Survivor's guilt

I had a day in clinic last week that hurt, emotionally. It was like my scheduling staff actually were trying to inflict psychological harm, because the morning was entirely booked with widows and widowers. I had 10 patients, all of whom were single and lonely, abandoned by their spouses who died.

Widowed patients are sometimes hard to see, but it's particularly bad when half those widows' spouses died under my watch. It's particularly painful to see the wife of Mr M, such a gregarious and lovable guy, a guy who had a massive coronary event and died at home, and now, his wife comes in like clockwork, every 6 months. Her medical problems have all gotten better, now that she is no longer subject to his bad habits of going out to restaurants all the time or indulging in sweets. She puts her faith in me that I am providing solid medical care, but really, her sample size to rate my performance is miserable. I killed the only other patient of mine she knows.

Mrs H is also so upsetting. She talks about her husband every time she comes in. He was a gentleman with such refinement and character, who never had a stern word. Even when he was angry, his words were like Socrates. She reminds me all the time that she has nothing to live for. She doesn't mean that in a bad way, and she's not even depressed, but that the efforts I put into extending her life, they are efforts she is ambivalent towards. If she died tomorrow, she would be fine with that, because the love of her life is dead.

One of my staff tells me that I should feel honored. Here are people that have been acutely exposed to my lack of ability to prevent the hand of fate. But they saw what I was able to do, and they want to continue with me. They are saying in each visit, "It's not your fault. That is life." I feel like really, they are silently consoling me. Because I mourn their losses too, because they are my losses also.

Greener grass

I think part of the difficulty with having a job you love is that it makes it very difficult to think rationally about major life decisions. I really do love my job, but my life is otherwise like plain yogurt. It has no flavor. I get no pleasure out of it.

So here I am, with every possible reason to move and start fresh, live an honest to God adventure, but I am at the same time deeply conditioned to patterns and caution. The same things that make me good at being an internist are simultaneously the qualities that lead me to live a bland and milquetoast existence. 

Recently, I had a couple patients retire and move. They've been with me for several years, and I will really miss them, but I will not miss them as much as I will envy them, because for some people, life is an adventure. But not for me. 

Don't become a doctor #18 - Meaning

When I am on the Internet, I often hear young people thinking about going into medicine because they are looking for meaning. This is a rather altruistic and noble vision, to pursue a career that benefits the world and humanity, and it is one that I held when I was younger, but it is sadly very naive, and very misleading.

Like many teenagers, I really struggled with the question of why do I exist and what is my purpose. It is really the first time we are aware that our lives can have a purpose. So I sought out a raison d'etre. I wanted a mission. Medicine really appealed to me because I could heal the sick, and the role of healer is full of meaning and purpose. If I could just put on the cloak of physician, then I too could have meaning, by extension.

However, the ugly truth is: a job is a job. There is nothing more or less meaningful about any job, and all jobs have meaning and purpose to someone. A plumber gives us running water and sanitary disposal of waste water. Without this, cholera would still be a worldwide killer. A janitor lets us have clean and safe facilities to use, whether at our work or places we visit. A chef prepares food for us for nourishment and pleasure. Every job offers some level of purpose. So the key is not finding a job full of meaning. Having a job full of meaning does not make YOU meaningful. It only gives you responsibilities and expectations.

In residency, I responded to a code for a lady in her 20's. I hadn't been phased by codes in a long time, but she was so young, and with so much life ahead. And somehow, I managed to bring this one back. Even though it was probably more luck than skill, it felt good. It felt like without me, she would be dead. I put everything I had into her case. And that good feeling, it lasted for about 15 minutes before I asked a terrible, terrible question of myself. "What if that was why I was put on this earth, to save that one person? What the fuck do I do with the rest of MY life?"

I know plenty of docs with amazing skills who have saved many more than I ever will, but they hate their lives and are going through the motions, locked into a profession that demands a lot of time and energy and dedication. I have avoided this by making sure I was able to answer to answer one simple question: is what I do meaningful to me? Do I love what I am doing? That is how you find meaning.

Privileged #6 - Enough

The first time that I pronounced someone dead was a very mild experience. I was an intern, and one of our patients was under comfort care measures only, and was due to expire sometime that night. I was on the floor to sign some orders, and one of the nurses grabbed me. "You need to pronounce Mr. S in 422."

I had no idea how to pronounce someone dead. Was there a procedure? Did I need to do an exam? How sure did I have to be? I wasn't going to take any chances. I felt for breath and for pulse. I did painful stimuli. I listened for heartbeat and respiration. I even printed a telemetry strip. He'd expired before the nurses could unhook his leads.

When I looked at the strip, I went back into the room. There was activity on the strip. There were occasional ventricular contractions. I needed to be sure. The nurse was a little impatient. She had a look at the strip too.

"Oh fuck, I forgot the magnet!" She ran out of the room and came back quickly with a round magnet and placed it on his chest. There was no more activity. Mr. S's pacemaker was off now.

I saved the telemetry strip from Mr. S and look at it every now and then. It helps to remind me of the amazing technological achievement in medicine, and that despite all of this achievement, sometimes a person has to say that enough is enough.

Don't become a doctor #17 - a checkered past

When I talk about the history of the United States, I use the word "we". We had a tragic history of slavery and institutional racism. We oppressed and slaughtered the indigenous people of this land. We fought difficult and deadly wars in Europe and Asia. But I wasn't a part of that, and neither were my parents who were immigrants to this country. I could not be more innocent to the checkered past of this country. But I was born here, and am an American, with all the positives and negatives that entails.

This is the part of being a doctor that people do not like to talk about. Being a doctor does not come with a clean white coat. It comes with a painful history. To take credit for all the amazing things done by physicians, we must also own all the terrible things we have done, and still do, and there are so many.

In the name of research, we have done things like the Tuskegee syphilis experiment, where we withheld treatment from participants for almost 30 years after penicillin was discovered to be effective. So egregious was this study that the government has forced any and all human research to be required to meet safety and practice standards, because we couldn't be trusted. And right they were, because we have also experimented on people in other countries, children, prisoners, and many other groups disadvantaged or with diminished ability to consent.

We have behaved like autocrats over the medical system, consistently devaluing and diminishing the roles and responsibilities of not only allied health professionals, but even the patient, to the point where we actually had to declare that a patient has the right to consent to treatment. Because we have, on so many occasions, fought this very point.

We have practiced our trade under the influence of business and industry, accepting benefits, gifts, and perks from all sorts of entities to influence the appropriate care of patients. There are no free lunches, but forget lunch. It was only 10 years ago that pharmaceutical reps could get a doctor vacations, trips, and outright money.

And still, we cheat patients, insurers, and Medicare out of money, to the point where President Obama's administration has stopped literal billions of dollars worth of fraud to Medicare. It's so bad, CMS has made a YouTube video about it.

So if you're coming into the profession of medicine, know that the ethical standard has now been set high, extremely high, because any less is not acceptable. And because we have done such a miserable job in the past of meeting any standard. If you're not willing to own the dark past of medicine and the failings of our peers, then you have no business enjoying the privileges of medicine.

Jobs vs professions

So, a doctor riding a bicycle to work gets Internet attention. It's a cute story for sure, but it's only a small appetizer of what it means to be a professional. If you want the entree, read about Carlo Urbani. I'm sure you've never heard of him. However, you've probably heard of SARS, the horrifying respiratory virus with a 11% fatality rate. It was discovered by Dr. Urbani, who recognized that this was a novel and lethal virus. He alerted the WHO, and tried to take steps to limit the disease spread. He caught the virus himself, and arranged for a makeshift isolation room, where his wife could only talk to him through an intercom. He died from SARS, and donated his lung tissue to science for study. He almost certainly saved millions of people from contracting the virus, and thousands if not millions of deaths.

If you want to know the difference between a job and a profession, this is it. A job is 9 to 5. A profession is part of who you are, and has a responsibility that extends into our social lives, our personal lives, and sometimes, it even costs us our lives. That's not a job. I don't mean to knock janitors, but no janitor should ever die with a mop in hand.

Privileged #5 - Reconciliation

One of my most memorable patients from residency was a very pleasant lady in her 50's that I met for a total of 10 minutes. I was called down to the ER to admit her to the ICU, and when I arrived in her room, she was sitting in the bed, smiling pleasantly, with a pO2 of 30. She had been in the ER for several hours, and they were as shocked as I was when the ABG came back. Once we realized her situation, she of course turned blue and coded.

Once we got her into the ICU, it became clear to me what was happening: she was in neutropenic sepsis. She had just finished a round of chemotherapy and did not have a single white blood cell in her blood stream. Without an immune response, she had looked quite decent in the ER, until she suddenly and rapidly decompensated.

Her vitals plummeted. The ICU staff looked to me with that classic look meaning, 'How long as you going to torture this woman? When will you let her go?' so I told the staff up front: "We will keep going until her family arrives." And we did. For a couple hours, we got everything the ICU had: fluids, colloids, antibiotics, pressors... any and everything. We managed to keep her alive, but just barely so.

Finally, family arrived. Her sister was the first one to come. She went immediately to the bedside and started weeping. Gently, we described the situation to the sister: this lady would most certainly die. Then, we let her sit with her sister and ponder that horrible news.

Next came the patient's boyfriend. The nurse didn't think anything about ushering him into the room, but as soon as he walked in, an argument ensued. The sister barred him from the ICU room, and asked for security to escort him off the premises. Sadly, family squabbles make their way into the ICU all too frequently.

We brought the boyfriend to the break room while security was called, and I asked the sister to step out to the nursing station. We sat over some coffee. With all 27 years of my life experience, I tried to give the sister, who was easily double my age, some perspective.

"Your sister is not long for this earth. I have done everything I can do with medicine. There is no other drug I can give or procedure I can do. She is going to die.

"Now, you have the exceptional duty to carry out her wishes, since she can no longer speak for herself. No one asks for this job, but it's fallen to you, and I'm sorry for that. But please, whatever you may think of this man, whatever your beef with him, please remember that you are speaking for your sister. Please think, what would your sister want?"

The task of a health care proxy (DPOA-HC) is never easy. It looks simple based on the paperwork. It sounds simple to say that you'll speak up for a loved one when needed. But proxies are only ever asked to make decisions in the worst circumstances, at the worst times, when the choices are between horrifying and terrifying. And when you most want to have someone to talk to, a loved one to help guide you, that person is lying in a hospital bed, dying.

The sister flinched, and turned it over in her mind. She eventually relented, and let the boyfriend into the ICU room. They sat together in silence as we turned off the medications and the ventilator. They both wept openly as I came in and finally pronounced the patient dead. They took turns grieving, and finally stepped out of the room, hugging each other tightly, desperately clinging for support.

Before she left the ICU, the sister stopped at the nursing station. She thanked me, the man whom she will forever remember as the person who let her sister die. She thanked me because when most important, love will always be more powerful than hate, and love will always win.

This was the exact moment when I learned that being a physician often has nothing to do with any medical test or treatment.