Lessons from the heart

This week has been, as one of my daughters would put it, a whole lot of no fun. My accountant is clamoring for my tax stuff, my health insurance needs to be renegotiated (can you believe how expensive it is these days?), my office staff is in turmoil because none of the ladies really like each other, I forgot to pay a couple of (household) bills because I've been so busy at the office, my feet hurt from standing around so much, an attorney called and asked if I might be an expert witness (I guess because I'm so experienced with the legal system), I have a couple of patients with Crohns that perplex me, my BP was 150/99 earlier today, and it's been drop-dead gorgeous outside and all I can do is sigh and think of the days of my youth when such a day would motivate me to ride my motorcycle or go gliding or to do something other than sit around and complain to a bunch of total strangers.

It's good of you to listen. Sometimes the only thing you can do is be there for me.

In the Christian tradition followers often withdraw to a quiet place for solitude and meditation. In the American medical tradition the best place for solitude and meditation is the bathroom. They never find me there, and if I turn off the pager for ten minutes I can be guaranteed peace and relief from whatever burdens I might be carrying, if only for a fleeting moment.

I can read a lot on the move, so to speak, because I download a ton of stuff to my handheld. During times of stress when I feel like hiding in the basement until my creditors drag me out, I'll turn to something uplifting so I'll remember why I went into medicine in the first place.

The article that helped me today is an article from JAMA entitled Twenty lessons from the heart of medicine (see the link above). Dr. Alan Guttmacher is a medical geneticist who suffered a heart attack in the late 90's and went through an arrest, cardiac electrical shock, and lengthy rehabilitation. The article is both amusing and thought-provoking, and I've extracted the lessons for your enjoyment. Enjoy.

1. Never sleep with anyone who doesn't know CPR (his wife, a nurse, saved his life).
   
2. Although neither may know it, patients are actually more motivated than their caregivers.
   
3. Patients feel guilty if they don't meet caregivers' expectations.
   
4. Both unconsciousness and amnesia can be good (why do they have such bad reputations?)
   
5. While not as bad as I imagined, 250 joules (of electric shock) is better to give than to receive.
   
6. The sicker you are, the more helpful a sense of humor, in you and in loved ones.
   
7. Patients do not fully share physicians' excitement in "interesting" cases.
   
8. Always wonder, "Why does this person have this disease?"
   
9. Illness may not be the patient's fault.
   
10. All physicians become patients.
    
11. Always ask about family history, particularly if the patient is a geneticist.
    
12. Even for a physician, it is easy to be passive as a patient, especially when scared.
    
13. To prepare for Olympic swimming or a heart attack, shave your entire body.
    
14. Too seldom inquired about, the patient's view of therapy often differs from the physician's, and is valid.
    
15. In medicine, one size does not fit all. Treat the patient, not the disease.
    
16. You can't overvalue family and friends.
    
17. Illness is an intense part of the human experience. While always unwanted, it is often literally invigorating.
    
18. Every day is a gift. Be well. Do well for our patients.

The little mouse in the corner

Mealtime for the family of a gastroenterologist is not for the weak-of-stomach. It's not my fault that seeing flaming Cherries jubilee brought out to our table prompts an uncontrollable reflex in me to discuss the really cool case of hemorrhoidal bleeding I'd seen lately. It just happens.

For that reason the rest of my family has no hesitancy in bringing up subjects that others might find a bit unappetizing.

One evening at a nice restaurant Daughter the Younger told us of a time she had been to a zoo and got to watch feeding time for the snakes. "There was this one fat old lazy snake they were feeding. The workers dropped a little white mouse in the snake's cage. The snake woke up and took one bite of the mouse's tail, lost interest, and fell asleep. There was the poor little mouse with half his tail gone, shivering in the corner as the snake slept. I kept thinking, 'Why are we just standing here? Isn't anyone going to rescue the poor little thing?'".

I agreed. We mammals had better stick together. Under threat of punishment we quickly changed the subject.

By the end of the meal, though, I thought I might break down and cry. Countless thousands of innocent people had died in the tsunami just the week before. Mice are eaten by other animals everyday. The hamburger I just ate required the killing of some cow who never meant me any harm. Yet this story touched something deep within my soul, a feeling that life-as-it-is-ordained is unjust and cruel and mean.

Somewhere in Florida a 'little white mouse' of a person is slowly dying as the snakes sleep and as we stand about wondering, "Why are we just standing here? Isn't anyone going to rescue the poor little thing?" People die all the time, cancer patients long for the day they will no longer hurt so bad, people with Lou Gehrig's disease look upon their future with only fear and dread, and life for the rest of us goes on. Yet this story touches something deep within my soul, a feeling that life-as-it-is-ordained is unjust and cruel and mean.

My pet alligator

During my recent vacation I visited an alligator farm in the Everglades. Because I had never paid close attention to Jurassic Park I hadn't realized that the gender of alligators is determined not by genetics but by the ambient temperature when an egg is fertilized. You learn something every day.

That alligators make lousy housepets didn't come as a shock. Baby alligators are cute in their weird reptilian way, and they grow up with nice toothy grins on their faces. They just don't posses a limbic system. Try as they might, they can't form emotional attachments.

You can take a freshly hatched alligator and nurture it for years, but it still wouldn't hesitate to bite off one of your body parts if it were hungry enough. Without a limbic system and a cerebral cortex, the alligator does not have the circuitry for sentimentality. Little wonder that people feed the alligators in their neighborhood hoping that the it will be grateful and behave accordingly, only to have it chomp down on an unlucky small mammal when given the opportunity.

I saw a very nice young lady in the office for evaluation of abdominal problems which get worse when she goes to court. As a trial lawyer she goes to court fairly frequently.

"I recommend you quit your job, go back to school, learn a trade, and make your living by helping people. Not only will your pain go away, but you'll also sleep much better at night."

In my dreams.

The reality is that she received the same treatment that I give all my patients. I reviewed the different diagnoses she could have, discussed diet and pharmacological therapy, and presented the diagnostic yield of the vast array of tests we have. She listened attentively and asked very good questions. It was a pleasure taking care of her.

For the life of me, I just could not get the image of those cute little alligators out of my mind the entire time she was there.

Tragically, all patients look a little like alligators these days.

Slow rabbits and fast wolves

Every morning the hungry wolf wakes up knowing that if he's not faster than the slowest rabbit, he won't make it through the day. Every morning the rabbit wakes up knowing that if he's not faster than the fastest wolf, he's not going to make it through the day, either.

This little fable kept popping into my head as I sat in on the coding and reimbursement seminar today. Lest anyone get the wrong idea, learning how to increase our reimbursements is not why we go to these things, even though that's nice should it ever happen. We go to these seminars to stay out of jail.

Trying to stay off the radar of the Medicare reimbursement and fraud prevention people is like driving along a tortuous road on a dark and stormy night in a car with no speedometer and where the cops change the speed limit every few days but it doesn't matter because they don't post the speed limit anywhere you can see it, and if you don't get to your destination very quickly a tiny little kitten will die a slow and miserable death.

The analogy might seem a bit overwrought, but to the doctor who's trying to be a good citizen, stay out of jail, and pay his malpractice premiums, it's actually understated.

I won't bore you with the details, but the consultants are warning us about some pretty ugly stuff coming along. Obesity is a growing problem in this country, and the surgeons performing gastric bypasses are seeing their practices burst at the seams.

Insurance companies are not happy pouring the feed into the trough, and their solution is very simple: put a lifetime cap on payments they'll make for bariatric patients.

My first reaction was a blase "Boy, that's too bad" until the consultant mentioned that in order to make the cap stick the insurance companies intend to limit what they'll pay for all digestive disorders.

"How can they get away with that?" Beats me, but with assets greater than most countries in the world, the insurance companies will find a way.

This means that gastroenterologists may simply not allow bariatric patients into their practice. And that would be a shame.

There are times that this old rabbit thinks his knees are getting just too sore.

A bad truth or a good lie?

"Doc, there may be times during your deposition that you will not like the answers you'll have to give", my lawyer intoned. "I'm telling you now, what ever you do, don't lie. I'm not telling you this for any ethical or moral considerations, it's just that a bad truth is always easier to defend than a good lie. The lies will come back to bite you in the butt every time."

I appreciated my lawyer not wanting ethical or moral considerations to get in the way of winning the lawsuit. Still, there are times when I'm trying to drift off to sleep that I hear my Bad Angel mutter to me: "You could have lied and gotten away with it. No one would have known except you and me, and you can always trust me. Let's face it, you're a fool. No one's going to give you a good citizen award for being honest."

My guardian angel whacks him with a flaming sword and off to sleep I fall. That's the advantage of trying to keep the lies you tell in your lifetime down to a bare minimum. It's a lot easier to get to sleep.

Perhaps that's one of the reasons so many people in America are sleep-deprived. We all struggle with dishonesty, but when it's required for career success it can wear a body down.

During a recent town meeting a representative of the Doctor Defender malpractice insurance company reassured the crowd that there was indeed no malpractice insurance crisis. What we're seeing is a market correction of sorts, but like all issues economic the market will soon take care of what ever inconvenience the doctors are experiencing.

What he didn't mention is that Doctor Defender had recently terminated coverage for the entire Department of Neurosurgery at the Local University, home to a very fine Level III trauma center.

I wish I would have had the pleasure of refusing to write the guy a prescription for sleeping pills.

Then again, I would have sympathized with him and called it right in, I suppose.

Two little questions

At the age of three or four we start asking two questions that would make us all a lot smarter if we made a life-long habit of it: "Who sez?" and "Why?". These questions don't tend to survive our college careers, not if we don't want to tick off our women's and ethnic studies professors.

The really bright doctors ask them all the time. At the GI rounds at the Major University in the Large City in the 80's, a bright GI trainee presented his study of Ogilvies Syndrome. Ogilvies syndrome is a nasty condition in which the patient's colon slows down and the cecum, ever obedient to LaPlace's Law, swells up with gas until it pops and empties stool into the peritoneal cavity.

The Wisdom of the Ages holds that the cecum will rupture when it reaches a diameter of 9 cm., so intervene before then or risk serious consequences.

"Who sez that 9 cm. cecum is on the verge of rupture, and why did he say it?" the GI fellow wondered. So into the library he went. He started with Roberts Rules of Medicine which cited a study in the 1978 edition of the National Medical Dispatch, which in turn cited an article from the 1969 edition of Surgery: Yesterday, Today, and Forever which in turn cited a 1961 edition of Rhode Island Surgeons Club which in turn cited a 1957 edition of the New Zealand Journal of Fish and Poultry which finally lead to an article from the 1952 edition of The Xray Journal in which the author admitted that he just made up the 9 cm. cecal diameter cutoff that had been accepted as gospel truth for thirty years.

This is not arcane lore. Knowing that there is nothing magical about the 9 cm. cecal diameter, we can give conservative measures a lot more time to work before risking any sort of surgical intervention.

These days I've been asking "Who sez?" and "Why?" about a study being quoted all the time asserting that there are 98,000 deaths each year from malpractice.

I tried to hunt the study down by googling it. The first fifty web sites were from malpractice firms informing us that doctors were killing off patients like flies and that only their law firms can protect the public. None of them referenced the actual study, and my Zoloft level wouldn't sustain additional research.

I then pulled up the statistics on cancer deaths. Colon cancer takes about 57,000 lives a year in the U.S.; breast cancer takes 41,000 lives a year.

If my math skills are holding up, the lawyers claim that for every person who dies of colon or breast cancer in this country, some doctor knocks off an innocent patient.

Think about it. If this were true, instead of wearing pink ribbons commemorating Susan Koman, patients would be wearing tiny little rope nooses on their lapels reminding them of the last time they dragged a doctor out into the streets and hanged him. The figure as cited by the lawyers is clearly nonsense.

There are legions of bright bloggers out there who may be more familiar with the study who can come to my aid. In anticipation of that assistance, I will maintain that the 98,000 figure defies common sense.

Parking diagonally in a parallel universe*

A long time ago in a parallel universe I lived in a small town with one of those charming weekly newspapers that had articles in it like this:

Mrs. Elma Tutweiller from Mt. Washington paid a visit this weekend to her first cousin-once removed, Doris Tutweiller of 231 E. Liberty Street. "I like the Shoneys here lots" Elma said. "The brownies in the chocolate-lovers delight are soft and chewy, not them little brown bricks they got back home."

Not all of the articles dealt with the social scene. Some very thoughtful comments hid amongst the high school sports scores and the crimes reports.

"A doctor's wife copes with the malpractice crisis", the tiny heading read, right underneath the article announcing that Joe Jimmerson's dog had given birth to a litter of beautiful lab puppies. The wife of one of the family doctors in town shared her thoughts of the shame and uncertainty that a lawsuit brought to her medical family. It was well-written and deeply moving.

I knew her husband and had heard about the circumstances of the lawsuit. My considered opinion was that the doctor should have been stripped of his license, tarred and feathered and run out of town on a rail. How the others doctors felt about him I was never sure, other than the fact that shortly after the occurence the doc was elected as president of the county medical society.

Few of us like taking care of the woman who shows up at the ER at all hours of the day and night, complaining of horrible headaches or backpain, severe pain that would get a lot better if the doc on duty would only write her a prescription for Percocet. The family doctor certainly let his feelings be known when he admitted the 35 year old "frequent flier" lady to the hospital for observation of belly pain.

"This lady is a loser, a blight on the town, happy only when we give her a Demerol fix" he wrote in the chart. Off he went deer hunting.

This was in the 80's and few had cellphones then. The doc didn't have one, or at least he wasn't answering it. He ignored the nurses' call letting him know that the patient's belly pain was worsening, even with high doses of pain-killers. He ignored the call letting him know that the patient's abdomen had become board-rigid and that the patient could barely breath because of the severity of the pain. He ignored the call letting him know that she was going into shock. When he returned from his hunting trip, he answered the call informing him that the patient had died from a perforated ulcer and peritonitis.

In my sinless perfection I had nothing but contempt for the man. I resented that he never showed any public remorse over this blunder, chosing as best I could tell to portray himself as the victim of some cruel joke the patient had pulled. I resented that the local medical community rewarded him with the presidency of the medical society. I resented listening to him at cocktail parties mutter to his colleagues about the number of young specialists that were moving into the community and what a threat to his income potential they represented.

And I resent him now. Try as I might, I'll never believe that what I write will ever strike anyone as being anything other than excuse-making for my own blunders.

*The title is courtesy of the tagline of someone at Free Republic. Where she stole it from I don't know.

Very bad karma

Life was hard as the dirt-poor son of a poor dirt-farmer in Southern Maryland in the 60's. To this day I remember the humiliation of Farmers' Market on Saturdays, seeing all the displays of neatly stacked corn and tomatoes as we sat trying to sell our dirt.

"Why would anyone want to buy that stuff?" the other farmers would say, laughing derisively at our wheelbarrow. "Anyone can dig that up in their own backyard!"

That was a long time ago and I admit that the recollection may not have been seared into my memory with total accuracy. It's true, though, that when I graduated from college I didn't have a pre-Carter-inflation nickel to my name.

Rather than take out a loan and graduate from medical school $80,000 in debt, I applied for a military scholarship. Everyone hated the military in the 70's, and getting a full ride to medical school courtesy of the Armed Forces was easy.

After medical school the Service owned my as-of-that-time unchapped hide. Part of the arrangement was that I could do as much of my post-graduate training in the Service as I wanted without incurring more "payback" time. I did all of my training (internship, residency, and fellowship) while in uniform.

I'm proud of my training. Some of the very brightest and best doctors I've ever known were also the progeny of dirt-farmers, drawn to the military by the lure of scholarship money.

That made it insufferable when we were led to the back of the academic bus as second-class citizens and third-class doctors by the civilian training programs. I remember the humiliation of sitting in a conference at the nearby medical school (the same school that was drilling Savary dilators into peoples' chests), decked out in uniform, listening to the audience yukking it up as the Distinguished Speaker recalled his own Army days:

"My title was MD, USA which some thought meant 'medical doctor, US Army', but which I knew meant 'Many Died, U Shall Also'."

Pretty funny if you ask me.

Adversity makes us better people, or as a famous philosopher once said, "That which does not kill me only postpones the inevitable." I studied my hide off and scored in the 96th percentile in both my internal medicine and gastroenterology boards. One of my colleagues scored even higher. Screw 'em if they thought we were nitwits.

All doctors have ugly memories of their training, often centering around the ER. ER's in the military were particularly ugly. We could not charge anything for anyone coming to the ER for any reason, so there was no incentive whatsoever for people not to use it for even the most trivial of illnesses. The result was that you'd have 100 folks checking in, only one of whom needed to be there. Would you be able to figure out who he was?

One busy night at the ER, a harried intern and his attending were dealing as best they could with the onslaught. A little boy had cut his lip and was raising five sorts of Cain, screaming and crying and otherwise very loudly expressing his unhappiness with the situation.

"Let's go ahead and sedate him until we can take a few minutes to sew him back up" said the attending. "Give him some Phenergan and Demerol."

Someone with a higher level of training than internship would have realized that the attending meant for the medications to be given IM, which would be slowly absorbed into the bloodstream, rather than IV, which would reach full effect very quickly. The intern didn't realize it and gave the meds IV. As the doctors were scurrying around, the little lad was placed on a comfortable bed in the corner where he stopped breathing. It was probably twenty minutes later that he was found dead by one of the nurses.

The first I heard about this case was when I read about it in the papers. The case was quickly and quietly settled out of court for large sums of money from the government, as well it should. If you are a military physician you can't be sued, only the government that employs you. The intern won't ever have to list this on his applications for malpractice insurance.

I probably didn't sleep for three or four days after reading about this. At the time I had two beautiful daughters at about the same age. It was beyond comprehension trying to imagine the shock, the loss, the anger and grief and misery that such an occurrence would have caused a parent.

It was also beyond comprehension trying to imagine what life was like for that poor intern. In my training I had some less than stellar moments, although nothing that came close to this level of error or consequence. With any of my own blunders I would lapse into a depression, wondering each morning why I should even go into work, fearing for anyone unlucky enough to fall into my clutches. Unless the hapless physician received electroconvulsive therapy or is heavily medicated, I can tell you that not a day goes by when he thinks about the little child under his care dying in the corner of the ER thirty years ago, his parents out in the waiting room ready to take him home, his lip all sown up, stopping at the Baskin-Robbins on the way as a reward for being such a good little boy.

Zen and the art of colonoscopy

As an erstwhile writer I fancy myself a cheap-imitation Robert Pirsig, the author of Zen and the Art of Motorcycle Maintenance. Though I didn't understand some of the book (I'll take his word on it regarding Poincare) and didn't agree with most of what I did understand, I admired his style and skill. Pirsig wandered about multiple subjects such as the nature of Quality, the care of motorcycles, and the relationship with his son, while tying it all in with the narrative of his slow descent into madness.

While I'm open the the possibility of the descent into madness, I prefer to think of the underlying theme of this blog as my march to extinction. I'm like a brontosaurus who wakes up one day and writes in his journal "Boy, it's cold today!" as the planet plummets into the nuclear winter of a massive asteroid strike.

Before too long, if I dwell on the dumb asteroids in my life, my limbic system melts down and I risk stroking out at the keyboard. Gotta change the subject for now. I'll return to my tail of woe later.

Which has precious little to do with either Zen or colonoscopy, so I'll leave you with this thought:

The fecal stream flows

Scopes go against the current

As the lawyers wait.

Fifteen minutes of fame

I'm not sure what category of blog SMLSLT is. I despise my cats, and my poetry output is so meager that this site would never qualify as either a kittyblog or blogerrel.

At times I think this is a Godblog, with two huge reservations. I often view my faith as being at least a bit of a fraud. W.H. Auden put it this way:

Those of us who have the nerve to call ourselves Christians will do well to be extremely reticent on the subject. Indeed, it is almost the definition of a Christian that he is somebody who knows he isn't one, either in faith or morals.

I also don't think Jesus would have taken a bold public stance on the malpractice crisis. I know that the malpractice attorneys out there are good people. You go to church and pay your taxes, plan for your children's college educations, and coach Little League teams. I just think you hurt people and place your own personal interests over the public good, like the doctors you condemn. I want to see most of you put out of business, or at least make you get by on one-fourth of your current income. It's not personal. It's just business.

SMLSLT is if nothing else a Hugh Hewitt inspired blog. After I read his book Blog I started this site and sent him a copy of what I thought was one of my better posts. As I was tracking my hits, wondering if I'd ever break the 20 hits/day ceiling, I noticed that I'd received something like 700 hits in one hour.

Hugh was very kind to make a reference to my site, and given his readership (several million hits a day, I'm sure) if just 0.001% of his readers visit this site it's still a lot.

Too bad I went on vacation the very next day, and refused to log onto the Internet for an entire week. Here's my fifteen minutes of fame and I make all of two posts over two weeks. Talk about a momentum killer.

As this week settles down, I'll return all the kind comments I've received during this "flash-in-the-pan". It's a pleasure to visit your sites, which I always do if your comment isn't anonymous. So many great writers, so little time...

Anatomy of a blunder

Some folks were offended when told, before they had the chance to see the movie, that the Titanic sank. If you're like that, skip this post. I'll continue my sorry fake-but-accurate shipwreck of a tale later in the week.

For everyone else, this is how the story ends: I didn't perform the colonoscopy demanded by the patient, and he turned out to have colon cancer, and I got my butt sued off.

How could something like this happen? For many of you this will be a once-in-a-lifetime experience to listen to a doctor admit to anything less than perfection.

These are the factors I've identified:

Over-reliance on technology. We have the finest diagnostics in the world, but we sometimes forget that all tests have their limitations. Sadly, we've let our physical examination skills and, to some extent, our clinical accumen atrophy. It's easier just to order a CT scan.

A misplaced sense of fiduciary responsibility. Healthcare costs are skyrocketing. The national debt grows every day. It would be wonderful if we docs cut back on all the tests we order. We'd save a lot of money.

Well forget it. Unless a physician participates in a capitated insurance plan (which I don't), there is little to be gained and a lot to lose by even thinking about being careful with your healthcare dollars.

Information overload. There are a lot of things vying for our attention. Sometimes the urgent crowds out the important.

Arrogance. I pride myself on my sense of humility, but there are times I make up my mind and don't want any additional facts to confuse me.

Guardian angel vacations. Evangelical lingo would sound like this: sometimes God, for whatever reason, removes His protective hand from us. Or like this: the Good Lord let Satan take a chain saw to my hedge of protection.

Relying on the work of other doctors. I never dreamed that the Best GI Guy In Town, Maybe Even The State would miss such a serious lesion.

Stupidity. Just what on earth was I thinking? Do the flipping test. Collect your fees. Don't worry about it. Hope the patient doesn't get a complication from yet another "unnecessary" test.

Now if you'll excuse me, I'm going to curl up in the fetal position and hide under my desk for awhile.

Guardian angels

Guardian angels are good to have around. Mine was quite busy in my misspent youth, given my proclivity for driving vehicles off roads and into trees.

As I began to acquire a little maturity and common sense, my angel kept track of me in different ways. I've noted that when I've been able to make an obscure diagnosis or use a novel form of therapy, the angel always seems to have put just the right medical article in my hands the week before.

Skeptics scoff at this. They'd say I'm not aware of what I've missed, or I wouldn't have missed it. I'll have none of it, though. It's occured too frequently to be happenstance.

The problem is what to make of times when the angel's not around. A hard working angel might just need to get away every now and then, dancing the night away on the head of a pin somewhere.

I once treated a man my age for heartburn and such. He was a bit of a malcontent, changing family doctors every two or three years. We got along well and he stayed with me for years.

While I was on vacation one summer, the gentleman developed signs of internal bleeding. For reasons I've never understood, instead of sending him to one of my erstwhile associates, the family doctor referred him to the Best GI Guy In Town, Maybe Even The State. The BGIGITMETS scoped the patient top and bottom, finding no significant pathology.

True to form, the patient took offense over some comment his family doc's receptionist made, so off he went to another family doctor, who in turn sent him back to me to repeat the studies performed by the BGIGITMETS. It wasn't clear to me why, given the short time that had elapsed (three months), so I dutifully reviewed all the scope records. The work-up looked to be thorough.

The patient returned several months later, this time demanding to have the scopes repeated. He just knew there was something lurking in his bowels somewhere.

I could have really used my angel's help just then. I reviewed the original work-up and the tests that had been performed in the interval and concluded that repeating the scopes didn't make sense. Medical costs are skyrocketing, and it seemed like a foolish waste of resources. And I told the patient so.

To be continued.

Personal best

I have just set a personal best: eight days (count 'em, 8) without any internet connection. It was available, to be sure, but I chose not to do as much as review my email during our marriage enrichment seminar. I realize that recent studies warn us of the risks of too much family time and the serious adverse consequences it can have on our internet relationships. I thought it wise to pay attention to the bride of my youth. A thriving practice with a lousy marriage is nothing of any lasting value, but a good marriage with a loving wife and three wonderful offspring is a pleasure in God's eyes.

But I've got a lot of catching up to do.