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A slender thread
: MEDICINE, SCIENCE, AND SOCIETY
A Slender Thread Michael T. Kovalchik, MD, Torrington,
I
Connecticut
love coming home. Often my children dash up to me, arms and legs flying in all directions, squealing, giggling, finally collapsing, a pile of laughter into my arms. Upon returning home at 7:30 one night, Adam, my 6-year-old son, leaped into my arms shouting, “Goody, goody Daddy, you’re home early.” While his exuberance dazzled me, his concept of “early” pierced my armor. With sobering clarity I understood the significance of my time away from home. Imagine holding a squealing squirming bundle of energy and feeling completely alone. We were in the midst of Little League season and I kept missing games. Aaron, my 9 year-old, struck out three times in his last game. I hadn’t been there to encourage him. After the game, he moped around the house, threatening to quit the team. Pulled between two worlds, I longed to spend more time with my children. Depressed at having again missed dinner, I continued the evening rituals. Aaron and Adam chatted away, their voices cricket songs on a stormy night. I searched for solutions. My time with them was bittersweet, enjoyable but far too brief. After tucking the boys into bed, I considered my priorities. Consumed by my professional life, I needed to claim some personal time. After hours of soul searching, I discovered more questions than answers. Surrendering to the darkness, I fell asleep. My night was restless. The conflict of roles: physician, father, husband, son, and confidante haunted me. Success in the hospital came at the expense of my family. I felt both full and empty; a living mixed metaphor. Looking at myself in the mirror while shaving I thought, “Which role would I assume - caring physician or thoughtful father?” After 15 years of practice I still did not know the answer. But today I resolved to change. Rolling a spoon through my cornflakes, I felt like General Schwarzkopf planning a day’s battle of coming home early. Could I be more efficient with patients? My stomach churned with the uncertainty of change. I reviewed my latest amalgamation of strategies for saving time. Mrs. Hill accosted me daily. She would ramble on about her husband who had been in the ICU for 6 weeks. Patiently, I always listened. Well now I wouldn’t. But...telling her I didn’t have time made me anxious. I had to save time. It was my only option. I needed to make tough choices. I had to recognize I couldn’t meet all my patient’s expectations. There would be other opportunities to explain a procedure, review a treatment plan or support a troubled family. Medicine and parenting were similar in one respect. You always had a second and third chance. Usually.
But I knew that saving a few minutes here and there would not be enough. Time, or more precisely my perception of time, was at the crux of my dilemma. My workload devoured time: dialysis rounds, meetings, hospital rounds, messages, procedures and emergencies. For me, time was the Great Satan, a very large Goliath to conquer. While reviewing my schedule, I remembered a conference with Mr. Parson’s family at noon. I didn’t have the courage to cancel the meeting-too many people were planning to attend-but I could miss it. Mustering the courage to beg, I would ask the social worker to run the meeting without me. Round one to me! Dreaming about the fun I would have with the children, I left for the hospital. Abruptly my daydreaming ended. A colleague waved me down as I turned into the hospital parking lot. He started with the usual small talk. “Did the Yanks win last night?” “How old were the boys now?” Eventually, he got around to business, asking about a patient we were co-managing. Omitting the usual formalities, I answered his questions and rushed off. Stealing in a back door, I hoped to avoid any more chance encounters. A faint tap on the library window startled me and brought me back to reality. Joyce, our medical staff secretary, motioned to me. Closing my eyes, I sighed while rehearsing my lines. “Joyce, not today, I just don’t have time.” Like warm snow on a sunny day, my intentions melted in the face of her simple requests. I stayed. Ten minutes later, while reviewing messages at my desk, I heard Adam’s voice. “Daddy, you’re home early.” I tried to suppress the anger burning my gut. A crumb, that’s all I wanted, one time-just once-to get home early. I took a few deep breaths. “You can pull it off Mike,” I murmured, as the rhythm of my breathing calmed me. I delegated two messages, a third required a return call to verify some instructions, but the fourth spelled trouble. The day’s roller-coaster ride began. Mrs. Anderson’s daughter described her mother’s illness in excruciating detail. I had little choice but to tell her to call an ambulance so I could see her mother in the Emergency Room. My office hours started at one o’clock. Mrs. Anderson’s illness changed everything. If1 did not finish rounds, I would have to return to the hospital. Hope and reality collided. I grew impatient. When would she get here! With control slipping away my frustration mounted. I tried to avoid small talk with the nursing staff and navigate my way through one meeting after another July 1994
The American
Journal
of Medicine
Volume
97
89
A SLENDER
THREAD/KOVALCHIK
with colleagues. But flying through rounds wasn’t as easy as I planned. Mrs. Jones refused to take her husband home. He was “too much trouble.” Mr. Knight, after 3 months in the hospital, threatened to leave against advice even though he had no legs and no transportation. Mrs. Sawyer held up the OR, refusing surgery until she could say good-bye to her husband who was en route to the hospital. I treaded water when I should have been freestyling through rounds. Scribbling in a chart at a nurses’ station, I heard a gentle voice say hello. Looking up I caught the warm smile of Mrs. Gray, foster mother of Cora, an adult Down’s syndrome patient who died several years earlier. During the last year of her life, Cora spent weeks in the hospital, always with Mrs. Gray at her side. Devastated by her death, 2 years passed before she could put aside her grief. Now she wanted to tell me she had accepted a severely retarded 4 year-old into her home. How could I walk away? Finally, Mrs. Anderson arrived. I weighed my alternatives as I rushed through rounds. Betsy, the ER nurse told me the patient appeared extremely ill. A bitter emptiness, born from years of experience swept through me. I had to face the prospect of spending hours treating her. Sandra, one of my dialysis patients with wild hair and an infectious smile, jumped out of her chair and grabbed my arm as I detoured through Radiology to look at Mrs. Anderson’s X-rays. Reduced to tears during a treatment the previous week, she confessed that dialysis allowed her to exist, but not to live. Becoming animated, she explained that after our conversations last week she felt relieved. Someone was finally listening to her. The past week had been one of her best in years. She wanted to share her experiences with me. Mrs. Anderson waited in the ER. My sons waited at home. Soon I would have an office full of patients.
90
July
1994
The American
Journal
of Medicine
Volume
97
I watched Sandra’s face while I sifted through my choices. Her ebullience called to me. I pulled up a chair and sat down. Noon! I found Mrs. Anderson alone in a tiny ER cubicle, gasping for air, her frail body weakening with every breath. I made the telephone call transferring her to ICU and began completing the necessary paperwork. At that moment one of my partners strolled into the ER. “Wadda you doing here?” he lectured. “You’ve got hours in a few minutes and everyone will be waiting for you.” I explained the situation. With a wave of his hand he banished me from the ER and charged into Mrs. Anderson’s room. Instantly, I was swimming in conflict. How could I abandon Mrs. Anderson? But I held fast. With 15 minutes to spare I marched out of the ER, ran down to the cafeteria, grabbed a sandwich and headed for the office. Between patients I gave myself little pep talks. “OK Mike, you’re doing well, remember stick to the issues and don’t tell any stories.” Stumbling into the last hour, I couldn’t relax. Any moment I expected a phone call describing a new catastrophe that would snatch my dream away from me. At ten to five I was near panic. I kept watching the clock and listening for the telephone. At 5 o’clock I cautiously celebrated victory. I cleared my desk and dashed out, leaving unanswered messages in my wake. My boys were playing catch in the driveway. Over they came, running and screaming. Breathless, they asked why I was home so early. Tugging off my tie, I bellowed, “I got lucky,” and tossed it onto the hood of the car. Soon I was pitching to Aaron, my strikeout king. After a few terrible misses he pulled down his hat, dug in his heels, and smashed the next pitch over the garage.
A Slender Thread Michael T. Kovalchik, MD, Torrington,
I
Connecticut
love coming home. Often my children dash up to me, arms and legs flying in all directions, squealing, giggling, finally collapsing, a pile of laughter into my arms. Upon returning home at 7:30 one night, Adam, my 6-year-old son, leaped into my arms shouting, “Goody, goody Daddy, you’re home early.” While his exuberance dazzled me, his concept of “early” pierced my armor. With sobering clarity I understood the significance of my time away from home. Imagine holding a squealing squirming bundle of energy and feeling completely alone. We were in the midst of Little League season and I kept missing games. Aaron, my 9 year-old, struck out three times in his last game. I hadn’t been there to encourage him. After the game, he moped around the house, threatening to quit the team. Pulled between two worlds, I longed to spend more time with my children. Depressed at having again missed dinner, I continued the evening rituals. Aaron and Adam chatted away, their voices cricket songs on a stormy night. I searched for solutions. My time with them was bittersweet, enjoyable but far too brief. After tucking the boys into bed, I considered my priorities. Consumed by my professional life, I needed to claim some personal time. After hours of soul searching, I discovered more questions than answers. Surrendering to the darkness, I fell asleep. My night was restless. The conflict of roles: physician, father, husband, son, and confidante haunted me. Success in the hospital came at the expense of my family. I felt both full and empty; a living mixed metaphor. Looking at myself in the mirror while shaving I thought, “Which role would I assume - caring physician or thoughtful father?” After 15 years of practice I still did not know the answer. But today I resolved to change. Rolling a spoon through my cornflakes, I felt like General Schwarzkopf planning a day’s battle of coming home early. Could I be more efficient with patients? My stomach churned with the uncertainty of change. I reviewed my latest amalgamation of strategies for saving time. Mrs. Hill accosted me daily. She would ramble on about her husband who had been in the ICU for 6 weeks. Patiently, I always listened. Well now I wouldn’t. But...telling her I didn’t have time made me anxious. I had to save time. It was my only option. I needed to make tough choices. I had to recognize I couldn’t meet all my patient’s expectations. There would be other opportunities to explain a procedure, review a treatment plan or support a troubled family. Medicine and parenting were similar in one respect. You always had a second and third chance. Usually.
But I knew that saving a few minutes here and there would not be enough. Time, or more precisely my perception of time, was at the crux of my dilemma. My workload devoured time: dialysis rounds, meetings, hospital rounds, messages, procedures and emergencies. For me, time was the Great Satan, a very large Goliath to conquer. While reviewing my schedule, I remembered a conference with Mr. Parson’s family at noon. I didn’t have the courage to cancel the meeting-too many people were planning to attend-but I could miss it. Mustering the courage to beg, I would ask the social worker to run the meeting without me. Round one to me! Dreaming about the fun I would have with the children, I left for the hospital. Abruptly my daydreaming ended. A colleague waved me down as I turned into the hospital parking lot. He started with the usual small talk. “Did the Yanks win last night?” “How old were the boys now?” Eventually, he got around to business, asking about a patient we were co-managing. Omitting the usual formalities, I answered his questions and rushed off. Stealing in a back door, I hoped to avoid any more chance encounters. A faint tap on the library window startled me and brought me back to reality. Joyce, our medical staff secretary, motioned to me. Closing my eyes, I sighed while rehearsing my lines. “Joyce, not today, I just don’t have time.” Like warm snow on a sunny day, my intentions melted in the face of her simple requests. I stayed. Ten minutes later, while reviewing messages at my desk, I heard Adam’s voice. “Daddy, you’re home early.” I tried to suppress the anger burning my gut. A crumb, that’s all I wanted, one time-just once-to get home early. I took a few deep breaths. “You can pull it off Mike,” I murmured, as the rhythm of my breathing calmed me. I delegated two messages, a third required a return call to verify some instructions, but the fourth spelled trouble. The day’s roller-coaster ride began. Mrs. Anderson’s daughter described her mother’s illness in excruciating detail. I had little choice but to tell her to call an ambulance so I could see her mother in the Emergency Room. My office hours started at one o’clock. Mrs. Anderson’s illness changed everything. If1 did not finish rounds, I would have to return to the hospital. Hope and reality collided. I grew impatient. When would she get here! With control slipping away my frustration mounted. I tried to avoid small talk with the nursing staff and navigate my way through one meeting after another July 1994
The American
Journal
of Medicine
Volume
97
89
A SLENDER
THREAD/KOVALCHIK
with colleagues. But flying through rounds wasn’t as easy as I planned. Mrs. Jones refused to take her husband home. He was “too much trouble.” Mr. Knight, after 3 months in the hospital, threatened to leave against advice even though he had no legs and no transportation. Mrs. Sawyer held up the OR, refusing surgery until she could say good-bye to her husband who was en route to the hospital. I treaded water when I should have been freestyling through rounds. Scribbling in a chart at a nurses’ station, I heard a gentle voice say hello. Looking up I caught the warm smile of Mrs. Gray, foster mother of Cora, an adult Down’s syndrome patient who died several years earlier. During the last year of her life, Cora spent weeks in the hospital, always with Mrs. Gray at her side. Devastated by her death, 2 years passed before she could put aside her grief. Now she wanted to tell me she had accepted a severely retarded 4 year-old into her home. How could I walk away? Finally, Mrs. Anderson arrived. I weighed my alternatives as I rushed through rounds. Betsy, the ER nurse told me the patient appeared extremely ill. A bitter emptiness, born from years of experience swept through me. I had to face the prospect of spending hours treating her. Sandra, one of my dialysis patients with wild hair and an infectious smile, jumped out of her chair and grabbed my arm as I detoured through Radiology to look at Mrs. Anderson’s X-rays. Reduced to tears during a treatment the previous week, she confessed that dialysis allowed her to exist, but not to live. Becoming animated, she explained that after our conversations last week she felt relieved. Someone was finally listening to her. The past week had been one of her best in years. She wanted to share her experiences with me. Mrs. Anderson waited in the ER. My sons waited at home. Soon I would have an office full of patients.
90
July
1994
The American
Journal
of Medicine
Volume
97
I watched Sandra’s face while I sifted through my choices. Her ebullience called to me. I pulled up a chair and sat down. Noon! I found Mrs. Anderson alone in a tiny ER cubicle, gasping for air, her frail body weakening with every breath. I made the telephone call transferring her to ICU and began completing the necessary paperwork. At that moment one of my partners strolled into the ER. “Wadda you doing here?” he lectured. “You’ve got hours in a few minutes and everyone will be waiting for you.” I explained the situation. With a wave of his hand he banished me from the ER and charged into Mrs. Anderson’s room. Instantly, I was swimming in conflict. How could I abandon Mrs. Anderson? But I held fast. With 15 minutes to spare I marched out of the ER, ran down to the cafeteria, grabbed a sandwich and headed for the office. Between patients I gave myself little pep talks. “OK Mike, you’re doing well, remember stick to the issues and don’t tell any stories.” Stumbling into the last hour, I couldn’t relax. Any moment I expected a phone call describing a new catastrophe that would snatch my dream away from me. At ten to five I was near panic. I kept watching the clock and listening for the telephone. At 5 o’clock I cautiously celebrated victory. I cleared my desk and dashed out, leaving unanswered messages in my wake. My boys were playing catch in the driveway. Over they came, running and screaming. Breathless, they asked why I was home so early. Tugging off my tie, I bellowed, “I got lucky,” and tossed it onto the hood of the car. Soon I was pitching to Aaron, my strikeout king. After a few terrible misses he pulled down his hat, dug in his heels, and smashed the next pitch over the garage.