Notes From The Practice

Physicians are commonly exposed to events more unusual and heart-rending than the most inventive Hollywood screenwriter could possibly devise. There are days when I think back over the stories patients have told me, the crises and turning points I have witnessed, and I can hardly believe they actually happened. One such episode took place several months ago on one of our hospital wards. Let me say in advance that you will find this story hard to believe. But I vow, with one hand on my Harrisons’ medical textbook, that what you are about to read did actually take place. Exactly as I will describe it.

Deep inside the human brain, in crevices and channels invisible to MRI scans and high-resolution CTs, lie reservoirs of memory that never run dry. They may overflow occasionally in a current of tears of happiness or sorrow — sometimes in a trickle, sometimes in a torrent — these subcortical pools are invariably replenished from uncharted wellsprings even deeper inside the brain, in regions known only to a few. After two decades practicing medicine, I am still amazed that no passage of years, no accumulation of decades, diminishes the freshness of this water. It is always clean. It is always clear. And it is timeless.

Sometimes the challenge is too difficult. Sometimes there is less than nothing a physician can do to help his or her patient. Sometimes it is best to hoist the white flag and walk off the field. One morning in clinic several years ago brought this truth home with a hammer.

It was a Wednesday morning in April. Spring was two weeks old, but you would not know it if you looked outside. Rain, morning fog, a chill wind off the bay. I drove into Vallejo the back way that morning, on Lake Herman Road, sipping my French Roast, gearing up for the day.

Physicians are supposed to be healers extraordinaire. It is our burden and our curse. Society holds us to lofty standards. We are expected to regularly perform miracles, or at least to pull reasonably healthy rabbits out of somewhat tattered hats. And do so with compassion and consistency. And to perform this role for several decades of our lives.

For over three decades, I practiced adult primary care medicine in various settings in California. I worked in a U.S. Public Health Service clinic, an Emergency Department, two different medicine departments in Kaiser Permanente, and a community clinic in Vallejo, California. I retired from clinical practice in 2016.

Practicing medicine was never quite what I expected when I went to medical school. During tens of thousands of patient interactions, I often found myself surprised — surprised by what patients were saying and experiencing, surprised by what my colleagues were doing, and surprised by my own reactions to patient encounters.

As I was going through this process, I decided to write about some of my experiences. Many of my reflections were published in the professional staff newsletter of The Permanente Medical Group in Vallejo. I recently re-read these pieces, and in doing so I recaptured the surprise and the evolution of my understanding of the doctor-patient relationship.

This website contains many, though not all, of the articles I wrote over a 15 year period. The intended audience at the time I wrote them was my fellow clinicians, but I think my reflections may also help others understand a little better what is going through the mind of their personal physician. All of the stories are true. In every case, I have changed the name to protect the privacy of the patients I am discussing.

Some of the articles obviously reflect a different time than the present, such as references to economic crises, watching DVDs, and other phenomena. To place each piece in context, I have included the date it was written at the end of each one. But the observations made during these earlier years still reverberate today.

I hope you enjoy reading these, whether you’re a clinician, or a patient, and I welcome any comments or feedback. Thank you.

Richard Fleming, M.D.

Benicia, California

Another holiday season has ended. And thank goodness!

Don’t get me wrong. It is not that I don’t like the holidays. I do enjoy parties, spending time with family, drinking eggnog laced with brandy and freshly-ground nutmeg, nesting before the fire with a stack of DVDs. It is enjoyable to see my clinic get decorated by the medical assistants. And the holidays always bring back fond memories from my childhood growing up on the Kansas plains.

Oh, when the tables turn! Over the last few months, I have spent more time on the receiving end of of health care than any prior period in my 57 years. This has helped open my eyes, jostle my brain, stir my heart, and put my role as a deliverer of health care into a new perspective.

I had a eureka moment recently. It came after what was probably the ten thousandth time a patient responded to my brightly warm greeting, “How are you today?” with a curmudgeonly, “I’m getting older. How do you think I am!”

Aha, I thought, now I see. So what if it took 22 years of practice to reach enlightenment. Wisdom was now within my grasp this fine Tuesday morning. But the understanding gained in that moment provided me scant comfort. It actually heightened my angst, obliterated endorphins, and caused my catechol levels to surge.

Thanks to the human heart by which we live,
Thanks to its tenderness, its joys and fears,
To me the meanest flower that blows can give
Thoughts that do often lie to deep for tears.

— William Wordsworth

Three decades with Kaiser Permanente. Half my life! The concept is both amazing and sobering. It is hard to fathom it was 30 years ago when I walked through the door and signed on the dotted line. After so much time, it is natural to pause and reflect. How did the years pass and what did I learn? What follows is not a comprehensive assessment, but rather random thoughts and reflections on my experience being a physician. I write these observations primarily for myself. If any of these musings resonate with you, well and good, but there are no lessons here. Just some notes from the practice.

What appears before us, in the exam room, in the hospital, in the OR, is an amazing human tapestry. We see people at their worst and their best. When they are most vulnerable and when they show incredible strength. When they are in the depths of despair and when they are enjoying some of the happiest moments of their lives. It is an amazing experience. Who else in society has the luxury to participate in people’s lives so intimately? And this is how we make a living! Wow.