Sunday, November 29, 2009

Reflections from the Clinic at Grady: The Vicious Cycle

The "deuce":
Sometimes the only thing that precedes the departure


"I don't wanna

I don't wanna
I don't wanna

I don't wanna

I don't wanna wait in vain. ."

Bob Marley's "Waiting in Vain"

"Can somebody please grab that?" I spoke out over the doctor room while gesturing to the blinking phone line. Four rings later, I reached over someone's half full Starbucks cup to greet the caller myself.
"This is the Green Pod!" I announced musically.
"Dr. Manning," said Mrs. J, our clinic receptionist, "I have a patient up here at the front desk that just got here for a 9:20. What do you want me to tell her?" It was one of the most everyday conversations one might overhear in the resident clinic.

I balanced the phone on my shoulder while writing on a prescription and scanned the clock hanging on the wall. 10:24 a.m. Before I could answer, Mrs. J. added, "She had to go to financial counseling first, and just made it back." Then she lowered her voice and said, "Girrrrl. She look like she 'bout to cry up here. Please let me check her in or otherwise it's 'bout to be drama."

The hard sell probably wasn't necessary. When I was new at this, I used to always walk up to the front desk to get the full rundown when a patient was late. Now I just ask a few simple questions. How late? Is this a recurring problem? Why is the person late? Oh yeah--and is the person an elder or disabled? That usually gives me more than enough ammunition to make a decision--and saves me a walk.

So as it turns out, this is a patient who is rarely late and happens to be well-established in our clinic. Patients who are seen regularly at Grady and who do not have commercial insurance (the majority of our patients) must go through a process called "financial counseling" which determines how much assistance they qualify to receive. Because employment and income situations are often dynamic, this "financial counseling" must be done at least every few months. This encounter results in the patient being issued a "Grady Card," which, if you don't pay close attention, will expire on you like that. (Insert fingersnap here.)

Okay, so this patient did arrive to the clinic on time, but neglected to account for the fact that her expired Grady Card would require some face time with financial counseling. I suppose one could argue that if she has been coming here for years that she should have known that her Grady Card might need an update. I wanted to just say "tough luck" but then I thought about her 9:20 appointment. I asked myself what the likelihood was that she would have actually been seen at 9:20 a.m. (I won't answer that.) So back to the patient. She's never late, keeps her appointments, and waits for us when we run behind? "Check her in," I told Mrs. J. and hung up the phone. Check in the patient for her 9:20 appointment at 10:30.

The Vicious Cycle

And so the vicious cycle begins. It starts with good intentions. First appointment is at 8AM, and the doctor comes out of the blocks galloping hard and fast. Or the doctor may start a few minutes late out of the blocks. . . . .either because they need to answer a few phonecalls or pages, review a chart or two, or maybe just because he or she can't seem to find a matching pair of socks for their child before getting them to school. The patient (interesting that this is what they are called now that I think about it) patiently, and sometimes not-so-patiently waits. Either way, the 8AM patient goes first, and perhaps the 8:30AM patient is seen at 8:37AM. The 8:30 AM patient just needs a medication refill and a blood pressure check. Blood pressure is high today, no big deal since the patient is out of medications. Patient is a "regular"--pretty straightforward--including small talk should take no more than 10 - 12 minutes. "Oh, by the way, doc, should I be worried about this little twinge I keep getting in my chest?" Damn. Patient smokes, has high blood pressure, and high cholesterol. Anything in his chest is newsworthy, and yeah, should be worth worrying about. "It's just a twinge, kind of like a pressure, but not pain. It comes out of no where when I'm just sitting there." Pressure not pain, yeah, not good. Next comes an EKG, more discussion, and more time. 9AM patient is gracious when they are escorted back at 9:20AM. Whew. Maybe this one will help the doctor catch up. Or not. Two minutes into that visit, the nurse knocks on the door to hand the doctor the EKG of the 8:30AM patient. Very abnormal. Page Cardiology. Draw some labs. Excuses self from the room to arrange a plan with the cardiologist.

Doctor finally returns to the room. 9AM patient is still gracious, even though it is now 9:38AM. "Somebody having heart troubles is important, doctor. It's okay." Gracious patient is also, as it turns out, not eating, not sleeping well, can't concentrate. Starts crying during the encounter. "I'm sorry, doctor. I don't usually do this." Take full history to screen for depression, make the diagnosis. Teach patient about anti-depressants and make sure that this is not a situation where the patient is suicidal. It isn't, but the patient is still visibly upset. 10AM. Rushing her is the wrong thing to do. Finish up at 10:09.

9:20AM patient is annoyed that she is not called back until 10:10AM. Rightfully so. Rolls eyes and folds arms hard when walking toward the room. "This is some bullshit!" she huffs looking at her watch. It actually is. Doctor needs to say something conciliatory. "We are so sorry, ma'am." Patient not having it. "Yeah, y'all are sorry. Sorry as hell." Ouch. Guess the only thing that could be worse is putting her in the room at 9:20 and not actually coming in to see her until 10:10. She probably would have met the doctor with a flying kick the minute he or she opened the door. (I'm just saying, it could happen.)

It's a vicious cycle that I've seen spiral out of control at just about every outpatient clinical environment I've ever been in. Sure, some places are worse than others, and sure, some offices have so much staff and technology that they run only a little late. But no matter how fancy, shiny, high tech-y, concierge-y, or non-indigent care accepting-y they are, they too get off schedule a bit--more often than not. It's definitely not just a "Grady thing."

My dad and I talk about this often. He is no fan of the "vicious cycle," and even more, he absolutely does not appreciate the fact that the doctor often doesn't acknowledge their tardiness at all. In fact, it's nothing for my dad to wait fifteen minutes and then throw up the deuces to the receptionist. ("Deuces": two fingers symbolizing the "peace sign"; a slang gesture used either with a statement or just as a nonverbal cue to say you are leaving, usually abruptly.) Yeah, so Dad is not shy at all about the "deuces"--nor is he shy about letting them know, like that 9:20 patient, just what he thinks about being seen well after his appointed time. (Fortunately, my father's language has gotten less colorful than that of "9:20" as he's aged.)

Daddy's doctor: "Hey there, Mr. Draper! How you doing?"

Daddy: looking real annoyed--"Not good. My appointment was at 1PM and it is now 1:39PM."

Daddy's doctor: Half-genuine reply--"Sorry 'bout that, Mr. Draper. Blood pressure and labs look good today!"

Daddy: Deuces

Isaiah throwing up a "deuce"

Okay, so the late thing is one part of it. Dad's doctor was a half hour late, and Dad had stuff to do. So the doctor walks in and acts like he didn't just leave a grown a-- man with business to tend to waiting for thirty minutes. To me, that's the other big part of the problem. No profuse apology, no preemptive strike in the waiting room, no nothing. It's inconsiderate, and it's the perfect recipe for getting a few choice words from my father--followed by the "deuces".

In that doctor's defense, it is probably something he learned in residency and medical school--we are conditioned to think that the "vicious cycle" is par for the course, and that patients should just fall in line. Interestingly, they usually do. At least, most of the time. I suppose it's kind of like the "theory of learned helplessness." The rats thrown into water who profusely try to swim their way out, but eventually, with repeated failed efforts, just lie there the minute they hit the water. What's the use? Nothing will change. Learned helplessness. The rats stop swimming, the patients stop fighting, and they stop planning anything important after appointments with us--unless, of course, they can manage to be the first patient of the day.

My dad has made me think about this differently. I can't always control things running a bit behind, but I have made some modifications in an effort to be more considerate. As the lead physician, when I see things getting off schedule, I'll go into the waiting room and thank people for being so patient. If a resident physician is running late by quite a few minutes, I may ask another doctor to see their next patient sooner, or I will offer to see the patient myself. Sure, it's a "work around" and not always ideal for a patient that wants to see their own doctor, but it does respect the patient's time, which folks seem to appreciate. Most important though, is that I immediately identify the elephant in the room as soon as I see the patient.

"Good morning, Mrs. Moore. Listen, I'm so sorry that you had to wait to see us. I really appreciate your patience. Your time is just as precious as ours, and I don't like waiting either."

Sometimes that makes all the difference in the world. A simple, genuine acknowledgment. Before they even get the opportunity to tell me that "this is some bullshit," I do my best to beat them to the punch. (Sorry to use the expletive again--I tried it with the word censored or as "b.s.", but it just didn't have the same effect.) I also recognize that the same folks that have waited for us over and over again, sometimes have bad days, too. Like the lady at the front desk whose Grady Card expired--I felt we owed it to her to return the favor. At least this time.

Okay, so I know my dad is reading this, shaking his head and sighing audibly. I know, Dad. We could space the patients farther apart to allot more time, but then our availability would be significantly decreased. We could shut folks down when they start adding in their "by the way, doc's" alerting them of our "3 problem only" policy. That seventy year old guy who musters up the courage to tell his twenty-eight year old female doctor that he is having trouble "with his nature" and "maybe could we talk about them Viagras" had better get that out in the first five minutes or else there will be no waltzing around the kitchen for him. (Like all those happy folks on the erectile dysfunction medication commercials.) Again, Dad. It's a vicious cycle that's hard to break. How do we simultaneously connect with our patients and keep it moving? I still struggle with that every time I'm in clinic.

I have a few thoughts, but they definitely aren't perfect solutions. For starters, those of us who are clinician-educators can keep on teaching the residents to be more efficient--and our staff, too. Those in private practice can do the same with their staff, too, I guess. More efficient, yes, but never at the expense of that human connection. If it takes you an extra minute to tell me that your grandson was deployed to Iraq or that you just became a deacon at your church, I'm giving you that minute. Maybe I can multitask more, checking your pulse while you tell me about your son winning the spelling bee, and perhaps I can palpate your thyroid while you give me your recipe for the perfect sweet potato pie. This way, we indeed connect--and your wait for me is not in vain.

So, on behalf of empathic doctors everywhere, I apologize to every patient who has patiently and even impatiently sat in an uncomfortable chair reading outdated National Geographics or watching a channel that cannot be changed--all because of our "vicious cycle." Yes, your time is important. No, it is not cool that you are asked to reschedule for being twenty minutes late when we usually are. And even more, I am even more sorry for those who grimace and bear the delay only to be rushed once their late doctor finally arrives. Not cool. Besides, who wants to wait in vain? Not Bob Marley, not my dad and certainly not you, either.

So, yeah, I checked her in, and probably delayed things even more.

And yep, Dad, I'll say it before you can--this stinks. Or as the 9:20 AM patient put it so colorfully- this is some bullshit.

Monday, November 23, 2009

Reflections from a November: A Lasting Impression

Walt Disney World, a magical place

"C.J." , a magical child (and the hugest fan EVER of Walt Disney World) :)

Death is, unfortunately, a huge part of what I do every day. The doctor in me always wants to intellectualize it--dissecting every aspect of the clinical details--but the mother in me knows that sometimes I cannot. This is one of those times. This loss taught me to love harder and to celebrate little things much more. Having more love and more joy makes me a better doctor. . . .and makes me enjoy and better relate to people, especially my patients. The thing about mixing joy and love together is that you just can't help but pay some of it forward. . . .

This is a story about the lasting impressions of love and joy. . . .

November 28, 2008

It was pitch dark and raining the night we drove in to Fayetteville, North Carolina from Atlanta. The usual chattiness that Harry and I share on long car rides was replaced with a palpable reticence. I could hear every single drop of rain as it slammed against the windshield, the tires on the wet asphalt, and the rustling "mapquest" paper in my hand that lead us to our destination. Occasionally, we would look at each other and want to talk, but instead we rode in silence. This was not a trip we wanted to make.

Just four days before, we had received the awful news that our dear friends had lost their beloved three year old son. Perfectly healthy. Absolutely beautiful. Wonderfully precocious and bright. Undoubtedly cherished. An overwhelming bacterial infection invaded his bloodstream, quickly spreading through his little body and ultimately taking his life in less than twenty four hours. It was unimaginable. Something you gasp about on the evening news, but not attach to someone you know or love. Someone you find yourself praying for without a face or a relationship. . . .but this time, it wasn't a stranger flashing across the screen, it was very real and close to home. On November 23, 2008, just one month and one day shy to the day of his 4th birthday, God decided He needed another little angel. His name was C.J.

C.J. (Cedric Jr.) was born on December 24, 2004 to our friends Cedric and Davina C. Cedric, or "Ced" as we all call him, was Harry's roommate during his Army days and was also a groomsman in our wedding. Davina, his wife, surely proves the rule of "six degrees of separation." Coincidentally, she and my best friend Lisa D. pledged AKA sorority at Hampton University together almost twenty years ago. The two "linesisters," who happen to be members of the sorority that rivaled my own in college, poked fun at my Delta sorority sisters and me over our wedding weekend. That was a fun weekend, our wedding weekend. And as it turns out, C.J. was a part of the fun, too. He was a special secret growing in Davina's womb that she and Ced would soon learn of upon their return home.

"I don't know what to say, baby," I murmured to Harry as we approached their home. I stared out the window as the freezing rain pelted the car. I could feel myself beginning to panic. Usually wise Harry had no poignant advice this time. He just looked at me and shook his head. "I don't either, babe," he uttered quietly.

I closed my eyes and started to silently pray. I asked God to please comfort the family. I asked Him to ultimately give all who knew and loved C.J. peace. I asked Him for mercy on them and the rest of the family . . . . . and all other parents. I asked for favor in Ced and Davina's lives going forward, and that God somehow reveal to us all what He wanted us to learn. Then, I selfishly asked God to please put words in my mouth that would somehow help and not hurt. In fact, I begged Him to.

We stepped into the threshold of their home and out of the relentless rain. The room was surprisingly light when we arrived. The love in the room wrapped anyone who entered it like a warm blanket. It was morose. . .yet celebratory. Ced's parents, the ultimate matriarch and patriarch, stood vigil in the foyer greeting visitors. Mrs. C, Ced's mom, reached out and hugged me. I managed to utter a few scratchy words. "I'm so sorry." I could feel her nodding her head.

"It's like a bad nightmare," Mrs. C replied while taking our coats. I wanted to cling to Harry, as a child does to a mother's leg, trying my best to disappear behind him as we made our way into the living room. Ced immediately stood when he saw Harry--always the poised military man. There was such a raw innocence about him at that moment. . . . his eyes so quiet and tired. He walked briskly to Harry, and they both dropped their stoic guards and embraced tightly. "I'm hurting, man," I overheard Ced say, his voice muffled into Harry's shoulder. As Mr. and Mrs. C stood by, it dawned on me that they had not only lost a grandchild, but also had to watch their manchild cry. You could see how badly they wanted to take the pain away from their child. . . .take the pain for their child. . . .I shook my head and started quietly praying again. Pleading with God. . . please God. . . .please. . . . .

Glancing around the room, my eyes finally rested on the kitchen table. Four women sat at the around it talking and laughing softly. Three of them were Davina's close sisterfriends, fiercely loyal and lovingly flanking her, and directly across from where I stood sat Davina. She looked her same beautiful self, but her grief stricken eyes told it all. I willed myself not to cry. Please don't. Don't. Then I made the mistake of scanning the rest of the kitchen. C.J.'s Thanksgiving artwork was proudly displayed on the refrigerator and his "kiddie table" still held his Lightning McQueen placemat. Why Lord? Why? I lost the fight not to cry right then. I quickly tried to regain my composure. Please Lord. Please. Give me a word. Just give me a word. Something. Anything. Not just "sorry". She knows I'm sorry. Davina slid back from the table and came toward me. Please God. Please. Anything. Something.

"Hey chica," she said hoarsely with a halfhearted smile. We hugged for a few moments in silence, sharing so much. Mothers of pre-school aged sons. Believers in God, desperately wanting to accept His will on something so unconscionable. Both of us knowing that there is nothing natural about a mother burying her child. No words to smooth it over, no real gesture to make it better, nothing. "It's as awful as you could imagine it to be," she once said to me. "Everything about it, girl." During that embrace, it came to me that although we had both been pregnant together (Isaiah was born six months after C.J.), and although our husbands were the best of friends, schedules, work, and life never allowed Harry and me the chance to actually meet C.J. in person. Right then, after that realization, God gave me something to say.

"Introduce me to your son," I spoke softly while holding her two hands. "Please. Introduce me to your son."

And that is exactly what she did. We locked arms and walked over to a shelf that held several family pictures, and of course, even more shots of photogenic C.J. at every stage. Davina picked up an 8 x 10 of C.J. wearing a Mickey Mouse hat. She smiled as she rubbed her index finger over his lips. "This is one of my favorite pictures." She gently kissed the glass covering his angelic face. Then, she shared with me stories of his experiences of going to Disneyworld "many times" before he was even four. The funny things he did, the parts that scared him, and how he liked to ride on his daddy's shoulders as they walked around the park.

We sat side by side on her couch and Davina took me on a photographic journey with C.J. to parks, museums, vacations, trick-or-treating, and even the most every day places of all. Unlike many of moms who promise that we will put those pictures in albums some day, Davina is one of those moms who actually did. One picture was taken in a restaurant, C.J. smiling brightly next to his mother. "What were y'all doing here?" I asked Davina--knowing that there was a good story behind it.

"Girl, we were at C.J.'s favorite restaurant, Outback Steakhouse. Most kids want chicken fingers, but this boy orders like a thirty-five year old man!" We both laughed. "We were there for me and Ced's anniversary. C.J. was my 'hot date' since Ced was deployed at the time."

I turned the page and saw several consecutive pictures of C.J. wrestling on the floor with his paternal grandfather, who he lovingly called "March." (They loved to be silly and march around the house together--hence the name, which according to Davina, really stuck.) Riding on "March's" back like a horse, playfully laughing on the floor with his uncles and cousins. . . .then I saw another photo of Ced lying in bed reading a book with C.J. perched right beside him, mimicking his every mannerism. I peeled back the next page, gasped, and looked over at Davina. Then, I threw my head back and laughed at the sight of Ced standing beside his spotless Harley Davidson, and with his "mini-me" C.J. right next to him -- and beside his own miniature "hog." "Girl, you couldn't tell C.J. nothing about his Harley!" Davina added, eyes sparkling. What a delight. She reached for a stack of black and white photos that were spread before us on the coffee table. "This is from the last time Ced returned from Iraq," she said sighing. The first one I saw was a great snapshot of C.J. in his daddy's arms, Ced fully clad in Army fatigues. There were other photos of the entire family of three, reunited and smiling. . . .Davina proudly wearing a t-shirt that read "I love my hubby." And finally, a photo of Davina holding C.J. with her back to the camera looking to the horizon. If you looked closely, you could make out a faint silhouette of Ced and the other soldiers who'd just stepped off the plane in the background. There was C.J. with his arms wrapped snugly around her neck, and with a tiny American flag in his tightly clenched hand, staring into the camera hauntingly. . .his young face was so serious and peaceful--and his eyes--almost knowing.

I was introduced to C.J. that day, and also learned from Davina during that introduction how to truly celebrate the ones we love. Her pictorial biography of C.J. was a glorious carpet ride of life through a child's precious eyes. Laughter. Imagination. Innocence. It is the best introduction I have ever had--with the most lasting impression.

Our hearts connected that weekend as more than just wives of old Army buddies. We forged a friendship of our own, growing sometimes over simple text messages, and other times over laugh out loud phone conversations, but in its every form special, easy, and authentic. The fear of talking with her about her son, and especially my own sons, melted away that day and never returned.

"Please don't let anyone forget my son."

A few years ago, one of our college friends, David S., passed away after a sudden cardiac arrest. A loving husband, a cherished father of three, and a beloved son also swiftly taken away from his loved ones. At his funeral, his grieving mother embraced my older brother, Will, and implored him-- "Please, don't let anyone forget my son." Will was a close friend of Dave's, yet all who knew him would tell you that he was adored by countless people. For that reason, I found it especially moving that his mother trusted Will with those words that day. . . and that charge. And by telling me what she said, he honored her request. Part of me believes that the Lord spoke to her that day, too. . . .and through those words she shared with Will, ultimately spoke to me as well.

I vowed to regularly remember Dave S. that day, and to do my small part not to let others forget him, either. In that same spirit, I also vowed to remember little C.J., and to be unafraid to talk about him, share about him, and to bring him to life just has his mother did for me on that dark and rainy November night. Even if it hurts a little.

"Tell me a story, Mommy."

This is a common request from my kids, especially Isaiah, (most often a thinly veiled effort to delay bedtime after being tucked in.) Usually, I'll tell him one of Davina's "C.J. adventures." I try to get every detail right, doing my best to honor his memory. I even placed a picture of him in the boys' playroom, and told them he was our "playroom angel."

"Is he a kid angel?" Isaiah asked one day.
"Yep. He's a kid angel," I answered.
"Why are some angels grown up angels and other angels kid angels?" Ut oh.
I swallowed hard and give my best reply. "If God takes you as a child, you are a kid angel."
He looked puzzled. "But why would God take a kid?" he asked with wide eyes. He really wanted to know. So did I.
"I don't know, baby. It's a lot of stuff God does that we don't fully understand. But you can ask Him when you pray tonight."
He looked down quietly. "Was his mommy sad when God took him?"
"Yes, baby. His mommy and his daddy were very sad and a lot of times they still are. But they are happy God gave C.J. to them for a little while, even. And now they have there very own angel and so do we."
"Oh," he responded, not completely comforted. Later on that evening, Isaiah told me he thought it was a good idea for C.J. to be our playroom angel, "'cause there are lots of toys in that room, and I bet kid angels like toys."

One day, I came in the playroom, and Isaiah had taken down the framed photo of C.J. "What are you doing with that?" I asked him.
"Oh, just playing with my angel," he replied with a smile. "We were going to watch the Care Bears Movie, and I thought C.J. could see better if I took him off the shelf." I could feel my eyes welling up.
"Actually, angels can fly, so he could see without you moving him," I said matter-of-factly.
"I know angels can fly," he quipped, "but I wanted to see him better." Of course.

Isaiah, C.J., and the Care Bears that day (courtesy of my iPhone)

"Please don't let anyone forget my son." This was one mother's plea, and is every mother's wish. We don't passively remember. It has to be deliberate. . . . .kind of like love. So today, I am remembering C.J.. . . . . I am running through toy store aisles with him, marching with high steps around the house with him, giggling out loud on carpeted floors with him, and sometimes crying, too. I am describing him to friends-- to you--and to my children. . . .promising to make his memory a living one and paying a little of that love mixed with joy forward, just like he did.

Dear C.J.,

Thank you for teaching me so much about love and joy. Thank you for your spirit and for continuing to be our special angel in so many ways. I am so honored that I finally had the chance to meet you. I look forward to continuing to introduce you to others, and to teach them what you and your mommy have taught me. You have both taught me how to make love a verb. . .active and always evolving.

It has been a year since you made your transition, but I promise to keep you fresh i
n my heart and my thoughts every day. . . .and to never let anyone forget you. Ever.


One of the many people who love you

Marion Cedric "C.J." Carrington, Jr.
a.k.a. "Heaven's Angel"
12/24/2004 - 11/23/2008

Monday, November 16, 2009

Elevator Observations Part V: Say it LOUD!

Grady elevator, courtesy of the iPhone

I stepped on the 'A' elevators at Grady which had arrived unusually fast this particular morning. Nice. A few moments later, a thirty-something year old woman reached into the door before it closed then looked at me and smiled. I glanced back at her and and nodded as the doors met and closed. She looked down in her purse to retrieve her ringing cell phone and I noticed a tattoo of a rose on her neck, barely discernible against her dark brown skin.

I briefly wondered about how one makes the decision to permanently ink the neck as opposed to some other more concealed area.


Like, did she wake up one day and say to her best friend, "Yeah, girl, I'm gonna tattoo my neck today!" and then did the friend give her a hi-five and say, "Yeah, girl that'll be hot!" Hmmm. Okay, I digress. (These are the important things I allow myself to think about on the Grady elevators. )

Opted to drop this question and mind my own business (as Harry often suggests I should do.) After we selected our respective floors, I refocused my attention to checking email on my iPhone. When my elevator companion ended her phone call, I could feel her giving me the once over. There was no way this ride would take place in complete silence.  

Sigh. Here we go.

" 'Xcuse me, doc. . .you mind me askin', what are you?"

For most people that would seem like a weird question, but it wasn't to me. This question was in no way foreign, and I knew exactly what she meant. "What are you?"-- as in, what is your nationality, your origin, your background, your race? Many folks reading this have never, ever had such a query come their way. . . . . but me? Please! I didn't even flinch.

So I bet you are wondering. . . .who does that? Who randomly steps on an elevator and asks a person something like that? It's not even something that one would even think to ask a friend, let alone a perfect stranger. So really, like who does that? I'll tell you who. My people, that's who.

That's right, I said it. My people. Black folks. There is something inherent in many of us (black folks, that is) that makes us want to determine with as much quasi-accuracy as possible someone's lineage and genetic makeup. Case in point, conversation in a predominantly African-American hair salon somewhere in the United States:

"What is Mariah Carey?"

"I'm pretty sure she's biracial."

"Are you sure? I thought she was Hispanic."

"Naw. Her momma is white and I think her daddy is black."

"Uh uh! You thinking about Halle Berry!"

"Really? I'm gonna Google it." (Pulls out her laptop under the hair dryer.)

"Let me know, girl, 'cause that don't sound right."

"I'm telling you, I'm right. You just confused 'cause she keeps it real mysterious. I think she's on some 'Tiger Woods' stuff."

"Still don't sound right to me. I thought she used to date Derek Jeter."

"What's that supposed to mean?"

"Isn't he Puerto Rican?"

"You thinking about A. Rod."

"Oh yeah. . . . what is Derek Jeter anyway?"

Perhaps it goes back to the dilutional mixing pot that African-Americans' genetic make up was subjected to during the centuries of slavery and beyond. . . . .or back to the turn of the century when some folks did their best to "pass" and when others were shunned by their own people for looking too African. Who knows? I can tell you this, though--in the nearly one hundred times that I have been asked that question, ninety nine of the times, I was asked by someone of my same culture--an African-American. So here's the deal. The "what are you" question really is code for, "You kinda look Black, but I'm not one hundred percent sure. What are you? Latina? Indian? Biracial? From the Carribbean? Ethiopian? Erytrean? Damn! What are you?"

Maybe since I understand the complexity of this innate curiosity, I never feel offended. Sometimes my standard one word answer--"Black"--isn't enough. This day was one of those times.

"Are you like, regular black?" Loaded question.

No, I'm not kidding. That was what she said next. And so I offered her what has become my standard follow up answer, "I'm from L.A. and my folks are from Alabama. I guess I am regular black."

"You look like you got something in you. That's why I asked." Of course.

I find this whole thing amusing, especially since it is my very own people that can't seem to place their finger on my origin. Perhaps it is the freckles or the texture of my hair (depending on the day and the weather.) When I was in residency, I wore my hair a bit longer, and got this question far more frequently. Back then, it was (still my own people) asking me if I was "Indian" or "Arab." And you guessed correctly--no one Indian or Persian ever mistook me for one of their own.

Me, as a resident of ambiguous origin, circa 1999

Once I cut all my hair off into my current shorn coiffe, it shifted to this more nonspecific thing. Sometimes the person, usually a patient, will just sit there squinting at me while I talk. They hear the "sista" in my voice, but still can't be sure. Kind of like the way you speak to someone over the telephone, and from the tone of their voice get a suspicion that they may be African-American. (Admit it, you do it.) I can always tell when it's about to happen, too. I can see a "what are you" coming a mile away.

Unlike my experience during residency, I have encountered a few folks in Georgia who have gone so far as to speak another language altogether to me, particularly Amharic (a language spoken in Ethiopia.) One guy at a parking garage let me park for free after greeting me by saying, "Salam!" I'm pretty sure that it was because he thought I was from his country. Another woman pulled into a gas station and asked me directions in Amharic, and when I told her I wasn't Ethiopian, she then incredulously replied with a heavy accent, "Wow! You look like my people!" Yeah, I get that sometimes.

True colors

Last month when I was on Grady wards, one elderly black patient kept referring to Adaeze A., my Nigerian-American intern, as her "colored doctor." Nobody ever seemed to hear her say it but me. She slid it in nearly five times before I just had to say something. Finally one day when we were rounding, I asked our patient, "Wait, what did you call her?" I gestured to Adaeze.

"My colored doctor," she proudly answered with a warm and toothless smile. This was in no way meant to be offensive. My late great auntie Mac used to refer to folks as "colored" and didn't think a thing of it. This patient was no different. It was simply an eighty-five year old black woman who happened to be born and raised in the southern United States doing her best to describe the young doctor who saw her every morning.

I looked over at Adaeze, my intern, and raised my eyebrows. Fortunately, she took it all in stride. Adaeze smiled and said to the patient, "Awww, come on, Mrs. S! You know folks don't say 'colored' anymore!"

Mrs. S. shrugged and smiled. There was no way she was changing her descriptor for an entire race of people after eighty-five years. Forget it.

"So, wait a minute, Mrs. S--what does that make me then?" I playfully quipped. She cocked her head sideways and gave me the "what are you" squint.

"I'm not sure what you is," she said initially--but then I think the "sista" in my voice resonated with her a bit. "Now that I thank about it, I thank y'all is both my colored doctors. And I love y'all." She looked around the room at the rest of the team--a variety of nationalities represented--Caucasian, Indian and Persian, flanking the foot of the bed. "I love all y'all." Love that. Colored or not.

"Say it loud. . . .I'm Black and I'm Proud!" -James Brown

Ironically, no white person has ever investigated the background of my DNA nor have they ever mistaken me for not being black. (I'm just saying.) Either way, the best part of all of this is that I love being the occasionally somewhat undiscernable black woman that I am, I really do. And I'm one person who doesn't need James Brown to nudge me with his battle cry. I'm proud of who I am. Even the parts of my culture that make me shake my head and say, "Lawd have mercy, chile!"

Honestly, I love the richness of every culture, love learning about other cultures, and celebrating them all. It's tempting to lose who you are by trying to assimilate, especially in a field like medicine. . . but that's just too much work. By not watering down who I am, I blur those lines that separate my race from the next just a little more. Being true to my roots around those who befriend me welcomes them to know more than just what they see on TV or read in magazines about black people.

Just as my friend Lisa B. teaches me Yiddish and all about her Jewish culture, I have no shame in sharing with her all that is unique to my African-American roots. Hey and now, the beauty in it is that when I see an overflowing stack of laundry, I now say "Oy vey!" and when she realizes that nobody did the dishes, she says, "Aww, hell no!"

Okay, but back to the chick on the 'A' elevator. . . .the real thing that should have immediately clued her, and each and every person of color who EVER asks me the "what are you?" question, that I am indeed black is this:

1. I was 0% offended by the question, and
2. I actually knew what the hell she was asking!

Me and my "sistafriends" (present and former Grady doctors) of several hues

The Godfather of Soul concurs, circa 1968

Tuesday, November 10, 2009

Reflections from a Tuesday: Who I am

The "old soul" Isaiah

Yesterday I was in the kitchen putting together something for dinner while Isaiah and Zachary sat at the table coloring. Zachary decided to jump down from his seat and run laps around the house. (Not unusual, if you know Zachary.) Isaiah, instead, engaged his mom in a little conversation.

"Mommy?" he asked with doe-like eyes, "I need to tell you something. I wasn't such a good listener in school today."

I turned around and looked at his face, apprehensive yet brave. Well that was honest. "Yeah, bud, I heard. Your teacher said that you guys were all horsing around a lot today. She called it 'Monday Fever.'" You have to give the kid credit for honesty.

"I'm sorry, Mommy," he said softly while peeling the paper off of his crayon.

"Listen, buddy," I replied with a smile, "We can just make tomorrow a better listening day, okay? And you know what? I really appreciate you telling me the truth about your day."

He looked back at me and flashed all of his baby teeth. "Mommy?" he spoke while peering at me with those same wide eyes. What is he about to say now? I turned around and raised my eyebrows. "Mommy. . .are you proud of me?"

Without thinking, I quickly answered, "Am I proud of you? Isaiah, I'm always proud of you, and so is Daddy. Always. And there is nothing you can do to make me not be proud to be your mom."

"Even when I'm not a good listener, you're proud?"

"Yep, even when you aren't a good listener. I don't really like it and I feel a little sad when you aren't a good listener, but I'm still proud."

He put down his crayon, planted his elbows on the table, and rested his chin in both palms. "And you always like to talk to me and you always love me?" Oh lawd. What is this about? I decided to stop what I was doing and walk over to the table. Wiping my hands on a towel, I scooted onto the edge of the chair across from him.

Isaiah is what we often refer to as an "old soul." He often says and does things that are much more characteristic of someone older and more experienced. Even though most of the time, he can be counted on to behave exactly his age, I am often floored by his abstract thoughts and mature emotions. Definitely what folks would call an "old soul." I had a feeling this was one of his "old soul" moments.

I looked in his eyes and then quietly spoke,"Isaiah, you know what?"

"What, mommy?" He looked at the paper on his crayon for a moment, but something must have told him to stop and make eye contact with me.

"I always want to talk to you, and I always want to hear what you have to say. There is nothing you can't tell me or daddy ever. Ever. We always love you and always want to listen to you. And we are always, always proud of you. Always." I nodded my head for emphasis all the while keeping my gaze fixated on him without blinking.

Suddenly, he erupted into tears. I mean full on, can't get a breath crying. Oh my gosh! What's wrong with my baby? Who hurt him? What does he have to tell me? I put my arms out and gestured for him to come to me. The pang of fear quickly rose in my heart and created a thumping in my chest that was deafening. Oh Lord. What? Oh no! Has someone or something robbed my baby of his innocence? Did we do something wrong? Is he okay? I wondered if I'd just given him the green light to share some awful secret that he had been holding inside. . .something he'd been afraid to tell me. He climbed into my arms and squeezed me tight, crying a little harder as I hugged him.

"What's wrong, sweetie?" I queried trying desperately not to sound too concerned. What is it? I wiped his face with my hand. "Baby, why are you crying? Tell Mommy. Why are you crying? Tell Mommy what's wrong." Tell Mommy. Please tell Mommy before she has a heart attack.

He looked up at me and shook his head. Again the suffocating fear, but it was immediately quiesced when he said, "Nothing is wr-wr-wrong, M-m-mommy. I'm n-n-not crying 'cause I'm sad. I'm cr-cr-crying 'cause I'm happy. Mommy, I'm h-h-happy." He then wept a little harder. Oh my gosh. I felt my eyes welling up. He looked at me, caught his breath, and then went on, "I'm happy I can tell you anything and I'm happy to be a part of this family." Then he cried a little harder. Part of me felt ashamed for thinking the worst. . . .

He went on to tell me that he learned in school that some kids don't have a family and that one of his friends in school only has her mommy but not her daddy. And he is glad to have his mommy, his daddy, his brother, and all of the rest of his family. He said they probably feel sad and some days want their daddy. He spoke with such amazing clarity--it was surreal.

"Baby, you know what they call that?" I asked while pulling him into my chest.

"What Mommy?" was his muffled reply.

"They call that 'blessed.'"

We sat there hugging at the table for a few more minutes, both of us covered with tears. It was a moment to savor. Every part of it--including free-spirited Zachary marching around the table singing at the top of his lungs,"Doe a deer! A female deer! Ray a drop of golden suuuuunnnn!!" Yep, I am savoring it, and being truly present as much as I possibly can.


Sometimes I worry that I'm not getting it all right. Not getting the doctor-thing right . .not getting the mommy-thing right. . . not getting the wife-thing right. . .not getting the me-thing right. Just when I start to get a little overly self-deprecating, something like this taps me on the shoulder and says, "Just keep doing you."

Get a life. . . .

I often tell my residents-- work hard, honor your patients, learn as much as possible--but be efficient so that you can go home to your family and your personal life. Being a physician, especially a Grady physician, is a ministry in itself. But being my best, most available mother, my most loving and supportive wife, and my most authentic self -- now that is my true calling. I make every effort to model priorities to my residents and students through the decisions I make for my family. I speak of my husband and my children often. I implore them to "do something fun" on their off days, and never hesitate to share with them when I have done the same. "Get a life," I tell them, "and that's an order, not a suggestion."

Just as we tell our learners that patients have lives outside of the hospital and that we should always consider this, so do physicians. We are doctors, yes. But we are also mothers, fathers, sisters, brothers, husbands, wives, daughters, sons, and friends. By honoring ourselves and remembering to strive for some kind of balance, we ultimately honor every patient we touch. I believe that.

Yeah, so the other day, my four-year old son was crying. . . .because he was happy. What that tells me is that I'm getting something right . . . .and it tells me who I really am. I am my authentic self-- which isn't half bad. I am Harry's wife and I am Isaiah and Zachary's mom. And finally, along with some other things, I am a Grady physician, who happens to genuinely find joy in every one of these roles. That's who I am.

Do you know what they call that? They call that "blessed." :)

Me doing the "Mommy-thing". . .and loving it

Saturday, November 7, 2009

Reflections from a Teacher at Grady: Growing, Growing, Grown. . . .

"Life is Change. Growth is optional. Choose carefully."


"We think she should stay in house for a cardiac catheterization," said the young, female Cardiology fellow consulting on our patient. "This EKG is concerning. . .definitely a change from her prior."

Okay, so confession: when I first saw that EKG, I wasn't 100% sure if some of the changes were worrisome or simply related to underlying disease. That's why I'd decided to review it with an expert. She held up the shiny piece of paper with its tiny pink gridwork embossed with black ink and squinted her eyes. Such a simple tool, that piece of paper--yet it holds so much information. The electrical activity in the heart, represented by the EKG tracing, can be the difference between life and death, or in this instance, home or the hospital.

"Thanks for your help, as always," I replied with a warm smile. She returned the gesture. I leaned forward on the nurses station with folded elbows and glanced sideways. "So, things are going okay for you?"

"Really good, actually," she answered while placing her pen down. The business part of this discussion was over. "You?"

"Girrrrrllll. . .busy as ever, but you know that's how I like it." I patted my hand on the growing stack of patient cards in front of me.

"That's for sure, Dr. Manning!" she responded. I narrowed my eyes and cocked my head sideways. She tapped her hand on her forehead lightly. "Oh that's right-- Kim! I'm sorry, Kim, I'm still getting used to that!" We both laughed.

I gathered up my billing cards and stuffed them in my pocket. "Thanks again, Tenecia, I appreciate you schooling me!" She gave me a quick hug and scurried off to see the next consult.

As I watched her walk confidently down the hall, I thought about the first time I met her. We sat in a circle of ten chairs in my colleague's office. She was a smart and spunky first year medical student participating in an "End-of-Life" Care learning group several years before. I still recall those earnest and incredibly green questions that she, and all her classmates for that matter, asked of us.

"Can't you just ask the person if they want to be off of life support? Like if you listen carefully are they able to talk?"

Uhhh, no. (How were they to know that no one talks with an endotracheal tube down their voice box--Bless their hearts.) So fast forward to 2009 where now Tenecia and former students just like her are now answering my "special" questions. The teacher has become the pupil. (Bless her heart.)


I have decided that one of the very best parts of my job is watching my students and residents blossom into mature clinicians before my very eyes. Their once ginger and nervous gestures have slowly become more deliberate and their statements, formerly with the intonation of a question, are now firmly punctuated with a solid period of authority.

This past month, I worked with Sameera A., a third year resident, on the wards. I've had the pleasure of supervising her before-- we work together in her weekly Internal Medicine continuity clinic. Her work product has always been meticulous and her care of patients thoughtful and complete. However, like many interns I've met over the years, Sameera was still learning to come into her own. Searching carefully for that balance between confidence and humility, firm and inflexible, pleasant and passive. It's such a delicate line. . . . .that generally gets mastered with only time, trial, and experience.

"I think we should keep this patient at least another day," Sameera stated to me on rounds one day with resolve. I had just suggested we discharge this young woman from the hospital with what we suspected to be a community acquired pneumonia. Sameera was concerned that there was more work to do. I decided to challenge her.
"She has no oxygen requirement, and she doesn't have a fever any more. What will you do differently if you keep her here?"
Sameera stood her ground as the entire team quietly watched. "First, I'd like to consult Infectious Disease, or at least discuss her case with them. That x-ray was pretty bad, Dr. Manning. Also, if her HIV antibody is positive, this will change things, and we don't have that information yet." The team looked over at me. Your turn.
"Okay. So even if her HIV antibody is positive. Again, what will you differently? She has clinically improved, and regardless of what Infectious Diseases says, the most important thing is her clinical appearance," I countered eyebrows raised. Eyes back on Sameera. Ooooooohhhhhh.

Sameera continued her seering eye contact and paused for a moment. Her words were always thoughtful. "I will assist her in getting outpatient management for HIV. I will have a social worker and an HIV educator come and talk to her about what it means to have HIV if she indeed has HIV. I will know for sure that she has this information and won't stay awake at night hoping she comes back to the clinic to get an HIV diagnosis." The spectators swung their heads in my direction. Take that, Manning.

I nodded my head slowly, eyes still locked on my resident, and tapped my billing card on the chartbox. I glanced over at the team and shrugged. "The boss has spoken. The patient stays. Let me know what the HIV antibody is and what ID says." I winked at Sameera and watched her stand just a little bit taller as we moved on to the next patient.

I'm pretty sure that Sameera would not have spoken with such conviction during those first clinic encounters of her internship. Even with such exceptional patient care, like most novice physicians, she needed some time to get her chops, spread her wings, and believe that she, too, was everything that we thought she was. That process takes some time. But, if this month hadn't revealed anything else to me, it revealed one thing for sure. This resident had arrived. Somewhere between internship and third year, Sameera had really arrived.

Later on that afternoon, I joked with Sameera and the team that they should be careful not to cross Sameera's alter ego "Samantha."
"Don't let the sweet exterior fool you," I quipped, "Samantha lays down the law, takes no prisoners, and is a hard core patient advocate. . . . she's never mean or unprofessional either--but she will put you in your place. Just when you think you have all the answers, Samantha hits you with some medical literature and says, 'I don't think so, boo!'" We all erupted into laughter. They, too, appreciated Sameera's growth into full on "big girl" status.

For the rest of the month, we made whimsical references to the Sameera/Samantha supergirl combination. It was an affectionate way to say that she had indeed begun to achieve that delicate balance that only Father Time can provide, and that some young doctors, unfortunately, never quite attain.

At the end of the month, I decided to put the jokes aside, and to be specific. "Sameera, it's been awesome seeing you grow up. I know I joked about the Sameera/Samantha thing, but what I was really saying is that you have really matured into a well-rounded physician. You articulate the patients' needs and management so well, you have learned to handle having authority, and also you are an exceptional leader and role model to the interns and students." (I figured 'great job this month' wouldn't be as meaningful.) I went on to describe instances where she excelled as a leader. The day she helped a family navigate the difficult decisions involving care for their dying loved one, the time she offered gentle feedback to a medical student which ultimately brought out the best in him, and the day she carefully pushed consultants to clearly communicate a plan for a complicated patient. I nearly got choked up, because her wide eyes during the discussion were so reminiscent of those from her very first day in the clinic nearly three years ago. . . earnest and green. . . . . but this time, I knew they were knowing and mature. Sigh.

Sameera a.k.a Samantha at work

"Thanks for letting me grow," she replied. Still that unwavering eye contact. Knowing and mature. "It felt good to be trusted to make decisions."

My eyes smiled with admiration. "Sameera, I took off the training wheels and walked behind you, just like someone did for me. It's tempting to hold the back of the bike the whole time, it really is. . .but you never learn to ride that way." I scanned her face to see if she understood my analogy. She did. I went on. "Now it's up to you to do the same thing for your interns and students. I'll be walking behind you, and you'll be walking behind them. You can grab them before they fall, and I can grab you before you fall." She closed her eyes and nodded, taking in the mental image.

I placed my palms down firmly on the table and added with a wide smile,"And you know what's really cool? Don't you know I'm grown, and I still have folks walking behind me?" She softly giggled as I allowed my mind to wander to my mentor, Dr. Winawer, my many colleague-friends, my boss, Dr. Branch, and my former Chair from residency--all of whom I still consult regularly. Still walking behind me. I meant that statement.

That feedback session ended with a hug. It was truly a delight to see her ride without training wheels that month. . . . just as it warmed my heart to have my former first year medical student teach me about the subtleties of reading EKGs. . . .and, in a way, walk behind my bicycle. Full circle.

Growing, growing, grown. . . . .

Right before your very eyes. . . . .if you don't take pause, they'll grow up and you'll miss it. Today, I am taking pause. Appreciating my role in all of this crazy medical upbringing . . . .and taking it very seriously. Perhaps a snotty remark from me to a nurse way back when might have affected Tenecia's ability to be warm and helpful during her Cardiology consults. Maybe if I had humiliated Sameera in clinic, she may have done the same to our students that month. Who knows?

The best part of all of this? I'm growing, too. With every student, every patient, and every resident, I'm slowly but surely mastering that balance just a little bit more each day.

"Life is Change. Growth is optional. Choose carefully."


I choose growth. :)

Me and Tenecia, my first year med student turned Cardiologist and teacher

Zachary finding eggs "all by myself" for the first time last Easter