Missing Medicine

Work has been getting me down as of late. It was a few short years ago when I was interviewing for medical school. I sat before a committee explaining why I wanted to be a doctor. I wanted to help sick people get better. In whatever creative way you say it, in essence, this is why people should be doctors. Instead I find year after year the patient less of a priority in the modern medical culture. We talk about evidence medicine and studies. We take board exams meant to be some sort of bar that we need to pass to prove we know the right things to do. Yet day in and day out I see these rules ignored, replaced instead by defensive medicine, lazy medicine, or just plain greed. It seems these days I hear more about the “cost” of things as opposed to the “right” thing medically to do. Before a patient is even in the system there is talk about their discharge planning and length of stay. Even taking a basic medical history is eroding away. Why take a history when you ask a consultant to solve a problem for you. I look at new trainees and many seem to be glorified secretaries. The top priority often appears to be writing a note and discharging a patient.

I often wonder what a hospital would look like if you put perfect strangers in there instead of doctors. Say for instance you took a stranger and said you are responsible for these 10 patients. Go! What would happen? I imagine the stranger would talk to the patient, noting their complaints. This person has belly pain. I better call the stomach doctor. This person has chest pain. I better call the heart doctor. Is this too far from what many actual doctors do these days? Perhaps it is a culture of defensive medicine or maybe it is just plain laziness. There are countless times when doctors fail to take even a basic history. My favorite is a person referred to cardiology clinic for left wrist pain. He sprained his wrist but no one bothered to take an actual history. They heard left upper extremity pain and sent them to the cardiologist. Sometimes chest pain can radiate down the left arm. A cursory 30 second conversation with the patient revealed this was certainly not cardiac.

Perhaps most bothersome is the culture change from a patient-centric to a business centric/shift based one. I will never forget a meeting in which I was arguing how defibrillators should be mandated on every floor. Someone promptly told me, we can’t afford that. There was no talk about the actual medical necessity, no talk about how we were no better than your average train station if someones heart were to stop on such floors. It clearly showed me how pervasive this culture of business replacing medicine has become.

Also, like a business, medicine has turned into a shift-based model. The future seems to be more and more of you being a patient in a hospital system as opposed to being a patient of a particular doctor. Private practices are being bought up by large hospital systems. The reason is simple. By consolidating, these systems can pay doctors less and be in a better bargaining position to get better pay from insurance companies. It seems inevitable that with a more corporate culture the doctor patient relationship will suffer. I don’t know about others but that relationship is a big reason why I wanted to be a doctor. The role of the doctor gets reduced. A doctor spends a decade training, learning what medicine to give for a particular condition only to not be able to give that medication because a particular insurance company on a particular day does not find it profitable. The doctor then has to take time out of her busy day to call and justify this decision to a secretary on the other end. The ludicrousness of this become apparent if you think of other professions having to do the same thing. A lawyer is about to give cross examine and is stopped, “Sorry in order to ask that question you have to get it prior approved by calling this number.” The lawyer would then call that number and for the next 30 min be bounced around before having to fax a form and try to get permission to use that question. If this example seems ridiculous it is far more ridiculous when people’s live and well being depends on such asinine protocols.

I guess I find myself longing for things to change. I miss medicine.


It has been way too long since I’ve written on this blog and for no over reason besides the fact that I’ve been exhausted. I’ve been a doctor going on four years now and I can’t help but feel that it isn’t quite what I expected. American society is in a debate right now as to what our health care system should look like. The reality of finite resources has finally come into play as the economy has taken a turn. We have to ask the fundamental question: how do we treat an ever aging population with more expensive treatment options given finite resources?

When I think back to graduating from medical school I was giddy with excitement. I had matched in my top program for residency was moving to Manhattan for residency, all was well. There was a sense of inspiration hope. As I’ve gone through training however, especially over the past year now in fellowship I realize this field I had gone into, the field I loved, was changing in a way that was turning me off.

I went to medical school to learn how to help treat sick people. Yet a good portion, if not all my time now is thinking about how to defensively justify my actions as to not get sued, save money, appease a particular physician’s style of practice. If I had wanted so much political and legal formulation I would have gone into politics.

The sad fact is while I still like the field I’m in, I no longer love it, mainly because it has warped into a paranoid distortion of an ideal I had when I graduated. I operate with one hand tied behind my back, one eye closed. Frustrations of physicians are never addressed in a meaningful way. Medical records are a key example. Advancements in informatics appears to be trickle last into medicine. At work I use computers over a decade old without a real medical records system, and only this past month did we move beyond VHS tapes for some of our imaging. This is how most of the country’s medical records are and it is insulting to patients and physicians. It is one of the many reasons why I am so frustrated. Without information I am driving blind and have to recreate the wheel.

It is 2011 and we still rely on FAX machines to transmit medical information, if we can even find them. Yes, fax machines. Think about that the next time you update your Facebook status on your mobile phone while transmitting funds from your bank account, and listening to your iPod. Medicine is in the stone age. When talk of online records came the public cried about how this would not be secure; paranoia. Perhaps they didn’t know of how things are really done. You can go to Domino’s pizza and get minute to minute information on the various stages your pizza is to completion yet I can’t find old records on a patient who is in a hospital a few blocks down the street, or even at my own hospital for that matter. Yet, there is no public outcry on this, probably because people don’t know. And yes people have died simply because we don’t have a coherent way to transmit information.

Then there is the systematic character assassination of doctors. The medical profession has been demonized, as selfish doctors doing too many procedures, charging too much. I am the first to say, yes there are bad doctors. But in fact doctor’s compensation has taken a huge hit in an attempt to curb this spending increase. Yet no one really questions why we spend so much. Is it perhaps because doctors are forced to do so much because if they didn’t they would be at risk of being sued? Is it because in the US our culture demands the maximum amount of care regardless of prognosis? Is it because we have failed to ration resources? These are the real issues.

I find medicine fascinating. The human body is remarkable beyond belief, a miracle that even the best engineers could not begin to comprehend. I get a high from understanding how it works, how it goes wrong, and most importantly how to fix it. It gives me so much joy when a patient smiles at me, says thank you, gets better. I’m tired. I’ve worked countless days and nights. But it was worth it. I’ve saved lives. I want to love this field again. I just need someone to untie my hands from behind my back.

Do No Harm

It was another sleepless night intern year.  I was called to bedside of a deathly ill old woman because her oxygen level was low despite being on the maximum amount of oxygen.  I pulled up her x-ray.  I squinted to figure out what I was looking out, in case it wasn’t obvious enough.  A massive white blob occupied nearly her entire chest cavity, it was cancer.  I knew where this was heading and immediately called the family.  I explained how her heart was going to stop because she was not getting enough oxygen and that if her heart did stop, trying to restart it would only be temporary.  The daughter stated that she wanted “everything” done.  She had just lost her father and couldn’t bare the guilt of her mother dying.  She instructed me to only do CPR and not put her mother on a breathing machine, something which made no clinical sense but by some law I had to do.  I tried to reason how this was futile but to no avail.  Any layman knows when your heart stops, you stop breathing.

For the next hour, I morbidly sat slumped in a chair in the woman’s room watching her monitor.  My eyes were heavy, I wanted so desperately to sleep and as soon as I found my eyelids falling I quickly looked up at the monitor.  I knew what was going to happen.  I knew what her heart would do.  I knew what I would have to do.  I knew the grim outcome.  My mind went back to a year earlier as I took that oath with a jubilant group of my friends and colleagues.  Do no harm.  Here I was, forced by a family member to do something completely medically futile.  Forced to ignore my clinical knowledge as a doctor, and like a foot soldier dictated by the medical legal complex  just do as told, not over-think my oath.

The blood pressure started to drop, the breathing mask bellowing air onto the face of this, frail ashen-grey woman.  I got up from my slumped position in the bed, and felt her neck, no pulse.  Like a good soldier I did the drill.  I yelled for the nurse, jumped on the bed.  Two hands together, I pushed on her chest.  The first press was followed by the crunch of ribs cracking, like someone breaking a bunch of celery stalks.  I turned to the nurse, “Push one of epi!”

“I can’t, I’m not a doctor”  The lawyers also forced her to do as  told, she technically wasn’t allowed to push the meds.  I stared her right in the eye.

“I’m right here.  Do it!”

A group of groggy eyed residents came in to help in the code.  As I hopelessly pressed on this woman’s chest I knew I was not allowed to put her on a breathing machine.  I knew even if I could that it would make no difference to her ultimate fate.  But in that moment I wasn’t a doctor, I was a cog in a machine stripped of power to act based on reason.

With each compression her frail body was jostling, eyes rolled back.  There was nothing and after three agonizing rounds of CPR it was over.  I left the room feeling sick.  I did my job like a good soldier, but it felt wrong even though I did everything right.  Hypoxia induced asystole with a code that was run like a textbook.

I called the daughter to tell her about her mother.

“I’m so sorry”

She quickly asked, “Did she suffer?”

I wanted to yell, to say how she forced me to torture this lady.  Did she not know what she instructed made no sense?  I actually had told her such before all this happened.  Yet she had lost her mother.  As much as I wanted to voice my frustration and tell her of the ribs I cracked, the pain I inflicted to no avail, I didn’t.  It was in that moment that I turned from a soldier back into a doctor, “A resuscitation is never easy.  We did all we could.  Would you like to come and see the body?”

“No.  Someone will come to pick it up shortly.”

I again refrained, mostly from shock.  How could someone not want to see their mother who just died.  It was then that I realized there were other forces at play: religion.  But who was I to judge.

The sun would shortly be coming up, and like a good soldier I went back to work trying to do no harm.

2:30 AM

The night was going smoothly, the numbers of pages were few, yet the whole day I had this unsettling feeling.  Perhaps it was a lack of food.  I decided to order in.  I looked at my watch seeing it was around 1AM.  Even though it’s NYC even here the options on the Upper East Side are limited.

I decided to order some pizza from the only pizza joint that was open to deliver.  A half hour later the pizza man delivered my slices.  I walked down the dark halls of the hospital going to the front door to get my food.  I went back to my call room.  The slices were half cold, greasy.  I didn’t care.  It was late.  I had barely eaten.  I ate the slices feeling a bit of regret as the nausea had started to set in.  I was tired, still with an unsettled feeling in my belly.  I figured it was the food.  I hadn’t gotten any significant calls that night.  Things were going well.  I lay on the old, squeaky bed in the cold call room.  My eyelids were growing heavy, maybe I would get some sleep.  Just as I was about to dose my pager started buzzing.  I tried to open my eyes, clumsily dialing the number.  The nurse on the other end had a scared, cold tone: “The patient’s heart rate is in the 20s he is unresponsive.”

I ran out the door down the stairs trying to figure out what i was giong to do.  I was tired, confused, anxious.  As I walked to the floor it was official “Team 7000!”  It was a code.

A frail 80 year old African American man with a curly white beard lay unresponsive in bed as the nurses started putting an oxygen facemask on him.  I quickly grabbed the pacer pads to put onto his chest.  His heart rate was in the 20s.  I was confused, half thinking it was a dream.  Perhaps I was dreaming all this, I was just lying down a second ago.  Yet the look of urgency on everyone’s face told me this most definitely was not a dream.  The senior residents came rushing in.  One quickly started a femoral line.  Just then someone yelled, “I don’t feel a pulse.”

I did what was reflexive.  I started doing chest compressions.  My angle was off, my body tired, stomach naseated, I pushed on his chest.  I climed on top of the bed pounding down, feeling the deep crunching sound of ribs being broken.  I handed it off to my fellow co-intern.  Back and forth we went, each cracking ribs as we went on.

“I feel a pulse.”

He was back.  We called the ICU and waited for him to be transfered.  I looked over at him a breathing tube in his throat.  He had no family, some remote friend, maybe relative lived in Alabama.  Nothing.

I looked over only to see his left chest expanding like a balloon.  “Why is his chest like that?”  His lungs had been punctured causing air to leak around them into the subcutaneous tissue.  I quickly pressed down trying to force the air back into his chest.  The cardiothoracic surgeon came and looked in his lungs with the bronchoscope.  He had a tumor.  We knew it all along but it didn’t help his situation.  The surgeons put a chest tube to drain his lung.  A while later I dragged his bed to the ICU.  We dragged him through the dark halls, the same halls I was in a few short hours ago anxiously awaiting my food.  All the while to the ICU I was giving him breaths of air through the bag mask.

It was now 6AM and as I tried to collect my thoughts for the day ahead I realized my nausea had settled.  The feeling of uneasiness was gone.  I would like to think I knew that this was coming.  You never do.  You have an unsettled feeling, a sixth sense, mostly you have no warning at all.  Dinner at 2AM, CPR at 2:30AM.  Now it was time for a nap.  Luckily it was in my own bed at home.


As a kid I hated going to the doctor; absolutely hated it.  I didn’t like the uncertainty.  There was the stick in the throat which inevitably made me gag.  The prospect of getting a shot.  There was the smell of disinfectant in the air.  I may go as far as to say I was scared to go to the doctor.  Luckily I didn’t have to go too often to the doctor and when I did they could usually pick up that I was scared and would comfort me.  I wasn’t sure what made it obvious to them.  I just stared blankly when I came into their office.

They say most communication is non-verbal.  The other fraction of is read between the lines, and a minority is actually spoken.  I remember a particularly frustrating patient on my medicine rotation as medical student in Seattle.  He was a “tough” guy, one who didn’t like doctors.  He always gave this annoying sigh when I walked in the room.  He was irate that I had to wake him every morning to check up on him.  I was beginning to think the guy was a real jerk.  He belittled me and always treated me like crap criticizing every little thing I did.  All I was trying to do was help.

One night I found that he had suffered a small heart attack.  The next morning he was his old self, insulting me and asking not to be seen in the moring.  Earlier that day he had kicked ou the cardiologist who came to see him after his heart attack.  He didn’t want the help.  I was fed up.  I expressed my frustration to my resident.  Later we went to his room and the patient again started to go off on us.  My resident, far more experienced that me as a third year student put it out there, “Are you scared?”  As if by magic the whole act came crumbling down.  His eyes looked downward as if the jig was up.


Suddenly I felt guilty.  I learned a lot from that patient.  I learned never to judge patients.  One who you may feel is a jerk or difficult may just be coping that way.  People react in different ways to stress and while as a child my fear of the doctor was manifest in a silent blank stare, his was to lash out at those around him.  Luckily he had a doctor who picked up on it.  From then on I became a lot more perceptive about how people act and the looks they give.  The looks speak volumes, not only about patients but about doctors as well.  They tell the story that often times word can’t or lie about.

There is the story of my night on call as an intern when the nurse called me in to see a patient that was short of breath and breathing 60 times a minute.  His eyes were wide open, he would follow my every move.  They seemed to quiver, tears wanting to form but couldn’t.  He could barely speak from his shortness of breath.  He started to get chills and shake.

“What’s going on?”

He looked at me his eyes pleading.  Thing is, I didn’t know what was going on.  No one really did.  Was he bleeding internally?  Was he infected?  Between his rapid breaths he looked over, “I…I..I’m ssccarred.”

My residents came to the bedside and saw the severity of the situation.  He couldn’t breathe this fast for long.  He needed to be intubated.  She looked over at him, “We need to put a breathing tube in your throat.  I think it is the best thing for you.”

His eyes darted across the room as if looking for something, or someone.  He was panting, desperately trying to get some sort of reassurance, but our eyes were also off int he distance trying to figure out what was going on.  Nonetheless his eyes lazered in on me.  “Do…do…do.. you… th..think it is a gooood i…i…idea?”  Only this time it wasn’t only his eyes that were on me but also my resident.  It was a feeling I hadn’t really felt before, that what I thought mattered. It was part of the transition out of medical student mode things.

“Yeah…I think it is a good idea.”

Within minutes the anesthesia team had come by and put a breathing tube in his mouth.  Every so often while he was awaiting transfer to the ICU I had to push in sedatives to keep him from waking up, to keep him from fighting and opening his eyes.  Maybe it was for the best until we could figure out what was going on.  But often you don’t have the luxury of time.

Then there is the most disturbing look of all.  It was around 6 in the morning when I heard that over head rush of adrenaline.  I ran to our patient’s bed where a code was called.  A mass of my co-interns started to get vitals and put her on oxygen.  The residents soon came and led the code.  Soon enough I was in that all too familiar position doing chest compressions, behind me a hoard of doctors, a family sobbing out in the hall eyes on the floor trying to come to terms with what had happened.  I hadn’t really eaten anything for breakfast and it was sheer adrenaline that kept me going.  As I was doing compressions there was a moment where things seemed to slow down, the mass of people in the room seemed to dissappear as I looked down at our patient’s face.  Maybe it was one last effort to communicate, a boost for us to keep going, it was probably from the jolt of pounding on her chest but one eye lid came up and I saw a dull black pupil, fixed, dilated.  There was no glimmer, no emotion, no plea, just darkness.  I kept going, frantically, hoping it would change.  Fixed.  A couple more compressions.  Fixed.  Dull.

I looked into the black hole as sweat started to form on my brow.  I was tired.  I had seen that black hole before, the story it told, the same ending it always seemed to give.  Three exhausting hours later, everyone came to grips with the ending.  The family came in eyes conflicted by looking at the ground and at the body before them.  The patient’s mom came in whaling, “she’s so precious!!”  I came out of the room and threw my glove away.  I didn’t know if I was more tired, exhausted or frustrated.  Half our team was in the bathroom crying.  I briefly looked over at my colleagues involved with the code only long enough to catch a glimpse of people’s expressions.  A glimpse was all I needed.  No one was really looking at each other.  Eyes were fixated on the floor, brows furrowed.  What could have been done?  What did we do wrong?  It wasn’t much past 9AM when we knew we had to move on.  We were on call that night and we had no choice but to look ahead despite wanting to dweel and look back.  Still just as a kid in the doctor’s office, I was still scared.

The not so awkward silence

It’s amazing how much can be said by silence.  In our ever changing (unfortunate) move to assembly line “pack as many patients as you can” medicine often patients are given the opportunity to talk.  Some times it’s what they don’t say that speaks the most, that tells their real story.  

The other day I had a patient with metastatic breast cancer.  I had just got done pronouncing the death of a 39 year old woman with breast cancer metastasis to the brain when I came to visit her, so I knew the prognosis all too well.  It was late.  I didn’t even bother to check my watch.  A shadowy skeleton of a figure was slouched in bed, the stubble on her shaved head catching the hints of light in the room.  She slowly moved her eyes up.  Her lips were curled down, defeated.

“Hi I’m Dr. Fallahi.”

I asked a few standard questions.  She recited her history like she had done countless times before.  She looked up at me, “I don’t want to do this any more, I’ve been going through this since 1989.”  She spoke in that agonizingly soft voice of someone that has gone to hell and back.


“I went through chemo.”

She looked up at me. Silent, as if expecting I knew what it was like. Her eyes told the story.

“I feel so weak.”  She then looked at me as if longing for something.  Here eyes intent, lips somewhat curled as if  it wanted to give some sort of smile of desperation but couldn’t.  There wasn’t much more that needed to be said.  No one was going to cure her cancer.  For that matter things were going to get worse.  She had metastasis to the lung, bone, and and she was starting to turn yellow from her liver metastasis.  I could have tried to lighten the situation with some sort of optimistic anecdote but I knew it wasn’t the time.  I finally broke the silence, “I’m so sorry.”

As I left the room, I looked back at her, paused.  This time she broke the silence with what I would like to think was some attempt at a smile, “Thanks for your help.”


So Much More

Being a doctor is not what it used to be.  More and more doctors become jaded at the system and on one hand who could blame them?   Insurance companies are becoming increasingly invasive in our decision making.  Paperwork is at an all time high.  Compensation is decreasing while work is increasing.  Still I find it hard to become jaded when I go home at the end of the day because in the end it is the reason I went into medicine, patients, that keep me going.

The other day I had a patient come in on a wheel chair.  He had been shot in the back paralyzing him below the waist.  The injury had caused other problems as well.  Due to his spinal injury he had a major erectile dysfunction and medicare had turned down his prescription for essentially an injectable viagra.  He was determined to have his case re-opened.  Like many things in our overly insurance run medical system his case was not looked over carefully.  Medicare didn’t even know he was a paraplegic.  I drafted a letter stating this was a common problem in people with spinal injuries and this patient was in fact a paraplegic.  His face was eternally grateful for essentially a medication refill but to him it meant so much more than that, it was one step towards being “normal.”  I just hope the insurance companies see it that way.

The other day as I was doing walk in visits in the clinic I saw a female patient’s name pop up on my screen.  Under reason for visit it stated that the patient was depressed and tearful.  As I called the woman’s name she slowly came in, trying to old herself together still trembling, eyes glossed over.  As she sat down she barely looked at me.  In the modern insurance-centric world of medicine this wasn’t a “regular” doctor’s visit.  The woman explained to me how she was scared for her life and that was the reason she came in.  Her daughter and grandchild were recently assaulted and stabbed in Central Park.  One was beaten with a hammer and sent to the ICU.  The criminals were free and they knew where she lived.  She didn’t feel safe at home so she came to me.  Needless to say I put her in touch with people that could help her out.  I billed the visit as depression for the insurance folks.  In eyes of the healtcare system that’s what she was, but as a doctor there was so much more to that visit.  It is because of that “so much more” that despite all the hours, paper work, insurance and lawyers I find joy in my work and how I keep sane on those tough days.

The Invisible Tourist

Growing up in Idaho was tough.  In a predominately Mormon community of cookie-cutter looks my dark hair and features never did fit in.  People soon figured I wasn’t Mexican which pretty much meant folks were confused as to “what” I was.  My sister to this day angrily recalls kids at school teasing her.  She had it worse than I did.  We were the ones that got funny looks.  It sucked.

Yet as I tour yet another country this time Istanbul, Turkey I came to appreciate those very features.  No matter where I go people never see me as a tourist (that is until I pull out my map or speak English).  Even when I speak English like today they assume I’m Italian.  Perhaps it is because I’m in the midst of making a film, but this trip more than before has made me think about the world around me.  I see things differently, looking for images, looks, emotions.  Being “invisible” affords you the opportunity to look at things more from the inside.

As I walk people don’t ask me to buy shirts, they just assume I’m like the other 14 million people in the fourth largest city on earth.  As a result, although I am a tourist I have the privelege of getting immersed.

The first thing that hit me in Istanbul was its beauty.  Lush green hills and waterways connecting Europe and Asia.  The people are exotic and beautiful.  Features break the norms.  Bright eyes, with dark hair.  Dark eyes with light hair.  Light skin, dark skin, inbetween skin.  Turkish, German, English, Italian, Farsi fills the air.  The next thing that struck me is how much it was like Iran.   Walking down the street the clanging of metal, old motor cycles and workers resonate.  Their is a tactile feel to products.  People still “make stuff.”  The air smells of dust, diesel and Chanel perfume.  An industrialized nation and third world mix.  As far as the eye can see are goods, shoes, belts, bags, shirts, mostly knockoff of designers.  While people must know these are fake they still buy them.  Perhaps it is trying to live the illusion of wealth.  The burden of money is constantly present.  A little girl with black hair and a red scarf, alone at night on a crowded sidewalk begs for coins a she taps her plastic bowl.  People rush to put coins in her bowl.  After half an hour her piercing teal eyes look out, glossy, lost, scared.  Down the street tourist fill the fish restaurants as traditional Turkish music is played.  At least culture is maintained somehow, albeit by entertaining outsiders.  But hey, at least people have time to vacation so kudos to them.

From my vantage point however, I feel like the tables are completley reveresed.  Almost without exception within two seconds I can tell that a group is from America or not.  It is a complex thing to explain but it is unmistakable.

I walked tonight to a small dessert bar and ate four different types of baklava (with an obvious thought to a few friends).  As I sat there by myself eating I looked over at my server, a guy with dark hair and features who was on his break.  He was eating a few pastries quietly in the corner.  His eyes were tired, it was 930PM and he was stuck feeding visitors like me.  As I left I told him how great the baklava was.  He gave a warm smile, his eyes lit up.

I walked the long way back to my hotel, not once did anyone ask me to buy anything.  Not once did I get a funny look.  Sometimes it’s good to be “different”