ethics


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.

Last year I got used to the idea that I was responsible for what the medical students did. I was supervising, so it was always my problem. If I hadn’t noticed what they did, that was my problem too.

“My problem” is getting bigger this year. Now I’m responsible for the interns too. If we’re on the phone, and I don’t ask them for some information, the fact that neither of us knows it is my problem because I should have asked, not theirs because they didn’t check in the first place. If I tell them to do something, and it doesn’t get done, it’s my problem, because I should have checked back on them. If they misorder something, it’s my problem, because I should look at their orders.

Human nature likes to blame other people. It’s really hard not to blame the interns; they’re so handy for it. But it’s not fair to them; they’ve only been doctors for three months. I’m the one who knows about all these details, and I’m the one who should be double-checking all of it. If anything gets missed or goes wrong, it’s my fault. Always.

I told myself that for three hours this morning. Now I believe it, and hence can feel appropriately guilty for the weekend’s errors. Every single mistake I make could change someone’s life. It’s starting to get to me. I don’t even need to bring the lawyers into the picture. After thinking about this for a couple more days or weeks, I’ll be so paranoid about hurting someone or missing something, lawsuits won’t even be part of my reasoning. That should make me a better doctor, but it’s no fun thinking about it.

(And nothing particularly bad happened this weekend; just details. I need to have a higher standard for myself than the attending does. I need to be more upset about what I miss than any attending or chief resident will be. Even when the attending agreed with my decision, if it didn’t turn out right, I can’t blame him; I have to blame myself. I should have known better.)

(And then some people call me ‘intense,’ with a connotation that means I should back off, let things go. I can’t. I make enough mistakes, without trying to let go too.)

I thought WhiteCoat’s story about medical professionals not having heard about Medicare’s new strategy to avoid paying healthcare professionals for services rendered (otherwise known as the “never” events) had to be an exaggeration.

Then I mentioned their upcoming enforcement (next Wednesday, Oct. 1) to a senior resident, and he gave me a blank stare. He seemed to think this was another piece of raving insanity, along with my defense of Palin (what can I say? when all the men in the room start attacking her, I morph into a Republican) and my objections to abortion. It took me quite a lengthy explanation to get him to think I might be right – this despite signs all over the medical records department warning physicians of the events that are now not permitted to occur, as well as notices popping up all over the charts, and random walls in the hospital. I had no idea that my time in the medical blogosphere was so well spent.

(For further information on the concept developed by some genius in Medicare (who really deserves a million dollar bonus – this scheme is going to save the government so much money – except didn’t they take it all from us in the first place? – until all the hospitals go bankrupt; do you think the government will bail out hospitals who fail because they tried to take care of patients, the way they’re bailing out the financial institutions that made foolish choices?) – excuse me. Back on track: for further information, see Buckeye Surgeon’s analysis, and this piece by Dr. WhiteCoat (as well as a good deal more on his site). Basically, the idea is that Medicare (and the private insurance companies will inevitably follow suit) picks several events which everyone would prefer not to happen, and unilaterally mandates that they will now not pay for these occurences; the goal being to promote “quality” healthcare. Which is fine for the “never” events like wrong-site surgeries and mismatched blood transfusions; those are rare and truly preventable. But then you come to things like urinary tract infections, central-line associated bacteremia, C difficile infection, wound infections, and on and on – things which we all deplore, but which there is no scientific evidence to suggest the possibility of completely eliminating. All the studies show ways to decrease their incidence, but not to prevent them from ever happening at all. I can quote you the statistics; that’s stuff I get pimped on. Anyway, basically, Medicare is going to penalize hospitals for existing in the real world. They’ll all go bankrupt. Somebody please help me figure out some alternative career options? I need to get out of this circus before the whole thing falls apart.)

(And in case you were wondering, I know that the goal of all this is to decrease costs to Medicare, not to improve patient care. Because if patient care were the point, hospitals could be held to evidence-based standards for acceptable rates of infections and other complications. But this whole rigmarole is being arranged by some accountants and their secretaries, who know nothing about taking care of sick people. . . . I’m looking for the exit, and that’s only partially rhetorical. I do not want to spend my life explaining myself to bureaucrats, and begging for permission to take care of the patients that I am morally and legally responsible for.)

Another thing I need to learn to be a real surgeon: When doing an open abdominal case on a patient who’s had practically any previous operations, there are bound to be adhesions to some extent (unless they’re on chronic steroids, in which case you get the prednisone effect – wonderfully smooth going in, and the near-certainty that they won’t heal afterwards). Depending on how many surgeries and where, and the patient’s genetic tendency toward scarring, there will be more or less adhesions, and it will be more or less difficult to get where you’re going.

When dissecting the adhesions apart in order to get to the underlying structures, you have to protect the bowel somehow. Touching the intestines with the bovie (electrocautery) is very much frowned upon, and can lead to all kinds of complications, ranging from post-op abscesses to enterocutaneous fistulas.

There’s a really simple maneuver to help avoid this. You slip your gloved finger under the band of adhesions, separating it from the bowel underneath. Then you bovie on your finger.

The bovie is hot.

This can really hurt.

If you don’t time it just right, you can go right through the glove into your finger.

The good surgeons 1) know how to time it, and 2) care more about protecting the patient than about how hot their fingers get.

I am still a source of frustration to my mentors for two reasons: If I ever have to put my hand under the bovie, I can’t take the heat, and I back off way too soon, which makes it take forever to get anything done (which is too bad, because it’s quite a privilege to be given the responsibility of putting your hand under and guiding where the incisions will be made, and I hate to mess up when an attending lets me do that). Or, when it’s their hand in there, I hit it. Either way, not popular.

I need to do some more surgeries.

My patient is dying (again), and I can’t do anything to stop him.

That’s such a horrible feeling. I can’t help him. I can’t stop the disease, I can’t change anything anymore. It’s too late.

At that point, the thought arises, if I can’t cure him, at least maybe I could make this quicker, easier for him and his family.

I never thought I’d understand (dare I say sympathize with) that idea.

I understood today, finally, how doctors, whose purpose is to heal, can end up wanting to kill (because that’s what euthanasia is, in the final analysis). I wanted to do something, anything, for this man; and if I couldn’t fix him, that left only one thing.

The problem is that I’m not God. There’s a very old joke about the difference between God and the surgeons; and I think death is his way of reminding us humans of our place in the world. Death is not under our control. It’s not a thing that we can order around, or organize, or turn off and on at our whim.

Life and death belong to God. He gives life, and he controls its end. The time of death does not belong to us. That’s our human arrogance talking, to think we can control every aspect of our lives, right down to death itself.

So I had to let go. That man was God’s creation. God let me care for him for a while; but ultimately I and my colleagues were never the ones in control. As the psalmist says, “Man returns to dust, and his spirit returns to his Maker.”

« Previous PageNext Page »

Follow

Get every new post delivered to your Inbox.