I have developed the silliest of silly crushes on one of the nurses. I say silly because it really is. She's way young, in a relationship, not my type at all (You know, she's not self-destructive or emotionally unavailable. ha ha), and I still have that no nurse policy. But I actually dedicate brain time thinking about how I can impress her. I am such a dork.
At least nowadays though, my crushes aren't these pathological obsessions that are emotional hell. It's just a guy trying to flirt with a girl too young for him and out of his league.
A friend of mine once referred to medicine as the cruelest of mistresses. It took me a while to catch his meaning, but eventually it became clear. Ask a doctor, even one that hates his job, what he would do if he wasn't a doctor. I'll bet most couldn't give you an answer. No matter how much you hate it, there's no other job we'd rather do. If I wanted money or prestige, I would've done something else. But I love medicine, as much as it hurts sometimes.
And it's hard for non-doctors to understand that there is something we value as much as anything else in our lives. I talked to a radiologist who had come out of retirement. His comment: what was I supposed to do, sail a boat? It finds its way into every part of our lives, and continually pulls.
As priorities go, I think most doctors find that the only important things are God, family, and medicine. The problems come that the order of those three is often not as clear. I know several doctors and medical students who celebrated the births of their children by taking an afternoon off.
And that's what I mean by a cruel mistress. A flesh and blood mistress, we could leave in a heartbeat if it meant our families, our happiness. But medicine? It will drag us down. And it's tough to love someone as fully or have as meaningful relationships because in the back of your mind is always medicine. And as much as you hate the pager, you still answer it.
If you're not ready for this kind of commitment, then think twice about medical school.
My car needs to go to the shop, and I'm having a hell of a time figuring out how I'm going to get to the shop to pick my car back up, muchless getting home from the shop, and I realized how much easier this would be if I had someone that could pick me up and drop me off without it being a big deal.
I know, that sounds really stupid, but there are some nice, simple things about being in a relationship, like having a ride, or having someone to come home to, or eating a meal with someone. It's simple, but there's an elegance to it, and there are times when I think it'd be nice to have someone like that.
I know, it's a dumb reason to want to be in a relationship, but when your car's in the shop and you've got no way to pick it up, it sure sounds like a nice time to have a girlfriend.
Aside from infectious diseases and surgical illness, it's somewhat scary to realize that there are no cures to things. We can't cure crap (literally and figuratively). All the big deals - cancer, heart disease, stroke, HIV, high blood pressure, diabetes - we can't do anything for other than try to prevent or try to make the disease tolerable. We are impotent.
It took me a while to realize that most of what I do is delay the inevitable. We all die, no matter what, and the only thing I have to offer is delaying premature death. Otherwise, if you're 83 and dying of metastatic colon cancer, then that's about right. And it took me even longer to see the value in doing this Sisyphean work, an endless stream of hypertensives and poorly controlled diabetics.
So if you're going into medicine to cure people, then please reconsider.
Every now and then, you'll meet the stereotypical doctor's kids. I think it's more the exception than the rule, but it illustrates my point well. These are kids that are simply starved for emotion. And it's no terrible surprise that this happens.
Throughout the whole process of learning and practicing medicine, we develop habits and strategies to deal with the horrors surrounding us. Some people become very emotionally labile, crying one minute then laughing the next, but most become emotionally distant, detaching themselves from patients. We learn to keep the world at an arm's length. And sometimes, with some people, it spills into the home, and either we've got nothing left to give, or have spent so long keeping everyone out that it's hard to let anyone in.
And so you'll meet some doctor's kids one day, and they'll be emotional vacuums, leeching emotional content from whomever is nearby. And what do you expect when parental affection is so sparse and emotional generosity is so unrewarded. It's easy to become a one way valve. It's not the rule, but it happens.
And the reason I mention this is that when your business is taking care of the sick and suffering, it is very hard to be emotionally available for the people in your life, because you've learned so very well how to suppress it all. And worse yet, you've learned how to fake it. You've learned how to put on the show, and 'be there' for someone without ever risking your emotional being.
And that's part of being a doctor too. And the best of us learn how to be a human again when we leave the hospital. And the worst of us are divorced 3 times and buy sports cars to make life seem more bearable.
I've gotten a lot of compliments on how I deliver horrible news. I've had to give the talk so many times now that it's more or less routine to me. It's a skill I learned in med school, but I've since honed in residency. I thought I might at least share my technique. Like all things though, it takes practice. One thing to remember is that it's always better to set the stage. You can actually use this very technique to deliver bad news over the course of a few days, which can help soften the blow a little.
(1) Set the time and place. Get everyone together. At a minimum, you should have the patient's next of kin, if not the patient himself. All available family should be there. It's also good to have the nurse, the social worker, a palliative care nurse, any relevant consultants, and of course the treating physician (that's you). Make sure everyone is comfortable and can hear you.
(2) Appoint someone to run the meeting. It doesn't have to be the doctor. In fact, it's better if someone else runs the meeting. Usually, the nurse is the best candidate. That way, the family can easily separate curative and palliative options. But hey, I've run tons of these meetings, so it's just a matter of someone doing it.
(3) Be prepared. Have the chart, review it beforehand, make sure the care team members are all aware of the agenda for the meeting (such as trying to get the family to consider DNR or Hospice, etc). Make sure you know or meet all the principal players.
(4) ALWAYS start by designating a family spokesperson.
(5) Have the family tell you what they already know. This way, you can get the family involved in the talk, and you can figure out exactly where they are in terms of dealing with their loved one's illness. If they already know everything, then why waste everyone's time and skip to the end.
(6) Now, starting from the BEGINNING, fill in any holes the family may have. Avoid all jargon. Your speech should be at a 5th grade level. Stop frequently to make sure that everyone is still following you. If you can't answer something, refer to the chart.
(7) Tell them what you are doing RIGHT NOW, and what effect that is having.
(8) Tell the family what other curative options are available, and the chance that those interventions would affect survival. Also note if there would be associated complications or effects to the patient's quality of living.
(9) Tell the family IN NO UNCERTAIN TERMS that your medical opinion is that the patient is dying.
(10) Give the family time to grieve. Offer tissues. Don't say anything for 5 minutes unless directly asked a question. Don't answer rhetorical questions.
(11) Now it is time to discuss code status. The family meeting cannot end until the family has at least thought about code status. I discuss code status by explaining what a code is, and then noting that in the ICU (as most talks are on ICU patients), we are already doing extremely aggressive measures, and that if the patient coded, there's little to no hope he's live through it, but it would be a very traumatic experience to the patient and to the family to witness.
(12) Now, let palliative care services discuss what they can offer to the patient, regardless of whether there was a change in code status. There's always a place for palliative care. Leave the room at this time if the family has no more questions for you. It's important to let the palliative care people proceed without your interference. Make yourself available to family if they have more questions.
Of course, it's different to see it in practice. This is just a framework. Following the same format, I've given amazing talks and I've given horrible ones. It's a matter of finesse.
But one thing you should take home with you. After you tell the family that their loved one is dying, they won't remember anything else you have to say for at least 10 minutes. You've got to let them grieve a little and regain their composure. When you start discussing code status and withdrawal of care, keep it simple. In the family's mind, withdrawing care is withdrawing care. Think of it this way. When you take your car in for a tune up, the mechanic doesn't explain the whole tune up procedure to you.
What I usually say is something like, "Currently, [patient] is a full code. That means if his heart stops beating, we'll do CPR and shock him and give him special emergency meds. But right now, we're already doing very aggressive things, and even using some of those emergency meds right now. I think if his heart stops, the shocks and the CPR won't help. The best we could hope for is to prolong the inevitable. I think the best idea is that if his heart stops, we let him go and make him comfortable."
Then, it depends on whether you think withdrawal of care is appropriate. If I think withdrawal of care is appropriate, then I'd say, "We are giving him very dangerous meds, things we can only give in the ICU, and instead of getting better, he's only gotten worse. And at this point, I don't see that these things are helping him at all. I think we should get rid of these meds and instead try to make him as comfortable as we can, and let him die peacefully." Let palliative care talk about the details.
Now, I'm sure some out there will find faults with my method, but honestly, it gets me results. And as long as it works, and families are happy with me, and patients die peacefully (when we can't save them...), then I'm going to keep doing it my way, thanks. And you may disagree with how I do things, but I've had families hug me and thank me, and it always blows my mind, that they would hug the person they will forever point to as the doctor that couldn't save their loved one.
Recently, the Cheerful Oncologist had this to say about wanting to be a doctor. I have indulged myself similarly, numerous times in fact (1 2 3). But reading through the Cheerful Oncologist's list, I was struck by the fact that we spend so much time talking about the qualities required to be a doctor, and it's always cast in such a noble light. Rather than rehash a trite list of admirable qualities, I thought I might point to the blemishes instead.
So for your benefit and amusement, I will start a continuing series of essays on why NOT to become a doctor, starting with this one. I think it goes without saying that if you can read through these and still be gung ho for medicine, then feel free to proceed. Currently, I'm planning on at least 16 of them. Yah. I'm surprised too.
If you wish to be a doctor, there are things that you should know. The first thing is that you cannot ever understand what it means to be a doctor until you actually are one. Life truly is a little different once you've put on the long coat. You can't talk to someone who's dying and not be changed. And so, all I can hope for is that when I'm all done with this series, you can read them and piece together what it is to be a doctor, and decide for yourself if it's for you. And with that, I'll begin.
I found this comic, "Nana's Everyday Life" on the web, and I have to warn you, VERY NSFW! Briefly, it's a humorous look at the life of a little Japanese girl who's a sex slave. Believe it or not, the idea of having sex with little girls is such a prevalent fetish that it has a nickname, Roricon (Short for Lolita Complex). The comic itself starts as a satirical and ironic piece, but by the end is very somber.
And while it's designed to be jarring, I was absolutely struck by this, because it brought back flashbacks to me of child psych, the field that I was considering but chose internal medicine instead. The reason why I couldn't do child psych was because of stuff like this. It's because I would meet these little kids, the most innocent of innocents in our world, and they've lived harder lives than I could ever imagine. They've survived rape, torture, neglect, assault, abuse, starvation, and every form of physical and emotional abuse. They've been scarred for life, scars so deep that we have nothing that can fix them, nothing to make them better. There is no amount of love or caring or compassion that can heal these little children's wounds. Never. They are destined to live existences tainted by the horrors inflicted upon them.
And that first week on child psych, I wanted to buy a gun and shoot their parents for doing what they've done. I wanted to mete out justice, the kind of justice I pray exists in this world or the next. And it took me a long time to realize this truth about medicine: you see people at their worst. You see the worst people, the worst of times, the worst done to them, the worst circumstances. Medicine isn't a field that makes you feel happy. It isn't full of sunshine and songs. It's people sick, people dying, people shitting themselves, or living with a tube in every hole and some holes we've had to make.
In medicine, you only see the very worst of the world. Those are the folks that need our help. And it drains you. It eats at you at night. It can convince you that the world is full of disease and death.
I was talking with a friend, and noted that a lot of Catholics are in internal medicine. Of course, he said. What better field to suffer in? But the catharsis isn't just for the patient. The profession of doctor is cathartic. If you aren't ready or willing to face the dark side of the world every day, then please don't become a doctor.
I hate Valentine's Day. If there was some way I could delete it off the calendar, I would. It's hard to see other people so damn happy. I'd like to throw up all over the whole thing. But really, I didn't hate V Day so much until 1999, when my love life became some sort of sick farce, and I found out my love interest at the time was anything but.
Since then, it's been ruined for me. I can't stand it. It's a big charade. But maybe I'm just envious. A friend of mine tried to explain the difference between envy and jealousy to me. There is a difference. Envy is when you covet what someone else has. Jealousy is coveting that which you already have, or lost. And I'll admit, I'm envious. I'm all sour grapes. I wish that instead of eating cereal and watching "House" that I was out on the town for a romantic dinner and a night of passion.
But there is a virtue to being single on V Day, and the nice thing about V Day being forever spoiled is that I can see the hypocrisy so very clearly. But y'know, I can't help wishing that I was a part of the big lie, and that this collective delusion was something I could share in.
I tried once to get my mom to see "The Joy Luck Club" but she refused. She didn't want to see a movie about made up stories, when she had her own story that she'd lived. Every now and then, she'd tell us a little bit about her childhood, almost by accident. She'd tell us about her life during the war, how her family ate nothing but squash for weeks and were grateful, or how her aunt was killed by shrapnel while walking across the street holding my mother's hand. Most of these stories stay hidden, memories of a darker time best forgotten.
My father has no stories. He was telling me about his life growing up, and it's a collection of stories about uncles and cousins and grandparents and friends, but never about himself. None of it is witnessed or experienced. None of it is substantial. It's more rumor than history. And so it's hard to take my father's stories seriously, because it reads like fiction.
And I think this difference is what cuts at me sometimes, because it's advice without even experience behind it, and what is that worth?
You know, it's really sick when you find yourself saying things like, "Oh, you're on an outpatient rotation! Sweet. It's like vacation!" That is how sick residency truly is. Working a 40 hour week is a vacation. So, after suffering through a sea of inpatient rotations, it's nice to get a few weeks of clinics.
And now, for real, I am on vacation. It feels so good to finally be free, for a little while at least. Even though most all of my time is spoken for, with visiting family and the like, it'll be nice not to have to put on a shirt, get my white coat, listen to other people's problems.
That sounds mean, but man, it's tough having other people tell you about their problems all day long. Itching and bleeding and nausea and need for vicodin. All this junk! The one saving grace is that I love my patients. I have a core of 10-15 patients that I *heart* seeing in clinic. They are fantastic folks, all with these strange but wonderful medical problems that they make their own.
So I feel a little bad abandoning them while on vacation, but it's nice to be free. I won't be blogging for a while. See ya on the flipside.