The chronicle of a lonely do-gooder family doctor who survived.
Saturday, December 19, 2009
Wednesday, December 2, 2009
Shireesha and I both commented that we'd never lost anyone as close to us as her.
Leela Lou. Little Lou. The littlest little. Little Scoop. Leela-pants. Little Fluff.
She played the foil to Kali's straight man. She was the playful one, carrying her favorite ribbons up and down the stairs all day long. No twist tie or string was safe with her around, and no empty box left unsat in. Little tufts of fur could be found all over our house, left over from some sudden pounce on something, often on her sister Kali.
There was just no end to the fur. I'd said before that you could construct a new Leela from what we would vacuum up on a weekly basis. Sometimes we'd catch her munching on giant ball of it after cleaning herself. I could be traveling in some far off place and pull out a sweatshirt and find it covered in traces of her hair. Now there are bits of her everywhere in places like India.
She was the most interactive, personality-filled, friendliest little kitty I'd ever known. She could carry a back-and-forth conversation with people for hours, with the vocabulary of a small child. I'd be sitting at the computer and before long I'd feel an outstretched paw on my knee, and I'd look to see her pleading eyes; I'd uncross my legs and Leela would climb on my lap and purr happily for hours in front of the warm glow of the screen. We'd have parties with crowds of people in our home and Leela, having been bottle fed by humans at birth, would make a dozen new friends, wandering from person to person all night. In quiet moments in front of the TV, she'd get on my lap and I'd unconsciously start petting her; within minutes she'd be rolled on her back with arms outstretched over her head in kitty-ecstasy. She slept on our bed almost every night.
She was weirdo too. If Shireesha was in the shower, she'd paw and scratch and mew incessantly at the bathroom door until someone opened it. Once open she'd usually just stand there and look at you. Any time a tin can was opened, Leela would come running, though to my knowledge, she'd never been fed canned food or tuna. On the rare occasion it was tuna I was opening, I'd give her some only to see her turn her nose up at it. She'd go crazy chasing the reflections of shiny objects on the wall. Don't even get me started about the laser pointer. She'd never known her mother, having been abandoned by a feral cat and bottle fed by the kind woman whose garage she was lucky enough to be born in, so she took to suckling on the tummies of us, her surrogates.
She was hysterically funny. Once, when we put on the DVD documentary Winged Migration, she was immediately and instinctually transfixed by the long quiet shots of birds in the wild, though she'd never been outside or actually seen wild birds. She used to chase the CNN ticker across the bottom of the screen. I would often wake up and find that she'd made a comfy nest of my old dirty clothes on which to sleep on. If she was in a feisty mood, I'd reach down to pet her and she'd take a swat; this would be followed by a long boxing match, my two index fingers versus her on her hind legs, never with her claws extended.
She was beautiful. A perfect little gray tabby with orange splotches on her body. Long fur that would fluff out in all directions. Big round eyes and giant paws with tufts of fur sticking out. When I first came to pick out two kittens from the litter she was born into, she was the first one that caught my eye.
Every day that we had her I was conscious of how special she was and we knew how lucky we were. This happiness led to an almost paranoid fear for her safety and well being. The first time I took her to the vet, I literally told him, "I'm here to make sure she lives forever, because I can't bear the thought of losing her." And despite the frequent hair balls, she was healthy, happy, and active all her life.
We came home from our Thanksgiving in California Monday night and when she didn't come running to the door to greet us, we knew something was wrong. Within seconds we heard the frequent meowing that only comes from a kitty in distress. She was lying on the carpet in the basement in a pile of urine and feces, unable to move her hind legs. Shireesha burst into tears and my heart sank, thinking the worst - that she must have broken a leg while we were gone. When I rushed her to the Veterinary ER, the story was much worse. Her legs were cold, she was insensitive to pain, and her heart was racing in an irregular pattern. The most common explanation, the vet explained, was a congenitally weak heart which dilates over time and clots form in the pooled blood inside. These clots can break off and travel within the cat's circulation, often to the distal aorta where they choke off the blood supply to the lower half of the body, a condition which is exquisitely painful. The fact that Leela wasn't in any apparent discomfort was ominous. Best case scenario: partial paraplegia with very high likelihood of recurrence. Okay, I said, do absolutely everything you can to save her, not quite grasping what they were saying. I called Shireesha and told her she should come up to the hospital.
As we held her in our arms, it was obvious she was scared and uncomfortable despite the sedatives they gave her. We decided to be aggressive with care over night, completely unprepared for the sudden shock of our previously healthy six year old kitty now dying. We said goodbye. At about midnight we received the call from the vet. Leela had a deterioration in her heart condition and had died.
It's been two days now and I'm still overcome with grief. I'm ashamed at being so affected by an animal. I have a small child. I'm a doctor and I deal with illness and death everyday. I'm not entitled to mourn such small things. I guess I'm lucky I've not experienced a lot of personal loss in my life. Right now I just want to feel her absence, as though this will keep her alive with me longer. I've been told me that writing helps one to cope with grief, so here I am. I'm going through the motions of life but the suddenness of all this has left me in a state of shock to say the least. There are reminders of her recent presence everywhere around the house, impressions in pillows and those ubiquitous tufts of fur. Her sister Kali, who never spent a night without her until Monday, just now seems to comprehend that she's really gone.
Still, I recognize I am better for knowing the lightness and sweetness she brought into our lives for six happy years. I know things will get better, she was just a pet and pets die. But I miss her.
My precious Leela. Leela with the pink nose and the big furry paws. Leela with the weak heart.
My Little Lou.
Sunday, November 15, 2009
For 40 weeks, this patient had greeted me with a huge smile at each prenatal visit. She was so excited to be pregnant again, having miscarried her last pregnancy at 13 weeks the year before. She had no insurance, and most of her family was in Mexico, so for her the care and support she received from the clinic each week was literally a lifeline. Each visit, I'd work so hard to reassure her that things looked normal, diffusing her anxiety with humor. I knew she and her husband had wanted a boy and so early on, long before her ultrasound, I laid my hands on her belly and told her "Yes, definitely a boy, you can tell just by feel." When she came in with her ultrasound results two weeks later, she and I had a huge laugh at the report of a single, healthy male fetus, despite the fact that I had a 50% chance of guessing right.
At her last visit the week prior, realizing I was going to be on call this weekend, I told her, "I want you to come in and have the baby on Sunday, this is what works best for my schedule," as if she had any control over the situation. When I received the page from OB triage announcing her arrival in active labor, I wasn't the least bit surprised.
Yet, I had really been hoping to make it to Kevin's party. All night I watched the clock. At 6, I thought, if we could get her membranes ruptured, maybe we'll deliver by 7 and I could get there by 8. At 8 I thought, if we could rotate the baby I'd get her delivered by 10 and I could still get there by 11 to say hello. Now it was midnight, the Sunday morning she promised me had arrived, I had abandoned hope of making it to see my old friends, and things were looking hairy.
We started oxygen, we tried position changes, I rotated the baby's head, I called an obstetrician, the first step in a process that usually results in C-section. But she was strong, focused, and determined and despite my plans to be elsewhere I was right there with her. At 130 am on November 15 she delivered on her own a beautiful healthy boy.
I finished my paperwork and drove past Kevin's house on my way home, surprised to discover everyone still up. Despite my exhaustion I still got to visit with my old buddies and share pictures of our kids. I told Kevin all about the delivery earlier and we both laughed at the fact that the parents decided to name this child that shared a birthday with my friend, "Kevin."
But the thing that blew me away the most, just as I left the hospital, was the look in my patient's exhausted, blissful, and grateful eyes as she told me, "Thank you for the work you do."
I swear I don't make this stuff up.
Friday, November 13, 2009
Guy tweeted his own seizure. That's hardcore geekery.
Get well soon, Matt. Metafilter is the only website that matters.
Sunday, November 8, 2009
The House bill, which has to go through further watering down in the Senate and is a *long* way from becoming law , is a step in the right direction. Problem is, I think we are *far* past the point where "steps in the right direction" are going to take us where we want to be: quality, accessible, evidence based health care. I honestly think that, with the exception of health care providers and people with serious medical problems, very few Americans understand how far we are from that goal and how entrenched the institutions are that are trying to keep us from this goal.
I am all for market based approaches that improve quality and drive down costs. The problem is that quality and cost aren't where insurance companies are competing. They compete with strong arm negotiations with hospitals, denials of coverage, and lobbying money. This bill, while setting up some standards for fair competition, is also requiring the American People to give more money to the insurance industry. I personally am just skeptical that they won't find other clever ways to screw us; their primary allegiance is to shareholders, not patients. Yes, this bill does currently include a limited public plan (which I highly doubt will make into the Senate bill) but (as I understand it) it is a self-funding plan for individuals without employer sponsored insurance who are going to be forced to buy something, and it will compete against similar plans offered by private insurers. Pretty weak tea. Anything that doesn't allow a person with employer provided insurance to opt into a public plan, you know, in case they're curious about what consumer-driven health care would really look like, falls short.
If our legislative branch wasn't totally corrupted by lobbyists, the negotiations should have started with "Socialize all medicine now!" and settled for the optional public plan. I am not a communist, I just want a better health care system that's in-line with the rest of the civilized world.
Sunday, July 26, 2009
Paul Krugman, New York Times Op-Ed, July 25, 2009
Monday, July 13, 2009
Last year I wrote about what an amazing time I had riding the Cascade Bicycle Club's Seattle to Portland Ride and how I just knew I'd be doing it every year for the rest of my life. This year, things went a little differently.
It started well enough. Clear skies, 80 degrees. Greg finally got a new bike. Things seemed all set. It's no surprise I'm not as fit as I was this time last year, but I had a few long training rides and I was ready.
Filmore left early to ride with the Major Taylor Project but got a flat almost immediately after the race began. After replacing his inner tube, as he went to pump it up, his tire stem snapped off in his pump and he had to wait 30 minutes for someone to stop and help him out.
I lost Greg and Matt in a pack of cyclists somewhere around Auburn. About 10 miles later when I still hadn't caught up to them, I thought to myself: "Those assholes, they can find their own damn ride home." I met up with Fil in at the lunch stop in Spanaway and he asked if I'd seen Greg and Matt. Apparently Matt caught a flat right when I lost them and I breezed right past them without seeing them or stopping.
Despite this, we made it to Centralia faster than the year before. After showers, it was straight to the McMenamin's for beer and pasta. A couple hours later, with full stomachs, we were getting ready to pack it in for an early night when I heard them turn on the Tour de France over at the Beer Garden. Ok, I'm not quite sleepy yet, I'll just go over and watch for a bit...
Wound up making some new friends that night who had bought a bunch of alcohol they were looking to get rid of. Some people can party. What was I thinking?
Woke at 5 AM to the sound of rain drops on the tent and 50 degree weather. This was going to be interesting. Sporadic showers and pervasive wetness with occasional hail followed us for all of day 2. We were pretty much riding into the cold front with a moderate head wind the entire day. It was good to have the support of my friends and we took turns drafting most of the way, but I don't think I could say that any part of the ride was "fun." In fact, it is hard to think of specific day that was more miserable; if it weren't for trading jokes with Matt, Greg, and Fil and laughing at the ridiculousness of the situation I don't think I would have finished the ride.
We rolled into Portland at 5 pm, significantly slower than last year. Meritxell was a sight for sore eyes and she is a saint for coming down to pick us up. After standing in the shower line for an eternity in our soaking wet, freezing cold cycling clothes we finally got warm, dry, and fed (oh my god -- East Burn, Portland, Oregon -- words cannot describe how awesome this place is) and we loaded up and came home.
It was an adventure and it had its moments, but I think each of us, separately, decided somewhere on the road between Rainier and Scappoose that this was the last time we'd do this. Next year we'll come up with our own tour.
Wednesday, July 1, 2009
Wednesday, June 24, 2009
Bouefcake has 9 or 10 proper original songs by now. It's pretty hard to share songs that you've lovingly crafted with a skeptical public. Songs can be very personal and it's easy to be self critical about even the smallest recording mistakes. Usually we'll work out various parts for weeks, trying out different ideas and someone will spend days coming up with lyrics.
That's not the case with these two songs. These ones basically came out as is, with Kevin improvising the lyrics. In fact, with The In Security Song, we literally made it up about twenty minutes before this recording was made; what you're hearing is exactly the third time we played it through. Somehow, it is so much easier letting go of things that you didn't try hard to create.
The In Security Song
Wednesday, May 27, 2009
For instance, did you know that the bassist for the Red Rockers is Paul Westerberg's manager? Or that one of the guys from Musical Youth died at age 24 of a congenital heart condition? Or that The Stranglers are still touring, and that their drummer is now seventy years old?
Monday, May 25, 2009
It was bad, probably six inches across. These things can get pretty nasty. Imagine the ugliest pimple you've ever seen and then think of the pint of foul smelling cottage cheese mixed with pus inside. Why do these always get scheduled right before lunch?
"Yeah, we need to drain it. This is a good procedure for the nurse practitioner to learn how to do, can you call her in?"
So with the cyst all prepped and numbed, I was explaining to K, my nurse practitioner, how you have to push down hard right after you make your incision, when the pressure is the greatest, in order to extrude the thing all at once and...BLAMMO!
Cheesy, rotting pus all over the walls, the table, and the ceiling. Miraculously, K and I were unscathed.
When it was all done, we came out of the room to talk to the medical assistant.
"Um, we're not going to want to use that room for the rest of the day."
Monday, May 4, 2009
That's right, male breastfeeding. Not only is it possible, but it's healthy, and it's my paternal right.
Discover magazine did a fairly serious take on this in 1995:
There are numerous conditions under which injected or topically applied hormones have produced inappropriate breast development and milk secretion in humans, both in men and in nonpregnant or non-nursing women. In one study, male and female cancer patients who were being treated with estrogen proceeded to secrete milk when injected with prolactin. Lactation has likewise been observed in people taking tranquilizers that influence the hypothalamus (which controls the pituitary gland, the source of prolactin), in people recovering from surgery that somehow stimulated the nerves related to the suckling reflex, and in women on prolonged courses of estrogen and progesterone birth-control pills.
All these cases involved medical intervention, but it is not always necessary. Mere repeated mechanical stimulation of the nipples suffices in some cases, since mechanical stimulation is a natural way of releasing hormones. For instance, sexually mature but virgin female marsupials can regularly be stimulated to lactate just by placing another mother’s young on their teats. Milking of virgin female goats similarly triggers them to lactate. That principle might be transferable to men, since manual stimulation of the nipples causes a prolactin surge in men as well as in women.
According to this home birth website:
I knew these two wonderful guys, very dear friends of mine for years. A mutual acquaintance of ours was pregnant, unplanned, and did not want to do the whole "adoption thing" so when the guys approached her about taking the baby, they just proceeded as if it had been a planned surrogate pregnancy. The guys were adamant that the baby should get breastmilk. So when she was in her 7th month we bought a really good quality breastpump and Ian started pumping, every 2 hours during the day and once during the night. He was wonderful about it! He used an SNS (supplimental nursing system) after she was born, with donated milk from several friends who were nursing. He was making milk but not a full supply. By the time the baby was 12 weeks old he was making a full milk supply! He stayed at home with the baby (he was a massage therapist) and nursed her exclusively until she was 8 months old!! I don't think many people outside their intimate circle knew about it, I'm sure folks would have had a fit if they'd known...but I thought it was wonderful!
Suite101.com has an interesting article about male lactation as well:
It is important to realize that you may not be able to produce enough milk to sustain your child on breast milk alone. Don’t be upset - there are special supplements that are delivered externally, by a tube near the nipple. They were invented for women, but work equally well for men...Finally, there is this inspiring story about a Sri Lankan widow who found he had the ability to breast feed his children after his wife's untimely death:
There are three herbs that are effective at helping breast-feeding: blessed thistle, alfalfa, and fenugreek. Of these, fenugreek is considered the most effective. There are also herbs that can slow down your milk supply and make successful breastfeeding difficult: herb Robert, lemon balm, oregano, large amounts of parsley, peppermint, periwinkle herb, sage, sorrel, and spearmint. Some drugs have a side effect of causing lactation and it seems like the best one may be Domperidone (Motilium™). Raglan has also been used to induce lactation, but it can't be used for extended periods of time without serious side effects.
Colombo - A 38-year-old Sri Lankan man, whose wife had died three months ago, appears to have the ability to breastfeed his two infant daughters, doctors said on Wednesday.
The man, from the central town of Walapone, lost his wife during childbirth.
"My eldest daughter refused to be fed with powdered milk liquid in the feeding bottle.
"I was so moved one evening and to stop her crying I offered my breast. I then realised that I was capable of breastfeeding her," the man admitted.
Dr Kamal Jayasinghe, deputy director of a Sri Lankan government hospital, was quoted as saying it was possible for men to produce milk if the prolactine hormone became hyperactive. - Sapa-AFP
So yeah. As concerned parents, we are committed to breast feeding our little Babu; it is the healthiest thing for him and only natural. What better Mother's Day gift could I give my beloved wife than to inject myself with hormones, take a bunch of supplements, and stimulate my nipples all day long to produce the milk I need to relieve her of the burden of the 2am feed? I think both her and the baby would appreciate the effort.
Wednesday, April 29, 2009
I promise not to turn this into yet another daddy-blog, but it's true that I have done very little in the last week outside of child care.
The level of exhaustion is nowhere near residency training. Newborn care is incessant, there is no time where you are free from responsibility, but I haven't had to do much thinking and there have been regular nap periods. I have lost my ability to do simple math problems such as figuring out the tip on take-out food.
It's amazing how much laundry one tiny little six pound human being can generate.
Breast feeding is difficult. Extremely difficult.
The ergonomic design of baby gear is incredible. I'm consistently impressed at the attention to tiny details that make your life easier. The way the car seat clicks in and out of the base. The handles on the laundry hamper are exactly where you want them. The way the baby bjorn holds Ravi exactly where he wants to be, without any back strain whatsoever.
The lithium battery on our TV remote went 3 days ago. This was a major crisis and we had to have one flown to the house overnight.
Baby care is all about rhythm and it is a team sport. Ideally, it goes diaper change --> feed --> burp --> nap --> repeat. It's pretty easy to get into a pattern of feed --> burp --> feed --> diaper --> short restless nap --> diaper --> feed; this is a Very Bad Situation. If both of us are functioning like a coordinated team, and the schedule doesn't get screwed up by something like a doctor's appointment, each parent can get 1-2 hours of relative freedom every three hours. Thank the gods that Shireesha and I have been working from the same playbook through all of this. I can't think of anyone I'd rather share this responsibility with.
Wet babies are extremely slippery and cute.
I'm really surprised by my capacity to love this child, but I am probably more surprised by my capacity for patience. By all rights, I should be totally pissed off when it's 3 am and he's been fussing for 2 hours and won't go to sleep. But I'm not.
I would do absolutely anything for the well-being of this child.
Despite a few frustrating nights, I think we've been doing pretty well. Shireesha's been going out for walks almost every day, and I've managed to exercise several times. The three of us made it out to the Ballard Farmer's Market at day 6 and I got to go to the My Bloody Valentine show on day 7. We even had band practice on Sunday. Ravi is gaining weight, he's clearly able to focus his vision on faces and seems to have a preference for his mother and father over other people. His feeding is getting better. I'm not sure what is going to happen when I go back to work but I think uncertainty and problem solving are probably the defining characteristics of child-rearing.
Monday, April 20, 2009
Saturday, April 18, 2009
This clip comes from Jupiter's Dance:
In 2006, the United Nations Development Programme helped them produce a song called "Let's Go and Vote" which became wildly popular in the run up to the Congolese elections and was reportedly responsible for a 70% increase in voter turnout. The track became one of the most recognizably popular songs in the history of central Africa. For all this, the musicians were paid about $50 each.
Well they finally have a real album out on Crammed Records and it is fantastically good. From the record company's website:
The band's mesmerising rumba-rooted grooves, overlaid with vibrant vocals, remind you at times of Cuban nonchalance, at other times of the Godfather of Soul himself. You can hear echoes of old-school rhythm and blues, then reggae, then no-holds barred funk...
The songs were recorded out in the open, mainly in the zoological garden near centre ville, using a dozen microphones, a MacBook laptop and a 100m mains cable fraudulously connected to a deserted refreshment bar nearby.
The album is available on both iTunes and Amazon and I hope it brings them all the success they deserve.
Wednesday, April 1, 2009
In the dream, I was holding little Babu in my hands just after he'd been born. He was crying and squirming, still glistening with amniotic fluid, his rubbery white umbilical cord still hanging from his tummy with a steel surgical clamp attached to the end. I found myself completely overcome with emotion, sobbing uncontrollably. Looking down, I saw in this one brief moment the limitless potential, a clean empty canvas upon which I would paint the world.
Pretty powerful stuff for someone whose attitude thus far in the pregnancy would best be described as "mixed ambivalence tempered by hesitant anxiety."
Appearing elsewhere in the dream was a more sinister figure, a patient I had seen earlier that day in clinic. This person wasn't your ordinary down-on-his luck drug abusing crazy person that we see all the time. This was a very seriously distrubed man, alcoholic, bipolar, with anti-social personality disorder, one year out from a twenty year sentence for murder one. He had been dragged in to clinic by his girlfriend who had just witnessed yet another 2 week long drug-fueled manic rampage. I was in the exam room contemplating how in the world someone gets so screwed up when she began to tell me about the time she went home to visit his family. What followed was a description of family dynamics that ranged from indifference to outright verbal, and then physical, abuse compounded by a history of sexual abuse.
I've taken care of literally thousands of families, from telling patients that their pregnancy test was positive, to taking care of their newborns in the hospital, to doing their kids' check ups, to dealing with behavior problems that develop in school. In the enduring war between Nature and Nurture, I come down firmly on the side of Nurture. I believe so strongly that any kid has the potential to grow and excel in the right environment and yet there are so many ways that the people on the fringes of society can get it wrong. Thoughtful, well adjusted parents simply don't raise bad kids yet inexperienced, stressed out parents so rarely raise good kids. On occasion, I have seen childbirth transform a few people into curious, careful, and doting parents, and it is inspiring to see, but this is sadly the rare exception.
Tony and I got into a discussion the other day about the things a newborn baby comes pre-programmed with. Lately, a trend has emerged to promote more paternal bonding, presumably to awaken some predetermined neural path that gives the baby a special emotional bond with their father. At these births, the newborn goes directly from mom's bare stomach (where studies show this increases maternal bonding and successful breast feeding) to dad's bare chest. I think this is a little silly, as babies at birth probably don't even conceive of the existence of any other people besides their mothers, but whatever imparts a sense of nurturing and responsibility to the male parent has got to be a good thing.
It's a strange limbo I'm living in right now, anticipating the arrival of my son yet holding an open heart free of expectations. I've always believed that music captures the wonder of emotional truth better than any other form of expression. When I was discussing this on Metafilter, someone suggested to me a song I'd never heard, called Born at the Right Time. Paul Simon wrote it about his son.
Down among the reeds and rushes
A baby boy was found
His eyes as clear as centuries
His silky hair was brown
Never been lonely
Never been lied to
Never had to scuffle in fear
Nothing denied to
Born at the instant
The church bells chime
And the whole world whispering
Born at the right time
Me and my buddies we are travelling people
We like to go down to restaurant row
Spend those euro-dollars
All the way from washington to tokyo
I see them in the airport lounge
Upon their mothers breast
They follow me with open eyes
Their uninvited guest
Never been lonely
Never been lied to
Never had to scuffle in fear
Nothing denied to
Born at the instant
The church bells chime
And the whole world whispering
Born at the right time
Too many people on the bus from the airport
Too many holes in the crust of the earth
The planet groans
Every time it registers another birth
But among the reeds and rushes
A baby girl was found
Her eyes as clear as centuries
Her silky hair was brown
Never been lonely
Never been lied to
Never had to scuffle in fear
Nothing denied to
Born at the instant
The church bells chime
And the whole world whispering
Born at the right time
Saturday, March 14, 2009
I just came across this video I took a couple years ago and I think it's pretty funny. This was taken at Xian's birthday party. He survived a bad scooter crash earlier that year and had just been discharged home so we threw him a surprise medical-themed party. Brian showed up as Dr Pepper and danced his booty off.
Monday, March 9, 2009
Saturday, March 7, 2009
Sunday, March 1, 2009
Shiree and I just attended our 37th (!) opera, The Seattle Opera's production of Bluebeard's Castle, a wholly engrossing twisted and dark psychological production. Every aspect of the performance, the music, the story, the set, the singing, and acting contributed to one of the most memorable evenings of opera I've had and was a perfect example of why we keep going back. Seattle, for being a pretty small city, is lucky to have such a world class opera.
The music, written by Bela Bartok 90 years ago is surprisingly modern with its loud-quiet-loud repeating pattern and quietly looping background melodies which perfectly suit the narrative, a series of dark revelations about a woman's new groom, a mysterious man with whom she fell in love and eloped before knowing him perhaps as well as she should have.
The story begins with a narrator appearing in front of the stage who tells us that the story exists as much in our minds as it does on the stage, setting us up for the powerful metaphor that the dark secrets that hide inside us are like the locked rooms in the basement of Bluebeard's castle.
The music begins with Judith and her new husband arriving at his castle, a dark stone set that suggests a vast underground hallway, with bars closing over the only gate off in the distance, and series of seven locked doors along one wall. Judith notes that the castle is cold and the walls are damp. She's scared and she begs her husband to open the doors to let in the light. Bluebeard refuses but finally relents after Judith makes it a test of Bluebeard's love.
The first door opens and red light comes pouring out, illuminating the opposite wall with an undulating red pattern. It's a torture chamber drenched in the blood of Bluebeard's victims. Bombastic music ensues as Judith sings of her shock. As she comes to grips with the unsavory work that goes along with her husband's title as Duke, she tells Bluebeard she must know what's behind the other doors.
Behind the second door, we find Bluebeard's armory, again the weapons are stained with fresh blood.
Bluebeard tells Judith he cannot allow her to see anything else, but she persists and he gives her the next three keys.
Room number three is looking better, a golden light pours out through she doorway and she finds a mountain of treasure and jewels, but it's only on closer inspection that they too are covered in blood.
The fourth door is a beautiful garden, full of bright flowers and the music begins to change, it's gentler. The shadow of trees blowing in the soft breeze illuminates the inside of the castle. But as Bluebeard sings of the beauty of his gardens, Judith again sees blood and realizes that the garden has been watered in blood.
When Judith opens the fifth door, we hear loud, loud, majestic music. Blue and white light project onto the castle wall, suggesting a view of Earth from space as they look over the vast lands that Bluebeard has conquered, at the cost of the blood of his enemies. Bluebeard pleads with Judith, let this be enough, please go no further. But she cannot resist the temptation to see more.
With the six door, we see a smooth peaceful lake. The music becomes quiet and sad as Judith runs her hands in the water and she is told that it is a lake of tears, though the question of whose tears is left to the imagination of the audience.
Bluebeard is adamant about her not looking beyond the seventh door, but Judith embraces him and repeatedly tells him how much she loves him. That if he doesn't allow her to see the final room she will start to believe the rumors that he has murdered his previous wives.
I won't spoil it by revealing what happens next*, but it's Hitchcockian in the extreme, and one of the great moments in opera. It must have totally bowled people over when Bluebeard's Castle debuted in Budapest in 1918. The psychological overtones are intense but given the abstract, unreal nature of opera, it all just worked and, as my friend Jeremy said afterward, there is no other artistic medium that gets away with this.
*Ok, here's what happened. The seventh door is unlocked and there is a perfectly still lake of blood. A woman dressed in a bridal gown, soaked in blood, slowly rises from the lake and begins to walk across the stage. She is followed in sequence by two other women in bridal gowns, and all three join Bluebeard as he sings about how much he loved his previous wives. Judith sees that each bloody bride is more beautiful than she, but terror strikes her when Bluebeard now calls her the most beautiful of them all. The three bloody brides then descend again into the pool of blood and disappear. Judith begs to be spared but is sucked down into the pool of blood and disappears as the seventh door closes. The final line of the opera is uttered. "All shall be darkness, darkness, darkness."
Monday, February 23, 2009
So far, it's really lived up to my hopes and the contrast with the "normal," insurance-funded system of health care has been stark. I have no idea why I stayed away from community health for so long. Every day when I make the seven block walk home, it gives me pause to reflect upon all the things I'm loving about this job.
1. The patients.
It's a community health center; its mission is to see people who otherwise have no access to health care. You'd think the patients here would bring in a truck load of unfixable problems that have been neglected for years (and certainly there are a few of those), but for the most part the patients are really focused on their one or two big problems, they want to get better quickly, and they are extremely grateful for the care they receive.
Contrast this to my previous practice, where patients were paying through their noses for access to a doctor whom they viewed as an agent of an inherently unfair system. The average patient in B-town would postpone care, store up a laundry list of problems for their visit, and then expect the doctor to do all of the work taking care of them. Isn't that what they're supposed to be getting for their $1000 a month premium?
2. My coworkers.
Everyone I interact with, from doctors, to nurses, to social workers, to the janitor chooses to work here, to serve this community, and usually they are making a financial sacrifice to do so. And still getting a job here is competitive. Every day, it is obvious that everyone is thankful to be here. There is nothing like a shared mission from which to draw sustenance and motivation. And because everyone wants to be here, there is a level of competence among the staff that I frankly haven't seen anywhere in health care before.
3. Support services.
In the community health system, there is an acknowledgment that providing effective primary care to a needy population has to involve a whole lot of other disciplines that cross over with medicine: social work, behavioral health, dental care, nutrition, and education. It's incredible to me that, as far as insurance companies are concerned, a 15 minute visit with a doctor is adequate time to tell a patient everything they need to know about diabetes. Or to diagnose their complicated psychiatric problem. Or to counsel them on quitting drugs. Yet this is exactly what I spent the last 7 years in B-town trying to do, having no other place to turn to, or at least no place that my patients would go. On site here, we have social workers, interpreters, a clinical psychologist, psychiatry 2 days a week, a fully staffed dental clinic, a diabetes educator, 2 nutritionists, and several other support services.
4. The expectation that I will push myself beyond my comfort zone.
There's been a lot of times where I've been scared as shit over the last month. Having to deal with stuff I've only read about or haven't seen since residency. Things that would have been referred to a specialist without a second thought when I was in private practice. Complicated office surgeries. Small children with mysterious symptoms that don't add up. Really seriously mentally ill people. For the most part, trying to find a specialist that is willing to see a sick, uninsured patient quickly turns out to be more difficult than figuring out what to do myself. These patients come to me with nowhere else to turn and when I'm able to work through a complex problem, it's a total thrill. A little bit of cowboy medicine right here in Wallingford.
5. Not dealing with insurance paperwork.
Yes, medicaid, medicare, and the state disability program have paperwork, but it is nowhere near as pointless and time consuming as the insurance paperwork used to be. I cannot tell you how many hundreds of hours of my life I spent filling out prior authorization forms for non-preferred meds ("Because doctor, Prilosec makes me feel not right.") or wrangling payment for things that insurance claimed were pre-existing conditions or trying to get a wheelchair into the hands of a little old lady. Insurance companies put up a wall to deny payment for most everything nowadays, and all of that somehow comes back to the primary care doctor's desk. Now I have one set of forms that more or less make medical sense, and they are for important things like food and housing money for the guy who can't work anymore because of his cancer.
6. Delivering babies.
I love delivering babies and doing newborn care. I had planned to do it when I was in training, and did a bunch of extra obstetric rotations in residency before I got sucked into the toxic job from hell. After my first two years in practice, I figured there was no way I would be able to get my skills back, let alone find a hospital that would credential me to deliver babies. Very few family doctors in Washington state are willing to take on the malpractice insurance burden anymore. But it's something that is totally consistent with the philosophy of family-centered medicine and I've always missed it. The community we serve at the new clinic has nowhere to go for obstetric care, and because of the low reimbursement, the hospital and our back-up obstetricians are happy to have us do these deliveries. My partners are so glad to have another person in the rotation and have been extremely supportive in mentoring me through my first dozen or so deliveries.
7. Learning Spanish.
Who hasn't told themselves, "You know, it would be really good for me to become more fluent in Spanish"? With a patient population that is about 50% Spanish speaking, I might finally get beyond "¿Tiene fiebre?"
I have two mid-level providers that work with me, a nurse pracitioner and a physician's assistant, who are just great about knowing when to ask questions and refer people to me. In addition, I will be a clinical faculty member for the Family Medicine Residency program at the hospital. I love it when people ask me clinical questions or I'm teaching a new procedure to someone. It reminds me that at this point in my career I actually do know some stuff and it's really neat to help other providers develop new skills.
9. Loan Repayment.
Ok, I haven't officially heard whether this was approved or not (The Washington state government, from which this money flows has an $8 billion budget deficit), and I *did* take a pay cut to work here, but just the fact that this possibility exists is awesome. Last year, I was paying about $1500 a month in student loan repayment and it was going to take me about 25 years to pay it off. Since taking this job, I ramped up my repayment to get me done in ten, and should loan repayment come through, I can do it in five. For a guy who's not sure he's going to be practicing medicine in five years, with a kid on the way, this is huge.
10. Humane work schedule.
In the insurance-funded world of health care, salaries are entirely production-driven. If you're not in the clinic billing patients for your time, no one's getting paid. My old job was 0.8 FTE which meant I was scheduled for 32 hours of patient contact per week, which ensured that I would be in the office for 60 hours a week. For an 80% job.
Because our funding isn't entirely based on patient volume, our clinic acknowledges realistic schedule limits. A full day of seeing patients is pretty long: 10 hours on your feet, face to face with patients, often skipping lunch. Sometimes you're up in the middle of the night on call. Full time here is capped at 28.5 hours of patient contact, 23.5 if you're on call. Schedules are blocked out for meetings and medical education. As a clinic run by family doctors, it is expected that every one be able to go home to their families at a reasonable hour, a revolutionary concept in medicine.
So the job is still new and I keep telling people I'm waiting for the other shoe to drop. Certainly, hours will get longer as I get busier and I'm taking call. But this job leaves me with a sense of satisfaction that I haven't felt in medicine in a long time and I might just be able to stick it out for a few more years.*
*This should not be taken as evidence of any emerging optimism from Dr. Sour Puss. I remain firmly convinced that, in the long run, everything in the world is in a constant downward spiral and that the worst possible scenario is also the most likely one. Furthermore, everything bad that happens to me is someone else' fault and everyone is goddamn idiot except me.