Last week I finally got to catch up with some John Stewart and The Daily Show.  I happened to see this clip:

Betsy McCaughy on The Daily Show

While I think most people have realized that “death panels” were nothing more than hyperbole and fearmongering, I think the underlying issue–how do Americans plan end-of-life care–still merits discussion.

In the interview with John Stewart, Ms. McCaughey seemed particularly concerned that there would be a checklist for doctors to go through with families, detailing their thoughts on hydration, nutrition, antibiotics, etc.  THAT’S AWESOME.  I think most people believe that if a patient chooses to have a DNR, then nothing will be done for them if they come to the hospital.  Absolutely not!  A DNR/DNR (Do Not Resuscitate/Do Not Intubate) covers what to do in a code situation–a person’s heart has stopped or they have stopped breathing.  This does NOT help doctors know what a patient would want if they have a UTI or pneumonia and can’t vocalize their wishes.  And while it seems callous to ask someone if they want nutrition in these situations, it’s an important question to ask.  This does not mean starving someone who can eat for themselves.  It means if I am so demented that I can’t eat by myself, do I want a tube inserted into my stomach so that someone can pour a can of Ensure down every 4 hours?  HELL NO.  If there is little or no chance that I will make a meaningful recovery from my illness/injury, than LET ME DIE.  DO NOT FEED ME THROUGH A TUBE.  DO NOT HYDRATE ME JUST TO KEEP ME ALIVE.  LET ME DIE.  A checklist is a great idea, because it takes the conversation past just the last few minutes of life (essentially what a DNR/DNI covers) and broadens the discussion to the quality of life issues than can arise in the last few days/weeks/months of life.  And I’m not saying everyone needs to feel how I do.  If you want a g-tube and Ensure, then by all means, you should get it.  What this proposal is doing is allowing people to think about these issues and vocalize their desires.  And that is a good thing.

Another reason I’m so glad that this is in the draft of the bill (although given the hoopla surrounding it, I doubt it will make it in to the final cut) is that doctors can now be paid for having a discussion with patients about end-of-life issues.  Working in the emergency department, I often grumble that primary care doctors aren’t talking with their patients enough about end-of-life care, even if they have a severe or terminal illness.  Then the patient arrives in the ED, sick as shit, and I have to figure out what they would like to have done.  I grumble, but I realize that a minimally adequate conversation on this topic can take a half hour or more.  In a pressured, tightly scheduled primary care practice, there simply isn’t time to do this and still cover the overhead (my feelings on how insurance companies have choked the life out of primary care doctors can come another time).  If, however, the conversation can be billed separately, then doctors can allocate the appropriate amount of time, and still pay their rent, their staff and their malpractice.  Trust me, doctors don’t want to get paid for this because it’s going to be quite the money-making scheme.  They want to get paid because given the amount of time it takes, they need to be paid for it.  You wouldn’t expect a surgeon not to get paid to take out your appendix, would you?  Well, a good surgeon can take out an uncomplicated appendix in less time than it takes a primary care doctor to discuss options, answer questions, explain alternatives and reassure patients that their wishes will be respected.

And why is McCaughey so up in arms about the possible penalties that doctors face about NOT having these conversations?  The government and various regulatory bodies have already decided that some specific measures should be implemented–certain vaccines for those over 65, antibiotics within a certain time frame for pneumonia, an aspirin and beta-blocker for those with acute coronary syndrome and so on.  Data is collected and doctors and hospitals must meet a certain threshold or they will lose money under the Pay for Performance structure.  So, assuming that it’s good if patients get a chance to say what they want done if  they are sick and can’t speak for themselves, then why shouldn’t it be part of Pay for Performance?  (The benefits of Pay for Performance can be debated another time).  It seems as if the proposal is simply trying to be consistent in how it approaches quality measures.

My last beef is that McCaughey feels that it is inappropriate for doctors to be assessed on how well they are adhering to advance directives/living wills.  If a patient and their family sits down, thinks about the options, discusses what should be done and then makes it into a binding legal document, is it not reasonable for doctors to adhere to that?

This issue is particularly fresh in my mind as I had a very challenging case the other day.  A family brought in their 97 year old grandfather.  He was very sick–his heart was pumping twice as fast as usual and his blood pressure was tanking.  His abdomen was rigid, a sign of possible infection or air within.  The usually spry and feisty man was simply lying in bed, murmuring occasionally in Russian.  I knew almost immediately that I had only a few minutes to intervene, but no matter what I did, I likely would not be able to change the outcome.  I said to the family, “Your grandfather is very ill.  I can be aggressive in his care but I may not be able to save him.  What would you like me to do?”  They said, “Do everything you can do.”  And so we did.  Several people held him down so we could put a large IV in his groin and a catheter in his penis and a tube down his nose.  We were thinking that soon we’d have to put him on a ventilator.  There were complications, leading to more needles and pain.  All throughout, I kept thinking, “This poor man.  Is this really how he wants to die?”  I knew that even doing everything I could, he was too sick, his body was too old for me to make a difference.  After two hours, we finally had the reason he was so sick.  An ulcer in his stomach had eroded through the stomach lining, realizing air and bacteria into the abdomen.  I went back to the family and explained that even if I could convince a surgeon to take him to the operating room (a VERY big if), he likely would die in surgery or shortly after.  I asked if they would like to stop intervening, stop being aggressive, stop trying to save his life and instead focus on treating his pain, on making him comfortable, on letting him die with dignity and grace.  With tears in their eyes, they said they would.  So we pulled out the tubes, we turned off the monitors and we let his son and daughter-in-law and grandsons gather around him and hold his hands and tell him how much they loved him.  It was beautiful.  And I know, beyond a shadow of a doubt, that it was the right thing to do.  My only regret in his care is those first two hours–the pain, the restraints on his wrists, the turmoil in the room as we tried to do a thousand things at once.

Please, please, please, talk with your family members about what they would like at the end-of-life and what you would like.  Be informed.  Know the options.  Discuss it with your doctor and put it in writing.  Five Wishes is a great way to learn more.  This is your body.  You should choose.

Ah, internets.  . .it’s been a long time.  But I’ve been busy.  Seriously.  And I’ve missed you.  I really have.

I just completed my first week as an attending.  A quick primer for those unfamiliar with medical education.

Steps to becoming a doctor:

1. Undergraduate education–”college”:  Fairly commonly understood. Pop culture reference:  Too many to choose from.  Pick your own.
2. Medical education–”Med school”:  Four years of schooling after college.  First two years are usually mostly book work and the second two years are “clinicals”–running around a hospital in a short white coat and experiencing various aspects of medicine.  Pop culture reference:  Abby on ER after she was a nurse but before the last season.
3. Residency–”Hell on earth”:  Three to eight years after med school spent learning a particular specialty.  Contrary to popular thought, these folks are “real” doctors.  Much medical care in many hospitals is given by residents and they do a pretty fine job.  Think of this as an apprenticeship where someone is learning a field from a more experienced practitioner.  Pop culture reference:  Meredith on Grey’s Anatomy.
4. Attendingship–”Real job”:  Once you’ve completed residency, you then get a job in that particular field, such as family practice, surgery, obstetrics, etc.  You can now take an exam in your chosen field and then be board certified.  In addition, you can supervise residents and help them develop their skills in that particular area.  Pop culture reference:  Dr. Cox on Scrubs.

So, now I’m technically on my own and in charge and know what’s up and all that.  Except I don’t.  I’ll go in and see a patient and come out of the room and get ready to put in orders on the patient and I’ll think:  “Hmm, maybe I should CT him?  No, maybe I should spare him the radiation.  But what if he needs the CT?  But what if he doesn’t?  I’ll just treat his pain and then reassess.  But wait, maybe I shouldn’t give this medication.  If he’s bleeding and I give him this medication, he’ll just bleed more.  But the narcotic might be too much, because maybe there is nothing seriously wrong with him.  But he’s in pain, so he needs something.  I could give him pills but what if it turns out there is something bad going on and he needs surgery?  Probably should give meds IV.  I wonder if he has insurance.  I don’t want to do an unnecessary workup that he has to sell a kidney to pay for, but I also don’t want to miss anything.  I should call his doctor.  Oh no, there are four new patients to see and I have three patients to dispo.  I still have to tell the guy in room 6 that he has an appendicitis but his wife will have a thousand questions so I really don’t have time.  But communication is important and since I’m now being evaluated on my patient satisfaction scores, I really need to get in there.  But I’m also being evaluated on my time to disposition so maybe I should dispo people first.  Oh, except I need to look and make sure all the results are okay.  Hmm, what does that mean?  I should call the radiologist just to double check.  But I need to get orders in on that other guy so that we can get his workup started.  Maybe I should CT him. . .”

I’m like a schizophrenic that can’t turn the voices off.  I find it hard to concentrate on what people are telling me, because the din in the back of my head just gets louder and louder.  And to add further fuel to the “maybe I’m not competent to practice medicine on my own” fire there was this little event. . .

The group that I’m working for actually staffs four separate emergency departments.  I’ll spend most of my time in the main ED but occasional will be at the other sites.  For my orientation week I went to each site once, just so I could see how things work, where they are at, etc.  All of the sites are in neighborhoods that I don’t know, far from my familiar grid-pattern surroundings.  I mapped out the locations and then set off.

As I exited the highway, planning to go “0.2 miles, then right on Willshire Boulevard.  Destination will be on your right.” I was surprised to see a hospital immediately on my right.  I quickly made the assumption that the mailing address was off Willshire, while the actual entrance was on a different street.  I made a quick turn in and after circling the hospital five times (a couple more times and maybe I could have brought the walls down, Jericho style) I finally found the physician parking lot.  My ID badge failed to get the gate to open but a free lot was right next door so I wasn’t too concerned.

I walked in, introduced myself to the very nice and mostly deaf man at the front desk who turned me over to Glenda, a pleasant, if no-nonsense nurse who started talking a mile a minute.  “Here are the green rooms we open those at ten o’clock but don’t worry a different doc will staff those and here are the charts we’re on the T-sheet system and these are the critical care rooms and . . .”  I tried to follow what she was saying but we were walking and she was talking and I was mostly trying not to run into things so I just nodded and smiled a lot.  A slight alarm went off in my brain when she mentioned the paper charts as I thought all the sites I’d be working at would have computer charting but I snoozed that warning and followed her down the corridor.  As we rounded the corner she stopped abruptly, “Oh there’s Dr. Mills.  Dr. Mills, the new attending is here.”

A very tall, very doctorly looking, very manly man turned around, looking puzzled.  He sized me up, noting the short hair and the nose piercing and the general lack of any doctorliness and said, “I’m sorry, who are you?”

I dug deep and pulled up all the confidence I could muster and stuck out my hand as I said, “I’m Dr. Moxie.  I’m here for an orientation shift.”  All alarms in my head were now going off. . . the entrance off the wrong road. . .the lack of access to the physician parking lot  . . . the paper charts. . .the different address.

As he continued to stare at me most quizzically I tried to suppress my panic.  “Who do you work for?” he asked, staring down at me from his lofty height.  I imagine he had trouble not adding the “my child” at the end of the sentence.

I barely was able to eek out the name of my group and as I did he chuckled.  “Well, my dear.  That group doesn’t work here, but if you’d like to work our weekend nights, I’d be happy to hire you on the spot.”

I wish there was a stronger word for embarrassment.  Something to convey the total and utter shame, mortification, chagrin and vexation I was feeling that moment.  I uttered some sort of apology as I fled the department, formerly friendly and now very perturbed Glenda staring me down for wasting her time on a tour.  Some kind soul gave me quick directions to the ACTUAL ED I was supposed to be at, a half-mile down the road.  As I drove away, I kept imaging that doctor and the rest of the staff standing there, shaking their heads and wondering how I’m supposed to save lives when I can’t even find the damn hospital.

Quite honestly, I was thinking the same thing.

Ah, April. . .the flowers are blooming, the air is warming and the mailbox is overflowing with wedding invitations. With June just a few weeks away, it’s time to get those invites out.

Last week we received three invitations. Two were addressed to “Mr. and Mrs. BH Moxie” and one was addressed to “BH Moxie.”

Two things crossed my mind:

1. I hate titles. Really, I prefer to take people as people and I think titles often times obscure that. Even at work, I go by my first name as much as possible. I know that some people, however, choose to be more formal. If you’re going to be formal, though, make sure you do it right.

I am not a “Mrs.” My formal title is “Doctor.” Now, I’m not saying people need to address me as “Dr. Moxie” (despite the title of this blog.)   I actually hate being referred to as Dr. Moxie, especially outside of the hospital. But if there is something I hate even more, it’s being called “Mrs.” Which leads me to my next point. . .

2. Who makes the rules of etiquette? Seriously. I want to know. Because they need to fast forward their thinking and recognize that women are now actually considered to be people. Independent people. With identities outside of their husband. I know that the appropriate way (as per my research on Knot.com this morning) to address a married couple on a wedding invitation is “Mr. and Mrs. John Smith.” But that’s bullshit. One hundred percent bullshit. Women have names and those names should be used. I am not “Mrs. BH Moxie.” I love BH more and more every day and I cannot fathom a life without him, but I am not just a subset of him. I am me. I am Moxie. And that deserves to be recognized, just as his identity is recognized. So future brides and grooms, I call out to you. Rise up! Rise up against centuries of patriarchal tradition! Rise up against outdated “etiquette!” Rise up against the idea that “it’s just a little thing.” Yeah, well, it’s the little things that give credibility to the big things, like denying the right to vote or requiring seperate drinking fountains.  We’re moving on and our stationary needs to reflect that.

An interesting sidenote–there’s an educational bias/discrimination built in to this whole etiquette thing.  The standard approach for a couple is to use the man’s first name only.  However, if the woman has a formal title, then her first name can be used, ie “The Honorable Joan Smith and Mr. John Smith.”  What a crock of shit!  As if a woman has to earn her own identity.

Sources:

http://wedding.theknot.com/wedding-planning/wedding-invitations/articles/wedding-invitations-etiquette.aspx

Ranting done.  Back to working.

So, BH was gone for the evening and after six hours of being glued to the computer I finally tore myself away and headed downstairs for some sustenance. When BH isn’t here I have to spend every moment that I can in front of the monitor because a) he is a computer hog and b) I have an addiction to the internets.

Today was a special day at conference so I wore my suit. I got home and wanted to take a nap so I discarded the suit jacket and suit pants but left on my special shirt and threw on some scrub pants. Big, oversized scrubs. So, when I finally went to the kitchen to get dinner I was still dressed a little bipolarly, with my pretty, clingy shirt and my scrub pants. As I hit the bottom of the stairs I remembered how much colder it is on the lower level so I turned to get a sweatshirt but all my sweatshirts were upstairs in my closet. And despite the fact that I am now four weeks post-op I’m having INCREASING pain in my hip every day, which is causing me to have INCREASING angst, as I go back to work full-time Monday. But I digress. Since I wanted to save myself from crawling back upstairs, I decided to just wear my puffy vest instead of a sweatshirt, which was a good option because it is probably my favorite piece of clothing anyway AND it’s super warm. Then I realized that shoes would also be a good idea in the quest to retain body heat but wouldn’t you know, my clogs were upstairs as well. So I grabbed the only other slip on pair of shoes that were downstairs. A pair of red patent leather ballet wedges.

So a quick recap:
* Hair all tangled for napping
* Turquoise-brown geometric patterned clingy shirt, appropriate for suit wearing
* Red puffy vest
* Way oversized in all dimensions scrubs
* Black dress socks
* Red patent leather shoes

Confirmed: It’s a miracle that I ever got someone to marry me.

As I’m sure many of you know, Washington DC’s nearly 600,000 residents don’t vote for their own Congressional representatives. That’s right, of the 535 voting members of Congress, no one is there on DC’s behalf. We still get to pay taxes to support the federal government though.  It’s good to know that we’re not totally ignored.

There have been a lot of proposed solutions to this problem. Make DC its own state. Add members to Congress to represent DC but leave it as a district. Give us back to Maryland!  (Ha!) Plenty more about all of that over here.

Others feel that we don’t need our own representative because everyone is our representative.  Yep, that’s right–you might get to elect three people to represent you but we’ve got 535!  Wow!  Of course, I didn’t get to cast a vote for (or against) any of them, but that’s not important, is it?  I know that each of you, when you choose your Representative and Senators, all think about us poor shmucks and factor that in to your decision, right?  I know, I know doesn’t quite seem fair to me either.  I mean, they are there for you, and then they have to look out for us as well.  But I guess they  are up for the challenge.  Senator Jon Kyl (R-Az) was just talking about it today in a Senate discussion on a measure that would give DC at least one voting member in Congress.  You folks in Arizona must sure have things together if he feels like he doesn’t need to focus all of his attention on your concerns!  Don’t worry, we’ve got plenty to keep him busy.  In fact, as soon as I read that he’s my senator, I wrote him and let him know how happy I am to have someone who’s going to work with me to make DC better.  Of course, I guess I should write the other 534 people who represent me as well.  Whew, it’s going to be a long day.

If you’re feeling like you’re getting jipped in this whole thing, I’d suggest letting your Congresspeople know that you’d prefer DC get their own representative(s).  You can look up their contact info here.

Here’s what I wrote this morning to my Senator.

Senator Kyl,

So good to know that you believe you represent me in Congress. It’s kind of funny, because I didn’t hear much from you during your last reelection campaign. I know, I can research your positions and policies online, but I always enjoying attending rallies, reading campaign literature and watching those finely crafted commercials. As my Senator, will you be sure to include me and my neighbors in your next campaign? We want to know and choose who’s representing us, just like the fine citizens of Arizona do. Oh, that’s right. We can’t actually take part in a vote for you. Hmm, makes you a little less our Senator, doesn’t it?

Well, nevertheless, I know the issues that face DC citizens must be as important to you as those of the people that actually get a chance to vote for you so I’ll still let you know what I’m concerned about. I’m an Emergency Medicine physician and practice at a hospital in DC. Most days our emergency department is operating at full capacity and oftentimes past that. The lack of rooms, beds, equipment, nurses and doctors to care for people (many of whom are your constituents as well I guess, since you represent all of us DC folks) appropriately makes the situation not just unsafe but nearly dangerous at times. Given that we’ve actually closed hospitals in DC (I’m sure that as our Senator you fought hard to keep DC General open), what are we going to do to increase health care, both preventative and emergency care, in DC? Ward 8 is especially scarce on resources. Perhaps you could hold a meeting with your constituents there, and hear the personal stories about how lack of access is truly killing people.

I know you must be busy representing the people in Arizona who need you to be their advocate, but I for one am thankful that you’ve seen fit to identify as our Senator as well. Perhaps if things get too busy, you could consider sharing responsibilities with someone? I know the other Senators are also busy taking care of the citizens they’ve been elected to represent but I guess you guys will work something out. Almost seems like there should be someone who focuses just on DC. . .

Thanks for your time and I look forward to hearing back from you about how we’re going to make the lives of DC citizens better.

Sincerely,

Dr. Moxie, MD

. . .creation

My mom loves to tell stories about how when I was young I said I wanted to have kids. Lots of kids. Twelve in fact. Perhaps I was just attracted to the symmetry of a dozen. Maybe I was smoking crack. I’m not sure–I just know that somewhere along the way I left those dreams (hallucinations?) behind.

When the brilliant husband and I got married I said, “Five years.” At that point I thought that would give us time to settle in together, to finish med school, to complete his Master’s. At the five year marked he queried me and I replied, “Five years.” I’m only a portion of the way in to that next chunk of time but I’m beginning to wonder if I’ll request another delay when that mark roles around.

A good friend of mine is due in just a few days. I’m so excited about her Sprout, although a portion of me still can’t believe she’s pregnant. And another friend delivered a gorgeous little girl last summer, one I can’t wait to meet. Yet another close friend from work is seven months along, right at the cute stage, where her belly is big but not huge and her boobs are filled out. Oh and if I counted all the babies friends from former lives have had! Oodles and oodles and oodles. Some are on to number three and four and beyond.

And then there’s me. No babies. No desire to have ‘em. And I just wonder, is there something wrong with me? By the time I want to will it be too late?

Just thinking. . .

9:43 AM–I assume that most people living in a major metropolitan area are familiar with parking garages.  You enter, get your ticket and then go around and around on the ramps until you are five stories higher and a parking spot is open.  The man in the car in front of me however, does not seem to have had this experience before.  On each new level as we round the corner to advance up another story he stops.  Completely.  For a good 15-20 seconds.  This is a parking garage, so there is no interesting scenery or captivating architecture to admire.  There are cars, concrete pillars and more cars.  The letter on the seat next to me clearly states, “Kindly arrive 15 minutes before your scheduled appointment.”  That means that with a 10:00 AM appointment I have just 120 seconds to finish the climb through the garage to the next available spot, secure said spot, wind my way back down to street level on foot, find the appropriate physician office building, locate the designated office and present myself.  If I hadn’t been waiting for weeks for this appointment I’d be willing to risk being a minute or two late, but I fear that an office ogre will be waiting for me, staring at her watching and denying me entry if I arrive at 9:46 or (gasp) after.

9:48–The car is parked and I’m dashing down flights of stairs and playing chicken with traffic to get into the building.  “Dr. Fredrickson’s office,” I gasp to the woman seated at the front desk.  She boredly points to the desk right behind me, clearly marked with Dr. Fredrickson’s specialty on it.  Her look clearly that she is glad I’m getting medical attention.

9:48:30–I smile brightly at the receptionist.  “‘I’m Moxie and I have a 10:00 AM appointment,” I state brightly, noting that the clock behind her is 27 seconds fast, making it look as if I’m a full five minutes late, when in actuality it’s closer to four minutes.  Although technically, I’m 11 minutes early, right?   She doesn’t care either way.  She hands me a stack of forms in exchange for my credit card and photo ID and points out the 134 highlighted places that I’m suppposed to sign or initial or sign and initial or stamp my crest or scrawl my name in blood.  I do as told and give the forms back.

10:01–The woman in the chair next to me comments on my shoes.  I think to myself that she doesn’t look sick and I wonder how many other people in this room are thinking the same thing about me.  A moment later her husband emerges from the radiology wing and I take in his gaunt frame and wasted temples.   BH has offered to come with me today but I told him no.  I don’t like doctors or their offices and find it unnecessary to drag him through this.   Now I wish he were here though.  I envy the guant man, his companion fixed at his side.  I wring my fingers nervously and swallow hard.

10:07–Cheerful Nurse calls my name and I follow her through the maze of hallways.  We start with the basics–I’ve gained 7 pounds according to her scale.  It must run heavy.  My blood pressure is fine.  I don’t have a fever.  She asks me the questions I’ve answered several times in the past several months–why am I here, how long have I been having symptoms, what workup has been done so far.  I hand over prior records and disks with MRIs on them.  I tell her my allergies.  She lectures me on not saying I have an allergy to Bactrim, but instead I should say I’m allergic to sulfas as it is usually the sulfa component that causes the allergy.  I nod and don’t bother to explain that actually I don’t have an allergy at all but type III delayed hypersensitivity.  After all, I’m not here as a doctor, but as a patient.  And her job is to educate patients.

10:15–I have now been educated about her first husband and her second and her daughter and where she went to nursing school and her friend that died of cancer.  I think this is their revenge for the fact that I was four minutes late.

10:30–Technically my appointment started 30 minutes ago but I am still alone in my tiny room, the shapeless gown hardly protection against the chilling drafts in the room.  I’ve brought work with me–an article to review, my board study book, papers to read for class.  This is the fifth medical appointment I’ve been to in the last two months and I’ve become a pro at staying occupied.  The first appointment was routine–I told him the problem, he told me his thoughts on it and we set up some tests.  It’s what I do every hour that I’m at work.  It’s what I’ve spent the past seven and a half years practicing.  Problem-hypothesis-tests-solution.  Repeat as needed.  The second appointment was for the first test.  It was two hours after I arrived that they finally got to me.  Like I said, I’m good with waiting.  That MRI showed a “spot.”  The doctor didn’t know exactly what it was so he talked to the radiologist.  The radiologist didn’t know exactly so she recommended more tests.  The word “tumor” was uttered for the first time.  I laughed at the idea!  Me, a tumor?  Surely not.  The third appointment was the second opinion.  He looked at the MRI as well.  He didn’t know exactly either.  I told him about the possibility of a tumor and I laughed again.  He didn’t.  “Well,” he said, frowning.  “It does seem unlikely, but I don’t think we can totally rule it out.”  And so he ordered more tests.  And a specialist.  The cycle really should read problem-hypothesis-tests-specialist-solution.  Or maybe problem-hypothesis-bills-tests-bills-specialist-bills-solution-bills-bankruptcy.  I have decent insurance and I’m over $1,000 in already and we haven’t even gotten to solution yet.  Who said nationalized healthcare was bad?

10:42–My trip down medical memory lane is interupted by a knock at the door–salvation at last!  A woman pokes her head in.  “Just checking to see how you’re doing,” she chirps.  “Do you need anything?”

I think to myself, “Um, a doctor?” but instead I just reply, “No.  Thanks.”  She leaves me alone again.

A this exact moment one week prior I was lying on a table in a dark basement room with a man stabbing needles into my hip.  Seriously, not a single word of that is exaggeration.  He poked and jabbed and sighed and finally said, “Well, your capsule must be small.”  I almost apologized but the pain coursing through my body hadn’t subsided enough yet to let me talk.  I just grimaced at him.  Later that night I stood over a woman, a needle in my hand, preparing to puncture her skin in nearly the exact spot he’d pierced mine.  I thought of all the times I’d inflicted pain on patients.  My hand shook, remembering his frustration at how poorly the procedure went.  I’d been that man so many times.  Tasked with a job that should be simple that isn’t.  Frustration at time allotments.  Embarassment at percieved incompetence.   I wish again I’d gone to law school.

10:53–It’s still just me and the diagram of a heart tacked to the wall.  I reach for my bag, remembering again all the work I’ve brough along.

10:54–I’m well on my way to beating my best time in demon solitaire on my phone.

11:07–Voices drift my way from the room across the hall.  That man was recently admitted to the hospital for two weeks.  He’s feeling better.  The chemo is going well.  I wonder if that will be me.  I know that I’m young and other than a few extra pounds, I’m pretty healthy.  But I’ve been in healthcare long enough to know that there are no guarantees.  I’ve seen younger, healthier people than myself slayed by cancer, by weird infections, by their own immune systems.  Why should I get a free pass?

11:24–I’ve now won three demon solitaire games in a row.  I’m clearly a genius.

11:32–Another knock.  I refuse to think that this could be it.  It’s probably Cheerful Nurse, here to give me the latest update on what she is going to eat for lunch.  But no, a man walks in instead.  Clearly he must be a doctor then, right?  He introduces himself as the fellow and I inwardly groan.  I’m all for medical education but I know the hierarchy and answers will not come from the fellow.  I need the Big Man and the Big Man isn’t here.

The fellow asks me the litany yet again.  We stumble over the words I use; I’ve slipped in some technical lingo.  It’s not intentional.  It comes out that I am a physician.  He nods and things go more smoothly.  He stammers a lot and doen’t look me in the eye enough.  I wonder if that’s how I am with patients.  He examines me.  He leaves.

11:45–I wonder if I should have packed snacks.  Cheerios.  Gummy bears.  Maybe some grapes.  Clearly we never leave our inner toddler behind.

11:53–The Big Man arrives!  He enters the room along with Awkward Fellow and Woman Whose Name I Never Learn.  I assume she’s the nurse manager/social worker/person that talks to you if the crying goes too long after a bad diagnosis so the doctor can get back to seeing patients.  The Big Man is smoother than Awkward Fellow and so I don’t mind repeating myself again.  After all, I’m the one who always says to patients, “It’s just that I want to hear the story right from you, to make sure I get it right,” when they complain about repeating themselves over and over and over.  The Big Man examines me as well and we talk about pain and levels of pain and how I’m 50% better after the steroid injection.  I tell him about the MRI and the spot on it and then the second MRI and how both Doctor #1 and Doctor #2 thought I should see him because he’s not just the Big Man, he’s the Big Cancer Man and if anyone will know what to do, it’s him.

He says he’s looked at the MRI and the second one and he is one hundred percent sure it is not a tumor.

I break out into a smile.  I can’t help it.  It had been there, in the back of my mind, worrying me, eating away at me.  And with those words “I’m giving you a clean bill of health, cancer wise,” it’s gone.

12:04–I’m free.  Literally and figuratively.  I know that I am lucky.  I vow once again to not forget it.

My wedding day was the single most happy day of my life. I’m not prone to excessive happiness. I put on a smile for the most part but deep down inside I’m a ball of discontent mixed with depression. It’s a good time.

But not on my wedding day. Nope, that was one day that my spirits soared and I was floating on air, to borrow just a couple of hackneyed cliches to describe euphoria. I remember arriving at the field where the brilliant husband and I got hitched up. A gorgeous summer evening, my friends and family all around and the man of my dreams right in front of me, stating that he was willing to spend the rest of his life with crazy old me. If I could bottle up the feelings I had that day, I’d be able to outsell the crack and heroin dealers in my neighborhood.

Sure, not every wedding day is that perfect. Hair goes awry, uncles get drunk, cakes topple. But for many people it stands out as a significant contributor to life’s overall well-being.

I remember my own wedding day when I think about Prop 8 and other measures which have been proposed/instituted to “protect marriage.” At this point in time, gays and lesbians cannot legally have the same experience that I did. They can’t look back and smile at the wide-eyed wonder. They can’t flip through photos and sigh another happy sigh. They can’t hear a song and think back to walking down the aisle.

Oh sure, they can throw a party and stage a wedding. But my wedding wouldn’t have been the same without the legal backing I received because I’m a heterosexual. And theirs aren’t the same either. Weddings are cultures traditions but legal ceremonies as well.

Many have argued that homosexuals shouldn’t marry because they are “choosing” to be gay, which is “unnatural.” I know many people who would love to make their heterosexual relationship work. They’d like to do the white dress and tuxedo thing and live happily every after as man and wife. They’d love to “fit in.” But as long as we limit intimate love to one man and one woman, they aren’t going to fit in. Because that’s not who they are. And just as I find it ridiculous to think that I’d ever be attracted sexually to a woman, they find it impossible to feign interest in a person of the opposite sex. They aren’t choosing to be lonely and denigrated. They are simply acknowledging who they are. They are owning up to how God made them.

And what is “unnatural” about two people loving each other? Sure, if you’re into heterosexual sex the idea of two people of the same gender gettin’ it on might seem unusual to you but let’s admit it, if all us heterosexuals talked about what we do in the bedroom I’m guessing some other “unusual” things might come out as well. Quite frankly, I don’t want to know what anyone is doing in there and I’d prefer not to talk about my adventures either. And since when is marriage just about sex? Sure, sex is part of it, but to focus on that would be to deny the other 99% of what goes into a relationship. Marriage is about companionship, support, encouragement, disappointment, disillusionment, surprise, hope and so much more.

Other people claim that America needs to define marriage as one woman and one man to protect “the sanctity of marriage.” What kind of bullshit is that? How does two men tying the knot threaten the relationship that BH and I have? If anything, it builds a broader base of people who will continue to talk us off the ledge when we’re struggling to make it on our own. It gives us more people who can set an example of what commitment and honesty and loyalty look like. It provides more occasions to celebrate, to gather round and toast to joy and happiness and cheesy, cheesy love.

I feel so incredibly passionate about this. When I think of how frickin’ lucky I am to be married to BH, I want that for everyone, should they also want it–never let it be said that I think that people need to be married to be happy/healthy/whole. But they should have the choice.

I gave money to vote against Prop 8 and I would have voted against if I lived in a state with that or a similar measure in the recent election. But I feel that really the best way I can influence this matter is to try to engage those who disagree with me on this. I want to respect your religious choices, but not at the expense of others’ freedom or happiness.

I welcome your comments.

Great work folks! It’s getting tight; several favorites have been eliminated and underdogs are fighting for the top while other strong contenders battle for their place on the kitchen wall.

Because of a three way tie in heat two of the semifinals, there are 12 finalists. And because of that, we’re opening up the voting a bit. This round, vote for your top 4 favorites. The seven photos with the most votes will be printed, framed and displayed for all to see–if you stop by the house. See, it’s a contest and an invite to dinner all at the same time!

Full contest details here.

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I am so freaking happy right now.