In the last ten years I learned, reading somewhere, that American doctors die young. They die an average of ten years before the rest of the American population. This bothers me for three reasons. One, I am a doctor. Two, my grandfather the psychiatrist died ten years before any of my other grandparents and 21 years before his wife. Three, why? What is it about doctoring that kills doctors younger?

It's not infectious disease. My grandfather died of adult chronic leukemia, cancer. The doctor here in town that died in the last ten years was a psychiatrist. He crashed his mountain bike and died of complications of a high spinal fracture. He taught tango with his wife and was an excellent bicycler and athlete. He was close to retirement. The medical community went into a bit of shock. He was also the only psychiatrist in town, so we had to handle his grieving shocked patients. As usual, we hid our feelings and looked professional.

And there it is. I think that it is partly the "looking professional". The white male Marcus Welby calm, confident, reassuring archetype.

Me, I want to be House. And I rather am. I'm not as directly mean but I am challenging and I argue. I was raised in New York State from age 3 to 14 and many New Yorkers are direct and think it's perfectly ok to yell at someone if you are mad and that it would be normal for them to yell back. Then we laugh and go have coffee, admiring the other for their passion. Also, my archetype is not my psychiatrist grandfather but his housewife. She was the fierce matriarch, could tease people close to the bone and lived to 93. She did not particularly seem to worry about being nice. I dreamed she was a witch when I was 8 and it was one of the most vivid dreams in my life. And I admired her and loved her. I'm not sure if I was truly afraid of her or just had a very deep respect for her, intermixed with the caution one would use around a tiger or other large predator.

Even a young tiger pays attention when mother gets impatient and whacks her.

I like House as an archetype better than Marcus Welby. He has feet of clay. He limps. He is damaged. He is addicted to painkillers. He is often not nice. He might be seen as mean or as direct. He calls what he sees, even if it isn't nice or doesn't fit the social niceties. And many of the cases that he works on are solved by delving below the social mask. Who is the patient really? What are their secrets? What are they hiding? And that is true medicine, not to accept the face value. To ask the next question when something does not ring true or sound right or there is something else.

In my first year here, my nurse once said, "I don't know how you do it. You walk into the room of someone with an infected toenail and you come out doing a scan for a chest tumor and it's there. How do you do that?"

I do it by addressing the unspoken. The unspoken hangs in a room like a cloud. I can't see it but it is as if there is a giant floating cloud hanging above the person. It is often crying, pressing to be named. I don't even know I'm doing it, sometimes, asking just another question and another. We aren't on the template for the infected toenail anymore, we have wandered far afield. Fuck the template, it is for the coders and the insurance and the billers, but it really isn't about good medicine. Good medicine is reaching out.

We were told to see patients for "one thing per visit." I saw a new woman with complex back pain. A long visit. Past surgery. Pain. Many things had been tried.

But she was hoarse. "How long have you been hoarse?" Yes, I am off the damn template again. She said, "About nine months." "Does it ever get better? Does it come and go?" "No," she said. "It is the same. Well, it's getting worse, actually."

Crap. "Ok, I'm only supposed to see you for one thing, but let me ask some more basic questions and I want to refer you to the Ear, Nose and Throat doctor too, because the worst thing it could be is cancer, and I don't want to miss it. Okay?" We fired up the second template and there's a nice new patient visit with two referrals. Yep, went overtime. On to the next room, apologizing as usual for being late.

She came back a month later. "Thank you," she said, "for being so thorough. I'm scheduled for surgery of my vocal cords. The ENT thinks it's polyps. He doesn't THINK it's cancer, but can't be sure."

"You are welcome," I said, "I'm glad we sent you and that you were willing to go." And then how can I feel bad for running late? I reserve my anger for the administration and the other providers who put pressure on me to see people for one thing, more people faster. Yes, that's the way the system pays the best and yes, I know the hospital needs to stay afloat financially, but in the end, I can't ignore the clouds. It would kill me. It would destroy me as a physician. It would be unethical. When I walk in a room, I have to deal with what is there, whatever it is, as best I can. Like our surgeon, who did an appendectomy on my mother, only to find out that it was ovarian cancer. It took four hours instead of 30 minutes and he came out apologizing. "I did the best I could," he said, "I did not have a patch for her diaphragm so there was a bit I couldn't get. I am sorry, but we didn't know until we got in there."

It doesn't matter what is on the schedule. I don't know until I get in there. Then I play the hand that is dealt, I call it as I see it, I gently touch a question to the cloud. Sometimes the person is not ready and withdraws. Sometimes the cloud opens and we are in another place. This is what makes me a good diagnostician and makes me pick up the unusual things, the zebra cases. I am open to the nonverbal communication, to the body language and sounds and shifts and pheremones that call to me without words.

If I don't name them, I am not a good doctor. And then I would certainly die young.

I am not saying that that is the whole reason why doctors die younger. I think that doctors die younger because they lose touch with their emotions. The role model is to be cool, calm, collected and reassuring, even in the cases that make me want to run screaming through the halls. I've had other doctors say, "You sound too angry." I use New York as an excuse, but I do grieve, my heart runs screaming through the halls, I smash plates on purpose when I am upset, I argue, I tell the administration what I think, I am not a nice girl. And don't want to be.

Now that I have done all the links, I am thinking who the hell cares? But I'm in the ironnoder, so I'm posting anyhow. Thus our principles go awry for the sake of expediency.

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