease realizing that each problem was well addressed and then let go of her image for another day or so.
The Thursday before Thanksgiving was one of those late fall days that serve as a preview of the misery to come over the next five months. An intermittent cold drizzle was occasionally interrupted by snowflakes and a penetrating gust of wind. It was so nasty outside that I was surprised to see her sitting on the cold metal folding chair in the corridor. She still wore a clear plastic rain cap that tied under her chin. Her old beige raincoat was pretty well soaked and a plaid umbrella was standing in a little puddle and leaning against the wall.
“Mrs. McCarthy you are soaked! Let’s get that coat off of you,” I said with genuine concern. “I’m fine Dr. Lindsey, there will be plenty of days worse than this one before long.” As I escorted her into the exam room I said, “ You must be feeling well to be able to get here.” She shocked me by saying, “Dr. Lindsey, I would have to be almost dead before I would miss my appointment with you.” I was startled and a little confused. I stammered, “Why that is a real nice thing for you to say.”
We had a typical appointment. I was pleased with her exam and decided that I would repeat her chest x-ray. I wanted to see (hoped to see) that her heart was smaller. I was pleased that her heart rhythm was regular and her rate was 75. I sent her to radiology and moved on to my next patient after telling her to come back with the film.
After about a half an hour she was back in the hall sitting patiently with the big manila x-ray jacket on her lap. I walked over and said, “Would you like to see your picture?”. She indicated that she would like very much to see the picture. We walked down to the viewing box at the far end of the hallway and I flipped up her current x-ray and the film from the night of our first meeting in the EW. “Wow, look at that,” I exclaimed. Her lung fields were clear. The pleural effusions were resolved. The heart was appreciably smaller. “What do the pictures show?” she asked. I led her through the appropriate findings as if she were an eager medical student. A comment my dad once made flashed through my mind. “Give most people credit for the ability to understand anything you’re smart enough to explain in plain English”. When I was finished with the presentation she exclaimed, “This is so interesting, thank you so much for showing me my x rays.” In reverent silence we stood side-by-side for a moment and soaked in the beauty of our collaboration.
I broke the moment by saying, “Let’s go in the office and make our plans.” She sat down by my desk as I wrote out refills for her prescriptions and completed the liturgy of the visit by reaching for my calendar to set the next appointment. She seemed very disappointed when I suggested that she was doing so well that a return in two months would be quite appropriate. Her face had fallen so far in an instant that I quickly recovered by suggesting that she return the Thursday before Christmas. As she left the room she turned around and surprised me by saying. I’m sorry but could I touch your hair.” She was too fast for me. Before I could answer she reached up and patted the hair behind my left ear that hung close to my collar and said, “It is no fair. Some woman should have had that hair. I’ve wanted to touch your hair for a long time.” She seemed very pleased with herself as she left. I called out weakly, “I hope you have a very nice Thanksgiving.” Once again I sat down to write up the visit not quite sure what was happening.
The holiday season and internships don’t mix very well. I worked on Thanksgiving, which meant that I would have a couple of days off for Christmas. My wife and two little boys came for the turkey served in the cafeteria to the house staff and other employees. The oldest boy ran up and down the deserted “pike” while my wife and I bravely tried to remind ourselves just why we were there at all. We lived in expectation. The previous seven years had been one long exercise in delayed gratification. I had the feeling that she had naively hoped that things would be easier after I graduated from medical school and began to earn a small salary. We did have a few more dollars. No one could have prepared us for the stress that the year would bring to every other aspect of our life together. The day itself was one huge representation of it all. Our families were gathering without us a thousand miles away. For the first time the issue was not whose parents do we see at noon and whose do we see in the evening. Those days were finally over. The hospital would be my world for sometime and it was not really a family experience.
As I walked them to the car the little one rode on my shoulders and held onto my hair like the reins of a horse. He got great pleasure by turning my head right then left as if controlling my direction. I followed his lead and he was giggling with delight. Their departure was interrupted by the intrusive sound of my beeper. The beeper can kill any conversation or put inflection in any moment no matter how sensitive. It is almost as if someone is watching and then just at the least opportune time from my point of view gives a signal to some cosmic operator or shouts, “OK, hit it now!” Thanksgiving was over with the beep and they left quickly. I watched them from the sidewalk as they pulled away to go home to Newton in the failing late afternoon light.
The anticipation of Christmas and a few days off carried me over the next few weeks as we used every spare moment like a precious gift. We took bits of time to find and decorate a tree, visit Santa Claus at Jordan Marsh and build the momentum of the season for the boys. I don’t remember thinking about Mrs. McCarthy at all.
[TO BE CONTINUED]
Home Again With “Great Expectations”
Writing the report from San Francisco General Hospital made the flight home literally fly by. After a week of balmy weather in California where, like the song says, “It never rains in Southern California”, it is great to be back where inclement weather is the expectation. Governor Jerry Brown announced this week that it never rains anywhere in California and that it hardly snows at all in the Sierras, in fact they are so short of water that by law you must ask for it in a restaurant. Governor Brown put regulations in place this week that will reduce the state’s water usage by 25% this year.
The greatest expectation for this coming week for some will be the completion of “March Madness with the probable crowning of Kentucky as the National Champion of semi-professional college basketball. For me the big deal will be opening day for the Red Sox in Philadelphia on Monday. Yes the Sox open against the National League Phillies. Now that is real change! Will they go from worst to first as they did in 2013? I hope so. The early spring sports scene in Boston is really interesting with the Sox beginning their come back as the Celtics and the Bruins try to end their seasons on high notes.
Even though the forecast is for some more snow in New London on Saturday I have high hopes for the near future. I hope that whether there is snow, rain or shine where you are that you will get out for a couple of walks this weekend. The idea is to act like the weather is good even if it could be better. Who knows? Better weather than forecasted could be the first of many pleasant surprises.
|
| | | | | |
|
