the oath of maimonides

(author's note:  this post isn't funny and isn't entirely about medicine...)

you may have heard or read about this event two days ago -- a young man, sasha fleischman, was badly burned while asleep on a city bus after a fellow student set his skirt on fire.  sasha identifies himself as agender, neither male nor female, and occasionally wears skirts.  when i read about this my gut reaction was of course, horror.  how could someone do such a thing?  and in such a public and aggressive way?  and why does a boy in a skirt invoke such anger and hatred?

at the same time that my heart was sinking, it was also lifted up by the beauty and hopefulness of sasha's self-love and self-acceptance. that he loves himself enough to know that this is who he is, and that he accepts himself enough to openly express himself through his dress is a joyful and inspiring thing to me. but, as this shows us, the bravery of self-actualization sometimes requires incredible vulnerability.

so what does this have to do with medicine? well, events like this, intimate acts of hatred between one human being and another, make me think of the oath of maimonides.  maimonides was a twelfth century physician, astronomer and jewish philosopher.  similar to the hippocratic oath, maimonides' oath was a call to the physicians of his time to 'do the right thing.'   the part of the oath that i love the most is this:

     'may i never see in the patient anything but a fellow creature in pain.'

in my mind, i have adopted it as 'before and above all else, see the human being in the person in front of you' and i think of this every day in my medical life, usually right before i enter the exam room. it sounds simple enough, but it is so easy in my job to center myself on the illness, the chief complaint, the test results, the computer screen, and the dozens of other tasks i must attend to with each encounter, that  i need to make a conscious effort sometimes to center myself on the patient.  when i say that oath to myself, then i can relate to my patients as persons, as individuals with real suffering, not simply as a list of medical problems or test results.  when you do this, you open your heart to your patients, and i believe you become a more compassionate physician.  i am far from perfect at this.  ask any of my patients! i have my harried days when i want to close myself off from my patients' pain or suffering, when i want to just check all the boxes and move on, but i do try to hold this tenant in my mind with each person i see. (i'm getting bogged down in this paragraph but i think you're getting what i'm trying to say...)

so getting back to sasha -- i believe there is something in the oath of maimonides for all of us. an opportunity to see the fellow creature in front of us as a suffering human being.  not as a boy in a skirt, but simply as a person to whom we are intimately connected by our shared humanity. that is what maimonides asked of his fellow physicians then, and what i hope for sasha and all of us now.

may i have the envelope please...

you may already know of my aversion to the proffered envelope or other item in the exam room (sure to contain something gross).  so when my patient reached into her purse and pulled out a sealed envelope, i ran from the room inwardly cringed.  in this envelope, she told me, were the pinworms she had pulled out of her carpet.  she described their pale bodies and hooked mouths to me in great detail.

i bravely pulled on my gloves and set out a drape to catch the worms.  i carefully unsealed the envelope and shook the contents out onto the drape.  oh, dear.

which of these things is a pinworm?

 a)  a down feather
b)  a piece of a pretzel stick
c)  the stem from a grape

answer:  d) none of the above

what is this woman's diagnosis?

answer:  sadly, hallucinations related to her underlying dementia.

the sounds of medicine

awesome sound:
the abbreviated ring of the phone before it kicks over to the answering service on friday afternoon.

not so awesome sound:
your pager going off at three am sunday morning. (that would be the patient who is too polite to wake her dentist...)

awesome sound:
the jet of fluid as it hits the side of the vacutainer telling you that you're in the pocket of acites you are trying to drain from your patient's abdomen.

not so awesome sound:
the whoosh of air sucking into the IV site as you pull a wide bore central line (but no so bad as the voice inside your head that is now saying oh, crap...)

awesome sound:
the rapid, but gentle and happy, thump of fetal heart tones

not so awesome sound:
silence when there should be none.

an honest answer

i asked my COPD patient how his breathing was, and he answered, 'expensive.'

may i one day find happiness in a can of paint

today i saw a very happy nonagenarian -- so much so that i was wishing i had a camera to capture the vibrant image before me.   her shock of unkempt white hair floated around her face.  her eyes were vividly blue,  and her skin was deeply tanned and wrinkled. turns out she has been painting the foundation of her son's house.  'i just love to be busy!' she told me through the kind of smile that even in your darkest mood you would immediately respond to with a smile of your own.

(later her son told me that he switches out the paint color slightly and she's already been around the house twice but, hey, whatever works...)

probably not

does running from my office to the front desk to hand something to my patient that i forgot count as exercise?  i probably do that 100 5 times a day.

a great patient quote on the joys of aging

my patient offered me the perfect analogy for aging the other day.  she said, ' you know how you don't know your baby can roll over until your baby rolls over? well when your old you don't know you can't get up off the floor until you can't get up off the floor.'

can't wait to get old -- so many adventures to look forward to!

senior parkour

as i was removing the sutures from my elderly patient's forehead, she informed me that she had been showing her friends how to fly when she fell off the curb.

good times

you probably need a more exciting life if coming to the doctor is how you get away from your kids.

wrong on several levels or file under 'not loving this old person'

here is the exchange i had with a patient of mine who may be lacking an edit button:

     pt:  have you lost weight?

     me:  yes, just a few pounds.

     pt:  i can see it in your face.

     me:  yes, if i lose a few pounds that seems to be the first place it shows up.

     pt:  well, better that than your breasts.

     me (squelching the idea of one, covering my chest, or two, whacking him on the head):  !


first of all, please don't mention my breasts to me.  i am your doctor.  second of all, in contrast to that decidedly male point of view you are proffering, a certain some of us women would be glad to lose a few pounds in our chests.

at least i have an edit button.

file under 'i love old people'

my 80 year old patient's take on dr. oz:  'he's everywhere. like shit in a manure spreader.'

sticks and stones

the earliest signs of spring are here.  birds are chirping, grass is greening, crocuses are blooming, and old folks are falling.  around here, in this rural setting, spring brings with it a universal stirring deep in the heart of old folks, an awakening, that spurs them out of their quiet homes and into their yards to pick up sticks.  the sticks, like sirens, call to them, 'come.  come!  we are waiting for you!'

gathering sticks in early spring is a ritual as deeply rooted in their souls as christmas.  but if you are old, i urge you, you must resist!  the ground is uneven, your balance - oh, your balance! - has all but abandoned you, and the wind is poised like a cat waiting to rush at you the moment you are at your most vulnerable - bent at the waist, reaching for that stick, stretching your arm just a little beyond what your shoulder and your equilibrium expected.  you will go down!

but don't worry.  i am waiting for you.  i will clean and bandage your wounds.  i will send you to PT for balance and gait training.  and yes, i will admonish you to leave those sticks to the younger folks, you're too old for that now.  but you and i both know, tomorrow is another day, and who are we if we don't at least occasionally heed our sirens.

where are you, spring?

i thought i could will it to be spring by wearing a nice bright blouse and cotton sweater today.  instead i'm just cold.

make love not war

in the throes of passion, things can and do go awry.  here of some of the unfortunate outcomes i've encountered in my practice:

hip dislocation
cervical disc herniation
cerebral hemorrhage

just a friendly reminder to take it easy out there folks!

burnout

there are always a small but steady stream of articles circulating in the medical world and elsewhere  about doctor burnout. (apparently we are more prone to it then other professions.)  reading them, i never felt they applied to me.  until recently at least.  they say the doctor who treats herself, treats a fool, but i am feeling pretty confident in my self diagnosis.

it seems a perfect storm has arisen in my professional life - a too busy practice, growing EHR demands that increasingly and unrelentingly sap my time, energy and spirit, and the most dreaded (and overrated)  Maintenance of Certification, a yearlong slog through marginally beneficial and mostly burdensome requirements culminating in an very expensive and stressful exam.

fortunately for me i am an eternal optimist.

my prescription:  time

it heals most wounds.

doctor nightmare

needless to say, i was very happy to wake up this morning and come to the realization that i do not have to repeat my last year of residency. it was just a dream nightmare.

note to self: floss

my dental hygienist was so nice until she got those instruments of torture in her hands. then the battle between her and my gums began.  when she put the suction tube in my mouth and i saw all the blood running up through the tubing i just closed my eyes and tried to go to my happy place.  my poor gums didn't stand a chance.