American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, November 19, 2015


“Inchworm, inchworm
Measuring the marigolds
You and your arithmetic
you'll probably go far.
Inchworm, inchworm
Measuring the marigolds
seems to me you'd stop and see
how beautiful they are.”
—Originally performed by Danny Kaye in the 1952 film Hans Christian Andersen

This morning I was in the Primary Care Center seeing a patient with 1 of my favorite residents. The patient was there for a follow-up and despite being on medication already, her blood pressure was high. She was already on 1 medication for it but it appeared that this wasn't enough. And the plan my very able resident had put together was evidence based and perfect reasonable. He wanted to add on a diuretic, or a water pill, to her regimen.

And that was mostly cool.

Except. She was wearing a ring with 6 different colored gem stones. And next to her chair was a red metallic cane with a black rubber stopper on the end. Though mild enough to not warrant joint replacement, the osteoarthritis in her hip was significant enough to cause her to use that walking stick for assistance in her ambulation.

“You want to give her a diuretic?”

“That or a calcium channel blocker. I mean, had she not been a diabetic, my first line monotherapy would have been a water pill, you know?”

I nodded and jutted out my lip.

“That's reasonable, right?” This resident, who is now a senior, was asking this as a rhetorical question. He'd been at this long enough in this clinic to know that it was perfectly reasonable to start an African-American lady with normal kidney function on a water pill for her blood pressure.”Dr. M, what do you have against hydrochlorothiazide?”

I chuckled and shrugged. “Nothing, man. I was just thinking about her Mother's ring with the 6 birth stones and her fancy red cane, that's all.”

He squinted his eyes at me for a beat and then pressed his lips together. “I get what you're saying, Dr. M. But she gets around really well with that cane. Seriously, she trucks it. Honestly, I think she can make it to the restroom, even with a water pill making her have to go a little more.”

“Okay. But did she have 6 vaginal deliveries? Because that's a game changer.” I raised my eyebrows after that question.

“You know? I don't know. But my guess is yeah, she did. Hmmm … okay. Gotcha.”

So that resident went back and chatted with that lady. And he learned that, like many women who pushed out 6 babies, even without arthritis making it harder to get to the commode, urge incontinence was a bit of an issue. Or better yet, it was a major issue. Given that fact, a water pill wasn't something that she felt too excited about, and since there were other options, we went with 1 of those instead.


You know? I noticed that ring but never had a big conversation about it. I just saw that it had those 6 stones and that it said “MOM” on it. And I did point it out and call it pretty at which point she said that her children had given it to her more than 20 years before. And that she'd always loved it.

And I could see why. I really could.


“2 and 2 are 4
4 and 4 are 8
8 and 8 are 16
16 and 16 are 32.”

You know? I am not the smartest person in my hospital by a long shot. I forget all the details of certain medical facts and have to look up stuff that many other people have long since committed to memory. I blank on the names of research trials and read probably just as much as a resident to jog my memory or teach me new things when I'm on the hospital service.


I do love people and, for that reason, I notice them and the stuff around them. I do.

Today when I parked in the garage at Grady for that clinic session I was a little late. This older gentleman who appeared to be also heading into work at some office part of the hospital system held the elevator for me which I appreciated. And when I got on, he looked right at me and said in the warmest, brightest way, “Good morning!” And the way his eyes twinkled under his salt and pepper eyebrows, I immediately knew it would be just that.

His shoes were shined. I knew it because my husband shines his shoes and irons everything he wears each day, so I sort of appreciate it when a man is attentive to such things. For a minute I felt slightly embarrassed when he caught me looking at his feet. But then I decided that it wasn't a big deal that he did.

“You shine your shoes,” I said it with a confident smirk.

He threw his head back and laughed deep and hearty. “That I do.”

“My husband gets his shoes shined every chance he gets.”

“Sounds like my kind of gentleman. Military?”

My eyes enlarged. “Wow. Yes. Previously in the army.”

Just then the elevator opened. “Same here,” he replied while gesturing for me to exit first.

“Alright then, sir. You have a great day.”

“It's already done,” he responded and waved good bye.

And that was that.

Right after that, from the corner of my eye, I saw 1 of our residents helping this lady figure out the payment system on the new electronic parking meters. They were both leaned over and peering into that contraption studying the LED lights and trying to make sense of it all. It looked like it was taking a lot of time but he was patient, I could tell just from his body language. I could tell she appreciated it. I did, too.

It had been raining for the last couple of days. The concrete was still brown and damp and the grass was glistening. The air felt more autumnal and crisp which I liked. The heels of my boots were clicking on the asphalt. I'd decided that I'd move into my fall-season attire regardless of the weather. So I was glad that, on this day, the climate seemed to be on the same page with that decision.

As I hustled by, I saw that a broken umbrella was lying on the grass, probably the aftermath of a gust of wind or from some frustrated person who'd reached their wits end with a dollar store special. It looked salvageable if you asked me.

“I like your boots!” That's what this man sitting on one of the smoking area benches called out to me between puffs on his cigarette. And it was kind of sweet, too, because the way he was smiling at me felt sincere and not fresh.

“‘‘Preciate that!” I called back.

“Go ‘head, then, Bootsy Collins!” He laughed loud and so did I. Because I know who Bootsy Collins is. And him saying that was pretty funny.

And that was that.

So yeah. I do this every day. Like, I walk through and around Grady and I just look and notice and take stuff in. The sights, the sounds, the scents, the all of it. I see flowers on window sills and allow myself to appreciate the tiny miracles happening in that place every day. And now it has become a habit. Which I love.

See, medicine is so serious, you know? I mean, you're trusted with caring for human beings and for making decisions that could hurt them if you aren't careful. You want to make the right diagnosis, prescribe the right treatment and stay up on all of the latest medical literature. And that, all of that, requires a level of precision, focus, and diligence that makes it hard to notice much else.


But medicine also opens you up to humankind in the very best ways. Especially at a place like Grady. There are some days where I get so bogged down with the medicine and the details that I forget that part. I neglect to notice the birthstone ring or to have a little small talk about whether or not the Falcons are better than the Saints. When I'm in that place, I miss things. No, not life or death things, but still things that just might change the trajectory of everything. Like the freckles sprinkled across a patient's nose that could create a space for us to start calling each other “cousins” since I have them, too. Which would be bad since sometimes I might be the only “cousin” or family that patient has. So yeah, whenever I get like that, I know it's not ideal. Like, even if the medicine is accurate and evidence-based, without the humanistic component it never reaches the gold standard.

Does this even make sense? Lord, have mercy. I know I'm rambling.

But yeah. It's kind of like that inchworm, you know? Measuring these gorgeous marigolds and never once marveling at their beauty whilst making meticulous measurements. I have always loved that song and sing it to my children to this day. I sing it as a reminder because these same lessons apply to every aspect of our lives--particularly family. So busy focusing on the to-do lists that we don't take in the experience. So consumed with making sure our kids are clean and have homework ready and are safe that we don't enjoy them. Yeah. Kind of like that inchworm.

Two and 2 are indeed 4. And 4 and 4 indeed make 8. But what about the marigolds?

At the very end of that clinic visit that patient told me about her grandchildren. Three of the 11 that she had were now in college. And that was a big deal because neither she nor any of her 6 children had attended college. And I told her that she should be proud and she replied that she was indeed very proud. I also loved when she said, “I'm especially proud that I raised the kids who are raising my grandkids.”


After clinic when I crossed the street, it was drizzling again. I popped open my umbrella and began hustling toward our faculty office building. Then, I caught a glimpse of a man in tattered clothing walking down Jesse Hill Jr. Drive in the opposite direction. He was holding what I am sure was the same umbrella that I'd seen earlier on the lawn that morning, and it was keeping him dry. And when he saw me looking in his direction, he waved at me and then called out in my direction, “I like your boots, doctor!”

And in an equally booming voice, I replied, “Bootsy Collins!”

He stomped his foot 3 times and laughed at that. He even slapped his thigh for emphasis. Which I think might have been the best thing I saw all day. In fact, I know it was. Because this probably homeless gentleman had something to protect him from the rain and he also had enough joy in his soul to still smile on a wet and wintry day.

I loved it all.
“Inchworm, inchworm
Measuring the marigolds
You and your arithmetic
you'll probably go far.
Inchworm, inchworm
Measuring the marigolds
seems to me you'd stop and see
how beautiful they are.”

I hope I never get too caught up in the arithmetic of life. Because these marigolds around me? Man. They're too beautiful to overlook.


Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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