It was around 2pm when I finally finished with Mr. P. His was one of the more challenging upper endoscopies I've done thus far in my training, and the extra time (over 45 minutes to complete what is usually a 20 minute procedure) was well worth it as we had an excellent outcome.
Mr. P is 70, and I met him in the emergency room a few months ago with rapid bleeding from his esophagus leading to vomiting blood and a subsequent quick ambulance ride to the hospital. I was initially called at 1am by the emergency room for the dreaded "we have a bleeder." Within hours we had an endoscope in his stomach, and after removing blood clots, we identified that his esophagus was full of large veins, called varices, which often result from elevated blood pressure in the liver circulation, referred to as portal hypertension. The curious thing about Mr. P was that he had no risk factors for this bleeding. He was not a drinker, had no hepatitis history, no drug use, very few longstanding medications. That night I placed small rubber bands on the recently bleeding veins, a procedure called "banding." And I placed him on medications to help prevent further bleeding. Mr. P did well. We found a cirrhotic, small liver and elevated pressures in the portal veins, but we did not find a cause. He was discharged to home and planned to see me in clinic for further evaluation.
Nothing seemed extraordinary about this story. More than 30% of all cirrhosis is "idiopathic" in nature, which means we don't know the cause. To label something idiopathic, we doctors will first do our best to make a diagnosis. But after enough testing, when we've reached the boundaries of what we know, we have to stop, and often where we stop is knowing the state of affairs (he had a cirrhotic liver and portal hypertension) but not knowing the root of the problem. This is often a huge source of frustration to patients who think we should know more, if not everything. And I don't blame them. Here is something wrong enough with Mr. P's body to hospitalize him. Something so drastic that he surely would have died if we had not intervened, yet the best we can do is describe what we see, with no explanation of how he got so sick. That, to me, presents a terrifying situation for the patient. Could this happen to his children? He asked. Will he bleed again? He wanted to know. Is this the result some strange virus? I wasn't sure.
But Mr. P interests me for reasons beyond his mysterious "idiopathy". After all, many people are told "we just don't know why" by doctors every day. The less arrogant doctors are more willing to put forth that sentence and not assure patients that we will find a cause every time.
In truth, what interested me most about Mr. P was his wife.
Ms. P is 72, from a Mediterranean country. She moved here at age 30 and shortly thereafter met her husband. She raised 3 children for him, and kept "the neatest home." She also was "the best cook in the world." Her specialty, he told me when we all met in my office the first time, "was lemon chicken with rice." I found it immediately interesting that in her presence, beyond these 2 compliments, Mr. P said nothing. In fact, I struggled in my interaction with him to focus on him, as she asked all of the questions, and looked skeptically at me when I told her that he would need two or three more endoscopic procedures to fully band his high grade varices. I explained that he remained a high risk for rebleeding. I explained that we were lucky last time, and that of the rebleeders, up to 25% die from bleeding to death. Her skepticism expanded: "No. No more. He's been through enough." I asked if her rationale was our uncertain diagnosis. She told me she didn't care what we said. When they left, I felt completely defeated. Here is a man I helped to save in the middle of the night just months before- who thanked us profusely when he was an inpatient- walking out of my office, muted by her anger, and possibly going to die if he didn't get additional medical attention.
So the question is: What was I to do next. In truth, what doctors are obligated to do by law, and obligated to do by oath are very different. The law states that we can do no harm, and need to do our best to do good. The oath I swore to (written by my medical school class- most med schools abandoned the not-so-politically-correct Hippocratic Oath 30 years ago) stated that my task was to have the "best interest of the patient in my heart and in my mind." There are few things I actually have to report to authorities. Child abuse is an obvious one. Elderly abuse is less obvious. Elderly Neglect starts to blur the line. And on and on the spectrum of what I observe vs. what I have the power to do continues. But when Mr. P, who clearly can make decisions for himself, decided to become a quiet lamb in the presence of a woman who had her own issues with the medical community and was willing to make him pay for those issues, my hands were tied. Still, I thought and thought. I had one of those dinners at home that night where my wife had to repeat a story because I was so deep in thought. I had one of those end of the day showers where she had to remind me to get out because I stood under the water for 1/2 hour pondering Mr. P- and how I might help him.
The next day I called- hoping to reach him. A lab result had returned normal and it was my excuse to call. But she answered instead, and refused to put him on the phone. She yelled at me for 10 minutes, telling me that no matter what I wouldn't "make money" on her husband. Little did she know that as fellow I make no money on endoscopies performed. So I did something else: I picked up the phone and called his primary care doctor. There I found a kind, caring man who clearly knew Mr. P and his wife well.
"She's beating you up!" he said laughing- "she does that to everyone except me."
"So what's your trick?" I asked.
"25 years of knowing them," he answered. And then I knew I had done the right thing. Within a week she had called to schedule his next endoscopy. And I arranged to be there. As the endoscope passed the first large vein that required banding, and I fired the band successfully onto the vein, I smiled.
I'll never know why Ms. P was so angry. Was it a brittle nurse who yelled at her husband one morning and reminded her of her sister when she was 13? Was it a lifetime of doctors making them pay co-pays and more and more expensive medications that didn't seem to provide all of the solutions she was seeking? Was it cultural differences- where American doctors ask completely different questions than those she is accustomed to? All of these and more probably. Regardless, I don't blame her. She did come to both appointments with him, standing by his side. She was there in the hospital to comfort him. Could I ask more of a wife? Even if her initial decisions weren't in his best interest, she was probably trying. And that is one of the toughest parts of my job- to look past blame and frustration and do what's best regardless of what I'm up against.
And believe me, there are more and more Ms. Ps out there- looking for a way to vent their frustrations with the state of medicine in America- and who better to yell at than the young man in the white coat?
Monday, August 31, 2009
Tuesday, August 18, 2009
11th hour
Ms. P is 87 years old, on a ventilator and nodding to me to come closer. She points to her throat which is sore and I nod "I know, Ms. P- that machine isn't pleasant." Yesterday, on a pad she wrote to me that she is doing this for her children and her grandchildren. By "this" she means living. She has a terminal lung condition called pulmonary fibrosis and it has progressed to the point of difficulty breathing requiring transplant for which she is too old and frail or a ventilator or option C, hospice and death. She voluntarily chose the breathing machine even though it went against her own belief that life isn't worth living if you can't enjoy it. (She wrote that on her pad a few days ago as well.)
If you missed it, this week, one of the boldest, wisest, kindest and downright most intelligent things ever offered by a president was shot down by a nation in fear. Our president proposed that Medicare pay for end of life counseling visits with the elderly and, hopefully, their families. This reimbursed visit would set the guidelines for a living will and let the patient and their family discuss options for the last days of life. Studies (many of them) have shown that such conversations are not only well received, but makes for a better death both for the patient and their families. This article sums up one such study: http://www.msnbc.msn.com/id/32463644/ns/health-health_care/
Within days of the proposal, conservatives, insurance companies and the PR firms hired by both began a slur campaign against the end of life counseling visits. Ex-governor Sarah Palin dubbed the term "death panels" and within 2 weeks the proposal was stricken from the health care bill. Here, ex-insurance executive Wendell Potter speaks out in his commentary on the role of insurance companies in this PR nightmare: http://www.cnn.com/2009/POLITICS/08/17/potter.health.insurance/index.html
Now I'd like to give a doctor's perspective on this situation, and I dedicate this to Ms. P and her ventilator:
We are a nation terrified of death. We lose our parents at ages 85 and think it's a tragedy. We lose our great grandparents and think they should have lived longer. The truth is, people die. They die at age 1, 12, 31, 51, 72, 102. They die every day. They die in accidents, and from illness. They die good deaths and get to say goodbye and they die quickly and do not. I am quite sure that death is as ultimate as anything. I have seen corpses on a fairly regular basis in my career. And in doing so, something amazing happened: I got over my fear of death. Call it an understanding of nature, or just an appreciation that what makes life valuable is the absolute certainty of its end. But why are so many of us petrified of dying? Are our lives so important that we want to be immune from the inevitable? As a young man, this is so. It is unnatural and unexpected for the young to die. And it is indeed tragic as it rare for a young person to die and often others get left behind for a lifetime of grief. To argue that one should just "get over" the death of a young person would be silly.
But what about Ms. P? 87 years- is that enough? She thinks so. But she never had a Medicare sponsored visit to the doctor- who is trained in not only the facts and procedures, but HOW to discuss this issue. I took classes on the subject in medical school, worked with mock patients to sharpen every skill (and they were all criticized at one time or another) from tone to facial expressions to listening well. This is tough stuff- and we need professionals to deliver the meat of the conversation, and to listen and translate what people are feeling into a plan. A plan that, perhaps, would have saved Ms. P from her horrible, prolonged, painful death on a ventilator.
For what it's worth, her family only visited once in 3 weeks. And I was there when her daughter squeezed her hand and told her to "hang on." And to her I ask: What for?
If you missed it, this week, one of the boldest, wisest, kindest and downright most intelligent things ever offered by a president was shot down by a nation in fear. Our president proposed that Medicare pay for end of life counseling visits with the elderly and, hopefully, their families. This reimbursed visit would set the guidelines for a living will and let the patient and their family discuss options for the last days of life. Studies (many of them) have shown that such conversations are not only well received, but makes for a better death both for the patient and their families. This article sums up one such study: http://www.msnbc.msn.com/id/32463644/ns/health-health_care/
Within days of the proposal, conservatives, insurance companies and the PR firms hired by both began a slur campaign against the end of life counseling visits. Ex-governor Sarah Palin dubbed the term "death panels" and within 2 weeks the proposal was stricken from the health care bill. Here, ex-insurance executive Wendell Potter speaks out in his commentary on the role of insurance companies in this PR nightmare: http://www.cnn.com/2009/POLITICS/08/17/potter.health.insurance/index.html
Now I'd like to give a doctor's perspective on this situation, and I dedicate this to Ms. P and her ventilator:
We are a nation terrified of death. We lose our parents at ages 85 and think it's a tragedy. We lose our great grandparents and think they should have lived longer. The truth is, people die. They die at age 1, 12, 31, 51, 72, 102. They die every day. They die in accidents, and from illness. They die good deaths and get to say goodbye and they die quickly and do not. I am quite sure that death is as ultimate as anything. I have seen corpses on a fairly regular basis in my career. And in doing so, something amazing happened: I got over my fear of death. Call it an understanding of nature, or just an appreciation that what makes life valuable is the absolute certainty of its end. But why are so many of us petrified of dying? Are our lives so important that we want to be immune from the inevitable? As a young man, this is so. It is unnatural and unexpected for the young to die. And it is indeed tragic as it rare for a young person to die and often others get left behind for a lifetime of grief. To argue that one should just "get over" the death of a young person would be silly.
But what about Ms. P? 87 years- is that enough? She thinks so. But she never had a Medicare sponsored visit to the doctor- who is trained in not only the facts and procedures, but HOW to discuss this issue. I took classes on the subject in medical school, worked with mock patients to sharpen every skill (and they were all criticized at one time or another) from tone to facial expressions to listening well. This is tough stuff- and we need professionals to deliver the meat of the conversation, and to listen and translate what people are feeling into a plan. A plan that, perhaps, would have saved Ms. P from her horrible, prolonged, painful death on a ventilator.
For what it's worth, her family only visited once in 3 weeks. And I was there when her daughter squeezed her hand and told her to "hang on." And to her I ask: What for?
Thursday, August 13, 2009
Do you care?
I start tonight by stating that I sat for a total of 30 minutes today, on my couch, and it felt great to rest. I never had much of a chance to sit today, and given that a friend of mine is studying sitting time, and has concluded in her work that time on one's derriere is directly linked to earlier death, I am not unhappy about that.
This may represent a slight change of tone, but I need to know who out there is really paying attention to what is going on right now. This op-ed is important, and summarizes many of my own thoughts. http://www.nytimes.com/2009/08/13/opinion/13gawande.html?_r=1&pagewanted=2 I heard Atul Gawande speak last night at my hospital and I was impressed that he is a man who truly understands the issues at hand and what needs to be done to begin to fix this mess.
This is so important, this issue of health care reform. Everyone deserves to be able to be insured. And everyone deserves a fair system with a common goal of doing good by the people.
But I need to ask Dr. Gawande, our president and all of you- do the 50 million or so people without insurance deserve this benefit without doing anything for it? Yes, the emergency room has become the new primary care physician-but why is no one talking about welfare reform? What about a national job bank and a six month limit on handout money for unemployment? How about a bill for those non emergent emergency room visits sent to the patient who has chosen not to be insured? And if collection agencies collect the money, people will have to come up with it, and if 25% of them did, we'd begin to chip away at this mess.
As a physician, I am thrilled by the thought of everyone being treated equally, but I am also worried that in America, we are so fixed on fair coverage, and not thinking rationally about ownership. Do we really need to pay for folks who are capable of work but unemployed? At what point do people need to have some onus for their well-being?
I was shocked this week to find out that a man won a lawsuit for the "damage" done to his wife by the Tobacco industry after she smoked 2 packs a day. I am no fan of big tobacco, but it's so very American to reward the smoker for damages! I liken the smoker to many of the uninsured in America. Of course the exceptions are those who are truly disabled mentally or physically and uninsured. (And yes, the smoker was 72, and lived through an era of lies and false advertising which despicably continues in 2009). Still, I cannot tell you how many patients walk into my office with 2 working arms, 2 working legs, often a college education and have been "out of work" for 2 years. I have been alive in prosperous and awful financial times. I have never gone a day without work when I wanted a job since I was 14 years old. I know that we have 9 plus percent unemployment and that some of that is layoffs. But somewhere in the past 80 years, the spirit of the 1930's New Deal was lost in a lazy haze. What happened to "Ask not what your country can do for you..."?
I am not turning a blind eye to those in need- I just want everyone involved in owning the problem. Everyone wants Big Insurance to fork over their secret stash of billions to fix this. And they do owe America more than record profits in these times. But the papers are also full of ideas of how to cut my salary. I'll gladly do so when I know that I am not in the only profession penalized for other people's circumstances. Where is the talk about tort reform? Where, in these discussions, are those snake lawyers making millions off my decisions which they later deem "mistakes?" And where are the millions awarded to people for bad lawyers? People behind bars because they weren't defended properly. People who got little or no money (myself included) when they suffered accidents. One multimillion dollar lawsuit against a lawyer would change the entire health care system in America. Put the lawyers under this microscope, give them checklists and pay them for performance. Embarrass them publicly in the papers for their "mistakes." And if you argue that health is more serious than prison time, or justice served, think through that one for a minute.
(As an aside, I work in a prison several months a year- and the health care delivery there is unique: Everyone behind bars is "insured" and not one prisoner pays the bill.)
So if you care, form strong opinions of your own. Disagree with all of this? I welcome that. Please, just make informed decisions about this crisis. Think about what's important to you. And if you're a hard worker, and always have been, I applaud you and believe wholeheartedly that we need to make insurance cheaper for you. Millions more people who are resting on their laurels can pitch in to help pay for that. They can work hard, even in non-profit government run jobs which help society- perhaps jobs in health care delivery, and accessibility, jobs aimed at keeping them out of the emergency room- and from sitting around.
This may represent a slight change of tone, but I need to know who out there is really paying attention to what is going on right now. This op-ed is important, and summarizes many of my own thoughts. http://www.nytimes.com/2009/08/13/opinion/13gawande.html?_r=1&pagewanted=2 I heard Atul Gawande speak last night at my hospital and I was impressed that he is a man who truly understands the issues at hand and what needs to be done to begin to fix this mess.
This is so important, this issue of health care reform. Everyone deserves to be able to be insured. And everyone deserves a fair system with a common goal of doing good by the people.
But I need to ask Dr. Gawande, our president and all of you- do the 50 million or so people without insurance deserve this benefit without doing anything for it? Yes, the emergency room has become the new primary care physician-but why is no one talking about welfare reform? What about a national job bank and a six month limit on handout money for unemployment? How about a bill for those non emergent emergency room visits sent to the patient who has chosen not to be insured? And if collection agencies collect the money, people will have to come up with it, and if 25% of them did, we'd begin to chip away at this mess.
As a physician, I am thrilled by the thought of everyone being treated equally, but I am also worried that in America, we are so fixed on fair coverage, and not thinking rationally about ownership. Do we really need to pay for folks who are capable of work but unemployed? At what point do people need to have some onus for their well-being?
I was shocked this week to find out that a man won a lawsuit for the "damage" done to his wife by the Tobacco industry after she smoked 2 packs a day. I am no fan of big tobacco, but it's so very American to reward the smoker for damages! I liken the smoker to many of the uninsured in America. Of course the exceptions are those who are truly disabled mentally or physically and uninsured. (And yes, the smoker was 72, and lived through an era of lies and false advertising which despicably continues in 2009). Still, I cannot tell you how many patients walk into my office with 2 working arms, 2 working legs, often a college education and have been "out of work" for 2 years. I have been alive in prosperous and awful financial times. I have never gone a day without work when I wanted a job since I was 14 years old. I know that we have 9 plus percent unemployment and that some of that is layoffs. But somewhere in the past 80 years, the spirit of the 1930's New Deal was lost in a lazy haze. What happened to "Ask not what your country can do for you..."?
I am not turning a blind eye to those in need- I just want everyone involved in owning the problem. Everyone wants Big Insurance to fork over their secret stash of billions to fix this. And they do owe America more than record profits in these times. But the papers are also full of ideas of how to cut my salary. I'll gladly do so when I know that I am not in the only profession penalized for other people's circumstances. Where is the talk about tort reform? Where, in these discussions, are those snake lawyers making millions off my decisions which they later deem "mistakes?" And where are the millions awarded to people for bad lawyers? People behind bars because they weren't defended properly. People who got little or no money (myself included) when they suffered accidents. One multimillion dollar lawsuit against a lawyer would change the entire health care system in America. Put the lawyers under this microscope, give them checklists and pay them for performance. Embarrass them publicly in the papers for their "mistakes." And if you argue that health is more serious than prison time, or justice served, think through that one for a minute.
(As an aside, I work in a prison several months a year- and the health care delivery there is unique: Everyone behind bars is "insured" and not one prisoner pays the bill.)
So if you care, form strong opinions of your own. Disagree with all of this? I welcome that. Please, just make informed decisions about this crisis. Think about what's important to you. And if you're a hard worker, and always have been, I applaud you and believe wholeheartedly that we need to make insurance cheaper for you. Millions more people who are resting on their laurels can pitch in to help pay for that. They can work hard, even in non-profit government run jobs which help society- perhaps jobs in health care delivery, and accessibility, jobs aimed at keeping them out of the emergency room- and from sitting around.
Monday, August 10, 2009
Training Wheels Part 2
So I am going to continue where I left off a few weeks ago (sorry for the delay- I need to find time to write this every day, especially now that I saw the film Julie and Julia yesterday and I am convinced that blogs can make a difference in this world if written well and with a purpose).
Let me start with intern year. Now here is a secret about the first week of training that is rarely disclosed: Interns are terrified. Let's face it, 3 weeks ago they were medical students. Then, off come the training wheels and on comes one of the most grueling years in our training. It isn't the work hours that make the transition from medical school to internship so difficult, it's the sheer weight and responsibility of actually being responsible for human lives. OK, so there are attendings who ultimately are legally responsible, and fellows and residents who know more and can help- but at 2am, in those tiny rooms, when the blood pressure is rising and you don't know why- or the chest pain is getting worse- or breathing looks more labored- it's just you and the patient, and occasionally a nurse waiting for what to do next (and another secret is that he or she often knows the answer which the smart interns figure out early on). Let me share a few of these tense moments from my first 3 weeks of intern year to set the tone:
One morning in my second week as a doctor I was told that Mr. S was bleeding out his bottom. I ran to the bedside and indeed, there was a small pool of fresh red blood on the bed. I lifted the sheet and found that the catheter in his penis was gushing blood. Knowing that a balloon inflates to hold this catheter (called a Foley) in place, I asked the nurse to deflate the balloon, push the catheter in further and reinflate it. The gushing continued. I asked another nurse to call my resident and to call urology. But then I was stuck with 5 minutes alone with the patient and the nurse to try to make this better. "Do you want a 3 way?" She asked me. I had no idea what this meant other than the obvious bad joke. She must have seen me look perplexed because then she explained that a 3 way catheter had a larger lumen and could be used to flush the urethra and bladder. Within a few minutes she got this in, and with some irrigation we dulled the bleeding and allowed for the Urology team to come and evaluate my poor patient.
A week later I arrived to check on my patients at the usual 6am start time to find that one of my patients had shallow breathing and wasn't responding to me. I asked the nurse to call my resident and then stood petrified for a moment next to my patient. I froze. I did not know what to do next. I did not know where I was. I was panicking. Then, I remembered some basics and started to tell the 3 nurses who had gathered to help what to do. Someone needed to get a blood pressure. Someone needed to get an oxygen level. I needed to do an arterial blood gas which I had only seen done once and now was in the unfortunate position of NEEDING to do immediately. Minutes later, as I slowly poked around for the radial artery with a needle I remember thinking to myself, "You can do this. You HAVE to do this." And I will never forget how it felt to watch the blood fill that syringe, my heart pounding, sweat beading down my forehead.
Then, during my first night call in my second month of being a doctor, I was told that a patient had died and to come declare the patient dead. I had done this in medical school and knew the routine- listen to the heart, check some reflexes and for a pain response. What I did not prepare for what came next. As I entered the room, a woman sat at the end of the bed holding the patient's cold hand. On her lap was a four year old, crying. He had lost his father. She had lost her husband. And just like that I knew for the first time what being a doctor really meant. I chocked up. I fought back tears of my own as I placed my stethoscope delicately on the chest of the dead man. I fought back tears as I said "I'm so sorry for your loss" to this woman and her boy. I did feel sorry for them. I felt vacant, alone, afraid. I felt unworthy to be there. I felt that the world was not a fair place at that moment. And finally I felt privileged to have been a part of comforting them in any way. That was my role. Confirming his death confirmed something. There was no doubt. She knew that the hand she was holding wasn't just cold, it was dead. And that provided something for a woman who had sat by a man's side for 6 months as he died of cancer. He was gone and I was the person who told her so. And as hard as that was to hear, and to deliver, that was the beginning of mourning, and the end of dying, and that was a gift.
The stories go on and on. There was the time my patient peed on his roommate because he thought he was a urinal. We laughed for 15 minutes in the lounge after that. We had to laugh. There was the man who called me to his bedside to thank me before his breathing machine was discontinued. He requested my presence when he died and that was the biggest honor I ever received. There was the woman who claimed that her quadriplegic husband on a breathing machine who could not communicate with anyone could speak with her through his eyes. And no one believed her at first but slowly some of us began to wonder and finally I was convinced that they were having dialogues without words. And no matter what the story, I was learning. I was learning how to administer medications, do procedures, determine who was really sick and who wasn't from the doorway. And I was learning how to handle someone screaming in your face, and lying about prescriptions being lost, and how to comfort someone who was beaten by a person or by an illness. I was finally living up to the MD that came after my name.
Then, in a blink that takes forever, it's June- and the intern class sniffs emotional smelling salts and suddenly realizes that they are about to be residents. Many say that the transition in July after intern year is complete is the scariest moment of training. It was for me. Suddenly we were sitting through training sessions on how to teach, and floods of emails began to circulate on what to do when and how to manage 2 interns at once. Suddenly I needed to know the rules of the hospital as far as how admitting worked. The things I was protected from as an intern made themselves unbearably clear to me on the cusp of the transition and then, in a blur, in came new interns. This time I was the one being called for the scary situations. My backup was often my colleagues. Attendings weren't always on the floors. They weren't always easy to reach even by phone. Now the real challenge began: Did I know enough? Was I competent to keep people alive? Was I teaching the real lessons of being a doctor or just medial minutia?
The first time I saw feedback from my interns was one of the best days of my training. One July intern described being on my service as a "safe place. " That was my goal. That made me smile. But those late night calls made my heart race as I walked into a room. Now not only was nature playing its role in what had transpired, now the intern had something to do with it, too. On good days, good things were done. On bad days, anything was possible. And as many times as the interns heard: Don't act alone, get help- there wasn't always time. Once, in the ICU, an intern of mine let a patient slowly drop his blood pressure all night until he was critically low in the morning. No one had noticed because the incremental drops were so small. It took new eyes to see what had taken place. That was the day I realized my role as resident. I was to see, and to have others act based on what I was seeing. I was to teach based on those experiences. I was to be a guide, but to let interns make mistakes as long as they didn't do harm and learn from them. It was the toughest job I ever had and the most rewarding. To see the look on an intern's face when she made a diagnosis correctly and helped someone- that made my day. To hug an intern after he had to tell a family that their young father was dying- that was hard, and necessary.
Somewhere in there, between those long nights, crazy days, tears of joy and tears of sorrow- I earned my degree, awarded too soon in my opinion, before I knew what being a doctor meant and what being a doctor took. It took, after all, from my life at home and my life outside of home. It took my tan skin and turned it pale. It took good eating habits. It took well controlled acid reflux and made it out of control. It took all of the patience I could muster and then some. It took my happiness on many winter days. It took my positive outlook on everything on some days and squashed it. But what being a doctor gave back made up for all of it. And I knew it even though I suffered through it. And that dichotomy is medical training summed up. And that's what people need to know before signing up for it.
Let me start with intern year. Now here is a secret about the first week of training that is rarely disclosed: Interns are terrified. Let's face it, 3 weeks ago they were medical students. Then, off come the training wheels and on comes one of the most grueling years in our training. It isn't the work hours that make the transition from medical school to internship so difficult, it's the sheer weight and responsibility of actually being responsible for human lives. OK, so there are attendings who ultimately are legally responsible, and fellows and residents who know more and can help- but at 2am, in those tiny rooms, when the blood pressure is rising and you don't know why- or the chest pain is getting worse- or breathing looks more labored- it's just you and the patient, and occasionally a nurse waiting for what to do next (and another secret is that he or she often knows the answer which the smart interns figure out early on). Let me share a few of these tense moments from my first 3 weeks of intern year to set the tone:
One morning in my second week as a doctor I was told that Mr. S was bleeding out his bottom. I ran to the bedside and indeed, there was a small pool of fresh red blood on the bed. I lifted the sheet and found that the catheter in his penis was gushing blood. Knowing that a balloon inflates to hold this catheter (called a Foley) in place, I asked the nurse to deflate the balloon, push the catheter in further and reinflate it. The gushing continued. I asked another nurse to call my resident and to call urology. But then I was stuck with 5 minutes alone with the patient and the nurse to try to make this better. "Do you want a 3 way?" She asked me. I had no idea what this meant other than the obvious bad joke. She must have seen me look perplexed because then she explained that a 3 way catheter had a larger lumen and could be used to flush the urethra and bladder. Within a few minutes she got this in, and with some irrigation we dulled the bleeding and allowed for the Urology team to come and evaluate my poor patient.
A week later I arrived to check on my patients at the usual 6am start time to find that one of my patients had shallow breathing and wasn't responding to me. I asked the nurse to call my resident and then stood petrified for a moment next to my patient. I froze. I did not know what to do next. I did not know where I was. I was panicking. Then, I remembered some basics and started to tell the 3 nurses who had gathered to help what to do. Someone needed to get a blood pressure. Someone needed to get an oxygen level. I needed to do an arterial blood gas which I had only seen done once and now was in the unfortunate position of NEEDING to do immediately. Minutes later, as I slowly poked around for the radial artery with a needle I remember thinking to myself, "You can do this. You HAVE to do this." And I will never forget how it felt to watch the blood fill that syringe, my heart pounding, sweat beading down my forehead.
Then, during my first night call in my second month of being a doctor, I was told that a patient had died and to come declare the patient dead. I had done this in medical school and knew the routine- listen to the heart, check some reflexes and for a pain response. What I did not prepare for what came next. As I entered the room, a woman sat at the end of the bed holding the patient's cold hand. On her lap was a four year old, crying. He had lost his father. She had lost her husband. And just like that I knew for the first time what being a doctor really meant. I chocked up. I fought back tears of my own as I placed my stethoscope delicately on the chest of the dead man. I fought back tears as I said "I'm so sorry for your loss" to this woman and her boy. I did feel sorry for them. I felt vacant, alone, afraid. I felt unworthy to be there. I felt that the world was not a fair place at that moment. And finally I felt privileged to have been a part of comforting them in any way. That was my role. Confirming his death confirmed something. There was no doubt. She knew that the hand she was holding wasn't just cold, it was dead. And that provided something for a woman who had sat by a man's side for 6 months as he died of cancer. He was gone and I was the person who told her so. And as hard as that was to hear, and to deliver, that was the beginning of mourning, and the end of dying, and that was a gift.
The stories go on and on. There was the time my patient peed on his roommate because he thought he was a urinal. We laughed for 15 minutes in the lounge after that. We had to laugh. There was the man who called me to his bedside to thank me before his breathing machine was discontinued. He requested my presence when he died and that was the biggest honor I ever received. There was the woman who claimed that her quadriplegic husband on a breathing machine who could not communicate with anyone could speak with her through his eyes. And no one believed her at first but slowly some of us began to wonder and finally I was convinced that they were having dialogues without words. And no matter what the story, I was learning. I was learning how to administer medications, do procedures, determine who was really sick and who wasn't from the doorway. And I was learning how to handle someone screaming in your face, and lying about prescriptions being lost, and how to comfort someone who was beaten by a person or by an illness. I was finally living up to the MD that came after my name.
Then, in a blink that takes forever, it's June- and the intern class sniffs emotional smelling salts and suddenly realizes that they are about to be residents. Many say that the transition in July after intern year is complete is the scariest moment of training. It was for me. Suddenly we were sitting through training sessions on how to teach, and floods of emails began to circulate on what to do when and how to manage 2 interns at once. Suddenly I needed to know the rules of the hospital as far as how admitting worked. The things I was protected from as an intern made themselves unbearably clear to me on the cusp of the transition and then, in a blur, in came new interns. This time I was the one being called for the scary situations. My backup was often my colleagues. Attendings weren't always on the floors. They weren't always easy to reach even by phone. Now the real challenge began: Did I know enough? Was I competent to keep people alive? Was I teaching the real lessons of being a doctor or just medial minutia?
The first time I saw feedback from my interns was one of the best days of my training. One July intern described being on my service as a "safe place. " That was my goal. That made me smile. But those late night calls made my heart race as I walked into a room. Now not only was nature playing its role in what had transpired, now the intern had something to do with it, too. On good days, good things were done. On bad days, anything was possible. And as many times as the interns heard: Don't act alone, get help- there wasn't always time. Once, in the ICU, an intern of mine let a patient slowly drop his blood pressure all night until he was critically low in the morning. No one had noticed because the incremental drops were so small. It took new eyes to see what had taken place. That was the day I realized my role as resident. I was to see, and to have others act based on what I was seeing. I was to teach based on those experiences. I was to be a guide, but to let interns make mistakes as long as they didn't do harm and learn from them. It was the toughest job I ever had and the most rewarding. To see the look on an intern's face when she made a diagnosis correctly and helped someone- that made my day. To hug an intern after he had to tell a family that their young father was dying- that was hard, and necessary.
Somewhere in there, between those long nights, crazy days, tears of joy and tears of sorrow- I earned my degree, awarded too soon in my opinion, before I knew what being a doctor meant and what being a doctor took. It took, after all, from my life at home and my life outside of home. It took my tan skin and turned it pale. It took good eating habits. It took well controlled acid reflux and made it out of control. It took all of the patience I could muster and then some. It took my happiness on many winter days. It took my positive outlook on everything on some days and squashed it. But what being a doctor gave back made up for all of it. And I knew it even though I suffered through it. And that dichotomy is medical training summed up. And that's what people need to know before signing up for it.
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