FOUR LESSONS

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FOUR LESSONS

We all know it.

Today's health care model is a mess. When I was a fresh Intern, I met an ornery patient I came to adore, and not only because I saw him on a near-monthly basis. The first day I met him, he was being admitted from his dialysis clinic because his blood pressure was too high. Upon entering his room, he grinned and said,

"I get a lady doctor this time round, coo-wee! I tell you, as soon as I get out, I turn right 'round and be back here again! That's fine, tho,' that's fine." He leaned in with a wink and continued. "This time, tho,' they fuh shore better tattoo a big ol' barcode on me. Instead of wasting everyone's time, you could just scan me with one of them fancy machines. Beep! Everything done! And maybe, just maybe, they'd bag me for free when I finally check out."

He was a good-natured black man born in the 1930s, somewhere in the bayou along Houma, Louisiana. He wasn't sure of his real birth date or his actual place of birth (aside being born inside the house his father built with his own hands). He loved to talk and I was easily captivated by his agile, river-rapid accent. It was sandy with touches of gravel, yet unmarred by his lifelong love of hand-rolled cigarettes. He would say "Nawlans" instead of 'New Orleans,' among other fascinating, drawn-out bayou words that were unfamiliar, if not outright comedic. Yet, he'd lived above the Mason-Dixon line just long enough that I manged to understand him most the time, even if I had to file some of his vocabulary to be figured out later (it took me forever to figure out what a beignet was).

He could still speak old-school Louisiana French (when he cared to) and I knew his traditional Cajun was a dialect that would fade away within my lifetime. To this day, I deeply regret my lack of courage. Each time his name appeared on my schedule or rounding list, I swore I'd ask if I could record his voice. Yet, doctoring always got in the way and I inevitably justified my hurried rush to the next patient by assuring myself I'd ask next time.

Sadly, "next time" never arrived. One night he arrived suddenly, too ill to speak or even recognize his doctor. He was taken to the ICU where he succumbed to sepsis within hours. Despite nearly three years of continuous care, I never got that recording. It would have been given to me gladly. More than anything, he loved to talk and have someone around to listen. Had I taken the time to appreciate his brief - but life-altering - gift within my too-preoccupied life I could honor him today by listening to him now and sharing his stories with my children. 

It never feels good to realize you've started to look like a cog in the machine. I had mistaken myself, the Doctor, as the "Person of Consequence" while relegating patients to "things." Patients were overbooked appointments; lists of diagnoses; time-sinking pain seekers; additional paperwork; more billing; and worst of all, they were "next times."

I was wrong. How did I stray so far from altruistic girl who just wanted to help people? How did I become this insensitive asshole? That was Lesson One:

Patients are people and they are valuable because of their own merits. I must never take that for granted again.

For three years, he was my regular patient. He had no remaining family - his strongest relationships consisted of his neighbor, a cat, and me - a doctor still learning the ropes. I never understood what that kind of isolation was like for him. I never once thought to go to his home and care for him there. I assumed he'd tick along on dialysis forever. That is, until he arrived in the ER that night and I received the admission call. One look at him and I knew the inevitable was coming, but no one else was. There was no one for me to call, no one to provide a preferred funeral home...no one but me. So I pulled up a chair and sat next to him, watching his heart monitor slowly space out until only a flat line remained.

When he died, his black, weather-worn hand was held in mine, white and bland. Yet, our palms were nearly the same color, creating the illusion that our skin blended into each other's. That was Lesson Two:

The only ideas that create separations between doctors and patients are the ones they create themselves.

Eventually, I left his ICU room to write his death summary. It took so long to complete that transport personnel finally wheeled him out, covered by a black sheet. And that was Lesson Three:

Medicine does bag you in the end, and it sure as hell wasn't free.

I never forgot the many injustices he should not have faced. His chronic illness; his poverty; his insurance; his race; his age - these were used against him by corporate medicine, turning a kind man's complex and fascinating life into a demographic and later, a discharge summary I was yelled at for not completing on time.

Leaving residency and joining a Hospitalist group did nothing to assuage the many grievances I carried from my medical education. In fact, I continued to accumulate anger on behalf of those who had less power over their care or their management: patients, nurses, and other vital care providers. Be it clinic or inpatient, nothing changed: patients and doctors had little time together; care was expensive and insurance was a mess; patients couldn't understand their medical bills because of intentionally-complicated forms; physicians were pressured to meet daily patient quotas; nurses were abandoned by busy physicians to manage end-of-life care without help; and always, always, medical providers were intentionally understaffed. By far, nurses were treated worst, despite being the hardest working employees in any care facility. As an Attending who could finally put the entire sham into focus, I came to learn Lesson Four:

 If you lead a health care team - which works best when all are treated as equal partners - you will feel ashamed because the "system" you're supposed to support is taking advantage of those receiving smaller paychecks, despite being the legs you stand on.

These four lessons changed who I was inside. I know myself well enough to know I will never again return to corporate medicine. There is a better way of doctoring, and I'm stubborn enough to figure it out.

Fuh shore.

AN ELEMENTARY MISTAKE

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AN ELEMENTARY MISTAKE

You know, there’s a lot of social engineering we take for granted.

Media. Organized religion. Politics. Public education.

We have allowed these social machines to make decisions for us, with the pretense of being vital to our happiness and, perhaps, our very survival. Even when we recognize their flaws, they continue to grow thanks to hungry commercial industries that profit from social engineering. While I can wax poetic about each of these topics (and will gladly do so in the future! I know! You’re thrilled!), this article tackles the giant manufactory of public education. My goal: to convince you that Schooling is essentially the Force. Oh yeah, really. Just look what it has done to these children:

Don’t let the Force destroy your child’s destiny…

Indeed. You see the inherent dangers. Like the Force, school has a light side and a dark side, and seems to hold everything together. And, lest we realize too late we’re serving Sith Lords, we may wish to consider the degree we allow schooling to dictate our lives.

Consider… we arrange our lives around a system which takes our children for a large portion of their early lives. That seems potentially dangerous to me, and we know many of our schools fail to meet minimum standards. Despite this, our society treats the school system as a moral paragon, which only ignorant, stubborn, ingrates reject. But… are homeschoolers the problem, or has traditional schooling robbed us of our children’s most precious years? Even worse, maybe the system actually does what its supposed to do?

Meaning… has the system been a huge success… at generating standard citizens?

Everyone is under the impression our children can live up to their greatest potential in America. Well, my ADHD husband, the son of a physician who could afford to send her son to private school his entire life, has a few things to say about that (a topic for another time). He had a faux impression of being given every opportunity. Everyone believed it, including his parents and his teachers. Oh, Robert, you have so much potential, but you’re just not motivated. And that’s what he heard his entire childhood until college. Then the mantra changed: oh Robert, you just can’t get yourself together. He was in his 30s before he started to think, maybe, the problem was trying to force himself through an improperly shaped cookie-cutter for too long. School may work for the 100% average student, but who determined what an average student should be? I’ll tell you presently. But I warn you, you’re not going to like it.

The “American Dream” is saturated by scholastic pedagogy. Education is the most extolled virtue in our country, immediately behind another dangerous, naive naive belief that with enough hard work you can get it/do it/be it. But here’s the problem: A majority of Americans have lost faith in achieving the Dream, which, to me, means its foundation was never sound to begin with.

American-Dream

We must routinely question the foundations, especially when they’re tied to American identity and self-worth. So why don’t we? Well… read on.

Now, I’m not an education, history, or psychology expert. I’m just a mom with a slightly unconventional family… different enough to realize the system doesn’t work for us, but “normal” enough to see hundreds of other families in the same boat. While I can’t claim to reveal any great epiphanies, my friends, family, and employers can assure you I have one unique trait, one that allows me to crash through institutionalized walls like a crazed Kool-Aid man. That talent? I am fantastic at being a giant pain in the system’s ass. Oh yes, my friends. From day one, I was sprinting down the off-beaten path, my two middle fingers kept in check only by holding a giant megaphone to ensure everyone knew how I felt about it. If the system was a cashmere sweater, I’d be the uncultured jerk picking at its lose threads. Unraveling the status quo is my forte.

I admit it wasn’t until recently I started to question the methods, practices, and history of public schooling. After all, I was in public school since kindergarten, and look how awesome I turned out!

world of warcraft

(I know, right? Just what I said…this is how everyone plays World of Warcraft.)

Now that I have done my research, I can’t look back.  But with our announcement to homeschool, we were reminded not everyone felt it was a good idea. In other words, our change of clothes was not only a social faux pas, but an assumed criticism of other people’s fashion.

Removing Kallan mid-kindergarten was met with stone-faced stares, tears, sadness, and downright anger. On average, however, the emotion was simple apprehension and worry about Kallan’s education. When Kallan was enrolled in Kindergarten, I was 100%  pro-public school. I never even questioned it. My thought process was: Son = 5 years old = Kindergarten. I knew about homeschooling, of course, but it was always that weird thing religious fundamentalists did to ensure their kids weren’t infected with ridiculous…. ideas.

creationism

(“Peace be with you, clever girl.”)

When Kallan’s mood and school work started to suffer, however, I realized I was left with the options of homeschooling or private school. Then I realized private school wouldn’t solve anything. The reason he was unhappy was because the system wasn’t made for an ADHD child. So, homeschooling was the only real alternative.

We started talking about it, with considerable apprehension. But as my research continued, I realized the apprehension wasn’t from any actual proof homeschooling was harmful. Rather, it was from the unspoken assumption that education was best left to the experts. The basic theory is as follows: Children’s education should be left to trained educators for the same reason haircuts should be left to trained stylists — doing it yourself will likely result in a lopsided hairdo, eventually requiring a buzz cut to fix everything you fucked up.

Well, I cannot deny that I suck at cutting my kid’s hair.

haircut

But, uneven bangs have only added to his adorable charm! Likewise, I came to believe this change in education, while unconventional, was completely within our ability to manage at home. Not only was it something we could accomplish, but, I realized, something we could do better than anyone else.

I will share the questions I asked, then you can see what you make of my findings. If you’re debating homeschooling, trying to convince a spouse/family member, or are my mother and terrified of more lopsided haircuts (love you, mom), then the following  may be worth your time.  Don’t be apprehensive — I’m only going to point out how your entire childhood was completely wasted by the system. :D

Question 1: Where did public education come from, anyway?

Remember when I asked who was responsible for determining what an average child should look like? The answer is surprising, and there’s no way to discuss it without sounding like some kind of basement troll conspiracy theorist. In a nutshell, when we talk about public education, we are referring to compulsory schooling. Meaning, mandatory attendance of school, six hours a day, five days a week, nine months a year, for twelve years. Do we actually need that much schooling to transmit fundamental academics?  Really? Have you ever asked? And if you did, were you ever given satisfactory proof of its necessity? There is no evidence, at all, anywhere, to prove children need formal education for that long. Benjamin Franklin, who lived before compulsory schooling laws went into effect, started his own Independent Newspaper when he was 15 years old. Can you imagine if he had been forced to remain in public school until 18? What could today’s children accomplish if their entire day, week, and year were not determined by what is, when you think about it, a rather uncompromising and entrapping schedule.

Before compulsory schooling, children learned from family and their community. They often found apprenticeships around 13 (what today is considered a helpless child), and learned a trade by doing. Children were not removed from the community, but were an active, creative, and necessary part of it. These days, if you see kids at the store during a Monday afternoon, they are out of place. That doesn’t seem right. What has the American culture done to itself?

Compulsory schooling became a thang in the early 1900s, about the time  a tremendous number of epic douchebags were diving into their vaults of gold. You may recall their names: George Peabody, Andrew Carnegie, and John D. Rockefeller are a few.

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These were the Scrooge McDucks of their age, and they realized mandatory education was the most effective way of creating a harmless electorate, servile labor force, and horde of mindless consumers. I wish I was being dramatic.

Before these social barons got involved, school was not something one went to, nor was it a legal obligation. Washington, Franklin, Jefferson, Lincoln…these dudes were not the products of a school system. They were self-educated men, and they excelled because they pursued their passions. Lincoln, for example, had less than a year of formal schooling, and the majority of his childhood was spent as a farmer and carpenter (this is why he was good with the ax). Still think we need 12 years of structured schooling? Here’s a fun aside.

Everyone knows Lincoln is one of the most famous lawyers in history, but he didn’t study law, he read law, and he passed the bar at 27 years old. Being a country man, he was out of his league when asked to defend a high-profile, city client. The city lawyers sharing the case thought Lincoln was dumber than snake mittens, so they basically stood him up when the case was moved to another city. Realizing the game had changed, Lincoln identified what he didn’t know, filled the gaps, then PWNed those jerks at a later date as the president. BOOM!

The basic idea behind mandatory school laws was essentially Social Darwinism — a method of ensuring poor and middle class children were not misfits in the streets, but productive members of society… productive for the social elite, that is. You see, in Lincoln’s time, our society was still (mostly) Libertarian. Everyone was still inventing stuff. Gobs and gobs of fantastic inventions and patents galore. But, the country was making a gradual shift from a productive economy of rural start-ups (when innovation is necessary for survival), to industrialized consumerism. It started with the Civil War, then bled into the World Wars. Compulsory attendance laws would be the legacy of an after-war world.

So, lets jump back to the business barons.

Let’s introduce ROCKEFELLER.

irocker001p1

Do yourself a favor and research this man, for his legacy is still affecting our politics. Look at that quote. Good God. What a privileged jerkface. Even now, our congress is fighting over building the Keystone Pipeline, a giant, environmentally destructive project which puts money in the hands of oil men (when we should obviously be investing in green energy). Like all epicly rich dudes, Rockefeller was into oil. He was the co-founder of the Standard Oil Company, which made him the world’s richest man, and the first to be worth more than a billion dollars. At the time of his death, his fortune was 1.5% of the American economy.

Holy shit.

Rockefeller did a lot of good for society and revolutionized philanthropy, but his personal motives were questionable, especially when set beside the wishes of the average, poor/middle class populace. Rockefeller’s projects were guided by two principles: Fundamentalist Baptism and Social Darwinism. I don’t have time to go into Social Darwinism here, but let’s summarize it as “not great.” Social Darwinism became a mechanism abused and distorted by politicians to declare blacks racially inferior, to forcefully sterilize mentally retarded people, and so on, ad nauseam.

Rockefeller formed the General Education Board in 1902. This is the point in American’s history when education fell under the control of the government. And it never left. As parents, we don’t think of our kid’s class room as government property, but it is. Behind the colorful billboards and smell of glue, hides the ever present government process at work. And who is in charge of school boards now? Lobbyists and corporations. Why are they so interested in public education? The answer is that public education is a hugely profitable business, worth about 650 billion dollars a year.

Because we’re used to seeing it, one has to stop to consider the influence commercialism has on our schools. When I was a Junior in High School, a product called Surge came onto the market, though it didn’t last long. It was a highly caffeinated, highly-sugared drink, a forerunner of today’s hugely successful energy drink culture. One can of Surge was 230 calories, 62 grams of carbs, and 51 mg of caffeine. I remember thinking it was “so cool” our school allowed Surge representatives to come to our assembly and toss free drinks to kids, during school hours. Now as an adult, and particularly as a physician, I am horrified my school allowed us to consume that kind of trash and I wonder what the administration got in exchange for hooking some of us on a drink that was a major contributor to childhood and adolescent obesity.

When I was in middle school, we attended a school-wide assembly to listen to a representative for “Bring it to the Max.” The speaker was skilled at motivational techniques, and he got us excited about selling magazines in exchange for small rewards. I remember being told if I sold ten magazines, I’d get some stupid key chain. The rewards escalated. If I could get a hundred subscriptions, I got something uber cool, like a set of shelves for my locker. The highest rewards included weekend vacations and bikes. The school earned money based on how much we sold. Man, I left there completely psyched to sell magazines! It consumed my next few weeks, and I was devastated when I couldn’t sell enough for a fun prize. I remember crying on the final day, because I had less than ten sales (all pity purchases). Looking back, I’m furious my school used me in such a way. And no one, including my family, saw the problem with a school using its students as private fundraisers. I can’t blame them. I mean, every public school was doing something similar.

Today, public students are forced to watch commercial-filled Channel One (a privately owned, “student-aimed” channel), to see Pepsi and Coke posters and vending machines in their hallways, to use curriculum materials printed by Shell Corporation and other big oil companies,  and thousands of similar exposures. Teachers, also, are the victims of commercial interests, often forced to adhere to government contracts to purchase school materials, or stick to “school-aka-corporate-approved” lists of subjects to cover. We cannot remain ignorant about the advertising aimed at our children, or the corporate bias influencing our schools.

The institutionalization goes further than academic exposure. It’s seen in the environment. Our schools often look like prisons or nuclear bunkers, with rows upon rows of straight desks, controlled activities, and schedules dictated by bells:

The first floor hallway in PS 149.

When I was in middle school, our principal decided there was too much talking in the hallways. Maybe this was true. We had hundreds of students in one building, and all regurgitated into the halls for four minutes between classes. In our hurried attempts for socialization, we congested the pathways. However, the chosen option was to demarcate small squares where conversation could occur. Squares were duct-taped in the hall, allowing for a max of three children to have conversation. Anyone talking outside was given punitive actions. Nice. Real nice.

All this because corporations were given free licence to use public education for their own benefit.

Just to emphasize the degree of corporate influence in the early 1900s, consider that, for many years, only two men, Rockefeller and his buddy,  Carnegie (of the Carnegie Foundation), spent more money on forced schooling’s early years than the government. They funded teachers, schools, Universities, and curriculum. They influenced the Education Board by awarding grants to those who followed along without complaint. And here was their philosophy, according to Frederick Gates, who was Rockefeller’s business adviser.

“In our dream we have limitless resources, and the people yield themselves with perfect docility to our molding hand.  The present educational conventions fade from our minds; and, unhampered by tradition, we work our own good will upon a grateful and responsive rural folk.  We shall not try to make these people or any of their children into philosophers or men of learning or of science.  We are not to raise up among them authors, orators, poets, or men of letters.  We shall not search for embryo great artists, painters, musicians.  Nor will we cherish even the humbler ambition to raise up from among them lawyers, doctors, preachers, statesmen, of whom we now have ample supply.”

Shocking, isn’t it?

If you want a complete timeline of compulsory education, here is a decent summary: Timeline of Compulsory Education

Public education was founded on the concept that, if you came from working class society, you didn’t go to school to learn (that was for private schools), you went to be taught how to be a good worker. Only then would you be effective fuel in the furnace of the industrial revolution. Furthermore, the corporate moguls used the Prussian educational system to base American school on. Yeah… Prussia really wasn’t the leader in hands-on enlightening experiences. Unless you were talking about a public flogging, in which case you might be quite satisfied.

So, how did Prussia surgically extract the soul from its children? By ensuring kids were separated by age, subject, and performance grading. Sound familiar? So, lets’ talk about those grades…

Question 2: Who Gives a Shit about Grades?

For adults, our time to escape the system is passed. Let’s face it… we learned to perform solely for the purpose of single letters.

That’s right. Grades. Oversimplified symbols representing our worth, intelligence, potential, and ability to please the institution. We lived our childhoods under the shadow of  A, B, C, D, and F. Let me say that again: our entire childhood, meaning a minimum of 12 years (since most public schools require you, by law, to be present in school from the ages of 6 to 18), was aimed toward the goal of earning a grade. This is such a prevalent part of American life we persistently fail to recognize how absolutely ridiculous it is. Unless you’re reading The Scarlet Letter, I defy you to tell me how a letter describes one’s worth. It can’t. Just look at the ways a person’s character is graded by a teacher in this example:

Report cards

After discussing corporate machinations, the idea of getting grades on character traits is spine chilling. Just look at the “worthy” traits… exactly what you hear about in corporate training when you get a new job. What about innovation? Creativity? Leadership?

In addition, there is no evidence out there that grades mean anything. No study has ever found a correlation between intelligence, quality, innovation, or potential, and the degree of one’s “good grades.” We constantly talk about how Einstein failed math and became a genius who changed our world. In other words, the uselessness of grades is part of our culture’s mythology, and yet, we still focus on getting good grades above anything else. It seems nothing is more important than good grades. If you have time, watch this documentary. Consider how brilliant this young man is, then watch him decline into anxious failure as he is forced to produce his work according to format. Then consider the reaction of well meaning parents and teachers, none of them who question that, maybe, the school is the problem:

Parents know there is more to our children than what is on a grade report, but that hasn’t stopped us from allowing our children to be filed under a grading system. I had it easy. I was one of the few who didn’t have to struggle to make good grades. Therefore, I didn’t think about it much. In fact, I was proud I didn’t have to struggle, and I admit it gave me a bit of intellectual superiority. Today, I realize I was one of the completely average children the school system was designed for. I am the factory worker. And now I’m a doctor working for a major corporation. I’m proud of my work, and I work for a company who treats me well, but there’s a part of my soul wishing to throw off the shackles and run to foreign countries to provide mission work. Maybe, some day, I will. Or, maybe I will remain a corporate monkey to ensure my children have the resources to escape the system. Who knows.

Let’s take my husband’s childhood as the opposite example. He has a spontaneous genius that far outweighs my textbook regurgitation. Yet, his entire youth was one giant string of anxieties and disappointments, all over his grades. An ADHD kid trying to make A’s in an institution already designed to cripple his natural learning style? It’s no wonder he started to have self confidence issues in fourth grade, when homework and grades start to count. Soon, school was nothing but a progressive trial in trying to prove he was a smart and worthy human being, all the while constantly disappointing teachers and parents. It’s not fair, and it’s a dumb way to waste a child’s potential. Was getting assignments in on time and making good grades really a measure of his intelligence and capability? Obviously not.

So, think about it. Really think about it. What does a grade mean? Anything of actual value? Prove it. All that time we spent making A’s?

Wasted.

It should have been spent learning something of value. Nature walks. Finishing the book you couldn’t put down. Exercising. Enjoying the evening with friends. Getting sleep. A thousand happy moments were wasted typing papers and filling out worksheets. And frankly, many of us are still recovering from the damage it caused.

Grades are necessary for college entrance, to give colleges a number (your GPA) for which to rank you. That is the only purpose of grades and, frankly, there’s something a little evil about it. How will my son’s life be different if he isn’t worried about making As? I’m not sure, but I’m going to find out.

Question 3: Don’t We Need Trained Educators to Teach Our Kids?

Um. Nope. Sorry. I’m not saying grade school teachers are worthless buttheads that should go get real jobs. On the contrary, I had delightful teachers as a child who had great personal interest in my life. But the truth is, it doesn’t take a degree to teach a child. They are naturally programmed to learn and the more we interfere with turning education into a process, the more harm we are likely to do.  And, in an effort to maintain Core Measures (more about that elsewhere), we are stunting our children’s growth. No Child Left Behind? More like, No Child Gunning Ahead, or No Child with Actual Enthusiasm. Or, even, No Teacher with Freedom. Do they really need to have every aspect of what they learn spelled out?

The answer is yes, if you’re attempting to make an army of employees and consumers.

But if you want your children to flourish? Let them manage their education themselves. Evolution has given us a delightful, complex, and wondrous brain capable of doing just that.  As products of the system, parents believe we are not competent to teach our children, but who could be more qualified? We do not need advanced degrees or training in childhood education to identify a child’s enthusiasm and to foster it. If you find a topic you are unfamiliar with? Learn it with your child!

When you free yourself from school’s schedule, you free up a fantastic amount of time to teach your children. Think  about the amount of time taken up by BS when you went to school: the time spent getting into lines, monitored lunch breaks, pep assemblies, changing classes at the bell, etc. Then think about the amount of time spent on projects that were meaningless! How often did you ask a teacher, “but what is the point?!” Just think how much children prepare for standardized testing (since good scores on standard tests are how schools get funding)?

In other words, how much actual learning takes place in which kids are interested in the subject matter, and the subject matter actually applies to usable skills? Now, imagine your child being free to pursue whatever he or she is into at the moment. Every day is open for them to jump into their passions, get involved in a volunteer project, or find an apprenticeship. That’s learning!

In the end, if you’ve made it this far, I hope I’ve convinced you that public schooling has questionable motives and questionable execution, and I hope I’ve given you some ammunition for those questioning your decision to home school. Keep in mind that what I’ve written about here are only three simple tracks leading into a much deeper rabbit hole.

Children are the best part of us. Don’t be afraid to teach them. Don’t be afraid to stand up to the establishment on their behalf. And, if public school is something you cannot escape, don’t be afraid to question school authority.

And try not to think too much about how much Surge you drank in high school. After all, you only need one kidney.

THE DIABETIC

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THE DIABETIC

It was Saturday afternoon. It was one of those rare days when the weather was perfect for laying in the cool, newly sprouted Spring grass while chubby white clouds drifted over. Glancing out the window with unadulterated yearning on my face, I ached for the rare potential to relive a careless day from my youth. Instead, I was making rounds in the hospital. Since it was the weekend, I had double the patient load. My hope to escape to the outdoors was piteous. There would be no escape from the sick today.

Standing inside a dark room while my pneumonia patient coughed violently into the bedside commode, I felt as if I was going through clinical withdraw from…from life. My dark reverie was cut short as the pager went off for the hundredth time that morning, its aggressive soul-puncturing beep calling me from the room on yet another unpleasant errand.

The nurse who paged me informed me her 53 year old patient, Ms. D, had a blood pressure of 220/120 and was refusing any medications. I sighed and reviewed the medical information on my patient list. “Morbidly obese, urinary tract infection, high cholesterol, chronic kidney disease; admitted for hypertensive emergency.” In other words, our average patient. I made a quick check of her morning lab work before visiting her and was unsurprised to discover her diabetes test had come back positive. Very positive.

When I entered the room, it was with a smile. Maybe the patient was scared and no one had explained the urgency of treating her high blood pressure. Maybe she just needed someone to spend time with her. I went in with a goal—to bring her blood pressure down to a safe level and to have a much needed discussion about her new diagnosis.

The nurse met my eyes when I entered. I could tell from her exasperated look the patient was being difficult. There’s a certain visual malevolence nurses get when they are fed up with a patient. It’s as unmistakable as a stray dog watching you from a bowed head…reach for that food bowel and you’re going to get bitten.

Ms. D met the profile I expected with her list of diagnoses. She was fantastically obese, her stomach overhanging down her thighs. Her small knees sat above large calves which were marred by the leathery skin changes caused by lack of circulation. Her gigantic upper arms strained the cuffs of her gown’s arm holes. She had an IV in place which was secured with half the hospital’s available tape…if that thing came out, it wouldn’t be replaced easily. Her legs jutted out in a splayed and aggravated fashion, her bed sheets kicked carelessly off the side of the bed. She was hot. The room was freezing. She looked old, much older than early fifties. She breathed heavily, a consequence of the pressure from her immense abdomen, as well as the pull from two massive breasts which rolled off to the side since she was also braless.

She was Caucasian. Her hair was flaxen and thin, pasted to her forehead and uncombed. It had the yellow tinge of nicotine, indicating she was a heavy smoker. She had a dour look on her face, accompanied by silver-framed glasses squished against the bridge of her nose. The lenses were covered with greasy finger prints. She had pig-like eyes hidden behind the flesh of her face. She had few teeth.

As soon as she saw my white coat, she ‘harumphed,” and turned her face to the wall.

I paused. The patient was easy to dislike from first glance, but I thought maybe I would be the doctor who could get through to her. “Ms. D, I am Dr. Ren. I’m one of the resident physicians here. I am helping to cover for the weekend.”

“You’re too damn young ta be a doctor. Get out and send a real one.”

I laughed, gently. “What does a real doctor look like?”

She turned then, looking as if I surprised her. “A real doctor is old…like me.”

“Unfortunately, I’m the only one here. My attending will be by later. He has grey hair, if that will suit you.”

She sat up with some effort. “Never mind. If you’re it, you’re it. I suppose you want me to take some of that crap for my blood pressure?”

“I do. Your blood pressure is high enough it could hurt your brain or your kidneys.”

She crossed her arms like a petulant child. “I don’t want it. I came here because I was pissing fire and now you all have me here like a prisoner! Day after day after day of medicine and bullshit! And the food here sucks! Just sucks! No salt, no taste!”

I smiled to myself as she ranted. Glancing at my patient list, I saw she was only admitted yesterday morning and had been placed on a low sodium diet because of her blood pressure.

“You’re always free to leave, Ms. D. Though it would be nice to take care of some of your other medical problems while you’re here.”

“I ain’t got no problems! Just this UTI or whatever you call it.”

“Actually, your high blood pressure is a big problem. If you would let me treat it, we could talk about it more.”

“No. No medicine.”

I thought maybe she didn’t understand what hypertension was. “Do you know what high blood pressure is?”

“Yeah, I know. Means my heart is working too hard.”

I was surprised. “Do you know what can happen with pressures as high as yours?”

“Yeah. I can have a stroke.”

I paused, not knowing where to go from there. “Can I ask why you won’t let us treat it?”

“CAUSE I DON’T NEED IT!” She burst into a shriek which was heard down the entirety of hallway. I sighed and sat in the chair in the room, hoping it might make her less confrontational. I kept a cool temper, though she was starting to irritate me. The outside looked lovely from her room and I couldn’t believe I was sacrificing a beautiful day to deal with her nonsense.

I thought a change in subject might help. “Can we talk about another issue? Besides your blood pressure, I saw some concerning things in your blood work. Would you like to discuss it?”

“Go right ahead, little miss doctor.”

I took a moment to cool down. The nurse was watching me with a conspirator’s grimace as I began to recognize the enormity of the problem this patient must have caused for the nursing staff.

“Do you know what diabetes is?”

The patient looked at me warily from the corner of her eye. “Yeah…a sugar problem.”

“In a sense, yes. It looks like your other doctor tested you for diabetes and it came back positive. I would like to tell you what tha—”

“YOU GAVE ME THE DIABETES?!” Her voice rose to an impressive level. I wouldn’t have thought her smoker’s lungs would have allowed such projected volumes.

“Diabetes happens over time—” I started to explain.

“I DIDN’T COME IN HERE WITH DIABETES, AN’ I’M LEAVIN’ WITH DIABETES, SO I GUESS THAT MEANS YOU GAVE ME DIABETES!” She said this with complete condescension in her voice, as if I were wearing a dunce hat instead of a white coat. I suppose that’s when I got…irritated. I stood.

“Ms. D,” I said tersely. “You have diabetes because you’re fat and you eat junk food. You did this to yourself. There is only one person to blame here.”

“AND THAT PERSON IS YOU! GET THE HELL OUT OF MY ROOM!”

A glance at the BP monitor continued to read her blood pressures at dangerous levels. Mine was probably not too impressive at the time either. I left the room and grabbed her chart so I could document. I had to ensure my story was written down, to protect myself legally whenever Ms. D inevitably stroked out.

I paused in the middle of the hallway, feeling defeated and angry. I’m embarrassed to admit it, but a part of me wanted something awful to happen so I could say, ‘I told you so.’ I wanted to scream back. Write a passive-aggressive note in her chart. I was full of rage that this fat, mouthy woman accused me of something ridiculous, tested me, and tossed my kindness back into my face. I wanted to cry, because the world outside was beautiful and I was tied to these awful people. These sick people who couldn’t take care of themselves or understand why they were sick. I felt enraged at a social system that encouraged chronic illness and failed to treat it. And I felt hopeless, because she would leave the hospital and be right back in, waiting for the next white-coated victim to try and help her.

Sometimes, there’s no way to help, no way to explain. And yet, I’m the one who felt like the failure, for losing my temper, for failing to reach her. All the training I had about trying to understand the core of a patient. Was she afraid? What was her emotional reaction reallycaused by? Did she want to die? Did she need attention so bad? What could I have done different? Did I do the wrong thing by giving up and walking out? And…is it really my job to proffer psychological analysis on each difficult patient? I just don’t have the time.

The nurse followed me out, asking what she should do.

“Just put her on a sugar free diet.”

I went to write my note.

THE PIANIST

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THE PIANIST

Mrs. G was one of the tiniest women I had ever seen. She was in her nineties. When I met her, she was enveloped in the blankets of her hospital bed, like a newborn wrapped in an over-sized baby blanket. She couldn’t have weighed more than seventy pounds. Her skeleton was easily traced for there was no muscle left. Purple veins cross-crossed under her skin, like a child had drawn on her with purple marker. Her skin was fragile and soft…ever so soft, like paper made from tissue wrap. Like rose petals. I loved touching her arm. Even over the hardness of her sunken frame, her skin was like silk.

You see, Mrs. G was dying. Quickly. Her tiny frame, her emaciated and fatigued body, was courtesy of stage four squamous cell carcinoma of the lung. That is usually a cancer caused by smoking, but Ms. G never touched a cigarette in her life. Her husband, on the other hand, smoked around her daily. He died three years prior of his own lung cancer.

Ms. G was a pianist. She loved music. Even dying, she recounted the works of all the great composers. She played the piano in the air, her deft and thin fingers commanding a tune only she could hear. She was sick but her mind was sharp. She had much to speak about. Her grandchildren. Her garden. Her parents. She tended to regress when she got her Morphine. That’s when she talked about learning to play the piano and that’s when her eyes were the brightest.

When in a peaceful delirium after pain medication, she told me about the keys of her father’s piano. The softness of the ivory. Her dad’s finger marks on the keys, telling her where to place her hands. Her father died when she was a teenager, but she continued to use his piano until she was older and married. She said following his fingerprints was like being taught to play by an angel.

As the days passed, she had more trouble breathing. Eventually, she was placed on a BiPAP. I’ll never forget how shocking it was to walk in the room and see this small woman strapped to an enormous face mask. She was alone at the time. The machine forced air into her. As it did so, it took away her ability to speak, dried her out, and imprisoned her. Never have I seen such a perfect example of a treatment being worse than the disease. Her delicate fingers were clutching the bed covers as the machine battered her with breaths. It was violence. The BiPAP was her aggressor. I couldn’t stand it and neither could she.

When I walked closer, I realized she was saying something under the mask. I lifted it. “Take it off. Off,” she whispered.

“Ms. G, if we take it off, we will have to give you lots of Morphine.”

She nodded.

I hesitated. “It will be…it will be the end. You won’t wake up.”

A single tear fell down her cheek. “I know.”

So we did it. We gave her a loading dose of Morphine and pulled off the monstrosity wrapped around her face.

She went quickly. Faster than expected. Her family did not get there in time.

But her hands were in mine when she passed.

Rose petals.

Playing music.

Forever.