It was six am and still dark. I looked around at the other zombies on the commuter bus to Manhattan. A few that had boarded at a previous stop had already dropped off to sleep. I could hear someone snoring. I was tired too, a sort of chronic-fatigue-kind of tired, but I couldn’t fall asleep. I thought about getting out my e-reader and finishing the novel I had started, but after the last of the undead had shuffled aboard, I decided to use my hour of peace and quiet to meditate. I settled in, and closed my eyes… got a sense of my body as a whole… relaxed… focused on my breath – oops, I was out.
I woke up as the bus pulled into the Port Authority, and had to make a choice – walk the 25 blocks to 17th Street, and enjoy a little daylight and exercise, or take the subway. I stepped outside through the revolving door. The wind was howling, it was 17 degrees. I was back through the revolving door before it had even stopped turning. I resolved tomorrow to wear a warm hat and heavy coat. Down the stairs I went, deeper and deeper into a state of resignation. I avoided a subway car that was pretty much empty. I had learned the hard way that an empty car meant there was a smelly homeless person inside, or worse yet someone had defecated. It reminded me I had something to be grateful for, at least I wasn’t homeless. My subway car had a couple available seats, but I preferred to stand – a feeble token towards my goal of a healthy lifestyle. After all, “Sitting is the new smoking.” I had heard that somewhere, and as a radiologist, I was screwed. I sat the whole day in the dark in front of a computer. Day after day, month after month, year after year… I scolded myself for forgetting to take my vitamin D. Ugh, what had become of me?
As the subway car rocked from side to side, I checked out the other people on the train. There was a very tall older woman with long gray hair and no makeup, wearing a cowboy hat and a long skirt. I had seen her before. She was frequently on my morning train; always wearing that cowboy hat; always getting off at the same stop, at times with a nice-looking gentleman. Maybe she was a professor of something interesting. I imagined she looked forward to going wherever it was that she was going. In all likelihood, she was happier and more satisfied than me. I wondered, was she appreciated? Did she feel like she belonged somewhere? She had probably accomplished a lot in her life, and would leave a rich legacy. I doubt that she had ever been traumatized by a lawsuit. She appeared refreshed, alert, vibrant. I bet she loved someone, and was loved in return. Surely, she was everything that I had set out to be, and had the life I had hoped to live.
Before I knew it, I was at my stop and flowed with the sea of people out the door, up the stairs, through the turn-style, and up the stairs again. I braced myself against the wind, held my breath through the smokers, and rounded the corner to Eighth Avenue and into the deli. I pondered the carbs which I craved and decided to just get coffee. I was always feeling hungry, and unsatisfied no matter what or how much I ate. I was slowly putting on weight. Not fat yet, but creeping in that direction. Out the door I went again, and noticed the Joyce Theater up the block. It reminded me that I hadn’t been to a live performance in what seemed like forever. The last live performance I went to was the opera over a year ago, and I had slept through the whole thing. I wondered who would be dancing at the Joyce this season. I loved dance, and in fact, I used to be a dancer. I used to be a lot of things, but before I could lament about all that I had given up, I was at work.
“Good morning doctor”, the receptionist said cheerfully, like she really meant it. It made me feel good that she genuinely seemed happy to see me.
“Morning,” I replied just as cheerfully.
My colleague joined me in the elevator. He began to speculate on whether our bosses were going to sell the office where we worked. Business was not what they had hoped it would be, and he heard that the bosses were seen giving a tour of the place to some potential buyers……..and on, and on. I didn’t give a damn because I was working on an exit strategy, but he seemed genuinely threatened. I might have found some words of comfort; reassured him that he was an excellent radiologist, and could get another job easily, but there was no time for connecting in any meaningful way. The patients were already lined up for their radiology exams, and the schedulers were already adding on walk-ins into time slots that did not exist.
My office door was open. A tech was finishing up the quality control on the mammography work station monitors. We chatted for a minute, before I took my seat. It was my job to look at mammograms and pick out the potential cancers in a veritable sea of camouflage, like “finding Waldo” in a room full of Waldo imposters. Biopsies are needed to determine which suspicious findings are actually cancers. Recommend too many biopsies, and you are causing harm. Recommend too few and you miss cancers. Even if the radiologist’s recommendations are “just right,” some of the biopsies will be benign (non-cancerous), and some cancers will slip by. The breast imaging specialty of radiology is a highly stressful and hazardous job, and I was longing for the day that I would be replaced with artificial intelligence. To make matters worse, there was an ongoing debate as to whether the “harms” of screening mammography outweighed the “good.” Really? Who wants to do something that is potentially harmful?!! I would go to dinner parties and be asked what my stand was on the mammography controversy. In the old days, I knew just what to say. I was saving lives, and I would back myself up with all the research in support of screening mammography. Over time I began to question, but I was sure of one thing, interpreting mammograms had lost its value to me. I no longer felt like I was doing anyone any good.
I sat down to face the grind, and dreaded all the patients that would be angry that day because they had to wait, and believed it was because I was out to lunch, or practicing my golf swing, or chatting on the phone with my nanny. I could hear them now, “What makes her think my time isn’t as important as hers?” I was already feeling resentful towards the practice manager that ran the place like a nail salon, and had put up a sign out front that said “Walk-ins Welcome”.
I pulled up the first case, and picked up my Dictaphone. We had an outdated voice dictation system that had difficulty recognizing my female voice, or so they told me. Personally, I thought voice dictation was just crap. It made lots of errors, and to get around them as much as possible, I kept my reports simple, and had templates that took care of the routine portions of the report. I began dictating; filling in the blanks in the template. When I got to the impression, I dictated, “The right breast has a normal appearance. The left breast has 3 areas of increased density, possibly related to the patient’s reported recent weight loss, as discussed above. She will be asked to return for additional views, and ultrasound, for clarification.” The machine typed out, “The right breast has an aberrant appearance. The left breast has thrill areas of released density, possible he related to the patiently aborted reinvented hate loss, as discussed above. She will be hacked for return four additional views, and ultrasound classification.” Oh my God! That’s it! That is the last straw!
I immediately got on the phone with IT, “Can you please come down here and see if you can do something about the voice dictation? You would not believe what it just did!” In dramatic fashion, I told him what I dictated and read him what it typed.
He laughed, “Oh, Doctor, you are so funny! Have you tried retraining it?”
“I am always retraining it. It doesn’t work!”
“Well, retrain it again. If it still doesn’t work, call me back.”
Believing retraining the machine again would be a waste of more time, I retyped the impression by hand. I couldn’t help but recall fondly the real human transcriptionists I had worked with in the past. The people that caught your mistakes instead of making them for you. The one that brought me comfort and coffee in the middle of the night when I was a resident on a 36 hour shift. The one that embroidered dish towels for me for Christmas and gave me a pair of earrings for my 50th birthday. Oh, yes, once upon a time we worked with real human beings. Referring physicians came around in person and reviewed cases with us, and valued our contribution. Those were the days before doctors just pulled up radiology images on their computers and only had time to read the impression of the report. Everything seemed so much more difficult now. No wonder I felt exhausted all the time.
There was also something eating away at me. I tried to keep it in some dusty corner of my mind, but that is hard to do when you are in the middle of a soul sucking lawsuit. It was the first thing that I thought of when I woke up in the morning. I had been convicted of malpractice based on the testimony of one of the accused, after the statute of limitations was up, without ever being named in the lawsuit in the first place, and without legal representation or a chance to defend myself. Sounds impossible? One would think so! Since I wasn’t named in the lawsuit, it was decided that my former practice, and the hospital where I had had privileges would have to pay up. So, my former practice, with no insurance coverage, threatened to sue me for the damages. The case was such an irregularity that the verdict was appealed, with the result that now I was going to be placed on trial, nobody else, just me. My defense was to be limited, because those who were originally accused had already been exonerated. What a mess! It threatened my very core, because I no longer trusted the legal system to work for me. Whatever happened to due process? I contemplated withdrawing the money from my retirement fund, faking my death and disappearing to someplace civilized, like a third world country. I settled on changing my political affiliation.
Ignoring my ever-present fatigue, and the chronic anxiety that manifested as a writhing discomfort in my gut, I pushed on. As the day progressed, one of my colleagues called and asked me to look over a case for her. I had always been happy to do so in the past, but I noticed that I was getting impatient about it lately, and it came out in my tone of voice, which made me feel disappointed in myself. She relied on me because somehow, I still had the ability to make decisions in cases that were not straight forward. What happens to breast imagers is that they get burned on a case, so they become afraid they will get burned again, and eventually they just resort to doing biopsies of everything they see. Hence, one of the “harms” of mammography – too many unnecessary biopsies. I reviewed the case for her, and suggested she recommend an MRI, so for the moment we dodged the biopsy bullet.
I was so busy that I forgot to order lunch until noon, so now it was 1:30 and lunch had just arrived. I was in the middle of a workup, so it would just have to sit there and get cold. I was recommending a biopsy on a middle-aged woman, who had been getting regular screening mammograms. Something showed up this year, so we brought her back for additional views and ultrasound. Now it was time to go over everything with her. Before the tech brought her to my office, she warned me, “This lady is a real piece of work, prepare yourself.”
When our patient came into my office, she eyed my lunch sitting untouched on the desk. After making a face, she told me that she was terrified and unnecessarily stressed, because she was notified of the need for the additional imaging by a letter which had taken three weeks to get to her! She raised her voice by a few decibels while expressing that she should have been notified by a phone call, and gotten an immediate appointment, and what did I intend to do about that?! I agreed with her; apologized, and told her I would speak to the office manager. Then she wanted the name and number of the office manager so she could write a formal complaint. As I was giving her the name and number, I was wondering what it would be like to just be able to do my job, and not have to suck it up for things I had no power over.
It looked like I was not going to get a chance to eat my lunch. The lady had just gotten started. Next came the story about how a radiologist had missed her friend’s cancer and by the time a biopsy was recommended, it was too late. I assured her that the suspicious finding on her mammogram was not visible on the previous mammogram, and I went over all her images with her. After I explained that she would need a biopsy, and went through the biopsy process with her, she told a lengthy story of the horror and pain her sister experienced during her breast biopsy. I summoned some patience, and did my best to reassure her that I would make her very comfortable during her biopsy, which prompted her to question my background and expertise. I summarized my credentials, at which point she asked if someone could fetch her daughter from the waiting room, and could I go over everything with her daughter, as she herself was bound to forget and confuse everything we had just been over. And so it went, for what seemed like an hour. Finally the tech interrupted and said another patient was waiting to see me. It was a lie, but I was grateful, because it prompted our difficult lady to excuse herself, but not without a jab. She implied that I might be recommending a biopsy merely to line my own rich pockets. I suggested a second opinion and she agreed that a second opinion would be a good thing. Phew! I secretly hoped she would choose to go elsewhere for her biopsy.
At the end of the day, when I felt like I couldn’t possibly make another decision, or deal with another whack-a-doodle, a young woman was added on to the schedule. Her boyfriend had felt a lump in her breast, and she was extremely anxious. I had to clear my foggy brain and find the energy to do a complete workup, when what I really needed to do was go home. Of course it turned out to be a probable cancer. Now, I had to beat back exhaustion, and muster some compassion in order to go over everything with her. When all was said and done, I was wiped out.
It was already getting dark when I emerged from the office. Around the block I went, back to the subway station. Even if it weren’t freezing cold, it was too late now to do the walk back to The Port Authority. As the subway train rocked back and forth to 42nd Street, I read the poetry posted on the wall. The poem was about financial struggle, and the joy of having enough money on pay day to be able to eat roast chicken and drink red wine, like everyone else. I related to the sense of deprivation, and the desire to have what others appear to have. I had a feeling that there would be a pay day for me eventually. The pain, mental and physical, would be over, and there would be lessons learned that would serve me. For now, I felt relatively lucky, because I was heading home to someone who would have a meal prepared to share with me, maybe even roast chicken. We would have dinner together, and drink too much red wine, and I would forget my situation, if only for a little while. Then back to bed, and up with the alarm, like getting kicked in the head.
It was six am and still dark. I looked around at the other zombies on the commuter bus to Manhattan. A few that had boarded at a previous stop had already dropped off to sleep. I could hear someone snoring. I was tired too…..