ethics


I’m going to try not to comment on this too frequently, as I get to operate more. But:

I had a case the other night. I did most of it myself. Being as objective as I can manage, I think I did not do it too badly, perhaps even very well at some points, but overall I was certainly slower than the attending doing it all himself would have been.

Now, a few days later, the patient is struggling through the post-op period. Nothing frankly technical (no vascular bleeding, or suture lines falling apart) – but I can’t stop going over the case again and again, trying to decide, definitely, whether if I had tied those knots faster, or run that suture line more adeptly, or not crossed that one tissue plane that we weren’t supposed to cross, would he be doing appreciably better now? Or was he just a sick man having a high-risk operation, and the current problems are no more than were bound to result anyway? Really, actually, I think I probably only added 15 minutes to a 4 hour case. But I operated on him; I cut on him – and now he’s sick. . .

This is scenario is replayed for every one of my patients who encounters what, last year, not operating, I would have regarded as a common and inevitable post-op complication; a bump in the road. But now, I touched the patient; I more than touched them; I was cutting things up; and now things are not perfect.

my fault – my fault – my fault

I take back what I said about the janitors and cooks and garbage men having jobs as demanding or exhausting as doctors. Actually we’re quite different. This job doesn’t stop when you go home. Even in this era of sign-outs, and cross-coverage, and restricted hours, the job doesn’t stop when you leave the hospital, or when the clock says you’re off duty.

I’ve spent the last five days, missing meals and sleep at the majority of meal-times and night-times, not because I was required to, but because I couldn’t not. I felt obliged to do some “extra” things – double-check this or that; spend extra time making sure an NG tube was in smoothly, or that there was iv access, or that an xray got done and looked at immediately, before leaving the hospital; driving back in – and back in, and back in – to see people whom I knew logically were just fine, didn’t need me — but I couldn’t guarantee 100% for sure that something bad would not happen, because I had wanted to sleep instead of checking on something. So I checked.

There were times when I could have chewed out a resident from another service, told him to stop being an idiot, take a look in an anatomy book before calling a surgeon to say such silly things, if that’s really how little he remembers from medical school, and do his own work for a change. But I didn’t. I explained politely how impossible his idea was, then told myself that I couldn’t be 100% for certain that he was wrong and I was right, and it would be unforgiveable if the patient got hurt because I was having a turf war. So I went and did his job for him, and wrote a polite note saying a surgeon wasn’t needed.

The point is not that I should have skipped any of those things: they were plainly my duty. But they’re not in the job description, and they have nothing to do with whether or not I get paid. When I go home, I can’t stop thinking about this job, and the nurses don’t stop calling me just because I left. My professional duty obliges me to do all kinds of things that are not part of a timed job.

Like talking to the family of a patient who died. He wasn’t on my service, I wasn’t really there for the death, I still can’t figure out how I ended up being the one doing the talking. But I know I’m the only one of all the doctors involved who knew him as a person, before he was just a disaster that we were working on; and I myself am sad that I can’t ever talk to him any more. And so I went and spent time with his family, all of them in various stages of grief: some unable to talk, some angry and trying to blame me because I’m “the doctor,” some being logical and wanting detailed explanations. . . and the air in the room so dark it was hard to breathe. . .

I didn’t really know what they meant when they started talking about professionalism in medical school. Now somehow I’m here. I don’t know if I was always this obsessive and paranoid (I can’t call myself dedicated or thorough; maybe someone else will, some day); but I am now, and I have to be, and there’s a compulsion inside me, that I caught from the doctors who trained me, and I can’t not act this way.

Early in my intern year, I started learning one of the key principles in any residency program, which is that if anything goes wrong it’s my fault. The applications range from the mundane to the serious: wrong date on the notes because I’ve lost track of what day of the week it is, let alone what day of the month – my fault. Didn’t preround on a patient because I didn’t notice their name scribbled on the bottom of my list of consults from the day before – my fault. Didn’t reorder the statin after the patient started eating – my fault. Didn’t get in to the OR in time to help write postop orders for the chief’s big case – my fault. Didn’t make important vent setting changes till late in the day – my fault (I think I’m making that one up; I can’t say I’m 100% sure it never happened).

Today it was definitely noticeable, and the event was somewhere between annoying and infuriating for various members of the team (not least myself). One could argue that I wasn’t the only one at fault. But so to argue would be a waste of time and energy. As I’ve said, whatever goes wrong, is my fault. The chief I have this month is very helpful in this respect. Some seniors allow a little doubt to arise about whether it was entirely my fault. This chief leaves it in no question: undoubtedly, at all times, under all circumstances, my fault. This certainty saves a good deal of time and mental effort on my part. . .

(I’m not even sure myself if this is written with tongue in cheek or not; as you like it.)

I have become my own old enemy. I used to wonder at the residents riding the interns and medical students – how could they be so harsh, when they had so recently come through the same thing themselves.

I know now. First, it doesn’t seem recent anymore. Intern year is a rapidly fading memory – let alone medical school. That was a different person, in a different galaxy. And second, I’ve realized that my program and my hospital will deteriorate rapidly if the interns aren’t taught surgical ethics. My seniors taught me – forcefully – about work ethics, responsibility to patients, responsibility to team members, deference to attendings and chiefs. I didn’t enjoy hearing about it when they thought I was out of line; but now I appreciate the strength of the standards they passed on – and I want the interns to learn the same thing. In a few months, they won’t be interns any more; and if my class has failed to communicate what seem to me basical principles (don’t leave till the work is done; don’t leave without signing out your patients properly to a responsible person; don’t walk away from a patient whom you’ve just decided to transfer to the ICU; don’t forget to write a note about any important patient encounter, or any procedure you do; don’t assume that the ER will get a patient to the OR quickly, or with appropriate medications; don’t assume. . . anything) – then they can’t teach it to the next class of interns.

I like my hospital, a lot actually; I feel very possessive about it, especially alone at night in the dark hallways; and I want it to continue to provide good care. Which is why my interns and medical students are going to find me being stricter for the rest of the year.

This job is unique because every decision, every action, seems to have a moral quality. If I make a mistake, it’s not merely an error, it’s wrong. I feel it to be so – a sin against my patients – and my superiors act similarly horrified. Not only major failures: misjudging the need for an operation; choosing the wrong course intra-operatively; failing to recognize an important change in the patient’s condition – but the small ones: tying a knot wrong; not cutting exactly in the plane between tissues; forgetting to order morning labs; one liter too much or too little in resuscitation; imperfect phrasing in a note.

I don’t think this is just in surgery. It seems to be across the board in medicine, part of the nature of professional responsibility. Perhaps the rigidity of surgical training means it’s voiced more clearly, but I think my friends the medicine residents feel just as badly about errors small and large.

That’s the problem, of course – there are no small errors in medicine. Every single mis-step could have disastrous consequences, even if most of the time things work out ok. Getting morning labs a few hours late, to take one example, could mean missing a significant acidosis or hemorrhage for a length of time that could impair our ability to respond quickly and effectively. Sure, it would be rare for a few hours to make much difference; but I can easily picture it happening.

So every decision, every action or lack there of, carries a tremendous potential for guilt, which only increases with the size of the decisions. And every night, you can go home and spend hours second-guessing yourself: was I wrong? and if wrong, how wrong?

Other jobs may have long hours, but I doubt that any have this weight of moral implication attached to every moment.

I have a knack for tripping over the elephant in the room. But I ask you, how was I supposed to know that the attending got consent for an operation, performed it, and explained the procedure to the family afterwards – without ever stating outright that the patient had cancer? I don’t know, maybe he said it and the family were too upset to hear it. But I hate trying to backpedal when I say “cancer” casually as part of my explanation of the recovery period, and the family acts as though they were still hoping the object in question was benign, or perhaps a false alarm entirely. I’m getting good at a spiel for “I don’t explain this, I don’t have a lot of experience with this, I don’t want to misinform you, my attending will explain in due course,” along with my spiel for “swelling after surgery is normal” and “use the incentive spirometer or you’ll get a fever” and “please start walking now or you won’t be able to go home.”

Most of the attendings here have a policy that they won’t discuss pathology results until the patient leaves the hospital after surgery. I can see their point, after watching families and/or patients so devastated after learning the extent of the cancer that they have no will for recovery. But then the attending isn’t the one talking to the patients and families three times a day, and trying to sidestep the only question that people really care about – what did you find, how big was it, how bad is it, is further therapy needed . . . and of course, how much time do we have. People always think they want to know the worst of it right away, but perhaps it’s not best for them to know. I’m ok with saying that I’m not the attending, so what he chooses to tell the family isn’t my responsibility; but I wish he would give me the cue card for what he did say.

This is unbelievable: a woman has an abortion induced at 23 weeks gestation, but the abortion is not completed. The baby is born alive, then bled to death and thrown in the trash by one of the clinic owners.

The story itself is horrific, but I’m more amazed by the tone of the newspaper article, and of the people quoted in it. Why is everyone so shocked that this could happen? Why is the mother acting as though she’s been wronged? After all, killing a 23-week old fetus is legal in Florida. The woman visited the clinic three times in the space of one week in order to plan and carry out the death of her unborn child. The child ended up dead. Why is she surprised?

It’s obvious, of course. We all recognize that a child outside the womb is human, and deserves care. But this story highlights the logical and ethical impossibilities of the pro-death position: What essential fact about the child changed when it was born prematurely? Outside her mother’s womb, the baby had the exact same physical makeup as she’d had had a few minutes earlier, inside. She was the same person, whether in the womb or out of it. The clinic owner only carried out the mother’s expressed wish: the death of a child she didn’t want to be burdened with.

Wake up, America. Millions of similar innocent children are murdered every year, and we stand by idly. If this story shocks you, think a little bit about the thousands of helpless babies just like this one killed every day. Simply because their bodies are mangled and mutilated before anyone ever sees them and recognizes their humanity doesn’t change the essential fact.

May God have mercy on this nation, and lead us to stop killing our babies.

I finally figured out what’s wrong with all the portrayals of doctors on TV. They show emotion.

They have to, of course; they’re actors, for one thing. And basically, the drama would be a lot less gut-wrenching if the doctor didn’t act heartbroken when delivering bad news.

Real doctors don’t do that. We learn to hide emotion, from everyone – our colleagues as well as our patients. For example:

- Fear. This one is especially important to hide, perhaps because it’s such a constant companion. After all, fear is what makes us good: you have to be scared of how easily something bad could happen, in order to work hard at preventing it. You have to have seen vent-associated pneumonia, and fear its return, to really care about preventive measures or early diagnosis.

But it has to be private. After all, they say surgeons are like sharks: they attack at the smell of blood. Fear of not knowing the right answers only draws more pressure.

As for fear of the outcome for a patient, that has to be hidden, because such things only get stronger by being shared. If everyone in the trauma bay getting ready for a bad level I admitted their fear, we wouldn’t be able to function. Some of the seniors lately have been demonstrating that to me. The trauma pager has been going off again and again, one trauma after another, and now a really bad one. The patient was intubated en route, which is not good, and the confused early reports suggest that there’s something seriously wrong. The nurses and techs run around, laying the room out, assembling the monitor wires, getting the ventilator set up beside the bed, laying out the needles for starting ivs and drawing blood. They’re efficient, but the atmosphere is hectic. Then the senior physician in charge walks in. It could be the ER attending, or a chief surgery resident. They walk slowly (when there’s time), and move deliberately; no wasted steps. Calmly, loudly enough to be heard, they start arranging: who will stand where, who’s responsible for which part of the resuscitation, who’s in charge of the airway, who’s standing by to place a central line, where the thoracotomy kit is if it should be needed. Their calmness settles everybody down, and keeps the room from exploding into chaos when the patient actually arrives. (The worse a trauma is, the quieter the room is. When things are really bad, no one chatters, for fear of drowning out important information.)

Fear also has to be suppressed when talking to patients or families. They ask for the truth, but they don’t really want to know what we know. Even when things are unquestionably bad, the news has to be broken gently, maybe over the course of a couple conversations – because they need to be able to keep functioning. And if the worst-case scenario is only a shadow in my head, there’s no need to torment the patient and family by discussing what will most likely never happen. If I look excessively worried, that scares people so badly that they can’t think; the other children still need to be fed and put to bed.

- Sorrow. I learned this probably in August or September of intern year, and keep relearning it: if you cry about every patient, there’s no time or energy for actually working. Really, I’m hurting my patient if I allow more than a minute or two to consider how awful their predicament is, and how tragic it must be for their family and friends. I need to be thinking about can be done to make him better.  Crying wastes time; meditating on the nature of evil wastes time.

- Of course anger has to be hidden as well (another emotion that TV doctors are frequently good at). Anger, like fear, wastes time and clouds judgment.

Above all, emotion is unprofessional. We’re supposed to be cool, calm, rational – in charge. And that means not showing our colleagues or our patients what we really feel. Drama is for the soap operas, not for professionals.

There’s a certain patient population that surgeons see too much of: a particular personality type among lonely middle-aged females, who tend to develop excruciating (to them, at least) abdominal pain, and turn up in clinics and ER rooms with distressing frequency. All too often, what they’re really looking for is a percocet script to last them through a difficult week. Unfortunately, it takes some expensive scans/consults/scopes to rule out other problems. (There’s more to this scenario, but I don’t want to give too many details; there’s a reason for my cynicism.)

I spent the last year figuring out that these patients do exist, and that some people with abdominal pain are never going to get better until someone (either a determined intern, an attending tired of hearing about them, or an efficient case manager) puts their foot down and shows them the door.

Now I have to relearn the fact that just because a patient fits a certain profile, she is not necessarily without real problems.

Two patients, actually. The first seemed a classic instance of nothing to treat. She’d been calling the office for a few weeks, complaining of vague abdominal pain, with alternating diarrhea and constipation (this kind of alternating symptomatology often turns out to be simply “irritable bowel syndrome,” which to my mind is GI-speak for “I have no idea”). Finally she came in to the ER; the pain was worse, she simply couldn’t stay at home. A CT scan showed nothing at all, not even anything to theorize about. She spent a few days in the hospital; we shook our heads every time we discussed her on rounds, and couldn’t think of anything particular to do. Eventually she felt better and went home.

But the calls to the office continued, and a week later she came back in. The pain had started at 3pm – precisely – and had never let up since. The CT scan was still impressively benign. But this time she looked so miserable that we had to rethink our conclusions. Plus, being able to pinpoint the exact moment the pain started is usually a bad sign. She was taken to the OR, and found to have a small fascial defect, with a loop of ischemic bowel inside it. Apparently the defect was so small that it was invisible on CT. The loop had probably been intermittently trapped in there for the last month, and this time it was squeezed tight enough to be ischemic, and swollen enough not to slide out on its own. The next day she was a different woman: walking laps in the hallway, smiling, anxious to get back home – and refusing any narcotics at all.

A week later, we got one of our favorite consults. The only time worse than five minutes before evening signout is ten minutes before morning sign-in. Do we have time to see the patient before the chief arrives? Is it better to do a quick job on the consult, maybe miss something in haste, or appear uninformed at sign-in, and then go take more time afterwards?

The patient was a retired gentleman who had been admitted by medicine with complaints nonspecific enough that the ER didn’t even consider a surgery consult. Overnight, he’d complained of increasing abdominal pain. A CT was at length obtained. The radiologist discussed various “unusual findings,” but couldn’t pin down anything specific. Most people who saw him were unimpressed, since he’d been admitted with a smorgasbord of nonsurgical issues (headache, leg swelling, palpitations, etc). But when we finally got to go through the CT carefully, we recognized the most classic case of an internal hernia I’ve ever seen. (These are usually difficult to visualize on CT, and radiologists often don’t call them; it takes a surgeon who’s been dealing with the population prone to developing them for years to have any reliable interpretation of them.) He rapidly earned a trip to the OR as well.

Take-home lesson: just because the last ten patients I’ve seen with this medical history and these complaints had absolutely nothing wrong with them, does not mean that this patient has nothing wrong with him. Each patient deserves a completely fresh slate, and a ground-up approach.

Ok, I think the unannounced hiatus is over. No administration characters came after me, so I’ll be around until the next time I can’t even stand to talk to people.

I was going to say even the politics hadn’t really gotten to me that much, but today I realized differently: being a junior is a bad place to be as far as politics is concerned. For one thing, we get a lot of attention: the attendings and chiefs interact with us more, and depend on us more, than they do the interns. So whatever we do right, or more likely, wrong, is sure to be noticed and commented on by multiple people – possibly in front of us, certainly behind our backs. This knowledge can induce near-paralysis in some juniors; and the resulting mockery only makes it harder to function. I’m trying to avoid that pitfall; but being too cocksure will get you in trouble, too.

In addition, since we’re sort of in the middle of the hierarchy (ok, only one step above the bottom), we hear from everyone: the chiefs find us safe confidantes for their views on the attendings, the other chiefs, the interns, and our fellow juniors (the hardest to handle). The interns, once they stop being scared, tell us what bothers them the most about the chiefs and attendings. And of course the juniors as a group are constantly trading between each other the latest gossip or tips about each other, the chiefs, and the attendings. (As in, “X chief will yell at you if you so much as give a bolus without letting him know; so I call him all night long.” Or, “Z chief is unlikely to answer pages or phone calls anytime after 7pm, so don’t waste effort on him unless you need him in the OR.”)

But it’s the up and down gossip that drives me crazy: in the last two months, I think every single chief has said something bad to me about every other chief, and every other junior. And I sit and listen to them. The worst part is, I know when I’m not there they have to be saying the same things about me to someone else – and which one of the people whom I think to be my friend is listening, and agreeing?

The last week I was planning what to write when I got back on here. I thought of reworking the old cliche, that we’re not really like those medical dramas on TV. Then I thought, with all the personalities going on here, and all the sick patients we take care of, and all the nurses and doctors who really do get together, the only differences are 1) the dramas play out more slowly, over days and weeks, and things rarely climax in a fight in the front lobby 2) the people who get together do it outside the hospital. Other than that, there are enough subplots going on to keep two or three soap operas running.

Next Page »

Follow

Get every new post delivered to your Inbox.