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A Piece of My Mind
November 22/29, 2000

No Time to Say Hello Good-bye

Author Affiliations
 

A Piece of My Mind Section Editor: Roxanne K. Young, Associate Editor.

JAMA. 2000;284(20):2564-2565. doi:10.1001/jama.284.20.2564

It was a normal day. I beat my alarm clock to the punch, waking up 10 minutes before 6, literally negotiating my way out of a dream: a back-and-forth arbitration with a business partner to strike a deal that would make us both feel brilliant. Under the shower, scrubbing: If he tries to discount our software fee by $500 per hospital, I'll insist on a minimum purchase of four clinical conditions. He'll want a rebate off development costs if we eventually go nonexclusive. Predictable. Brushing my teeth vigorously: I just can't be sure of his moves.

I call my voice mail. Late-night message: I need to join a "high-level" meeting at 11. Mental note: Ask V. to reschedule my other interview with the PR firm at the same time. Comb struggling through my intransigent curls: I mustn't forget to e-mail the development-team MDs to speed up work on the patient-safety prototype. Pop one contact lens in my eye: We'll need to begin pitching the tool before it's fully built to keep ahead of the competition. Pop the other contact in: Drop a colleague a voice mail about a new programmer. Hunt for the blue shoes with the painful backs: Jot a new product idea on a scrap of paper. Ouch: Better to have something to go with my dress than to worry about my Achilles tendinitis. What's a little pain when you match?

Dialing the e-mail on my low-speed Internet connection . . . drumming fingers on the desk . . . c'mon, c'mon, c'mon . . . Beep, beep, beep, beep, beep, beep, beep . . . now the grating sound, and then the magic telephone ring. Twenty-seven messages overnight. Outrageous. I thought I was the final person to leave the office last night, and yet . . . the world never sleeps. I skim first to the only friendly message in the box, from Mom, who still wakes before me and wants to remind me to remember lunch—a nutritional one, with calories—and to avoid getting overstressed. She believes in the power of e-mother advice—and I am momentarily uplifted as I hit the reply button and send her my love.

Then I'm headlong into proposals, invitations to speak on evidence-based medicine, invitations to teach the med students, flights here, flights there, flights anywhere—more weekends of work. I will have to cancel the Monday night dance lessons; they weren't really that good anyway. Several e-mailers want to know how our research and products group is doing on the breast cancer evidence-based guidelines. Odd, but the topic doesn't assault me as it once did—crashing like a bull in the china shop of my childhood. Life as I had known it was over at age 14 . . . my beloved mother stricken with cancer at 43. And now my group, the outside "experts," the credible, objective-evidence-based gurus, is creating care recommendations for clinicians everywhere based on the evidence.

The literature is controversial on screening women 40 to 49. For every trial concluding "yes," there is another paper saying "no." Political static is in the air. HMOs are skeptical. Women's health groups are vigilant. Everybody has an opinion and everybody is convinced his or her own is indisputable. How should we present this? Radiologists say, start annual screening at age 40. Purists say, evidence to support this practice is based on flawed methodology; there has been virtually no impact upon mortality from screening younger than age 50. Can I, the daughter of a 20-plus-year survivor of ten-positive-nodes cancer, dispassionately explain the lead-time bias inherent in the "pro 40-49" studies and report that it isn't cost-effective to screen every woman? Do I stress the quality-of-life angst waiting for "wet-readings"? Do I emphasize the working-up-the-false-positives outcomes generated by the seek-and-ye-may-find mentality? Or should I forego my evidence-based oath, embrace anecdote (my own), join the right-to-screeners, and recommend mammography for all women every year of their post–40-year-old life?

It is hard to hear for whom the bell tolls and then turn a deaf ear. Easier by far to analyze absolute risk reductions and P values than to recall the scent of frightened women in the waiting room. Less disturbing by far to focus on strict statistical methodology than to remember the terrified face framed with surgical cap en route to the operating room, to relive the nightmare of a CMF regimen, the interminable wait for films, tissue types, nodes, body scans . . .

I'm in the car, necklace in hand, looking up in the rear-view mirror to see the hue of venules beneath the thinning skin of my eyes . . . oh well, I don't have time to think about growing old. I need to get to the office quickly for my 7 o'clock meeting. The pedestrians have stepped off the curb just as I was about to turn right on red. If that man walked any slower, he would lose a race with a tortoise, I fume. If he were a patient in my examining room, I would delve with fascination into the details of his life. On the street, he is an anonymous body putting a crimp in my day.

Once inside the office, I tread water in conferences and phone calls, trying to pack a full day of activities into half since Tuesday is my clinic afternoon. At 12:45, I dash from the business office to the local medical group. I run first to the downstairs pharmacy to grab some M&Ms for lunch. The old lady in front of me in line is taking the change out of her wallet in slow motion . . . placing pennies on the counter one by one, so the clerk has to pick up each one rather than getting the full amount in hand. . . . "Get a move on, lady!" I am screaming inside. My patients are waiting. The clerk is rolling her eyes at me. I chance to look at the old woman's face—and my heart stops. Her expression is more sorrowful than any I could have imagined and, as she takes me in, I feel accused. Her eyes are crystal blue—they were once beautiful. Her hands were once graceful; they did not shake. As she looks at me, I am reminded of an accosting inscription I once saw in an antique grandfather clock: Don't forget to die.

I run upstairs and dive into the managed care appointments, one patient scheduled each 15 minutes. Of course I do not see them this fast; each is of interest and needs the release of verbal-unburdening. They tolerate my lateness since they know that everyone will get extra time. I am uplifted by the gratitude they bestow upon me, but I feel a throbbing sadness within me as I witness the inexorable suffering of so many—emotional, physical, both. The visages of pain—the will to live despite the death sentence—consume me. "Daddy!" I gasp involuntarily as I get in the car at 7 PM, unable to suppress the connection between the plaintive struggles of others and those of my own cherished flesh and blood.

I wonder at the defense mechanisms of physicians who see patients full-time. How do they bounce professionally from room to room, pedaling hope and optimism amidst such palpable unhappiness? Do they allow themselves truly to tune in to the stories of their patients, so that their understanding transcends the clinical details of a SOAP note? How do they go home to a sumptuous dinner at the end of day, without remembering the trembling faces of the anorexic? Do they calcify in the interests of self-preservation and patient beneficence, drowning out their own terror in a sea of overweening work? I am hurrying back home, to hop back on e-mail and find out what's happened in the business world for the last six hours.

I speed home, whimpering softly behind the wheel. Daddy! Steeling myself, I think of my lucky, overstuffed life. I have a proposal to write tonight and a Powerpoint presentation to finish for tomorrow's Grand Rounds. I enter the lobby. Rose, the old matriarch of the building, is bent over by the mailbox, struggling to open it with her key. I am tempted not to retrieve my mail right now and run up the stairs, but, drat, she sees me. "Oh, Doctor?" she brightens. "Hi, Rose, how are you?" I punt, hoping to get the standard fine-thank-you-and-you dismissal of the business world. But no, Rose is not fine and she wants me to know how awful it is to get old. I listen to her story about the hip replacement and the spinal stenosis and I watch the avidity with which she clings to my presence.

"You really should come down some time—to my apartment and visit," she says. "I have a lovely apartment, number 101, even after 19 years. You could borrow some milk or something. Don't forget to come down one day," her brown eyes bore into me. "Thank you, Rose, have a good evening. And, by the way, your hair looks lovely."

I slink up the stairs, forcing my thoughts back to work. There is so much to do; there is no time to worry about the old lady in the pharmacy line, the long-suffering patients, Rose on the bottom floor.

After an evening of e-mail, I fall into bed, eyes heavy, body spent. I toss and turn, trying hard to think about tomorrow's noon lecture, trying hard to blot out the haunting voice calling after me, "Don't forget to come down one day."

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