生气
很不想生气，尤其是在值班的时候，因为这不仅将影响自己的工作情绪，也很容易引起别人的不满。昨天真的好累，一整天已经停不下来，还要遇到一些不可理喻的人，我有点压抑不住情绪。一大早电话就响了，说是内科有个病人需要紧急插管，到了那病房，获得家属同意后，一群病房的负责医生就随着专科医生巡房，所有该具备的仪器都没准备好，就丢下我和几位护士，也罢，那气喘的病人是心脏病患者，因肺部细菌感染，已需提升血压的药物，而他只有仅仅一个点滴，我真的很想骂人，但还能压抑怒意。
傍晚时分，发现一个普通病房的病人从早上有个同事检查时就有神智不清的迹象，需要插喉，没人采取行动，和病房值班的主管沟通时，她居然不知情，言语间有责备我的同事没有通知她的意思，天啊，这是你的病房，你的病人神智不清你在巡房时难道没有发现？当然，一切只成了心底话，有些话说了既会伤感情，也不会改变什么，何苦？我只是同情那位病人。
到了晚上，差不多同时接受五个referral，我好希望自己会分身术，这种状况虽不属于罕见，但也不常发生，既然发生了，也只能权衡轻重，先看了不能耽误的个案。我搁下了急诊室的两位病人，赶紧到内科病房看一位二十几岁的down syndrome 病人因肺部积水，其母亲拒绝让病房医生插管把水抽出，而越来越缺氧。我自认一开始就心里有气，因为这绝对是可以被避免的！更何况类似病人的呼吸管和一般人不同，插管会比常人更具风险，但我们别无选择。我简略地解释了程序，她坚持要与家人商议，已是半夜时分，没人接电话。情急之下，我只能说狠话了，说如果她不让我们这么做，儿子会死去等话来恐吓（其实也非恐吓，因为如果我们置之不理，这会是必然的结局），以为她会“就范”，怎知她还是冥顽不灵，拿着电话不放。我气得快爆炸了，也没时间去理会她的不安，看着她越来越疲惫的儿子，纠缠了近半小时，她竟然还不能决定。我只吩咐实习医生在她有了决定后才再通知，就匆匆到急诊室。忙着忙着，再有消息时已快两个小时，还好她儿子年轻，勉强撑得住，顺利插喉。下班后太累了，睡醒后有事到医院，查看电脑，发现她还是不许病房医生给她儿子插管子抽水。我无语，因为插喉后不把积水抽出，治标不治本，白费功夫。我想再见她一次，我真的很想知道这母亲到底在想什么，她是否知道自己的决定会带来什么后果？我会心平气和，为了她儿子，一个可以医治的病例，只有二十几岁的生命，多么可惜。
Friday, September 30, 2011
Tuesday, September 27, 2011
一分温暖--我一直在寻找的“human touch"
刚工作的第一天，就要回到icu值班。一如往常，若非病入膏肓，也不会住进深切治疗病房，一整个上午至下午都忙得团团转，不是这儿有个病人血压太低，就是那个病人心脏停跳，需要抢救。遇上了这么一个个案，一个六十五岁的阿伯，细菌感染导致肾脏功能衰退，需要洗肾，血压也得靠四种药物勉强维持，用尽了最强的抗生素，病情仍急速恶化。一开始我们仍不愿放弃，已告知家属病情不乐观，但我们仍在努力。一直到傍晚，发现瞳孔放大，病情毫无起色，上司才决定放手，我把家属叫到一旁，再次告知病人状况，为我们的无能为力而深感抱歉，然后残酷地，诚实地把他们的父亲将会死去的事实说了出来。这是身为家属者多不希望从医生的口中听见的话，但他们不但能接受，还感谢我们已经尽力。我允许家属轮流进来为病人祷告，并协助他们处理一些医生证明之类的问题。这，是我第一次在病人逝世后，有家属向我致谢。其实一切只是沟通上的问题，很多医生都以忙为理由，没向家人解释病情，没让他们知道事实的真相，而往往最让人不满的不是事情最后的结局，情况有多严重，而是他们毫不知情。icu 的医生和普通病房的住院医生在告知坏消息时，所用的字眼和方式是不同的，我们常直接说出情况，为的是不让病人或其家属抱着假的希望。而为何那些家人不在我说出真相后上前揍我一顿？我觉得最重要的原因是我们在他们最茫然时告知病情，并愿意解答任何疑惑，让他们知道我们到底在做什么，让他们感觉到我们是站在同一阵线的，愿意和他们一起去面对生命的考题。所以，即使最后我们还是束手无策，他们还会对我们表示感激。这就是我一直想要找的东西，不是他们的感激，而是和他们一起面对，在冷酷的命运跟前，传递一丝暖意。跨入这行业三年了，我必须承认在医学院的时候，教授就常说‘don't be too attached to ur patient'要我们和病人保持专业的距离，我一直都是如此，所以才会觉得自己越来越无情，这是我首次觉得在工作里能找到一些温暖，希望这是个好的开始。
刚工作的第一天，就要回到icu值班。一如往常，若非病入膏肓，也不会住进深切治疗病房，一整个上午至下午都忙得团团转，不是这儿有个病人血压太低，就是那个病人心脏停跳，需要抢救。遇上了这么一个个案，一个六十五岁的阿伯，细菌感染导致肾脏功能衰退，需要洗肾，血压也得靠四种药物勉强维持，用尽了最强的抗生素，病情仍急速恶化。一开始我们仍不愿放弃，已告知家属病情不乐观，但我们仍在努力。一直到傍晚，发现瞳孔放大，病情毫无起色，上司才决定放手，我把家属叫到一旁，再次告知病人状况，为我们的无能为力而深感抱歉，然后残酷地，诚实地把他们的父亲将会死去的事实说了出来。这是身为家属者多不希望从医生的口中听见的话，但他们不但能接受，还感谢我们已经尽力。我允许家属轮流进来为病人祷告，并协助他们处理一些医生证明之类的问题。这，是我第一次在病人逝世后，有家属向我致谢。其实一切只是沟通上的问题，很多医生都以忙为理由，没向家人解释病情，没让他们知道事实的真相，而往往最让人不满的不是事情最后的结局，情况有多严重，而是他们毫不知情。icu 的医生和普通病房的住院医生在告知坏消息时，所用的字眼和方式是不同的，我们常直接说出情况，为的是不让病人或其家属抱着假的希望。而为何那些家人不在我说出真相后上前揍我一顿？我觉得最重要的原因是我们在他们最茫然时告知病情，并愿意解答任何疑惑，让他们知道我们到底在做什么，让他们感觉到我们是站在同一阵线的，愿意和他们一起去面对生命的考题。所以，即使最后我们还是束手无策，他们还会对我们表示感激。这就是我一直想要找的东西，不是他们的感激，而是和他们一起面对，在冷酷的命运跟前，传递一丝暖意。跨入这行业三年了，我必须承认在医学院的时候，教授就常说‘don't be too attached to ur patient'要我们和病人保持专业的距离，我一直都是如此，所以才会觉得自己越来越无情，这是我首次觉得在工作里能找到一些温暖，希望这是个好的开始。
一个病人的故事
July 16, 1995
The Boston Globe Magazine
UNTIL LAST FALL, I had spent a considerable part of my career as a health-care lawyer, first in state government and then in the private sector. I came to know a lot about health-care policy and management, government regulations and contracts. But I knew little about the delivery of care. All that changed on November 7, 1994, when, at age 40 I was diagnosed with advanced lung cancer. In the months that followed, I was subjected to chemotherapy, radiation, surgery, and news of all kinds, most of it bad. It has been a harrowing experience for me and for my family. And yet, the ordeal has been punctuated by moments of exquisite compassion. I have been the recipient of an extraordinary array of human and humane responses to my plight. These acts of kindness — the simple human touch from my caregivers — have made the unbearable bearable.
· · · · ·
DURING SEPTEMBER and October of 1994, I made several visits to the outpatient clinic of a Boston teaching hospital for treatment of a persistent cough, low-grade fever, malaise, and weakness. The nurse practitioner diagnosed me as having atypical pneumonia and prescribed an antibiotic. Despite continued abnormal blood counts, she assured me that I had a post-viral infection and didn't need an appointment with my physician until mid-November, if then. By mid-October, I felt so bad that I decided I could not wait until November 11 to be seen. Disappointed with the inaccessibility of my physician, I decided to seek care elsewhere, with the hope that a new doctor might be more responsive.
‘‘The rule books, I’m sure, frown on such intimate engagement between caregiver and patient. But maybe it’s time to rewrite them.’’
Kenneth B. Schwartz
My brother, a physician who had trained at Massachusetts General Hospital, arranged for an immediate appointment with Dr. Jose Vega, an experienced internist affiliated with MGH. Dr. Vega spent an hour with me and ordered tests, including a chest X-ray. He called within hours to say he was concerned by the results, which showed a ‘‘mass’’ in my right lung, and he ordered a computerized tomography scan for more detail. I remember leaving my office for home, saying quickly to my secretary, Sharyn Wallace, ‘‘I think I may have a serious medical problem.’’ Indeed, the CT scan confirmed abnormal developments in my right lung and chest nodes.
The next day, Dr. Vega, assuring me that he would continue to be available to me whenever I needed him, referred me to Dr. Thomas Lynch, a 34-year-old MGH oncologist specializing in lung cancer. Dr. Lynch, who seems driven by the ferocity of the disease he sees every day, told me that I had lung cancer, lymphoma, or some rare lung infection, although it was most likely lung cancer.
Mimi Bartholomay, RN, MSN, an outpatient oncology
nurse with the author at Massachusetts General Hospital
Photography by Bill Greene / The Boston Globe
My family and I were terrified. For the next several months, my blood pressure, which used to be a normal 124 over 78, went to 150 over 100, and my heart rate, which used to be a low 48, ran around 100.
Within 72 hours of seeing Dr. Lynch, I was scheduled for a bronchoscopy and a mediastinoscopy, exploratory surgical procedures to confirm whether I indeed had lung cancer. Until this point, I had thought that I was at low risk for cancer: I was relatively young, I did not smoke (although I had smoked about a cigarette a day in college and in law school and for several years after that), I worked out every day, and I avoided fatty foods.
The day before surgery, I was scheduled to have a series of tests. The presurgery area of the hospital was mobbed, and the nurses seemed harried. Eventually, a nurse who was to conduct a presurgical interview called my name. Already apprehensive, I was breathing hard.
The nurse was cool and brusque, as if I were just another faceless patient. But once the interview began, and I told her that I had just learned that I probably had advanced lung cancer, she softened, took my hand, and asked how I was doing. We talked about my 2-year-old son, Ben, and she mentioned that her nephew was named Ben. By the end of our conversation, she was wiping tears from her eyes and saying that while she normally was not on the surgical floor, she would come see me before the surgery. Sure enough, the following day, while I was waiting to be wheeled into surgery, she came by, held my hand, and, with moist eyes, wished me luck.
The author with wife Ellen Cohen
and their son Ben
This small gesture was powerful; my apprehension gave way to a much-needed moment of calm. Looking back, I realize that in a high-volume setting, the high-pressure atmosphere tends to stifle a caregiver's inherent compassion and humanity. But the briefest pause in the fre netic pace can bring out the best in a caregiver and do much for a terrified patient.
The nurse left, and my apprehension mounted. An hour later, I was wheeled to surgery for a biopsy of the chest nodes and the mass in my lung. I was greeted by a resident in anesthesiology, Dr. Debra Reich, who took my pulse and blood pressure and said gently, ‘‘You're pretty nervous, huh?’’ She medicated me with tranquilizers, but that did not stop me from asking about where she lived, where she had trained, and whether she was married. I jokingly asked her how come she was the only Jewish doctor I had met during my time at MGH. When it turned out that she lived down the street from me and liked the sandwiches at the same corner shop, Virginia's, I felt comforted. She squeezed my shoulder, wished me luck, and wheeled me into surgery.
When I awoke, I was told that I had adenocarcinoma in my right lung and in several chest nodes — in other words, advanced lung cancer. I don't remember a lot about those hours, but I remember Dr. Vega's face with tears in his eyes. I also remember feeling very sad and scared.
A few days later, I received a letter from Dr. Reich: ‘‘Remember me, your friendly anesthesiologist? I came by to see you this afternoon as my professional duty but also to express my sadness in hearing about your diagnosis. Your door was closed and there seemed to be a lot of activity, so I decided not to disturb you.
‘‘As I'm sure you know, we as physicians are taught not to become emotionally involved in our patients because then we would be continually devastated. But I guess because we had such a nice interaction before your surgery and because your life was one which I could relate to so well — being Jewish, professional, renovating a house, sandwiches at Virginia's, etc. — your situation really struck a chord in me. (Hey, maybe you can't even remember any of this because of the medicine I gave you, but hopefully you do...)
‘‘I was very impressed that during the fear and anxiety you were experiencing, you still maintained your composure, your sense of humor, and even thought to ask me when I was getting married.
‘‘So, anyway, as you told me, keeping your wife and son in mind will make you fight strong, and I know this to be true! I know that you have a very loving and supportive family who will help you through this as well.
‘‘Best wishes, and maybe I'll run into you sometime at Virginia's.’’
I had not forgotten Dr. Reich, nor will I ever forget her willingness to cross the professional barrier, hold my hand, and write those words.
· · · · ·
IT WAS CLEAR THAT I WOULD soon begin a new chapter in my illness and undergo the classic treatment for such advanced cancer: intensive chemotherapy and radiation, followed by surgery to remove the tumors, nodes, and entire lung, if necessary. Dr. Lynch told me that this option presented the real possibility of a cure.
Over the next week, I had a series of additional radiologic scans to determine if the cancer had spread beyond my chest. These scans are incredibly scary: You are placed in a tube resembling a sarcophagus, with only 6 inches between you and the walls, and you may spend several hours inside, deafened by the clanging machine. And the scans always raise fears about whether more bad news is around the corner.
Dr. Vega or Dr. Lynch always made it a point, though, to relay results within 24 hours, so my family and I didn't have to endure the anxiety of uncertainty any longer than necessary.
The scans of my body, head, liver, bones and back were clear. I was relieved.
The doctors soon began an intensive regimen of chemotherapy and radiation, with the goal of destroying the cancer and preparing for surgery to remove my lung.
Before being admitted for my first five-day course of chemotherapy, I had a radiation-simulation session. During such sessions, therapists meticulously map their targets by marking your skin where the radiation should be directed. I was asked to lie on a table in a large, cold chamber. The radiation therapist, Julie Sullivan, offered me a blanket and, mentioning that the staff had a tape deck, asked if I had any requests: I recalled my college days and asked for James Taylor. Listening to ‘‘Sweet Baby James’’ and ‘‘Fire and Rain,’’ I thought back to a time when the most serious problem I faced was being jilted by a girlfriend, and tears ran down my cheeks. As therapists came and went, Julie Sullivan held my hand and asked me if I was OK. I thanked her for her gentleness.
After having a Port-o-Cath implanted in my chest — a device that allows chemotherapy to be administered without constant needle sticks in the arm — I was admitted to MGH in mid-November. During that and other hospitalizations, either my mother or sister would stay overnight, often sleeping in cramped chairs. When I awoke at night in an anxious sweat or nauseated, I would see one of them and feel reassured.
While doctors managed my medical care, my day-to-day quality of life and comfort were in the hands of two or three nurses. These nurses showed competence and pride in their work, but they also took a personal interest in me. It gave me an enormous boost, and while I do not believe that hope and comfort alone can overcome cancer, it certainly made a huge difference to me during my time in the hospital.
During the period between my two chemotherapies, when I also received high-dose radiation twice a day, I came to know a most exceptional caregiver, the outpatient oncology nurse Mimi Bartholomay. An eight-year veteran who had experienced cancer in her own family, she was smart, upbeat, and compassionate. I had to receive fluids intravenously every day at the clinic, and while there we talked regularly about life, cancer, marriage, and children. She too was willing to cross that professional Rubicon — to reach out and talk about my fear of dying or, even worse, my fear of not living out my life, of not biking through the hills of Concord and Weston on summer weekends with my brother, of not seeing my child grow up, of not holding my wife in my arms. And she took the risk of talking about her own father's recent bout with cancer. I cannot emphasize enough how meaningful it was to me when caregivers revealed something about themselves that made a personal connection to my plight. It made me feel much less lonely. The rule books, I'm sure, frown on such intimate engagement between caregiver and patient. But maybe it's time to rewrite them. THE BEST MEDICINE
In my new role as patient, I have learned that medicine is not merely about performing tests or surgeries, or administering drugs. These functions, as important as they are, are just the beginning.
· · · · ·
AFTER MY SECOND ROUND of chemotherapy, I was ready for the final stage of what we hoped would be a cure: surgery. Before this could happen, Dr. Lynch repeated my radiologic scans, to be sure that the cancer had not spread. He assured me that the chance of any such metastasis was remote — less than 5 percent — although it would be a disaster if it occurred.
The scans were endless, scary, and lonely. While members of my family stayed with me in the waiting rooms, they could not accompany me to the scanning rooms; the experience again was harrowing. But I felt my greatest fear while awaiting the results. After a week of tests, I had one last scan of my bones. I was concerned when the technologist asked to do a special scan of my back that had not been done before.
The next day, I called Dr. Lynch's office and asked his assistant, Mary Ellen Rousell, when I could come in to find out the results. She said, ‘‘How about this afternoon?" and then added, ‘‘You might want to bring someone.’’ My heart skipped. When my wife and I entered Dr. Lynch's office and saw his face, our hearts sank. He was ashen. He said that while all the other scans were clear, there appeared to be a metastic tumor in my spine. He explained that this meant that lung surgery at this point would be futile, since other metastases were likely to surface.
Dr. Lynch said that he could n ot be 100 percent certain that this was a tumor and that, because so much was at stake, we should do a biopsy. My wife and I wept openly — in part, because, looking at Dr. Lynch's face, we felt that he had lost hope.
I could not help but ask what treatment options were available, and he mentioned a drug called Taxol. Still being the lawyer, I quizzed him:
Me: What is the percentage of people who benefit from Taxol?
Dr. Lynch: Forty percent.
Me: How much do they benefit?
Dr. Lynch: They can get several years of life, although it is not a cure. And the median survival for patients on Taxol with your advanced stage of disease is nine months.
Nine months! My wife and I cringed. I ended the session by asking Dr. Lynch, ‘‘How do you do this work?’’ And he answered, in genuine pain, ‘‘By praying that I don't have days like today.’’
· · · · ·
I BEGAN TO HAVE TROUBLE sleeping, and when I awoke, I was filled with dread and despair. I thought frequently of the observation of Richard Block, the founder of H&R Block, who had survived lung cancer after being told initially that he had only months to live: ‘‘I lived for five days without hope and...my life during those five days...was far worse than at any time during the 'horrible' ordeal of tests or treatments.’’
And when I contemplated not living to see my son grow up or not cherishing my wife for a lifetime, I thought of King Lear, who, at a low point, wailed:
I am bound
Upon a wheel of fire, that mine own tears
Do scald like molten lead.
I desperately needed to regain hope, and I needed Dr. Lynch to regain his sense of hope.
A few days later, I had the biopsy. Dr. Lynch met with my family to report that, indeed, after considerable searching, the pathologist had found small deposits of adenocarcinoma in my vertebra. It was now confirmed that I had metastatic lung cancer. Although my brother and my father, who is also a physician, raised the possibility of radical surgery on my back and lung to remove all the tumors, Dr. Lynch and the surgeons rejected this option because further metastases were likely to appear, and the surgery would be debilitating and reduce my quality of life at a time when my life could well be substantially shortened.
The clear treatment was more chemotherapy. Dr. Lynch again recommended the use of Taxol, with the hope of slowing the cancer's spread.
My wife and I were largely silent during the medical discussion. I asked my father and brother to leave so my wife and I could talk not facts and figures but matters of the heart. When they had left, I said to Dr. Lynch, ‘‘You told me two things all along: One, that you were aiming for a total cure and if that were not feasible, you would tell me at that time. And two, you would never, ever give up on me, never stop trying to fight, to extend my life as long as possible. Am I no longer on the cure route?’’
He looked somberly at us and explained that there were no known treatments to cure this stage of cancer.
‘‘And will you stick by me and fight to the end?’’ I asked.
He nodded vigorously and then outlined a number of state-of-the-art, experimental protocols from which I might benefit after Taxol.
And, leaving statistics behind, he talked of several patients who had defied the odds and lived for years beyond expectations. He advised that my goal should be to be here the same time next year, and then the year after, and the year after — one day at a time, one month at a time, one year at a time. He mentioned several breast-cancer patients who had told him that they had relished their final years with their children in a way that they had never known before. It felt good to leave the medical talk and speak heart to heart, and it felt to me that he had regained a sense of hope — not for some magical cure but for the possibility of extending my life.
It was crucial to my wife and to me that he not give up hope. I understood his surprise and disappointment at the metastasis; in fact, as one friend suggested, his distress at that event was a sign of his caring about me and his involvement with my case. But we desperately needed him to give us a realistic basis for hope — and he had.
‘‘If I have learned anything, it is that we never know when, how, or whom a serious illness will strike. If and when it does, each one of us wants not simply the best possible care for our body but for our whole being.’’
Kenneth B. Schwartz
· · · · ·
THE NEXT DAY, I BEGAN A NEW chapter in my fight. And once again, Mimi Bartholomay was by my side, monitoring my reaction and assuring me that most people tolerated Taxol very well. I had no allergic reactions, and I felt good that the battle was under way. I had hoped that maybe this could buy me time.
Time was now my best friend, since it could allow medical research to advance and doctors to find new strategies and maybe even a cure for advanced lung cancer.
During this period, with help from my father, who has had a long and distinguished career in academic medicine, I began to explore potential cutting-edge protocols that could supplement or follow Taxol.
My father arranged a meeting for my wife and me with Dr. Kurt J. Isselbacher, a distinguished researcher and director of the MGH Cancer Center. He is a small man with a large presence and piercing blue eyes, and he was surrounded by medical books, papers, and many pictures of his family. He was upbeat, telling us of protocols under way that showed promise in fighting metastatic tumors. Like several others, he told me a personal story that cut to the bone: A close family member, he said, had been diagnosed with advanced cancer, which the attending oncologist had said was ‘‘very, very bad.’’ The family member had said to him: ‘‘Kurt, you have helped so many people in your life, can you now help me?’’ He personally treated the family member in that person's home with chemotherapy, and, 21 years later, that person is thriving.
Dr. Isselbacher offered to serve as an advocate for me, to work with my father and Dr. Lynch to find the most promising protocols. I told him at the meeting that while I had no illusions, I was deeply moved by his refusal to give up and by his abiding hope; I was especially affected because such hopefulness was not coming from a faith healer but a distinguished researcher. He had strengthened our resolve to fight.
‘‘I was especially affected because such hopefulness was not coming from a faith healer but a distinguished researcher’’
Kenneth B. Schwartz
As I grappled to maintain my hope in the face of the advancing disease, I was referred to Dr. Ned Cassem, a senior MGH psychiatrist who not only had had vast experience with the seriously ill but was himself a Jesuit priest. I had met with him once during my second hospitalization, and my memory through the haze was that he was the first person with whom I had discussed death. I remembered that when I asked him if, when, and how I should say goodbye to people, he said, ‘‘You know, you don't have to wait to say goodbye; you can express your love and appreciation for people right now, every day.’’
After the devastating news of the metastasis, I felt the urge to seek out Dr. Cassem again, in part to ask if there was anything more I should be doing to help my son, Ben, cope with my illness or the eventuality of my death. I mentioned that several people had suggested I make a videotape for Ben but that I thought I couldn't do that. Dr. Cassem replied that every time we played or laughed together, we were creating building blocks, precious memories that will be a part of him forever.
I also asked him if he thought I should be doing more to prepare for the possibility of an early death. He looked perplexed and asked, ‘‘Have you prepared your will?’’ I said yes. ‘‘Are your affairs otherwise in order?’’ I again said yes. ‘‘So it sounds like you are prepared. ... Remember, death is a minor matter. Living ... that's the challenge.’’
I then told him of the paradox that moments of great pleasure — playing with my son, snuggling with my wife, talking intensely with friends — also caused me great pain and tears. Was I depressed? Was this something to worry about? He looked at me thoughtfully and said: ‘‘When you cry about your son, it's because he has touched you deeply. It's an affirmation of your love for him. When you weep about the joy you experienced with your wife or close friends, that's an acknowledgment of your love for them. That's not a bad thing. ...Maybe a day without tears has been a dull day.’’ I nodded and then could not help but ask: ‘‘Do you believe in the power of prayer?’’ Dr. Cassem nodded. ‘‘Absolutely,’’ he said, ‘‘and your name is on my prayer list.’’ I felt warmed in his presence, by his wisdom, his common sense, and his spirituality.
· · · · ·
IN RECENT MONTHS, I have had several setbacks: a bone scan that showed four to five additional tumors, and a CT scan that showed significant progression of the cancer in both lungs. The only good news was that it had not spread to my head or liver. I am pained, but not surprised, at the relentlessness of the disease, and I am straining to retain hope that one of the experimental treatments may succeed where chemotherapy has failed.
For the first time, I recently mentioned to Dr. Lynch the idea of a hospice service and wondered how I might reduce future pain as the cancer progresses. Dr. Lynch answered that we were still a long way from that discussion, that we still had many avenues to explore, and that he remained as committed as ever to doing whatever he could to extend my life in a quality way.
Around the time of the CT scan, when I was feeling particularly dejected, I had an appointment with Mimi Bartholomay for an injection. She was running late, and as she approached me in the clinic waiting room, she looked harried. But as she got closer, she could see how unhappy I was, and she put her arm around me and directed me to a private room. I began to cry, and she intuitively responded: ‘‘You know, scan days are the worst. But whatever the results, we are not going to give up on you. We're going to fight with you and for you all the way.’’ I hugged her and thanked her for hanging in there with me.
If I have learned anything, it is that we never know when, how, or whom a serious illness will strike. If and when it does, each one of us wants not simply the best possible care for our body but for our whole being.
I still am bound upon Lear's wheel of fire, but the love and devotion of my family and friends, and the deep caring and engagement of my caregivers, have been a tonic for my soul and have helped to take some of the sting from my scalding tears.
Kenneth B. Schwartz died of lung cancer in September 1995. Shortly before his death he founded the Kenneth B. Schwartz Center at Massachusetts General Hospital, which is dedicated to strengthening the relationships between patients and caregivers.
July 16, 1995
The Boston Globe Magazine
UNTIL LAST FALL, I had spent a considerable part of my career as a health-care lawyer, first in state government and then in the private sector. I came to know a lot about health-care policy and management, government regulations and contracts. But I knew little about the delivery of care. All that changed on November 7, 1994, when, at age 40 I was diagnosed with advanced lung cancer. In the months that followed, I was subjected to chemotherapy, radiation, surgery, and news of all kinds, most of it bad. It has been a harrowing experience for me and for my family. And yet, the ordeal has been punctuated by moments of exquisite compassion. I have been the recipient of an extraordinary array of human and humane responses to my plight. These acts of kindness — the simple human touch from my caregivers — have made the unbearable bearable.
· · · · ·
DURING SEPTEMBER and October of 1994, I made several visits to the outpatient clinic of a Boston teaching hospital for treatment of a persistent cough, low-grade fever, malaise, and weakness. The nurse practitioner diagnosed me as having atypical pneumonia and prescribed an antibiotic. Despite continued abnormal blood counts, she assured me that I had a post-viral infection and didn't need an appointment with my physician until mid-November, if then. By mid-October, I felt so bad that I decided I could not wait until November 11 to be seen. Disappointed with the inaccessibility of my physician, I decided to seek care elsewhere, with the hope that a new doctor might be more responsive.
‘‘The rule books, I’m sure, frown on such intimate engagement between caregiver and patient. But maybe it’s time to rewrite them.’’
Kenneth B. Schwartz
My brother, a physician who had trained at Massachusetts General Hospital, arranged for an immediate appointment with Dr. Jose Vega, an experienced internist affiliated with MGH. Dr. Vega spent an hour with me and ordered tests, including a chest X-ray. He called within hours to say he was concerned by the results, which showed a ‘‘mass’’ in my right lung, and he ordered a computerized tomography scan for more detail. I remember leaving my office for home, saying quickly to my secretary, Sharyn Wallace, ‘‘I think I may have a serious medical problem.’’ Indeed, the CT scan confirmed abnormal developments in my right lung and chest nodes.
The next day, Dr. Vega, assuring me that he would continue to be available to me whenever I needed him, referred me to Dr. Thomas Lynch, a 34-year-old MGH oncologist specializing in lung cancer. Dr. Lynch, who seems driven by the ferocity of the disease he sees every day, told me that I had lung cancer, lymphoma, or some rare lung infection, although it was most likely lung cancer.
Mimi Bartholomay, RN, MSN, an outpatient oncology
nurse with the author at Massachusetts General Hospital
Photography by Bill Greene / The Boston Globe
My family and I were terrified. For the next several months, my blood pressure, which used to be a normal 124 over 78, went to 150 over 100, and my heart rate, which used to be a low 48, ran around 100.
Within 72 hours of seeing Dr. Lynch, I was scheduled for a bronchoscopy and a mediastinoscopy, exploratory surgical procedures to confirm whether I indeed had lung cancer. Until this point, I had thought that I was at low risk for cancer: I was relatively young, I did not smoke (although I had smoked about a cigarette a day in college and in law school and for several years after that), I worked out every day, and I avoided fatty foods.
The day before surgery, I was scheduled to have a series of tests. The presurgery area of the hospital was mobbed, and the nurses seemed harried. Eventually, a nurse who was to conduct a presurgical interview called my name. Already apprehensive, I was breathing hard.
The nurse was cool and brusque, as if I were just another faceless patient. But once the interview began, and I told her that I had just learned that I probably had advanced lung cancer, she softened, took my hand, and asked how I was doing. We talked about my 2-year-old son, Ben, and she mentioned that her nephew was named Ben. By the end of our conversation, she was wiping tears from her eyes and saying that while she normally was not on the surgical floor, she would come see me before the surgery. Sure enough, the following day, while I was waiting to be wheeled into surgery, she came by, held my hand, and, with moist eyes, wished me luck.
The author with wife Ellen Cohen
and their son Ben
This small gesture was powerful; my apprehension gave way to a much-needed moment of calm. Looking back, I realize that in a high-volume setting, the high-pressure atmosphere tends to stifle a caregiver's inherent compassion and humanity. But the briefest pause in the fre netic pace can bring out the best in a caregiver and do much for a terrified patient.
The nurse left, and my apprehension mounted. An hour later, I was wheeled to surgery for a biopsy of the chest nodes and the mass in my lung. I was greeted by a resident in anesthesiology, Dr. Debra Reich, who took my pulse and blood pressure and said gently, ‘‘You're pretty nervous, huh?’’ She medicated me with tranquilizers, but that did not stop me from asking about where she lived, where she had trained, and whether she was married. I jokingly asked her how come she was the only Jewish doctor I had met during my time at MGH. When it turned out that she lived down the street from me and liked the sandwiches at the same corner shop, Virginia's, I felt comforted. She squeezed my shoulder, wished me luck, and wheeled me into surgery.
When I awoke, I was told that I had adenocarcinoma in my right lung and in several chest nodes — in other words, advanced lung cancer. I don't remember a lot about those hours, but I remember Dr. Vega's face with tears in his eyes. I also remember feeling very sad and scared.
A few days later, I received a letter from Dr. Reich: ‘‘Remember me, your friendly anesthesiologist? I came by to see you this afternoon as my professional duty but also to express my sadness in hearing about your diagnosis. Your door was closed and there seemed to be a lot of activity, so I decided not to disturb you.
‘‘As I'm sure you know, we as physicians are taught not to become emotionally involved in our patients because then we would be continually devastated. But I guess because we had such a nice interaction before your surgery and because your life was one which I could relate to so well — being Jewish, professional, renovating a house, sandwiches at Virginia's, etc. — your situation really struck a chord in me. (Hey, maybe you can't even remember any of this because of the medicine I gave you, but hopefully you do...)
‘‘I was very impressed that during the fear and anxiety you were experiencing, you still maintained your composure, your sense of humor, and even thought to ask me when I was getting married.
‘‘So, anyway, as you told me, keeping your wife and son in mind will make you fight strong, and I know this to be true! I know that you have a very loving and supportive family who will help you through this as well.
‘‘Best wishes, and maybe I'll run into you sometime at Virginia's.’’
I had not forgotten Dr. Reich, nor will I ever forget her willingness to cross the professional barrier, hold my hand, and write those words.
· · · · ·
IT WAS CLEAR THAT I WOULD soon begin a new chapter in my illness and undergo the classic treatment for such advanced cancer: intensive chemotherapy and radiation, followed by surgery to remove the tumors, nodes, and entire lung, if necessary. Dr. Lynch told me that this option presented the real possibility of a cure.
Over the next week, I had a series of additional radiologic scans to determine if the cancer had spread beyond my chest. These scans are incredibly scary: You are placed in a tube resembling a sarcophagus, with only 6 inches between you and the walls, and you may spend several hours inside, deafened by the clanging machine. And the scans always raise fears about whether more bad news is around the corner.
Dr. Vega or Dr. Lynch always made it a point, though, to relay results within 24 hours, so my family and I didn't have to endure the anxiety of uncertainty any longer than necessary.
The scans of my body, head, liver, bones and back were clear. I was relieved.
The doctors soon began an intensive regimen of chemotherapy and radiation, with the goal of destroying the cancer and preparing for surgery to remove my lung.
Before being admitted for my first five-day course of chemotherapy, I had a radiation-simulation session. During such sessions, therapists meticulously map their targets by marking your skin where the radiation should be directed. I was asked to lie on a table in a large, cold chamber. The radiation therapist, Julie Sullivan, offered me a blanket and, mentioning that the staff had a tape deck, asked if I had any requests: I recalled my college days and asked for James Taylor. Listening to ‘‘Sweet Baby James’’ and ‘‘Fire and Rain,’’ I thought back to a time when the most serious problem I faced was being jilted by a girlfriend, and tears ran down my cheeks. As therapists came and went, Julie Sullivan held my hand and asked me if I was OK. I thanked her for her gentleness.
After having a Port-o-Cath implanted in my chest — a device that allows chemotherapy to be administered without constant needle sticks in the arm — I was admitted to MGH in mid-November. During that and other hospitalizations, either my mother or sister would stay overnight, often sleeping in cramped chairs. When I awoke at night in an anxious sweat or nauseated, I would see one of them and feel reassured.
While doctors managed my medical care, my day-to-day quality of life and comfort were in the hands of two or three nurses. These nurses showed competence and pride in their work, but they also took a personal interest in me. It gave me an enormous boost, and while I do not believe that hope and comfort alone can overcome cancer, it certainly made a huge difference to me during my time in the hospital.
During the period between my two chemotherapies, when I also received high-dose radiation twice a day, I came to know a most exceptional caregiver, the outpatient oncology nurse Mimi Bartholomay. An eight-year veteran who had experienced cancer in her own family, she was smart, upbeat, and compassionate. I had to receive fluids intravenously every day at the clinic, and while there we talked regularly about life, cancer, marriage, and children. She too was willing to cross that professional Rubicon — to reach out and talk about my fear of dying or, even worse, my fear of not living out my life, of not biking through the hills of Concord and Weston on summer weekends with my brother, of not seeing my child grow up, of not holding my wife in my arms. And she took the risk of talking about her own father's recent bout with cancer. I cannot emphasize enough how meaningful it was to me when caregivers revealed something about themselves that made a personal connection to my plight. It made me feel much less lonely. The rule books, I'm sure, frown on such intimate engagement between caregiver and patient. But maybe it's time to rewrite them. THE BEST MEDICINE
In my new role as patient, I have learned that medicine is not merely about performing tests or surgeries, or administering drugs. These functions, as important as they are, are just the beginning.
· · · · ·
AFTER MY SECOND ROUND of chemotherapy, I was ready for the final stage of what we hoped would be a cure: surgery. Before this could happen, Dr. Lynch repeated my radiologic scans, to be sure that the cancer had not spread. He assured me that the chance of any such metastasis was remote — less than 5 percent — although it would be a disaster if it occurred.
The scans were endless, scary, and lonely. While members of my family stayed with me in the waiting rooms, they could not accompany me to the scanning rooms; the experience again was harrowing. But I felt my greatest fear while awaiting the results. After a week of tests, I had one last scan of my bones. I was concerned when the technologist asked to do a special scan of my back that had not been done before.
The next day, I called Dr. Lynch's office and asked his assistant, Mary Ellen Rousell, when I could come in to find out the results. She said, ‘‘How about this afternoon?" and then added, ‘‘You might want to bring someone.’’ My heart skipped. When my wife and I entered Dr. Lynch's office and saw his face, our hearts sank. He was ashen. He said that while all the other scans were clear, there appeared to be a metastic tumor in my spine. He explained that this meant that lung surgery at this point would be futile, since other metastases were likely to surface.
Dr. Lynch said that he could n ot be 100 percent certain that this was a tumor and that, because so much was at stake, we should do a biopsy. My wife and I wept openly — in part, because, looking at Dr. Lynch's face, we felt that he had lost hope.
I could not help but ask what treatment options were available, and he mentioned a drug called Taxol. Still being the lawyer, I quizzed him:
Me: What is the percentage of people who benefit from Taxol?
Dr. Lynch: Forty percent.
Me: How much do they benefit?
Dr. Lynch: They can get several years of life, although it is not a cure. And the median survival for patients on Taxol with your advanced stage of disease is nine months.
Nine months! My wife and I cringed. I ended the session by asking Dr. Lynch, ‘‘How do you do this work?’’ And he answered, in genuine pain, ‘‘By praying that I don't have days like today.’’
· · · · ·
I BEGAN TO HAVE TROUBLE sleeping, and when I awoke, I was filled with dread and despair. I thought frequently of the observation of Richard Block, the founder of H&R Block, who had survived lung cancer after being told initially that he had only months to live: ‘‘I lived for five days without hope and...my life during those five days...was far worse than at any time during the 'horrible' ordeal of tests or treatments.’’
And when I contemplated not living to see my son grow up or not cherishing my wife for a lifetime, I thought of King Lear, who, at a low point, wailed:
I am bound
Upon a wheel of fire, that mine own tears
Do scald like molten lead.
I desperately needed to regain hope, and I needed Dr. Lynch to regain his sense of hope.
A few days later, I had the biopsy. Dr. Lynch met with my family to report that, indeed, after considerable searching, the pathologist had found small deposits of adenocarcinoma in my vertebra. It was now confirmed that I had metastatic lung cancer. Although my brother and my father, who is also a physician, raised the possibility of radical surgery on my back and lung to remove all the tumors, Dr. Lynch and the surgeons rejected this option because further metastases were likely to appear, and the surgery would be debilitating and reduce my quality of life at a time when my life could well be substantially shortened.
The clear treatment was more chemotherapy. Dr. Lynch again recommended the use of Taxol, with the hope of slowing the cancer's spread.
My wife and I were largely silent during the medical discussion. I asked my father and brother to leave so my wife and I could talk not facts and figures but matters of the heart. When they had left, I said to Dr. Lynch, ‘‘You told me two things all along: One, that you were aiming for a total cure and if that were not feasible, you would tell me at that time. And two, you would never, ever give up on me, never stop trying to fight, to extend my life as long as possible. Am I no longer on the cure route?’’
He looked somberly at us and explained that there were no known treatments to cure this stage of cancer.
‘‘And will you stick by me and fight to the end?’’ I asked.
He nodded vigorously and then outlined a number of state-of-the-art, experimental protocols from which I might benefit after Taxol.
And, leaving statistics behind, he talked of several patients who had defied the odds and lived for years beyond expectations. He advised that my goal should be to be here the same time next year, and then the year after, and the year after — one day at a time, one month at a time, one year at a time. He mentioned several breast-cancer patients who had told him that they had relished their final years with their children in a way that they had never known before. It felt good to leave the medical talk and speak heart to heart, and it felt to me that he had regained a sense of hope — not for some magical cure but for the possibility of extending my life.
It was crucial to my wife and to me that he not give up hope. I understood his surprise and disappointment at the metastasis; in fact, as one friend suggested, his distress at that event was a sign of his caring about me and his involvement with my case. But we desperately needed him to give us a realistic basis for hope — and he had.
‘‘If I have learned anything, it is that we never know when, how, or whom a serious illness will strike. If and when it does, each one of us wants not simply the best possible care for our body but for our whole being.’’
Kenneth B. Schwartz
· · · · ·
THE NEXT DAY, I BEGAN A NEW chapter in my fight. And once again, Mimi Bartholomay was by my side, monitoring my reaction and assuring me that most people tolerated Taxol very well. I had no allergic reactions, and I felt good that the battle was under way. I had hoped that maybe this could buy me time.
Time was now my best friend, since it could allow medical research to advance and doctors to find new strategies and maybe even a cure for advanced lung cancer.
During this period, with help from my father, who has had a long and distinguished career in academic medicine, I began to explore potential cutting-edge protocols that could supplement or follow Taxol.
My father arranged a meeting for my wife and me with Dr. Kurt J. Isselbacher, a distinguished researcher and director of the MGH Cancer Center. He is a small man with a large presence and piercing blue eyes, and he was surrounded by medical books, papers, and many pictures of his family. He was upbeat, telling us of protocols under way that showed promise in fighting metastatic tumors. Like several others, he told me a personal story that cut to the bone: A close family member, he said, had been diagnosed with advanced cancer, which the attending oncologist had said was ‘‘very, very bad.’’ The family member had said to him: ‘‘Kurt, you have helped so many people in your life, can you now help me?’’ He personally treated the family member in that person's home with chemotherapy, and, 21 years later, that person is thriving.
Dr. Isselbacher offered to serve as an advocate for me, to work with my father and Dr. Lynch to find the most promising protocols. I told him at the meeting that while I had no illusions, I was deeply moved by his refusal to give up and by his abiding hope; I was especially affected because such hopefulness was not coming from a faith healer but a distinguished researcher. He had strengthened our resolve to fight.
‘‘I was especially affected because such hopefulness was not coming from a faith healer but a distinguished researcher’’
Kenneth B. Schwartz
As I grappled to maintain my hope in the face of the advancing disease, I was referred to Dr. Ned Cassem, a senior MGH psychiatrist who not only had had vast experience with the seriously ill but was himself a Jesuit priest. I had met with him once during my second hospitalization, and my memory through the haze was that he was the first person with whom I had discussed death. I remembered that when I asked him if, when, and how I should say goodbye to people, he said, ‘‘You know, you don't have to wait to say goodbye; you can express your love and appreciation for people right now, every day.’’
After the devastating news of the metastasis, I felt the urge to seek out Dr. Cassem again, in part to ask if there was anything more I should be doing to help my son, Ben, cope with my illness or the eventuality of my death. I mentioned that several people had suggested I make a videotape for Ben but that I thought I couldn't do that. Dr. Cassem replied that every time we played or laughed together, we were creating building blocks, precious memories that will be a part of him forever.
I also asked him if he thought I should be doing more to prepare for the possibility of an early death. He looked perplexed and asked, ‘‘Have you prepared your will?’’ I said yes. ‘‘Are your affairs otherwise in order?’’ I again said yes. ‘‘So it sounds like you are prepared. ... Remember, death is a minor matter. Living ... that's the challenge.’’
I then told him of the paradox that moments of great pleasure — playing with my son, snuggling with my wife, talking intensely with friends — also caused me great pain and tears. Was I depressed? Was this something to worry about? He looked at me thoughtfully and said: ‘‘When you cry about your son, it's because he has touched you deeply. It's an affirmation of your love for him. When you weep about the joy you experienced with your wife or close friends, that's an acknowledgment of your love for them. That's not a bad thing. ...Maybe a day without tears has been a dull day.’’ I nodded and then could not help but ask: ‘‘Do you believe in the power of prayer?’’ Dr. Cassem nodded. ‘‘Absolutely,’’ he said, ‘‘and your name is on my prayer list.’’ I felt warmed in his presence, by his wisdom, his common sense, and his spirituality.
· · · · ·
IN RECENT MONTHS, I have had several setbacks: a bone scan that showed four to five additional tumors, and a CT scan that showed significant progression of the cancer in both lungs. The only good news was that it had not spread to my head or liver. I am pained, but not surprised, at the relentlessness of the disease, and I am straining to retain hope that one of the experimental treatments may succeed where chemotherapy has failed.
For the first time, I recently mentioned to Dr. Lynch the idea of a hospice service and wondered how I might reduce future pain as the cancer progresses. Dr. Lynch answered that we were still a long way from that discussion, that we still had many avenues to explore, and that he remained as committed as ever to doing whatever he could to extend my life in a quality way.
Around the time of the CT scan, when I was feeling particularly dejected, I had an appointment with Mimi Bartholomay for an injection. She was running late, and as she approached me in the clinic waiting room, she looked harried. But as she got closer, she could see how unhappy I was, and she put her arm around me and directed me to a private room. I began to cry, and she intuitively responded: ‘‘You know, scan days are the worst. But whatever the results, we are not going to give up on you. We're going to fight with you and for you all the way.’’ I hugged her and thanked her for hanging in there with me.
If I have learned anything, it is that we never know when, how, or whom a serious illness will strike. If and when it does, each one of us wants not simply the best possible care for our body but for our whole being.
I still am bound upon Lear's wheel of fire, but the love and devotion of my family and friends, and the deep caring and engagement of my caregivers, have been a tonic for my soul and have helped to take some of the sting from my scalding tears.
Kenneth B. Schwartz died of lung cancer in September 1995. Shortly before his death he founded the Kenneth B. Schwartz Center at Massachusetts General Hospital, which is dedicated to strengthening the relationships between patients and caregivers.
Sunday, September 25, 2011
工作心情
在飞机上，翻阅了一本杂志，一篇有关著名发型设计师的专访，谈及她的工作，她说每天早上起床，她都会抱着兴奋地心情去上班。我自省了一阵子，怎么我没有这样的热诚？假日结束，该回到工作岗位了，心情反而是沉重的。即使没有放假，日复一日，机械化地操作，我的工作不曾让我感到兴奋和期待啊？！是麻醉科接触清醒的病人时间太少？是这科系不合适？是工作环境，对上司的不满，对“政治”的厌烦？工作应该是一种享受，不是吗？她说，面对挑战让她更充满力量；不知是否因行业区别的关系，不仅是我，就连工作经验比我丰富的上司在遇上难题时都会眉头深锁。因为很多决定，很多当机立断，赌上的可能是一个人的健康，甚至是生命，我们怎可能感觉雀跃呢？难道这职业真的没有让人愉悦的空间吗？
和友人的父母闲聊。他们问说，这份工作，辛苦吗？我说，只要值得，就不辛苦。但为何我不快乐呢？为何我不对工作有期待的心情呢？是我觉得不值吗？焦点错了，如果工作会想获得上司的重视，公平的待遇，怎么可能快乐呢？但这是正常的，不是吗？我找不到自己想要的满足感，所以我没有爱上自己的工作，我这样总结着。该怎样才能满足呢？或许我该问--自己的欲望究竟是什么，才能想办法填补这心灵上的空缺。人的欲望不外乎钱`权`情。钱嘛，能自给自足就成了；权，我最讨厌管理层乏味的工作，还有那副政治家的嘴脸。我觉得，我想要的，反而是最难得到的--情。我不喜欢自己的无情。曾有那么一次，接收紧急传召为一个三十几岁的癌症病人插管。已是第四期的癌症了，肿瘤压着呼吸管，导致只有一个肺部还能操作。我翻了病历，发现已有其它同事看了这位病人，与上司商议，决定不插管，选择不急救策略，换句话说，如果她能靠自己的能力活着，是个奇迹，如果不能，是命运。外行人一定不明白，为何这个医学还算昌明的世纪，居然会有由病人自生自灭的景象。这方策其实只有在一种情况下才能实行--当你认为延续其生命等于延长其痛苦，医学或医院没有把病人治愈的能力，所以选择放手。但命运总爱弄人，有些癌症偏选上了较年轻的病患，让我们更难取舍。放弃吗？三十几岁的生命，多么可惜，看着喘不过气的病人苦苦哀求，该怎么说不？该怎么告诉那站在一旁，泪痕满面的丈夫，反正插不插管，死亡对于他年轻的太太是必然的结局？我心疼，但电话响了，又有其它的紧急传呼，我没有多余的时间去安抚。对于自己的无情，我无法释怀。医生不是应该给病患带来希望的吗？但我的科系，却让我一而再地面对这一切。记得有一次因资源的问题，我只好告诉一个内科的同事，筛选你的病人。我讨厌让人心力交瘁的无力感，让我快乐不起来的压迫感。我们不是上帝，别人的命运凭什么由我们来决定？
写着写着，我似乎找到自己不快乐的原因，我想在自己的工作里找到带给病人及家属欢笑的成就感，在面对不治之症时和他们一起面对生命的无奈，我希望他们能了解我们已经尽力，也希望他们能继续相信，在能力和资源允许的情况下，医生不会选择放弃他的病人。现实是残酷的，但总得去面对，有谁会喜欢？但总得有人去背负这样的使命，但我希望去面对的心情不再是无奈的，而是充满着使命感与成就感。
在飞机上，翻阅了一本杂志，一篇有关著名发型设计师的专访，谈及她的工作，她说每天早上起床，她都会抱着兴奋地心情去上班。我自省了一阵子，怎么我没有这样的热诚？假日结束，该回到工作岗位了，心情反而是沉重的。即使没有放假，日复一日，机械化地操作，我的工作不曾让我感到兴奋和期待啊？！是麻醉科接触清醒的病人时间太少？是这科系不合适？是工作环境，对上司的不满，对“政治”的厌烦？工作应该是一种享受，不是吗？她说，面对挑战让她更充满力量；不知是否因行业区别的关系，不仅是我，就连工作经验比我丰富的上司在遇上难题时都会眉头深锁。因为很多决定，很多当机立断，赌上的可能是一个人的健康，甚至是生命，我们怎可能感觉雀跃呢？难道这职业真的没有让人愉悦的空间吗？
和友人的父母闲聊。他们问说，这份工作，辛苦吗？我说，只要值得，就不辛苦。但为何我不快乐呢？为何我不对工作有期待的心情呢？是我觉得不值吗？焦点错了，如果工作会想获得上司的重视，公平的待遇，怎么可能快乐呢？但这是正常的，不是吗？我找不到自己想要的满足感，所以我没有爱上自己的工作，我这样总结着。该怎样才能满足呢？或许我该问--自己的欲望究竟是什么，才能想办法填补这心灵上的空缺。人的欲望不外乎钱`权`情。钱嘛，能自给自足就成了；权，我最讨厌管理层乏味的工作，还有那副政治家的嘴脸。我觉得，我想要的，反而是最难得到的--情。我不喜欢自己的无情。曾有那么一次，接收紧急传召为一个三十几岁的癌症病人插管。已是第四期的癌症了，肿瘤压着呼吸管，导致只有一个肺部还能操作。我翻了病历，发现已有其它同事看了这位病人，与上司商议，决定不插管，选择不急救策略，换句话说，如果她能靠自己的能力活着，是个奇迹，如果不能，是命运。外行人一定不明白，为何这个医学还算昌明的世纪，居然会有由病人自生自灭的景象。这方策其实只有在一种情况下才能实行--当你认为延续其生命等于延长其痛苦，医学或医院没有把病人治愈的能力，所以选择放手。但命运总爱弄人，有些癌症偏选上了较年轻的病患，让我们更难取舍。放弃吗？三十几岁的生命，多么可惜，看着喘不过气的病人苦苦哀求，该怎么说不？该怎么告诉那站在一旁，泪痕满面的丈夫，反正插不插管，死亡对于他年轻的太太是必然的结局？我心疼，但电话响了，又有其它的紧急传呼，我没有多余的时间去安抚。对于自己的无情，我无法释怀。医生不是应该给病患带来希望的吗？但我的科系，却让我一而再地面对这一切。记得有一次因资源的问题，我只好告诉一个内科的同事，筛选你的病人。我讨厌让人心力交瘁的无力感，让我快乐不起来的压迫感。我们不是上帝，别人的命运凭什么由我们来决定？
写着写着，我似乎找到自己不快乐的原因，我想在自己的工作里找到带给病人及家属欢笑的成就感，在面对不治之症时和他们一起面对生命的无奈，我希望他们能了解我们已经尽力，也希望他们能继续相信，在能力和资源允许的情况下，医生不会选择放弃他的病人。现实是残酷的，但总得去面对，有谁会喜欢？但总得有人去背负这样的使命，但我希望去面对的心情不再是无奈的，而是充满着使命感与成就感。
台北之旅
一个比预期更难忘的旅行。由抵达台北市的第一个夜晚，就对这个城市留下好印象。公共巴士（称为客运）由司机一人负责开车，为旅客处理认领行李等工作，坐在车上的我们，用不着担心行李会让人趁机领走-这可是一般的客运哦，在我国可没有这种服务。记忆中几乎每一家店铺的员工或是夜市小贩的服务态度，总结--赞！非常有礼貌，回到了吉隆坡，实在看到了非常直接的对比，去过台湾的人肯定知道我并没有夸大其词。谈到公民意识，捷运不曾见过互相推挤的现象，大家都会守秩序；今天搭KTM时，又目睹天渊之别的现象，让我不禁怀疑究竟是别人的国家太进步，还是我国太落后了？或许是我不曾到过先进国的关系，这是我第一次觉得自己的国家和社会与别人相比，实在是望尘莫及。问题究竟是什么？要如何才能塑造一个这样的社会？再过五十年后的今天，我国人民是否也能那么有文化涵养？购物`乘搭计程车，也没有让人敲诈，我在想，如果我是由台湾到吉隆坡观光的旅客，肯定不会对这里留下好印象。我国商家对游客的“额外关照”，还有那服务员让人印象深刻的服务态度，唉，我们有太多需要改进之处。台湾是一个会让游客想再回去的地方，不仅是因为其名胜地，我认为更重要的原因是其人民对旅客的诚实和友善，让他们可以安心地享受整个旅程。
一个比预期更难忘的旅行。由抵达台北市的第一个夜晚，就对这个城市留下好印象。公共巴士（称为客运）由司机一人负责开车，为旅客处理认领行李等工作，坐在车上的我们，用不着担心行李会让人趁机领走-这可是一般的客运哦，在我国可没有这种服务。记忆中几乎每一家店铺的员工或是夜市小贩的服务态度，总结--赞！非常有礼貌，回到了吉隆坡，实在看到了非常直接的对比，去过台湾的人肯定知道我并没有夸大其词。谈到公民意识，捷运不曾见过互相推挤的现象，大家都会守秩序；今天搭KTM时，又目睹天渊之别的现象，让我不禁怀疑究竟是别人的国家太进步，还是我国太落后了？或许是我不曾到过先进国的关系，这是我第一次觉得自己的国家和社会与别人相比，实在是望尘莫及。问题究竟是什么？要如何才能塑造一个这样的社会？再过五十年后的今天，我国人民是否也能那么有文化涵养？购物`乘搭计程车，也没有让人敲诈，我在想，如果我是由台湾到吉隆坡观光的旅客，肯定不会对这里留下好印象。我国商家对游客的“额外关照”，还有那服务员让人印象深刻的服务态度，唉，我们有太多需要改进之处。台湾是一个会让游客想再回去的地方，不仅是因为其名胜地，我认为更重要的原因是其人民对旅客的诚实和友善，让他们可以安心地享受整个旅程。
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