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Saturday, October 24, 2015

NO EASY WAY OUT

Life is characterized by change. Time passes, clouds flit by, feelings come and go and we grow old and then are gone. It is as if nothing stays the same. I sound like a Buddhist. Of course death is the ultimate change, and it doesn't always involve bodily demise. The Grim Reaper assumes many forms. The end of a marriage, a move away from home, a career change are all so many types of death. (But what lies after death, if not new life?)

I have experienced death many times and am here to talk about it, because bodily death has not yet visited my person. But I have lost grandparents and my younger brother. And now my mother is ill, so ill that death once again becomes a hot topic - oddly, since it leaves the body so cold. But I have had other life-altering experiences that didn't involve rigor-mortis. Take medicine. My medical education lasted 5 years. The first two I really enjoyed. They were classroom-based, filled with lectures and textbooks. In anatomy and histology and microbiology labs, I got to explore the structure and function of the human body from the gross to the microscopic level. (And actually anatomy did involve rigor-mortis.) I was a diligent medical student who earned straight As and became class valedictorian.

Then came two years of clinical medicine. Long hauls at the hospital, lots of scampering from room to room, and often from building to building, treating diseases known by acronyms like CHF and COPD and DM and HTN and CAD. And prescription writing, and patient outcomes not nearly as impressive as all the paperwork was onerous. It was in the hospital that I learned the business of medicine, and medicine is nothing if not a business. Get patients in, fill them up (with drugs and IV fluids) and send them out with a referral to one or more specialists. And do this as quickly as possible. And try not to let them die!

What a change this was for me. In basic sciences I studied the human body in all its glory, fantastic dance of a trillion cells that it is, all these island organs functioning as one organism called you (and me). But there in the hospital all I encountered were organ systems in disarray. Sure, there was lots and lots for me to do between admit and discharge, so much running around and tracking Xrays down, and reams and reams of hospital records to read through, but little in the way of real treatment achieved. Hey, at least I earned my MD.

The fifth and final year of my medical journey was what is for most their first year of residency, a period in a doctor's education where you learn by experience, on the job, during 12- to 30-hour shifts for which you are paid minimally and ridden heavily. I chose family medicine, which is the most general speciality (excuse the oxymoron) and arguably one of the hardest areas of medicine to practice, since the family physician must know enough about each of the body's many organ systems to diagnose and treat everything from head and heart to neuromuscular, circulatory and skin disorders.

I didn't like my intern year. Too much of an emphasis on drugs. And the long hours at the hospital were wearing me down. So I had a sit-down with myself. "I have not enjoyed 3 of the 5 years of my medical experience," said I to me. That's a 40 percent success rate. The odds are better in Vegas! And this disenchantment looks to continue, since many, many long hours at the hospital with my blood-shot eyes affixed to a computer screen and my cramped fingers on my pager lie ahead. How do I get out?

In my morning workouts I began listening to the soundtracks from the Rocky films, to imbue me with the fighting spirit I guess. And in the 4th installment of the film franchise is the song "No Easy Way Out." This song became my anthem. Because there was no easy way out of medicine. How to exit without ruffling too many feathers? There were familial expectations, the pressure I felt from my superiors, my own ego - not to mention the great unknown, a future without an income or career. I would be like Al Gore after he left politics following his loss to George Bush in the 2000 presidential election. "I didn't really know what I was going to do with my life," Gore has said.


I had just signed a contract to begin my second year of residency. Should I honor this contract even though my heart isn't into medicine? If I convince myself to enjoy what I dislike, and ignore the inner voice telling me it is time to move on, will a day come that I'll no longer even hear this inner voice let alone heed it? If this inner voice is the intuition, the reason, the voice of God, will ignoring it make me dead inside?

The day came for me to exit residency. My window of opportunity, as I call it. I was midway through my month-long stint in the ICU. It was my team's day to admit patients. I was the third member of a team that included two other medical residents. The other teams in the ICU were made up of not three residents but two. So I was a third wheel because, as a family physician who spends most of his time in clinic, it was felt I didn't have the know-how to carry my own weight amidst such severe cases as are commonly seen in the intensive care unit. My team's superior had just been replaced by a new doctor, whom I hadn't even met. I remember sitting alone in the call room asking myself, Is now the time? I had the book Secret Garden in my hand. It is a children's book fittingly about the conflict between common sense and the accepted wisdom of the day. My inner voice (common sense) said: If you just slip away, you won't even be missed.

I knew that if I waited a couple hours I could get a new patient and would be obliged to remain on the team for the duration of the patient's care, which could be weeks. And then would come a new rotation, which I'd feel obliged to fulfill; or maybe the distaste I had for medicine would pass and I'd feel refreshed and rearing to go. Or would I? There had not been a day in the previous 3 years in the hospital that I had enjoyed playing doctor. If this is my window, then now is the time to jump. So I called my program's director and scheduled an emergency meeting. Then I called an ICU team member and said I was leaving medicine. And I walked out the front door of the hospital, never to return. I fulfilled the last two weeks of my rotation in clinic, diagnosing sinusitis and refilling blood pressure meds, and then my days as a practicing physician were over. And I've never looked back. The end of one life, the beginning of another.

My mother who has end-stage cancer is grappling with this very same phenomenon, death, and I with her. Of course her death experience is bodily, and the end of one life means passing on to another plane of existence. I have watched my mother grow progressively weaker and more compromised since her rediagnosis with metastatic cancer in 2010. When cancer spread to her colon and initial treatment proved ineffective, she was left lying in bed, bloated, backed up, and in racked with severe pain. But at least she was home and in her own bed, we both agreed. The question was: Do we take you back to the hospital for surgery, or has your time come? Fight, or throw in the towel? Accept death or resist?

I asked my mother what her wishes are for this final chapter of her life. Is it to live one or two or more years? To do what her family wishes her to do? To visit Sicily home of her ancestors as she had always wished? Her answer: I just don't want to be in pain. Her wish, my command. As we were about to put in a call to her physician to provide pain relief, the proverbial shit hit the fan. Not literally, since my mother was still very much backed up. But at that moment my grandmother and aunts came over, and then the doctor called, and together they urged my mother to undergo surgery.

Before the ambulance carried mom away I impressed upon her the following: Your desire is to be pain-free; abdominal surgery will be very painful, and the pain likely will go on for weeks if not months. That is, assuming you survive the procedure and recovery. (Blunt is what they teach us to be in school.) And even if you do survive, with cancer throughout your body, you will likely experience a recurrence of the tumor in some other organ, despite taking debilitating chemotherapy, and you will then have an even bigger battle to face, which will involve still more pain. If you will ultimately lose the war on cancer, it is up to you to pick your battles. You can go now, this is your window, or else you can go to the hospital and enter the next phase. I told her this because I have made my peace with mom's condition and with her eventual bodily departure. But others haven't. My grandmother burst into tears, saying "I cannot lose another daughter!" (I had an aunt who passed away years ago.) It is true what they say, that we hang around to give others time not to miss us so much when we're gone.

The very morning of my mother's hospital admission she told my father she didn't want to return to the hospital. Life is complicated. These choices are not easy. It is after all, life and death! But mom is a pleaser. Perhaps doing what others wish for her, even at the expense of her personal comfort (and who wants their belly sliced in half!) provides greater satisfaction and enables her to bear the pain. After all, she had me, and as any mother knows, pushing a nearly 9-lb baby body out is certainly no walk in the park.

And so my mom has chosen to do as her family and doctors wished, and to continue her fight, despite the suffering. Suffering which thankfully will be mitigated at least in the short term by morphine. But what if she dies in the hospital? As just a number. Around strangers. In a room without fresh air. Is this the way to go? But she is not in any pain.

The point is that like the Rocky song, there  really is no easy way out. Change is often rough. You never know if it is your time until you jump. And sometimes the promptings of the inner voice can be drowned out by the wishes of others.

What lies ahead for my mom, for me? I don't know. There is no obvious next step. But whatever happens, the time is always right. There exists a cosmic order, a divine intelligence, which, working unseen, perfectly orchestrates all of life's great dramas. There was no obvious next step for Al Gore when he exited the White House in 2001. But he had faith that it would all turn out okay. And 15 years later he is a hugely successful businessman, who during this time having also won an Academy Award and the Nobel Peace Prize, is now worth hundreds of millions of dollars.

So every cloud has its silver lining, although my mother prefers gold. And faith is a good thing.

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