Customize your JAMA Network experience by selecting one or more topics from the list below.
A Piece of My Mind Section Editor: Roxanne K. Young, Associate Editor.
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 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
"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."
Greengold NL. No Time to Say Hello Good-bye. JAMA. 2000;284(20):2564–2565. doi:10.1001/jama.284.20.2564
Coronavirus Resource Center
Create a personal account or sign in to: