Tuesday, July 5, 2011

What remains.

*names and details changed to protect anonymity. . .yeah, yeah. . .you know the drill.
image from here

In Shel Silverstein's children's classic "The Giving Tree" he tells the story of a boy and his best friend, a tree. And though some people have real strong and sometimes negative feelings about the meaning behind this book--I mostly think the story is beautiful and selfless . . . .in that prodigal-son-kind-of-way, you know?

Kind of like many of the people who have given selflessly to me in my lifetime.


Early on, all that the tree has to offer the boy is obvious--outstretched branches for shade from the summer, sprawling limbs to climb, and ripe, juicy apples to eat. But later in that book the boy grows older. Eventually as an older man, the boy comes to the tree, who is now a stump.  At this point the tree feels convinced that he doesn't have what the boy is looking for but as it turns out his request is simple and doable; he wanted a place to sit.


My children are only six and four, so they generally need me for most things. I often wonder what things will be like when they grow older, and then secretly cross my fingers behind my back hoping they will always need me (but in that gainfully employed, fully independent kind of way, of course.) Just when I start to worry, I think of how much my parents have had to offer me in my adulthood and breathe a sigh of relief. And I tell myself of Isaiah and Zachary--of course, they'll need me.  Of course they will.

But raising up doctors is different. Especially resident doctors. They come to you as clinical babies, cooing and sometimes crying. Over those three to four years you stand behind them as they take their first steps, applaud their every achievement, place band-aids on their boo-boos, and offer tough love and redirection when they make mistakes.  Their learning trajectory is fast and furious, and one day, when you least expect it, they're just as tall as you.  Some even taller.

And so they grow. You sit across from them in clinic or stroll the wards on rounds realizing that your shoulders are at the same level. They speak of things cutting edge that just maybe you haven't heard yet and pull out electronics that perhaps you've never even seen. They prove to be responsible drivers so you let them drive sometimes without you, and when you do get in the passenger seat, you find yourself surprised at how well they can maneuver a five speed without your two cents. 

So you wonder. What can I do?  You've climbed my limbs and basked in my shade. What can I do?

Today I am reflecting on something that recently reminded me of the answer to that question.

image credit

Grady Hospital Primary Care Clinic, Spring 2011

"Okay, so we'll see how things go with diet and exercise in terms of his blood pressure. I think he's pretty motivated to work on shedding a few pounds."

"Didn't you say he had diabetes?" I asked with my eyes squinted.  With diabetes and a blood pressure reading of 161/94, "diet and exercise" didn't sound like the best game plan. At all.

I was slightly surprised considering who I was talking to. This resident was in the last half of his final year of training and usually gave such pristine patient presentations that I'd find myself grasping for teaching points. With some of our strongest trainees in the latter portions of their residencies, finding something to "teach" or "correct" can be downright intimidating. But this? This was odd.  And hearing this guy say that someone with diabetes and such poorly controlled hypertension should simply move more and eat less--without any medication changes--didn't quite make sense.

He sighed and looked down at the ink pen twirling nervously in his hand. "I know, Dr. M. But this guy?" He sighed again and chose his words carefully. "I mean, he's just. . .I mean he's totally against being put on more medication. I mean. . .and he's such a great patient. . .like. . .he really takes an interest in what's going on with his body. I just. . .I don't know. . .I just want to respect his wish and see what we can do without adding new medication that's all."

I stared at him and nodded slowly. My eyes then darted back over to the monitor displaying the patient's electronic medical record.  A few mouse clicks later and it was quickly confirmed that a conservative approach had been taken to his blood pressure at the last visit.  "Wow. His blood pressure wasn't controlled at this visit either." I scrolled downward and then brought up a page trending his blood pressures. Initially "borderline" but for the last two encounters, officially uncontrolled.

Next I moved to the page with lab values. Highlighted in bright red was one abnormal result--the patient's kidney function. I winced and peeked back at  my resident with an eyebrow raised.

"I know," he whispered. My resident pressed his lips together and shook his head.

I leaned my elbow on the counter and rested my chin in my hand. Keeping my eyes on him I said exactly what was on my mind. "Okay, I'm confused. What's going on?"

Because something was going on. This resident was an all-star. I was 100% certain that he knew the specific guidelines and the exact literature on management of high blood pressure in patients with diabetes and kidney disease. In fact, at this point he more than likely knew these kinds of details even better than me, his supervisory attending. So the question was simple. What was going on?

He shrugged his shoulders. "Dr. M? I need some help with this. Like help communicating," he finally said. "I mean. . .this patient is super nice, like I said. . .but so opinionated and firm in his resolve, you know? Like he's taking notes and asking questions and. . . it's hard to explain."

I nodded and waited for him to try.

"I think I want to. . . .like. . .I think it might help me to watch you talk to him. What I want to do is add a second medication.  He's maxed on an ACE inhibitor and I'd really like to add a calcium channel blocker. I mean, honestly? His cholesterol is slightly over goal, too, but I didn't even touch that today. I just didn't know how. He's not angry or difficult or anything. Just. . . .determined. I need help with this, Dr. M. Can I just watch you talk to him?"

And no, he wasn't throwing me under the bus. This all-star senior resident who could recite journals like the alphabet and conjure up obscure facts like a computer was asking me to teach him something. And it felt wonderful. Like that way I suppose parents feel when their kids are blossoming adolescents or savvy young adults but still come back for help with something simple. Or like in The Giving Tree when the boy just wanted to sit on the stump and that was it.

Watch me? Watch me talk to your patient and that's it?

And so I did my best to conceal the tiny wave of emotion that rolled over me and said, "Okay. I can try."

Mr. McCutcheon

When we came into Mr. McCutcheon's room, he immediately stood in deference. "Good morning, doctor!"

"Oh my," I laughed, "You don't have to stand!"

I liked his firm hand shake and pleasant demeanor.  My resident leaned against the sink as I initiated encounter.  With Mr. McCutcheon's permission, I repeated a few key elements of the examination and then gestured for him to sit down across from me.  The first thing I noticed on the desk was a neat stack of colorful papers.

"What is this, sir?" I inquired.

He turned two of the sheets around to face me.  One was a computerized graph of his blood sugars which had been beautifully controlled.  The other was just as colorful and consisted of two months worth of blood pressure readings, all averaging somewhere between 140's and 160's systolic (top number) and 80's to high 90's diastolic (bottom number.)

"This is amazing."  I said that because it was amazing.  I decided then to cut to the chase. "Mr. McCutcheon, sir, it's my understanding that you and your doctor have been trying to avoid adding more medications."

"Correct.  I lost four pounds since the last visit, and just started a walking club a few months back. I cut out bread and it's been going well. I am pretty sure I can do without another medication if I keep this up."  His face was still pleasant and just like my resident said, motivated.  Nothing about him was confrontational or difficult. Just. . . determined.

"I see."  I picked up the sheet with the blood pressure readings on it, and beneath that was a piece of notebook paper with a few notes he'd taken.  "I'd bet you were a good student during your school days."

"You know, Dr. Manning? I just always loved learning. Always.  School didn't come easy to me, but I always tried hard, you know?  My mama always said that I was hungry to learn."  He chuckled a bit, which made the redundant folds on his chin shake a little.

"Okay, Mr. McCutcheon. . . well that gives me an idea on how we can proceed."  He looked a little puzzled for a moment, but mostly intrigued.  I pulled out my pen and grabbed a sheet of blank paper. He scooted up his chair and craned his neck to show that he was fully engaged.  "What I want to do is talk about your visit as I would to another doctor or a medical student. Is that okay?"

His face lit up as he nodded in the affirmative. He reached for a steno pad out of his bag in case he needed to take more notes which warmed my heart.

And so the lesson started. First I explained to him the classifications for hypertension or high blood pressure. I wrote at the top of the paper--PRE-HYPERTENSION, STAGE I HYPERTENSION and STAGE 2 HYPERTENSION. "Once the top number or systolic is consistently160 or more, this is stage 2. And the thing I always remember about stage 2 is that 'two means two.'"

"What does that mean?" Mr. M stopped from his notetaking to ask.

"It basically means that if you have stage 2 hypertension, you almost always will need at least two medications to treat it." He nodded to show me that he was with me. "Okay, but now here's a more tricky part. You have diabetes, sir. Your last lab work also showed that your kidneys have weakened just a little bit--not so much that it is terribly alarming--but it's something we need to pay attention to. Were you aware of this?"

"Yes, ma'am, my doctor told me. Does that mean dialysis or what does that mean?"

"No, it definitely isn't at that point. See, we look at this test called the creatinine. It's something your body breaks down from muscle and your kidneys should be able to filter it out. We check the blood to see the level of the creatinine and if it creeps up, we know that filter is off some. Your number was 1.6. It really should be under 1.4.  Since we know that diabetes and high blood pressure affect your kidneys, experts recommend that we get pretty hard core when it comes to getting blood pressure down in people with both diabetes and kidneys that are getting weaker. We call the weaker kidneys 'nephropathy.'"

"Like a nephron, right? A kidney cell?"

"Exactly, sir. Exactly." I drew in a sigh and continued.  In block numbers I wrote a 140 and a 130 on the sheet with a big arrow next to the 130.  "In people without diabetes, we want to see the top number under 140.  But in people with diabetes and especially with diabetic nephropathy, that number needs to be even lower." I drew an 'x' over the 140 and circled the 130.

"Like under 130?"

I nodded.  From there I even launched into cholesterol guidelines and how they relate to heart disease prevention in diabetics and simple things like taking a daily aspirin. Mr. McCutcheon hung onto every word and yes, his mama was right--he was hungry to learn it all. "So here's what I need you to do for me.  With the student doctors and resident doctors, this is the point where I ask them to tell me what should be the next step in the treatment plan. I want you to take a second to look at your notes. Then look over this blood pressure graph you brought in, your cholesterol level and at your medications. Now what I want you to do for me is tell me how you would manage yourself as a patient if you were the doctor--not based on what you want, but now that you know what you know. You are the doctor trying to prevent a patient from getting worsening kidney function or heart disease."

And you can guess what happened next. Mr. McCutcheon obliged me--big time.  Over the next three minutes, he looked over those notes and jotted things down on his paper. He circled things and drew arrows and scratched the side of his head.  Finally, I playfully told him that his time was up.

"Okay, doc, tell me how you have assessed this patient and what you plan to do for him." We both smiled, feeling connected during our little role play.

My was he a great sport.  Mr. McCutcheon broke everything down and then some. He told me that his 'patient' had stage 2 hypertension, yet was only on one agent.  He explained that 'two means two' and that although the patient was reluctant to do so, the right thing to do was add another medicine. Then he added that if the patient continued losing weight, that maybe we could revisit it. Genius! Next he told me that having 'sugar' is like having had a heart attack before so the cholesterol level needs to be lower.  "The LDL," he said firmly, "and just remember that the 'L' stands for 'lousy' because that's the bad one."

I glanced up at my resident for the first time during the encounter whose face was painted with a big, proud smile.  Mr. McCutcheon recommended that in addition to the daily aspirin to protect the patient's heart that it's time for us to go ahead and get him on some cholesterol medication, too.  But of course, if he keeps losing weight, we could revisit that, too.

And so, that's exactly what we did. We followed every one of Mr. McCutcheon's recommendations and he willingly accepted them all.  It was one of the greatest patient-doctor communication moments I've had in a very long time.

When clinic ended that day, my resident pulled me to the side. "Thank you so much for taking all that time with Mr. McCutcheon, Dr. Manning.  You have no idea how much I learned.  But you know what? I always learn something when we work together."

You do?  

See? The person who criticized "The Giving Tree" missed the point. They misunderstood it all, thinking that the tree gave and gave but got nothing in return. . . .

Au contraire, mon frère.

Yes. There's something in it for us. We are more than just old stumps . . . and no matter how much time goes by, our branches are still sprawling and fit for climbing whether we realize it or not.

Happy Tuesday. May you, too, be a giver that takes the time to also recognize the gift.


Oh yeah, and if after all that you are still feeling like reading-slash-goofing off-slash-not studying-slash-not working-slash-whatever important thing you are supposed to be doing instead of reading my ramblings, you might enjoy this post from last year (full of more ramblings) on "The Gospel According to Shel Silverstein." ('Cause I love me some Shel Silverstein, y'all.)


  1. You always make me cry--always and in all good ways. You are really amazing, you know that?

  2. You do realize, don't you, that you are constantly teaching? And that those of us who visit with you here can't help but learn.

  3. You are an amazing woman, mother, Dr. and teacher. Anyone working or a friend of yours should be reflecting on the boundless wisdom you have. I am in awe.

  4. I miss being in clinic with you! You taught me so much over the years- thank you for being such a wonderful doctor/teacher/friend.

  5. Okay Dr. Manning, now you have made me understand my nephropathy diagnosis, even though my creatinine levels aren't so bad. See, you are always teaching. I have been taking the medication, but felt the diagnosis was a bit overstated. Dr. Cohen owes you a thank you.

  6. Just want you to know that even when I am quiet I am reading. You are such a bright light, a human giving tree, and i wish for you everything in return. love.


"Tell me something good. . . tell me that you like it, yeah." ~ Chaka Khan

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