Walking the Ghost Road

Working as a doctor in small towns on the High Plains, I have learned to do without a lot of luxuries. Those practicing in larger centers would consider many of these things necessities, such as being able to consult someone to the bedside, ever.

I do, however, have one luxury that is exceedingly rare in world of Modern Medicine, time to reflect. As I often only see 5-10 patients in a 24 hour period, I sometimes have a good deal of this.

Moreover, now that I have an infant at home, the time I have to reflect while at work is even more precious. I have yet to find a way to sell my 2 month old daughter on the value of quiet contemplation.

Since high school, I have tended to reflect while walking. When I screwed up a test, or embarrassed myself at school, that evening I would go on a long walk, sometimes for hours. I would meditate to the slow movement of my small town past me.

I still do this. Today, I took a walk on the slight hill above the hospital. A “wellness path” winds its way through the buffalo grass, prickly pear, and yucca. I walked the path in laps, waiting to be called in.

Those Who Came Before

Halfway through a lap, I came to the single grave that marks the halfway point. It is a modest affair. A small white headstone with only three letters marks the spot.

The earth over the grave is covered in the same high plains vegetation as the nearby pastures. Prickly pear and rabbit brush grow up around the headstone. Eventually, someone erected a very sturdy pipe fencing around the grave, likely to keep cattle from rubbing on the grave marker.

Perhaps most interesting, this lonely, solitary grave belongs a fellow physician. In the late 19th century, a wayward doctor had settled in this water stop town on the railroad. The townsfolk laid him to rest on a slight hill that overlooks the shallow, cottonwood-dotted valley of a seasonal stream.

I lean against the iron fence and stare up at the night sky. It is a wonderfully clear and dark night. I savor the lack of light pollution and the horizon to horizon views. Scanning the southern sky I see the milky way.

The Ghost Road

In Lakota cosmology, the milky way is known as the Ghost Road. It is the path all spirits must walk on their way from this world to the next. I let myself get lost in the imagery of walking through the galaxy as a spirit.

As I imagine my spirit side-stepping stars, I remember my fellow physician next to me. He walked that road over 100 years ago as a young man. Less than forty, it looks like. It is near impossible to imagine the life and profession of a true frontier doctor.

Nonetheless, profession and location bind us together. We have both doctored and cared for people in this little town. Even if the march of time makes it impossible for us to know each other as people, we are related.

This is also a Lakota idea – Mitakuye Oyasin – We Are All Related.

I reread the plaque explaining this grave.

A Life in a Paragraph

The good doctor had arrived in 1880. Two years later smallpox erupted in town (could he have imagined an era when doctors would have never seen a case of smallpox?). An old cow puncher came down with disease, and the good doctor cared for him.

The old cow puncher recovered, but the good doctor contracted smallpox. He eventually succumbed to the disease and was laid to rest on the same lonely windswept piece of prairie where I talk my contemplative walks.

“A good doctor…and a good man.” The plaque states.

Does the brief story on the plaque have meaning for me as a physician?

This physician died in the service of others, and I complain about not feeling fulfilled by modern medicine. In his calling, he sacrificed everything. Noble? Maybe, but also a complicated legacy.

From the plaque I also learn that he left behind a wife, who had accompanied him from the East. It does not say what happened to her out on the alien High Plains, alone, in grief. He also left behind an isolated, frontier town without a doctor.

How many went undoctored in his absence? I will never know.

Doctors Get Sick, Too

The irony of his death from the disease he was treating is not lost on me. Physicians are part of the societies they inhabit. Inextricably linked. In medical school, I often heard vague citations that physicians have higher rates of heart disease than other professions.

Most of these statistics came from before we started to turn the tide on heart disease. This was before cholesterol drugs and anti-hypertensives were mainstream, but when smoking still was.

Now, on the internet, I read about the burden of stress, anxiety, and depression doctors bear. It is no surprise, mental illness and its complications (i.e. addiction) seem to be an epidemic sweeping our country.

Why should doctors be immune? Especially, if we spend hours and hours caring for people with these diseases, is it no surprise some of it might rub off on us? You cannot vaccinate yourself against despair, loneliness, and disconnectedness.

Yet, We Are All Related.

I step away from the fence, feeling indebted to this long departed colleague of mine. Many, many things have changed in Medicine. Nonetheless, some things seem not to change.

Being a doctor is a hard job. It demands a lot. More than any one person can reasonably be expected to give. Yet, we do give, repeatedly and sometimes to excess.

The good doctor on that hill on the High Plains gave all he had to Medicine. It was sacrifice, yes, but I don’t want to glorify it. I will not say Dulce et Decorum Est Pro Medicina Mori.

Nonetheless, for a moment, I feel connected to a different kind of Medicine.

Not the Medicine of RVUs and production targets and treatment algorithms, but a deeper calling to serve humanity.

I’d like to think I can be doctor without sacrificing everything. But it is a delicate balance, and more often than not and I am too far one way or the other.

My eyes trace the line from his headstone to the Ghost Road in the southern sky.

At least, I think, I am not alone on this road.

Back to Work

I haven’t posted in a while. Not surprisingly, I have been somewhat occupied. Our new baby requires plenty of work, time, and love. Blogging hasn’t seemed all the important in comparison.

However, I am back on the High Lonesome, which brings with it periods of down time. This time is ripe for blogging.

Being back in the doctor’s role is an interesting transition from new father. Especially, after all the struggle over the last year and a half.

A Baby Brings Perspective

In some ways, I have a newfound acceptance of the failings of medical culture. All the pettiness, greed, and self-importance of many of the actors in a hospital are easier to tolerate, because the reason I show up is so much more important now.

Sometimes the work is its own reward. The times when I actually connect with a patient can sustain me – for a time. The rare critically ill patient who my team triages, treats, and transfers effectively can boost morale and help add meaning to the work.

Nonetheless, the reality is, most of any profession or job is mundane. Having a reason to go to work outside of paying off of my loans and funding my own diversions adds meaning to the mundane – especially when you are paid by the hour.

Knowing that my daughter is home and depends on me adds a certain nobility to the simple paycheck. It helps put a little shine back on the tarnished image medicine has for me.

Yet, on the first day of returning to work at one of my frequent work locations, I end up in my first meeting in over a year. Somehow, we are now having meetings….as locums.

I was scheduled to work and the ED wasn’t busy, so it didn’t turn out to be a big deal.

Of course, the main action item of this meeting was how to improve our billing and reimbursement. After only 3 years in practice, I am almost positive no other kind of meeting exists in healthcare.

This one specifically focused on improving critical care and procedure billing.

Good to be Back!

Other than this inauspicious start, the first day of the shift went fairly well. Going back to a familiar site was a good call for a first shift back. Weirdly, I seemed to actually enjoy being in the hospital.

The hospital had changed the way the local docs rounded in the hospital. This had actually improved communication and the nurses were asking me less questions about patients whom I didn’t know.

Finally, a change whose goal was improving patient care that delivered some results.

The first two patient’s were turfs from clinic for a DVT rule out and a CHF exacerbation. I quickly and efficiently ruled out the DVT. The CHF patient was known to me so the work up and admission to the hospital ended up being fairly straightforward.

Having wrapped up this work, I noticed a lull had set in. I went to the doctor’s quarters in a nearby house to rest and put some space between me and the hospital (it always seems to make the shifts go quicker). I felt good.

Watching some Netflix and making dinner, I waited to be called in. Around 11 pm, I got a call. An ambulance was out for someone who was found down and unresponsive.

An Actual Emergency

I find this chief complaint to be one of the most varied in actual cause. Benzodiazepine overdose, DKA, patient already deceased, sepsis, vasovagal episode, seizure – it could be practically anything.

In small low acuity EDs it tends towards the more mundane. Nonetheless, I headed back the ED and arrived right as the patient was being wheeled into the ED bay.

I recognize her immediately. She is a chronic respiratory disaster.

At 57, She already has end-stage COPD with multiple intubations in the last 12 months. This is, of course, coupled with right-sided heart failure. Shockingly, her kidneys are okay.

Her family has been told multiple times she may never come off the ventilator and she always has – so they now think she always will.

I know her to be angrily, vehemently, and obstinately FULL CODE, despite her terrible chronic disease and inability to care for herself at home.

She has had repeated blood transfusions for anemia which is of unknown source because her respiratory status is too tenuous for endoscopy. Not surprisingly – she also has terrible veins and recently finished a prolonged course of IV antibiotics through a PICC line (which I noticed sadly had already been removed).

“Oh, Shit,” I think to myself.

I look at her on the gurney. She is on a nonrebreathing oxygen mask. Oxygen is actually reading in the high 90s – remarkably good for her. But you can hear her audibly wheezing. Her chest heaves almost off the bed as she breathes in, and then her breath just slowly leaks out.

Her GCS is 3. Yelling, sternal rubs, nail bed pressure – nothing.

Getting to Work

We all get to work. An intraosseus line is placed in one leg – she gives no indication of being aware of a needle being drilled into her tibia. The nurses draw blood and send it to lab.

We give her narcan – she is on a large number of narcotic pain medications. Again no change.

I have the team set up for her intubation as her oxygen levels are starting to drop. Positioning myself at the head of the bed the intubation kit lays ready. I tell the nurse to push the anesthetic, then the anxiolytic, and finally the paralytic. She stops breathing.

Opening her mouth, I slide the laryngoscope into her mouth, visualize the cords, and slide a number eight endotracheal tube into her trachea.

We secure the tube, verify correct position, and begin to breath for her. All in all, it goes pretty well. The chest X-ray shows pulmonary edema, possible infiltrate, ET tube in good position.

Her labs come back, possible sepsis, blood gas shows a PCO2 of 124 prior to intubation. Methamphetamines in her urine. We start sepsis and influenza anti-infectives, give steroids, and get her ready to transport to ICU.

All in all, from arrival to transfer, we do this all in less than 3 hours. Not bad for a family doc in a two-bed emergency department 100 miles from the closest trauma center. Also, it is snowing, so the helicopters won’t fly – she has to go by ground, of course.

The Thrill of Being Present

As she leaves in the ambulance. I am feeling pretty good, alive. We just saved a life – for now. I just spent three hours completely engrossed in something pretty amazing – working as a team with people who gave a shit on something important. It can be intoxicating in small doses.

I like critical care. I like obstetrics (though I don’t deliver babies non-emergently anymore). What I love is the focus on the task at hand. The power of a small group of people fully engrossed in what is happening in that very instant can be amazing.

Both critical care and obstetrics demand this kind of focus. We should all strive for that kind of focus in all aspects of our practice. Sadly, this is difficult given the seemingly coordinated effort to destroy it going on around us.

The High Fades

After a rest and a drink a water, I walk back to get some sleep – it is 2:30 AM after-all. On the walk, I can’t help but feel a tension between the excitement of caring for a critical patient and the ethics of how we spend healthcare dollars in this country.

How many intubations is too many for one person? Is it ethical to repeatedly intubate and, God forbid, actually code someone who lives on death’s doorstep every day?

Does one person have a right to unlimited medical expenditures to prolong their life? How many childhood vaccinations could that cover? How many addiction treatments, or early parenthood interventions could we pay for?

The methamphetamine in her urine and her 3 different narcotic prescriptions are evidence of a life of great suffering. That suffering predated her current illness. Indeed, the smoking and drug use which caused it were likely attempts to numb that suffering for decades.

Is it ethical because these are the patient’s stated wishes? Or are we just hiding behind a weak patient autonomy argument so we don’t have to wrestle the suffering we witness – and prolong.

The things we do to save a life, needles drilled through bone, tubes into bladders and lungs. It would be torture in any other situation.

I feel guilty about how excited I was afterwards – even though I saved her life. I also kind of feel guilty about that…

When is it too much? When is continuing to torture someone to keep them alive, and suffering, unethical – even if they demand you do it?

Are these even questions we can ask in American Healthcare?

Recognition

A week later I get an email from our new ED medical director:

“Doctor HP,

Great job with the care of patient #1234567 in the ED last week. Your documentation of the intubation and critical care time was excellent!

Sincerely,

Your Medical Director”

I sit back and sigh, good to back working again….

A Note of Gratitude to Medicine

The end of the year is always a time for reflection.  The darkness leads to more time indoors, more time with our thoughts, and often with our families.  Reflecting on this difficult year is a strange exercise for me.

A Tumultuous Year

My wife and I have passed the one year anniversary of my daughters birth and death.  Moreover, I am now more than 6 months into my new gig as a traveling critical access doctor.  Life has started to settle into a bit of rhythm. 

After all of the grief and upheaval of the last year, simply living a relatively normal life can be rather unsettling.  I seem to even seek out problems or reasons for dissatisfaction.  I have a bit of a restless soul – a blessing and a curse.  

For one, the holidays seem to be a negative trigger for me this year. 

I always struggle from the time the clocks change to the first week or two of January.  The loss of light affects my mood for the worse.  Prior to last year, I had a great ambivalence about the holidays – neither a grinch nor a lover of the season. 

The Shadow of a Loss

That being said, last year’s holiday season was not a good one for our family.  The holidays came very quickly on the heels of our daughter’s passing and I was on call for a good bit of both Thanksgiving and Christmastime.  

With those memories so fresh, this year’s holidays are hardly buoyant.  Sure, the pain is not as fresh and does not burn quite as bad, but its shadow stills falls on the season.  

Living through this holiday season is like walking through the burnt-out shell of an ash-covered family home.  The shock and wailing pain of watching the flames tear everything apart has past.  Nonetheless, an eery sadness lingers over everything. 

To keep myself from falling into a hole of self-pity, I have taken some advice to actively practice some gratitude.  God knows I have plenty reasons not to feel gratitude, but I also have plenty reasons to do so.

Giving Gratitude a Chance

Even last year, my wife and I took time to be actively grateful for the arrival of our daughter, even if her presence with us was far too short.  She taught us a great deal and the heart cannot be overfull of love.  

Finding gratitude about the current state of medicine and my role in it takes a little more effort. I have written a lot about my experience in medicine and life over the last few months (and it hasn’t all been rosy).

Yet, I also remember the ones and things we love are often what can hurt us the most.  My relationship with medicine is much more complicated than it once was.  

I struggle to accept the imperfections of a system charged with healing yet is highly profit driven and largely inhumane. 

This system charged me a steep entrance fee.  The cost comes in actual dollars but also in time and stress and tears.  In the end, I felt expendable.

Yet, I also have to remember the care our daughter received in that same system.  I cannot forget our neonatologist sitting in front of our house with us as we held our daughter without tubes or machines for the first and final time. 

Humanity does still course through the veins of our healthcare system, even if the system neglects it at every opportunity. 

Nonetheless, My Privilege is Great

Doctors are a pretty privileged lot, all things considered.   I don’t mean to minimize my own or other’s distress at the current state of affairs.  On the other hand, I see how my situation may have played out very differently for someone else.

Few other careers exist where you can quit your job, move to another state, and have to turn down work immediately.   That is how it worked out for me. 

I simply showed up and had my choice of work location and practice type within my speciality.  Not only that, but I have been able to improve my worklife balance with an acceptable sacrifice of income.  

Physicians skills are in such need that not only was I able to find a different job, but a completely different way of working.  Hard to complain. 

Medicine giveth, and medicine taketh away.

Work isn’t Everything

Even more importantly, medicine had given me wisdom.  Caring for people who were very ill or had suffered great loss or trauma gave me access to life’s most difficult moments.  Few other professions allow for the gaining of such wisdom without personally suffering those blows.

Learning how to help guide people through their struggles led me to read books and literature I never would have read otherwise.  This knowledge was invaluable when our daughter was born.  I didn’t have a how-to guide, but at least I knew the big ideas.

Most importantly,  I had learned the value of connection.  When our daughter was born, our gut reaction was to circle the wagons, raise the drawbridge.  My patients had taught me this was not the right move. 

Love and loss must be shared, inextricably linked as they are.  We called friends and family and offered for them to come to meet our daughter.  To be present with us in a difficult time. 

Without exception, the responses we received were full of gratitude.

“We are honored to come,” was the common answer.  

In our moments of grief, this might surprise us, but it shouldn’t.   Wouldn’t all of us respond the same way if someone we loved extended us the same offer?

Moreover, the decision has paid great dividends.  To those who met her, the people we love, our daughter is not simply the nameless baby we lost.  She was a person, has a name.  We can talk about the shape of her nose, or her special little movements with so many people. 

Having her in more people’s memories does not just preserve her memory, but means she was even more alive when she was here.  Hell, we even have a social security card for her.

It is the caring for patients that taught me this knowledge before my family needed it.  In the end, I am still thankful for medicine.

“When you are sorrowful look again in your heart, and you shall see that in truth you are weeping for that which has been your delight.”

― Kahlil Gibran

Cold and Dark Return to the High Plains

moon over the snow

I walk the outskirts of town, the cold and dark are everywhere.  The darkness has returned to the High Plains.   From daylight’s savings until the return of sunlight becomes perceptible again in January are the low parts my year.  I don’t mind the cold, but I miss the light.

The cold can be clarifying tonic on the High Plains.  It is not suffused with the dampness of Eastern cold.  It is a freeze-drying cold.  Bracing is the word for it.  The darkness can be disorienting, but the cold wakes you up – keeps you focused on the fact you are still alive.

Moonlit Night on the Dniepr – Arkhip Kuindzhi – 1880, Tretyakov Gallery, Moscow. Public Domain.

Tonight is cold and brightly dark, punctuated by the shine of a waning moon, though still nearly full.  It has been a tough past few days on call on the High Plains.  The darkness and the holidays bring out dysfunction and mental illness.  Without a clearly lit path, people quickly wander back into their own darkness.

A razor-thin slice shy of freedom

For the second time in 12 hours, I am reapproximating the flesh on the left forearm of a man in chains – offenders as the guards say.  The same man. Two cheeked fragments of a razorblade did the work, the second one not found in time.  I had known he was serious about wanting to die.  While stitching up the wound when it was only 4 inches long, he had calmly made small talk.

Disinterestedly watching me sew his numbed arm, “I guess it is harder than on the movies.  In them it is one smooth slice and they die quick.”

I pulled my running vicryl suture, the fatty subcutaneous tissue tightening. He didn’t flinch – a good anesthetic field.

“The body is designed not to die,” I replied. “The body wants to survive.  I might not be able to get your tattoo back to what it was before.”

I ligate an small oozing vein, luckily for his blood volume, he didn’t know the vital vasculature is quite a bit deeper.

“That’s okay.  It’s just their to cover the name of a girl who isn’t my girlfriend no more.  I don’t suppose you can tell me this, but what’d I do wrong?  Where’d I miss?” He asked.

“You’re right, I can’t tell you that.”

That was the first time. After stitching his arm back together I thought about the safest place for him.  Prisoners don’t have a lot of options.  A locked unit for prisoners in the county hospital 2 hours away?

The prison guards assured me he would be watched and would have access to telepsychiatry within several days.  All the options sucked, this one seemed as good as any other. I discharged him back to their care with signed orders for follow up. I even asked them how they were going to keep him from ripping it back open – they had had an answer.

just looking for some peace

Within 12 hours, he was back.  The wound twice as long, but only minimally deeper.  Still no muscle or large vessel damage.  Killing yourself with a half-inch long piece of broken safety razor is not for the faint of heart.

Shit, I think.  I should have found harder for a different solution.  Clearly that didn’t work.  Was I cavalier with his safety?

Me: “So, how did you get another razor blade?”

Offender/Patient(O/P): “I had another one hidden.”

Me: “Where was that?”

O/P: “Well, I can’t tell you that, its privileged information.”

He sprouted a mischievous grin.

“Was it somewhere sensitive?” I pushed.

“No.” He seemed ashamed of the implication. “I had it cheeked.”

shit, he had a back up plan…

A different facility would not have been any safer – he really wanted to kill himself.  Who tries to kill himself and holds something back, just in case he fails?  Someone who knows life is worse than death.

Me: “Well, why do you want to die?”

O/P: “I just want some peace. I’m tired of my shit getting fucked with, of me getting fucked with.  I am not affiliated, so everyone fucks with me.  I just want to be left alone to do my time.”

(Affiliated, if you are not familiar, means not in one of the prison gangs)

Me: “How much time do you have left?”

O/P: “Well, I am up for parole soon, but I don’t have much hope for getting out.  My latest possible release date is 2024.”

Me: “What would it take for you be able to want to live that long?”

O/P:  “Just to be alone, in peace, doing my time.”

Me: “Like solitary?”

O/P: “Yes.”

I place the last 3-0 prolene horizontal mattress suture – for strength, just in case he has another back plan.  Well-approximated, I muse.

the lonely moon

Sitting on the hill, I take in the pale moonlight glancing off the water tower.  It sands in front of the red warning lights of the wind turbines on the distance ridge, which are blinking in unison.

The guards placed O/P into a prison van and took him to the state penitentiary’s system infirmary.  He would be kept shackled the entire time, to prevent a similar incident.  Likely shackled to a bed, with minimal to no freedom of movement. Additionally, the guards assure me he will have urgent access to mental health resources.

I don’t know what this man did to be in prison.  The prison nearby holds serious offenders.  He likely needs to be in prison to protect the rest of us.  Whatever he did was probably enough to sacrifice his right to freedom.

I can’t help see the irony in his desperate attempt at finding peace.  Trying to free himself from his current version of hell, he lost the last of his freedom.

I take in the peace of the night.  The moonlight reflects off the recent shallow snowfall.  My breath freezes in the air and slowly drifts off, without any perturbation. I think about Johnny Cash’s classic – Folsom Prison Blues.

Well I know I had it coming, I know I can’t be free
But those people keep a movin’
And that’s what tortures me

Shit is fucked up, I think to myself.  I start to slide into my cerebral self-flagellation.  Am I supporting the prison-industrial complex?  Am I profiting from it?  Who am I kidding?  Continuing to breathe in this world necessitates a tarnished soul.

I watch the bank of red lights blink.

O/P seems to have accepted his sentence of time.  I cannot and do not want to pretend he is a gentle man or a kind man.   True compassion doesn’t require a made- up story to make the person worthy of it.  He probably needs to be where he is.

Nonetheless, I do wish him some peace and hopefully it does not require his death.

 

 

 

 

What Could We Have Done Better….Part 1

Everything that comes after in this blog will be informed by this experience.  So, I feel that I have to start with it.

Scene: My last medstaff meeting in my previous job after making my resignation official:

One of my partners: Can you elaborate on why you are leaving and what we could have done better to help keep you?

Me:  I have found that emotional intelligence is not valued here.  I feel less human because of the year I have spent here.

Same Partner: That is very sad.

Other partner: Can you elaborate on what you mean by that?

Me(tears starting to form):  Not right now.

Later that day I was told by our clinic manager that all of the medical staff told him that they had no idea I felt that way.  I felt my point about emotional intelligence proven.

Stepping back a few months…

I had been in this practice for almost a year and we were expecting a new baby.  Because of how tight the call schedule was, I had only opted to take the 2 weeks off around the suspected due date.  I had repeatedly asked the administration and my partners to arrange for back up coverage because things often do not go according to plan with babies.  Things did not go according to plan.  My wife was induced at 37 weeks (3 weeks early) for polyhydramnios.  Our beautiful little girl was born and required significant resuscitation, ending up in the NICU on a ventilator with a feeding tube.  I called and told my partners not to expect me back until further notice.

The news didn’t get better.  She failed extubation twice, she didn’t have the strength to swallow or breath without mechanical support. We never got a diagnosis, which wasn’t surprising or upsetting.  Diagnoses rarely help patients as much as they do doctors.  A rose by any other name would still require ventilator support.

We started hospice/end of life discussions with our neonatologist.  That same week my partners called to see if I could cover call on a Saturday because “no one else was available.”  Not like I had anything better to do….(I refused).

We took her home on hospice.  She was extubated on our front deck in the sun and she passed peacefully.  It was beautiful, and terribly, heart-wrenchingly sad.  She was three weeks old.  We cried, a lot – we still do.  We a took a week and scattered her ashes on a sacred mountain.

Rachel Weeping
Photo Credit: By Charles Willson Peale – Philadelphia Museum of Art, Public Domain, https://commons.wikimedia.org/w/index.php?curid=7365050

I decided I should ease back into work.  It had only been 4 weeks since she was born, less than 2 since she passed.  It was probably too soon, but I figured that I would have to sooner or later and easing in would be best.  No one gives you a guidebook for navigating the death of your newborn child.

I felt that I had communicated that I wanted to ease back into work.  My partners felt that it was appropriate for me to take back on my full call burden.

This included the following: 120 hours of ED call within 7 days including Thanksgiving.  The 72 hours of call before 8 AM on Christmas morning, and the 24 hours following Christmas. I was still the f***ing new guy, apparently it didn’t matter that I had lost a baby with whom my wife and I were supposed to spending our first holiday season, but weren’t.

When I tried to back off and protect myself, here is a greatest hits of things I heard:

—–

After effectively being told that it would be too difficult to find someone else to take my call:

Me:  You know, I still have over 30 days of paternity leave I could take.  I don’t have to be here, I came back to help.

Partner:  Well, it would have been easier to arrange coverage if we could have planned for it.

——

CEO in one conversation: We want to support you however we can, but the other docs are already run pretty ragged right now.

CEO in another conversation: We may not always do the right thing, but our hearts are in the right place.

——

Same partner as above in a conversation about me possibly switching to do just hospitalist/ED work for a time: I would hope that you think about the burden it would put on us to cover the outpatient work if you were to do that.

what could we have done better to help keep you?

I guess you could have just been the human beings and caregivers you say that you are….