Sunday, November 29, 2009

on the fifteen-second diagnosis

Often times in the OR, I am thankful that the patient is asleep. Not so much for their comfort and safety, though obviously that's the primary goal, but more so they don't have to hear the conversation in the OR.

Do doctors talk about their patients? Yes, of course we do. Do we talk about them differently to each other, behind closed doors (or at least closed eyelids) than we do to the patients and families themselves? Yes, we do. And I'm going to be honest, usually this is not a good thing. Sometimes it's more just about an honest exchange of information--a surgeon telling the anesthesiologist that despite the surgery they're performing, that the patient's cancer is most likely terminal, in a frank way they've been unable or unwilling to talk with the patients themselves. Sometimes we complain about patients for things that make our jobs harder, even if it's not really their fault. Morbidly obese patients are difficult to operate on, patients who have smoked three packs a day for the past 45 years are difficult to oxygenate, patients who have been on chronic steroids are difficult to start IVs on. And then sometimes, there are things said in the OR, unrepeatable things, that would make Hippocrates turn over in his grave. (Or sarcophagus, whatever.)

I am not saying that the way that doctors talk about patients when patients aren't around is OK. I'm just letting you know that it happens. Certainly, things are better now than, say, in the 1960's and 70's, when doctors would ogle their naked lady patients and everyone was clad in unfortunate nubbly earth-toned fabrics. People overall are much more PC, and people are certainly much more mindful of patient privacy and respect and just basic comfort than in the more paternalistic age of medicine, where the doctor's word was the word of God. But like any profession in a highly emotionally charged atmosphere where you work closely, day in and day out with people going through potentially life-changing events (see also: those in law enforcement, the armed forces, social work), the attitude of those in the medical profession might to the outside observer often seem callous or vulgar. And probably, sometimes it is.

My last post, I made a comment about how having more than three cats or more than five drug allergies was a soft sign for mental illness--though perhaps more accurately, I meant "neurosis." Though I had a twinge of conscience even as I was typing that last, I want to apologize for not listening to it and if my five allergy statement discounted the fact that behind every chart, there is an actual living, breathing human patient behind.

I think this is a problem we fall into a lot in medicine. When you first start medical school, you're so shiny and new, your skin so pearly pink and translucent, you take everything personally. The first time you witness a bad medical outcome, you cry. The first time a patient tells you something that is not completely true, it knocks you to the ground. The first time you make a mistake--the first of many, many, many times--you beat yourself up about it endlessly. You feel everything. Patients haunt you. Every experience leaves a stain.

And then, for better or for worse, you start to get a little jaded. Your skin thickens up. Things don't affect you quite as deeply. Big things start to become banal. At the end of my residency, called in for stat intubation for a patient in the ICU, I put in the breathing tube while chatting casually with a classmate about how her new baby was doing at home. The life-changing becomes the everyday. The catastrophic becomes the mundane. I'm not sure if it's a good thing or a bad thing, but it certainly helps you get through the day. If I had to feel everything as intensely and deeply the way I did when I was a third or fourth year med student, there's no way I'd still be able to work today. In fact, most likely I'd be rocking back in forth in a fetal position in some sort of sensory deprivation tank. You need to toughen up in order to help your patients, but the toughening up can also have a distancing effect, sometimes to the disservice of those you're working to help.

It has been said before that the practice of medicine is all about pattern recognition. The more patients you see and the longer you've been in practice, the better you are at recognizing the patterns, and the faster you can react. Fever, nausea, elevated white count, right lower quadrant abdominal pain? Appendicitis. Tachycardia, hyperthermia, hypercapnia, muscle rigidity? Malignant hyperthermia. My guess is that the more fast-paced and stressful the work environment (the ER and the OR come to mind as probably the prime environments), the more likely practitioners are to make snap judgements. We are taught to group and classify patients, often in knee jerk ways, and while this can usually be helpful from a diagnosis and treatment point of view, this tendency towards generalization can sometimes bite us in the ass. Not all patients are a "type." Not all patients with the same list of diagnoses are the same. It might be easier if they were, but they are not, and we shouldn't act like we know more than we do just because we as medical practitioners have privileged access to people in ways that few other people do.

This was probably an overlong tangent to spin off of the fact that many have noted--myself included--that a long list of med allergies either indicates a long chronic illness or, alternatively, a patient who is a little bit kooky. That's part of that pattern recognition again--after a certain point, you just start to see patterns in everything. But I do need to be reminded, as do all of us, that there's a story behind every patient, and there's a patient behind every ID band.

(I still think that having more than three cats means you're crazy, though.)

(That's a lot of cats.)

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