Sayed Tabatabai, MD
@TheRealDoctorT
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Physician. Writer. My debut book “These Vital Signs” @HarperCollins is now available in stores and online. Owner of @iggythepetrock
San Antonio, TX
Joined October 2013
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“THESE VITAL SIGNS” is now available in stores and online, in hardcover, e-book, and audiobook formats.
Click on this link for buying options:
Or seek it out wherever you buy books.
It makes a great gift for students, friends, family, anyone!
Thank you
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The medical student shadowing me looks over my clinic schedule. She sighs exaggeratedly.
“Doctor T, your YOUNGEST patient today is 70. Don’t you get tired of only seeing older patients?”
I look down at my patient list, and smile.
I don’t see what she sees... 1/
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The surgeon’s hand is visibly trembling.
The scalpel’s blade glints as it catches the light.
I’m a medical student, scrubbed in on the case. I’m not going into surgery, I know that. I’m here for him.
He glances at me and notices I’m holding my breath.
He grins.
“Relax.” 1/
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There is a car, in the hospital parking lot.
It is a faded red, covered with dust.
Other cars have parked and left on either side of it, every day, but this car remains.
I pass by it, as I find parking, on my way in to work.
I know what it means. 1/
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TW: pet animal death.
My last patient of the day sits across from me in the exam room.
A hulking tree trunk of a man, his arms are folded across his massive chest and he has his usual irritated look.
He leans back in his chair.
We begin the rituals of the office visit. 1/
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“Don’t you wanna see young patients? Isn’t it rough seeing old people, on so many meds with so many medical problems, all the time?”
I look up from my patient list, and my reverie, to respond.
“This... is a privilege.”
My student doesn’t seem to understand.
Someday, she will.
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“They just told me I have cancer. It’s everywhere in my body. And you say you’re a kidney doctor? What the hell are you doing here?”
His voice is gruff, and as he looks at me, I feel the weight of his gaze.
For a moment I hesitate, then ask.
“Mind if I sit down?” 1/
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“Why do you want to be a doctor?”
I answer without hesitation, “I want to help people.”
“There are many ways to help people.”
“I want to save lives.”
“There are many ways to do that too. So I’ll ask you again, why do you want to be a doctor?”
“Because I believe in it.” 1/
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Days later, as I round in the hospital, I find myself glancing at his room number when I walk past it.
Remembering.
The longer you practice medicine, the more faces never leave you. The more memories linger.
“What did it take?”
Nothing at all.
Time.
Every last thing.
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It’s 2020 and students are rotating with me now.
I feel the awesome responsibility of trying to impart something meaningful.
I try to draw upon the wisdom of the many incredible teachers I’ve had along the way.
The students will learn the science.
It’s the art that’s elusive.
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Sometimes I wonder.
How much gas is still in the tank? How many journeys were still planned, or unplanned? Where did it go? Where was it going?
It was a beautiful car, once, I can see that.
As I drive past it, I pray for rain.
(For all the love we leave behind - ST, 2/20.)
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There’s a ghost on the corner of 3rd and Broadway
I noticed him the other day, as I made a left turn at the light.
He wasn’t there a week ago.
He must be new.
Nobody I recognize, but then again, his face is blurry and indistinct.
I look at him now, and I drive past. 1/
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Nephrologist here. Avoid coaches like the guy in the tweet below, and familiarize yourself with heat stroke warning signs:
This is the 3rd leading cause of death for high school athletes. Don’t die because your coach doesn’t understand basic physiology.
Imagine your kid's high school football coach posting this on Facebook.
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It isn’t easy being 80 years old.
Things don’t work like they used to. People don’t treat you like they used to.
I’m standing before the shower in my hotel room.
“Temperature?” A voice asks me.
“Warm, but not too hot,” I answer.
The shower starts, the water’s perfect. 1/
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One day Mike doesn’t show for his appointment.
I know something’s wrong when his wife sends us a bouquet of red and white roses, and a note.
“Mike passed away in his sleep. It was peaceful. He loved you and your office staff very much. Thank you.”
My heart is broken. 10/
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Twenty years ago, I gave a medical school interview.
I wore my best suit. I sat up straight.
I said I believed in medicine. I meant it.
Some part of me once burned brightly, but that fire is down to flickering embers.
Our lives mean more than this.
More than this.
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Anjali brings me food, without fail.
All sorts of delicious desserts that she cooks herself. I once tried to refuse (I’m trying to lose weight), but she looked like she would cry.
Her husband explains. Their son died in a car accident years ago.
She used to cook for him. 5/
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“Doc, why did you stop asking about the smoking?”
“Because I know you quit.”
He grins. “Maybe I just washed my clothes real good.”
Considering this, I sigh.
He laughs, “Just messin’. Crap was getting too expensive anyways, I just bought a Tesla...”
I can’t help but laugh.
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John and Lucy always come to their appointments together.
Sitting beside each other, they hold hands. Every. Single. Appointment.
I’m always moved by how quiet each one is when it’s the other one’s “turn” during the appointment.
They’ve been married for sixty years. 4/
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Howard can barely hear me.
Every single visit he apologizes for being almost deaf, and explains “I LOST MOST OF MY HEARING IN THE WAR!”
He has a photo in his wallet, of him in military uniform. I ask him how he won the medals he’s wearing.
He grins.
“I KEPT MY HEAD DOWN!” 6/
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Alma has an amazing knack for gardening.
I look forward to her appointments so I can learn more about what’s in season in South Texas this time of year.
We discuss how therapeutic it is to watch a plant sprout.
Her secret?
“Love.”
Every living thing needs love to grow. 7/
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Every day I see the same cook in the hospital cafeteria.
I say hello, and ask him the same question.
“How’s it going?”
He always smiles and shrugs, “Eh, not bad for a Monday.”
Except he says “not bad for a Monday” every day of the week.
Finally I ask him about it. 1/
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I’m on call this weekend. Anyone else out there noticing an uptick in severe nausea/vomiting/diarrhea cases, or is it just me?
Feels like something unusual going on.
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Steve plays tennis almost every day.
He’s in his late 70s, and one day, finally, I have to suggest that he start toning it down. I’m worried about dehydration.
He says he understands. He’ll tone it down. He promises.
Then he starts walking his dogs for four miles a day. 8/
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Gladys shows me a photograph.
She seems proud, and I regard it carefully. It’s a black-and-white shot of a concert. A young singer has his back to the camera. The rest is a sea of screaming fans.
A young Gladys is in the front row, clearly visible.
The singer?
Elvis. 3/
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Mike is one of the kindest human beings I’ve ever met.
He brings my entire office staff a bouquet of red and white roses every single visit.
His smile is gentle, his eyes are kind.
He asks me how I’M doing at the start of every appointment, and really wants to know. 9/
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At first glance, you might find Carl a bit intimidating.
Gruff and with a jaw that stubbornly juts out, as if DARING you to try him, he seems perpetually irritated.
But Carl runs a dance studio, and still dances every day.
At 70.
And when he smiles, the sun shines for him. 2/
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“Did you see how happy you made that kid? You make someone happy like that, and it’s special. And what did it take? Just a toy.”
I nod.
“What did it take?” becomes a mantra for me.
How simple kindness can be, how easy, if you’re mindful.
How positivity can ripple. 9/
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A time will come, after COVID, when our society will need us to rely on each other to do the right thing again.
There’s a ghost on the corner of 3rd and Broadway
I noticed him the other day, as I turned at the light.
He wasn’t there a week ago.
He won’t be gone tomorrow.
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The first feelings were overwhelming gratitude.
Gratitude for the privilege, for the science.
And then I thought of everyone who will never get a chance to feel the small sting in their shoulder, and the warmth of hope.
I made it back to my car, and sat down.
And I wept.
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Thank you so much to everyone for the feedback and shared stories and kindness! I made a promise once that I would respond to every single comment. I intend to keep that promise but unfortunately my lunch break is over so it’s back to work for me. I’ll be back.
Thank you 🙏🏻❤️
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Our healthcare system is too often unethical, immoral, unsustainable.
The insurance paradigm is focused on revenue generation. It strips the basic human dignity from patients, to the point where they can’t even make eye contact anymore.
I know that I’m part of this system. 9/
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All I did was sit down in his room every day. Sit down and listen, and eventually talk.
There was no great medicine I prescribed, no cure.
And yet I faced the music with him, and it was my privilege.
As I get up to leave, we say our goodbyes. I feel a wave of grief. 14/
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I turn off the lights.
These bulbs are old, not the newer LEDs. There is a lingering glow as the hot tungsten filaments gradually cool.
I watch them as the room slowly goes dark.
A lingering glow... and then nothing.
I am exhausted, but I can’t sleep.
A monster awaits. 1/
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He shows me photos of his new buddy, named Tesla, because he can’t afford the car but now he can still say he owns a Tesla and impress the ladies.
I groan, but can’t help but laugh at his newfound (cheesy) sense of humor.
I make a mental note to name my future dog “Castle.” 10/
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I feel it.
There’s something insidious here.
A casual cruelty we’re all complicit in.
“I can’t go to rehab, insurance won’t cover it.”
“Insurance won’t pay for that medication.”
“I can’t afford any of this.”
“I’m uninsured.”
This isn’t right. None of this is right. 12/
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On the morning of his 95th birthday, Joe woke up at exactly 6AM.
This small irony never failed to irritate him: he had never been a morning person, but the more the years passed, the earlier he woke.
“Well, this is it!” He said, to no one, as he swung his legs out of bed. 1/
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The elevator doors slide open.
There’s already someone inside, one of the hospitalists. He moves over to one side as I enter, subconsciously distancing.
I look at him and smile, “Coming or going?”
He doesn’t answer right away.
Instead, he pauses, as if trying to remember. 1/
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“Sure you can doc. But people already know. Lots of people deal with this. It ain’t that people don’t know. It’s just that nobody cares. Nobody gives enough of a damn to change anything. Nobody... cares.”
The visit ends.
My Zoom window closes.
His window closes too. 11/
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Every Halloween one of the amazing PAs I work with dresses up as her attending, and it cracks me up every time.
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I went into medicine to help people.
No, really, I did. I know it sounds corny now, or fake, I suppose. But there was a reason for this.
At least once.
I have to keep telling myself that. Keep remembering that.
Because I’m running out of time.
And I want you to know. 1/
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And just like that, I’m again struck by the cruel illusion of what I do.
The system I’m part of.
This patient did everything right; got insurance, paid his taxes. And he still has to barter years of his life.
And he can’t bring himself to look me in the eyes as he does so. 8/
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There are always questions at the end of the visit.
It’s only natural. Nobody remembers everything. I’m used to clarifying and reiterating.
But your question catches me off guard.
“Did you know that hummingbirds remember every single flower they’ve ever visited?” 1/
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He suffers from a rare cardiomyopathy, and has been hospitalized for weeks.
He awaits a transplant.
His heart is failing.
He’s 23.
I am a resident on the heart failure service. It’s known as “the rock garden” because of how chronically ill and complex the patients are. 1/
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Someone who’s always immaculately dressed at work sent me this little explanation as to why.
I wasn’t expecting reason
#3
, and it hit me hard. It’ll stay with me.
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Sitting in my car, I exhale deeply.
I look at my hands gripping the steering wheel, something I can control, knuckles turning white.
Was today a Monday or a Friday?
A blessing? Or just another damn day?
Tears threaten my vision.
It’s a long road back.
I drive.
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Oh I get it. I understand the stats, and the low likelihood of serious illness.
I get all of that.
I just don’t see it.
I see another full hospital.
I. Am. So. Sick. Of. This.
All that remains of me is raw exposed nerves, and deadened scar tissue, in equal measure. 8/
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It starts with a subtle unease.
She can’t describe what’s wrong with her because she isn’t even sure there’s anything wrong.
Something just feels ... “off.”
Maybe she’s a little tired. Maybe she’s a little stressed. Maybe her college classes are too much.
Who knows? 1/
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I don’t talk to him about smoking anymore after that.
Instead, every time I see him in clinic, I let him talk, and I look at old photos of him and his dog, Lucy. The only friend he’s ever had who never judged him.
What intensely lonely lives some of us live.
So many of us. 7/
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I shadowed a surgeon once upon a time, and saw him write a progress note:
“Surgery.
Stable.”
And then he signed his name with such a flourish it took up 3/4 of the remaining page (paper charts back then).
I think about that progress note. Often.
#callweekend
#notesnotesnotes
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Working in a hospital every day, I am always aware of time’s passing.
Babies are being born on one floor, as people die on others.
This life is delicate, and finite.
If there’s one thing I wish I could convey in all my writings, it’s how fragile all of this is. 1/
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I don’t understand why some events leave such a collective mark on our psyche, while others we’re supposed to just let slip away.
800,000 people dead and counting.
We aren’t equipped to grieve on that scale. But we can, we should, acknowledge it instead of pushing past. 9/
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*phone rings*
“Hello?”
“DAD!”
“Yeah! What is it? Aren’t you at work?!”
“YES, HE FOLLOWED ME BACK”
“Huh? Someone’s following you?!”
“NO, ON TWITTER!”
“Who?!”
“THE PRESIDENT!”
“Biden? Oh wow, that’s a big deal-“
“NO, THE PRESIDENT OF MEDTWITTER!”
“…”
*click*
“DAD?”
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The day I quit medicine was a Thursday, in 2004.
I was a freshly minted intern, arriving at my teaching hospital with that uniquely confusing mix of optimism and imposter syndrome that had defined my medical education.
I thought I was ready.
Instead, I was hopelessly lost. 1/
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The phone call comes in the early morning hours.
It is a call they’ve been dreading.
His wife’s hands shake as she fumbles with her phone, trying to use FaceTime, her vision blurry with tears.
He sits silently beside her.
While she sobs, he remembers.
These crooked paths. 1/
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“When the dog looks at you, the dog is not thinking what kind of a person you are. The dog is not judging you.”
-Eckhart Tolle
“My name is Dug. I have just met you, and I love you.”
- Dug, the dog, “Up.” 2009.
(A 🐶 Thread)
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Medicine, like life itself, is an exercise in managing uncertainty.
It’s okay to be unsure. It’s okay not to have all the answers. And it’s okay to figure things out as you go.
Cultivate resilience, and patience.
You’re not alone.
You’ll be fine.
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@PplwhoannoyU2
@closecalls7
Turned off the volume, called my parents to say goodbye, pre-dialed 911 for cardiac arrest, propped up the phone against the wall on the other side of the room, stared just above the screen so I could watch it through my peripheral vision…
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He has chosen to pursue hospice care, and will be going home to his family.
I am grateful that he will be at peace, surrounded by people who love him.
He thanks me for spending time with him, and “facing the music” as he gruffly puts it.
I thank him for his kindness. 13/
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COVID patients are short of breath, again. I’m looking at the same damn chest x-rays, again.
They tell me this is a milder variant.
What does that mean? “Milder?”
Can you please sit down and explain it to the ghost outside that room over there?
That it was only “mild”? 7/
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It’s a strange feeling, to realize that everything you ever wanted and worked for was a dead end.
I am a third year medical student and I have no idea what to do with myself.
My whole life I’ve worked for this, and now... nothing. 1/
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They’ve been married for forty-five years, and reached the point in their relationship where most of the communication happens wordlessly.
A subtle smile, a nod.
A “hmm” or a “yeah” or the occasional “fer sure.”
Their love reaches a place, deep down. 1/
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“You said you lost people you knew.”
I nod. “Almost everyone did, in the end. Everyone knew someone.”
“Did you lose something too? A part of you...”
I know what she’s asking. We rarely discuss it.
Some scars never leave you.
You have to heal.
I smile, and say nothing.
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At some point your parents picked you up, set you down, and never picked you up again.
I don’t know who first said that, but the thought has been lingering with me.
There are invisible milestones we cross every day, unknowingly.
Last times, and first times, for everything. 1/
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Someone once told me I have no taste, because I like pretty much all cuisines and most genres of music and film.
I think it comes from working in a field that constantly reminds me that our lives are short, fragile.
Finding joy in as many places as I could is a choice I made.
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The COVID wards are being reopened, again.
This time, however, it’s different. There’s no sense of imminent danger like there was before.
The feeling of fear has been replaced by a grim inevitability.
Return to work, fast as you can.
You are expendable.
You always were. 4/
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He shows me the photo taken of him cradling her the day she was taken to be euthanized. I look up at him and see his eyes filled with tears.
And suddenly I understand, clearly. The quiet anger, the folded arms, the smoking, all of it.
We grieve in so many different ways. 6/
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At the day’s end, he asks me if I have any questions.
I have one.
“How did you know that patient had a dog?”
He smiles. “Doggie bone on the keychain, bedside table. There’s another lesson Sayed: observe!”
I laugh as his bushy eyebrows wiggle to accentuate his point. 20/
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At the end of the day I head back to the parking lot.
As I walk, I remember a conversation I had earlier in the day.
“Did you know in some languages the words for “tomorrow” and for “yesterday” are the same?”
Time is a circle.
We only perceive the direction of its flow. 15/
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“Treat everyone you meet with respect, and kindness. Especially the patients.”
He pauses for a moment, looking back at me over his shoulder, as if making sure he didn’t lose me.
“Especially them, ok?”
“Ok.” I nod, filled with the enthusiastic resolve of the novice. 10/
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The patient is a relatively young man. He is confused, mumbling nonsensical phrases. I ask him what his name is. He stares at the ceiling with glassy eyes and says “cookies and cream.”
His kidney function is normal. I have been asked to see him for acidosis. 1/
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As death lingers in the hallways, and steps into the rooms, I think of you.
I remember you, and your trivia questions like flowers.
Like a hummingbird, I remember every single one.
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Wake up with a strange feeling in the pit of my stomach.
Not quite anxiety, not quite fear.
Shower and it doesn’t go away.
Drive to work, construction on the roads, take the detour. Park and exhale, overcome inertia and get out of the car.
The air is unexpectedly cool. 1/
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It’s a strange mindset to want others to suffer in a toxic system that you suffered in, but now have the power to change for the better.
If you went through something terrible, making sure it’s perpetuated is a sickness, not a strength.
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“I’m trying to make you better. Learn from me!”
I know you were talking about a video game.
But I also know your words will never leave me.
I am so deeply sorry.
I hope someday I’ll see you again, in a place where the wi-fi is always great, and all hearts beat strongly.
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The harsh truth is that my day would be easier if I didn’t sit down.
If I just stood at his bedside and spoke fast, did a perfunctory physical exam, and moved on.
The system incentivizes me to see more people, faster. And the faster I’m done, the faster I can go home. 3/
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I notice the small details, soaking them in.
He knows all the nurse’s names. The clerical staff. The janitors. The security guards. The transport staff. And he greets everyone.
He even pronounces “Tabatabai” correctly, on the second try.
I realize it’s about respect. 12/
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He’s old enough to be my father. Some part of me imagines that he is my father. Tears threaten my vision, as a hot anger floods me.
Now I wish I could angle my camera away.
I ask him if I can write about him. Because people need to know.
His response lingers with me. 10/
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It makes me think of World War I and trench warfare.
We keep digging these trenches to nowhere and convincing ourselves everything’s okay, only to hear the whistle again and be given the order to charge.
And so we charge into No Man’s Land, side by side.
Surge by surge. 5/
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If I don’t respond to your survey on physician burnout, it’s probably because it’s in the middle of a COVID surge and adding to my burnout.
There’s no need to send any more reminder emails.
I chose not to do it the first time.
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@BHayes63
I’m done trying to convince people. I just write for myself now, to deal with it and to make peace with it, somehow.
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We start having conversations that extend beyond the scope of his illness.
Conversations about life, and our experiences.
We have unexpected things in common, and discovering them is a unique joy.
The day finally comes where I take a seat in his room for the last time. 12/
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I have only ever known you within the confines of this exam room in my office.
Years ago, you were sent to me for a consultation.
Understandably nervous, you had all your questions written out on a notepad in your spidery handwriting.
You believe in being organized. 1/
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The thought occurs to him repeatedly, as he feels the slow rush of air in and out of his lungs.
The irony isn’t lost on him.
He is a pulmonologist, and all he can think about now is how he took every precious breath for granted.
He knows where this is going.
Dying breaths. 1/
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The question, when he asks it, is one I don’t expect.
“Doc, which kills you faster? Blood pressure you don’t control, or blood sugar you don’t control?”
The surprise on my face must register, because he explains further.
“I just can’t afford all these medications anymore.” 5/
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Back in the elevator, I close my eyes and breathe deeply.
Almost everyone I see these days tells me I look tired.
Time off helps, but it’s a temporary salve. My writing helps, again, only temporary.
Gotta get to the root of it all.
Where the ghosts live.
I can’t today. 14/
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At some point, your parents picked you up, set you down, and never picked you up again.
I don’t know who first said that, but it’s been lingering with me.
There are invisible milestones we cross every day, unknowingly.
Last times, and first times, for everything.
✍️
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To medical students:
Time takes many things away from you as it passes.
Life is often a difficult lesson in letting go.
But Time also gives you one gift; a precious, powerful gift.
A gift that can alter your very reality.
The gift of perspective.
So here’s mine. 1/
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If someone’s good at what they do, tell them.
If someone’s trying their best, tell them you see that too.
If someone’s there for you, thank them.
If someone’s taught you a lesson, even a painful one, thank them for that too.
And if someone’s already gone, let them go.
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“All I know is a door into the dark”
-Seamus Heaney.
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I am sorry you had to wear a mask.
I know it’s an inconvenience.
It makes breathing feel stuffier. It muffles voices. It hurts your nose, and your ears.
I know it feels like losing freedom.
I know it’s scary.
I am sorry you have to wear a mask. 1/
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There is a car, in the hospital parking lot.
It is a faded red, covered with dust.
Other cars have parked and left on either side of it, every day, but this car remains.
I pass by it, as I find parking, on my way in to work.
I know what it means. 15/
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Break-up lines by specialty:
ID: Sorry, our relationship is showing no growth to date.
Pulm: I feel like we need to breathe. We’re too restrictive.
Cards: This relationship is one giant stress test, and we’re failing it.
Endo: All we are is negative feedback loops. 1/
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Rounding today, the first patient I went in to see was eating an apple, so I left.
#AppleADay
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The following thread is based on a true story.
Since 1955, vaccination programs have reduced the incidence of polio by 99% worldwide.
However, in one of the most dangerous places on Earth, in the depths of the deepest poverty, one of the last footholds for the virus exists. 1/
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I get off the elevator at the ICU.
Nowhere in the hospital are there more ghosts than here.
They pace the hallways.
Angry, at the way they died. Disbelieving. Disoriented at how fast it happened. Feeling cheated.
They all want something more.
More than this. 6/
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I finish my work for the day.
I’m exhausted.
The kind of exhaustion that makes your soul ache.
I get on the elevator as the doors slide open, and a nurse gets on with me.
“Hey Dr. T,” she smiles, “coming or going?”
I smile, and then pause for a moment, trying to remember.
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“How many letters in the alphabet?”
I had been expecting a question, just not this one. Damn.
Uhh. Twenty-six. Right?
… Right? Argh, this is so simple, but why is it so difficult?
“Twenty-six,” I say.
The cardiology fellow who asked me the question grins, “Perhaps.” 1/
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I write my note and leave before the family arrives. Normally I would stick around for this conversation, but today I leave it to the intensivist.
There is a gravity in the presence of death and dying that exerts a palpable force.
I can only be exposed to it for so long. 12/
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That’s all so many of these ghosts want.
Acknowledgment.
One of my last patients of the day is also my sickest.
This is a pattern I have seen many times before: lungs too ravaged to salvage, multi-organ failure, kidneys struggling to maintain their beloved homeostasis. 10/
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Some days, yeah, all I want to do is go home early.
Some days.
I sit down and make eye contact. His gaze is angry, accusing, and beneath it all, afraid.
He is twice my age, and for a moment, I see myself through his eyes.
Young. Detached.
An agent of the system. 4/
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