Rituals

It's so cliche that you already know how it happens. The doctor walks up to the family member and says, "We need to talk. Please come with me." The person is ushered into a room and asked to sit. If they don't sit, then they are encouraged to sit.

"I have some bad news." Colloquially known as a warning shot, this is the clue to the person that this is bad. There will be no 'good news, bad news' game here. It's only bad. Next comes a formula repeated in every hospital in the country. A recitation of facts about what happened, and at the end, telling the family member that their loved one has died. The doctor says, "We did everything we could, but we couldn't save him, and he died." There are accusations, and shock, and tears. Tissues are provided. Hugs sometimes or a hand on a shoulder.

While it seems like a cliche, it serves a purpose. When people experience a situation they know, then it helps to provide structure to the process. It's no different than a Catholic mass. There are no surprises. You know exactly what is going to happen, what people will say, and when it will end. So when faced with terrible circumstances, it's reassuring to know that there is a structure to it, and a role to play. The doctor knows what they're supposed to do, and the family knows as well. So while reciting the words and gonig through the ritual, a person has for a brief moment the chance to truly grieve, cloaked in the words and actions already predetermined.

If you're looking for advice on breaking bad news, then there are lots of formulas. I think that SPIKES is as good as any. I do have a few tips.

  1. Make sure you say that you did everything you could. In fact, use that exact phrase. "We did everything we could."
  2. Make sure you say that the patient died in no uncertain terms. Not "passed", not "lost". Something like, "We couldn't save him, and PATIENT died."

You would not believe, despite saying those exact words, how many people will question you on those two points. And that's natural. Don't be defensive. The human creature can only process so much trauma at one time. People want to make sure that everything was done. People want to make sure that their loved one is indeed dead. It's not blame. It's shock.

Pencils and crayons, part 2

The word "acumen" means a quickness of perception and discernment. In medicine, someone with clinical acumen is sharp and fast to an accurate diagnosis with minimal effort or information. A doctor will walk into the room, take a quick smell and a glance, and pronounce to the patient, "You have a bleeding peptic ulcer." The patient and all the house staff are astonished at the quickness and the veracity of the diagnosis, and sure enough, the endoscopy proves him right.

The reality is that the doctor could smell the distinct odor of melena, and observed upon walking into the room that the patient was eating a plate of hot wings his wife had brought in, and had a beer belly. It was a pretty safe bet that he had an ulcer.

Acumen comes from the Latin word for a sharp point. And so, just like sharpening a pencil, clinical acumen needs to be sharpened too, but it's hard to keep sharp, easy to dull, and sharpening itself takes work. Because the way most of us physicians keep our acumen sharp is honed on the bodies of the dead and dying left in our wake.

I won't miss pancreatic cancer again because Mrs R is dead now, and maybe I could've done something to stop it if I'd only found it sooner. I won't use steroids to treat acute arthritis if I haven't ruled out a septic joint, because I've seen what happens to an infected joint that gets steroids.

Keeping a pencil sharp takes some effort, not much but some. Keeping a crayon sharp is an exercise in futility. At the end of the day, it's not just the sharpening that takes work, but we have to strive to be something worth keeping sharp.

Pencils and crayons

Getting compliments from patients can be funny. I like to get compliments, don't we all, but in my heart, I know that most of the time, these praises are unearned. I didn't do anything marvelous or spectacular. I did the doctor equivalent of a teeth cleaning, and for that, the patient is singing my praises to everyone they know. It's not earned. I'd rather get praise that I earned.

Lot of patients don't have good relationships with their doctors, for whatever reason. Sometimes, it's the patient having unrealistic expectations or demands. Sometimes it's the doctor not communicating well or not providing good care. Sometimes, it's just personalities not harmonizing. There are lots of reasons that a patient and a physician don't end up on the same page.

For this patient, I did nothing. I was assuming care for the person after their previous physician left the area. We talked about his medical issues and medications, about the clinic policies and my own personal policies, and then I did my exam. He was so shocked at how thorough my physical exam was (it was actually pretty cursory and mediocre), how detailed my history-taking was, and how well I explained what was happening next. He thanked me, and proceeded to sing my praises to my staff and then to his wife in the waiting room. But the reality was that the care I delivered was perfectly mediocre. It was dinner at Applebee's.

My MA was surprised. "What did you do in there?"

My reply: "When all you’ve ever known is crayons, then a pencil is gonna seem pretty awesome."

Evidence

When I was in medical school, we spent a lot of time learning about evidence. The only way we could make good decisions was to base them off of good evidence. And so, we learned about what constituted evidence, how to critically appraise evidence, how to consider the risks and benefits, what are the ways to understand different methodologies and practices, and how to understand hidden biases.

So when I first saw the Covid studies coming out in the early Spring, I was really shocked, because we were setting global health policies on extremely shoddy evidence. Half the time, we were basing direct patient care that day on what new preprint* had just come out. None of us really knew if HCQ had done anything whatsoever. We were reacting, based on bangs and flashes, like an animal scared by lightning.

And colleagues assailed and harangued me for doubting the wondrous effects of HCQ, based on the anecdotes they had heard. And when we were scolded as a profession for hoarding and stockpiling HCQ for personal use, several colleagues got defensive and belligerent, clearly caught with their hands in the cookie jar.

I've been surprised by how people act during this pandemic. I have seen a lot of questionable things done, and the reality of the situation is that when you don't know what to do next, then sometimes people will do anything, because anything is something, and something is better than nothing. There's a reason why I have that quote, "ut aliquid fieri videatur". Sometimes in medicine, we do things not because it's right, but so that we look like we did something.



*A preprint is a submission to a journal for publication, not yet peer reviewed.

Daughters

When I was early in my career, I was working with a medical student and we walked into a patient room. This was my first day on rotation, picking up my list from a colleague who told me that the family was very needy, and patient was ready to go to subacute rehab in a day or two. Instead, when I walked into the room, there were two daughters seated bedside. They greeted me by saying, "How do I spell your name? I want to make sure we get it correct when we sue you."

Anyone who's worked in medicine for long enough knows the story of daughters. My nurse doubted me, but over the last several years, she has seen it too. Every hospice patient, every terminal situation, every tough cancer case, there's always a daughter in the room, demanding answers.

Rather than get defensive, I sat down with the two daughters and said, "Let's talk. Tell me what's bothering you." And I listened for thirty minutes about how they didn't have any answers, about how their father continued to worsen slowly and wasn't getting better, and finally about how their father had a solitary pulmonary nodule on the CT scan before and nearly died from an aggressive lung cancer. Sure enough, he was deteriorating. His mentation and cognition were dimmed from numerous acute medical issues, and he never recovered from the aggressive chemotherapy that sapped his body and mind. I listened, and I agreed. I didn't have answers. I didn't know what this nodule was. I didn't know if their father would ever leave the rehab facility.

By the end of that thirty minutes, I examined the patient, barely conscious, and then said good-bye to the daughters after going through the details of the plan that lay ahead. I hugged them both, and while they fought back the tears, they both thanked me profusely, telling me that I was the best doctor they'd ever met, and how that time spent with them meant so much.

My student was totally awestruck. He had no idea that such a chance encounter in the hospital could lead to such a profound moment for a family. We stepped into the nursing station for a moment while I talked to the patient's nurse about modifications to the discharge plan. While writing some orders, I turned to my student.

"I did nothing skillful in there today. I sat and I listened to two daughters who care very deeply for their father, and who desperately want answers. The lesson you should take away from this case is--"

"We should listen to our patients and their families?" my student suggested.

"What? No. The lesson is that if you go into a room and see daughters at the bedside, get yourself ready. You're about to get rocked."