Privileged #1 - How are you?

One of my most memorable patients was a wonderful lady with floridly metastatic, unresponsive to treatment, triple negative breast cancer who developed subsequent cardiomyopathy from chemotherapy. She had an EF of <10% and during the course of her hospitalization underwent multi-organ system failure from end organ ischemia. To translate this into normal speak: she had the worst possible breast cancer, with the worst possible response to treatment, and the worst possible side effects.

I was only an intern but I had to give 'the talk.' I sat her family in a conference room, went through the facts of her case slowly, and gave my assessment: she had two terminal conditions, both of which we could not fix. The family cried, and the oncologist piped up about radiation, or another round of chemo if we could get her heart back, or something ridiculous. I ignored him completely. I sat there for five painful minutes while they cried and asked me "Why?!" Once you have done this a few times, you realize that as much as a family wants the answer, you do not have it. Bad luck? Fate? God's will? There is no right answer to this question, only tissues and holding a hand.

The family consented to weaning off vasopressors (medications to elevate blood pressure), and with her loved ones at her bedside, we turned off all the supportive measures. I declared her dead about 30 minutes later. As memorable a moment as this was, it was not the most memorable.

The privileged moment came one day earlier. The oncology attending had just met with the family and discussed keeping their hopes up as well as future chemo options. It was a pep rally, to be sure. I was eating lunch at the time. My senior resident asked me to check on the labs, so I headed back to the ICU, and ran into the patient's sister in the hallway. I said, "Hi! How are you?" with a little wave.

She looked at me, and managed say, "I'm fine, tha-" before bursting into tears. She collapsed to her knees in the hallway, and I had to help her into a chair. I got her some tissues and sat with her for 15 minutes. We joked a little about some funny things her sister had said. After regaining her composure, she looked at me directly, and asked, "Dr ifinding, is she going to die?" I told her that we should get her family together and talk about this, leading to the family meeting the next day.

I am still amazed that this small, chance event of saying hello could be so profound. It was the opening she sought, the chance to ask the question everyone had avoided. She just needed a chance to ask. And it made me realize that even the smallest interactions can have big impacts.

I also felt very honored by the trust placed in me by this family. I was the wet-behind-the-ears intern, but they saw me every morning doing my job, and that was enough for them, because being a good doctor means that you are someone worthy of trust.

Privileged

In today's world of medicine, I think that people forget that being a physician is a privilege. There are plenty of things in life that you earn with hard work and skill, and medicine requires those things too, but it is a unique privilege to be a physician. We are asked to do things to people that are painful, we are told things in confidence, we are asked to make life or death decisions. We are the ones who have to tell the family that their loved one is now dead.

I have had a lot of fun writing the "Don't be a doctor" series, but I think it might be nice to write something a little more inspirational, and so I am going to embark on another series of posts, about moments I was privileged to witness in my medical career.

You'll have to excuse me for repeating some post content. I have undoubtedly blogged about some of these events before.

(1) How are you?
Even the smallest interactions can have big impacts.

(2) Happy birthday
We took a minute to celebrate her life, even as it ended.

(3) Kindness
It is possible to do good in this world.

(4) Thankful
She had so little to be thankful for.

(5) Reconciliation
Love will always be more powerful than hate.

(6) Enough
Sometimes a person has to say enough is enough.

(7) Comfort
I was not a stranger in his life. I had been a part.

How do you know?

Perhaps the most common question I receive on this blog is a simple one: how did you know you should be a doctor? Well, I have written no less than 4 times on that subject, and posted a litany of reasons why to avoid medicine.

But the truth of the matter is that there is no way to know for sure. Is there any way to know for sure about any career decision until you've already made it? What I can tell you is this: all the reasons YOU think you would be a good doctor are bullshit. Total 100% crap. Because I had the same thoughts, and it just wasn't true.

I want to help people. I'm compassionate. I care. I had a grandfather who was really sick. Blah blah blah. This is all trite garbage, and doesn't cut to the heart of the matter.

In high school, I decided that I would consider being a doctor. Instantly, my teachers were enthusiastic. They thought I'd be an excellent doctor, as did a few college professors and a boss or two. What did they know? They didn't see my transcript. They didn't read my admissions essay. They knew nothing about my motivations.

In truth, being a good doctor is not one quality, but a myriad. It is compassion, but it's also conviction, empathy, faith, indignation, professionalism, perseverance, reverence, charity, dedication, hope, intelligence, skepticism, forgiveness, anger, and so much more. It is a whole subset of skills and traits that you don't know you have at the tender age of 18.

I realize now that all those encouraging words from my teachers and superiors, it was because they could see in me things that I could not see in myself. I wanted to become a doctor because I thought it would change me, make me different. They saw that the other than some coursework and a stethoscope, I didn't need to change a thing.

I needed that

I saw a patient today, and had some bad news. We talked about what we can do and how to approach it, but ultimately, things are getting worse, and we'll have to see if we can turn things around or not.

As I finished up, he said to me, "Dr ifinding, you gave me all kinds of news today that I didn't want to hear, but I'm glad you were the one telling me."

Thanks, dude. You have no idea how much I needed that.

Quality improvement

Our length of stay is too long. That means on average, we are keeping people in the hospital longer than we should, given their diagnosis. But we will be penalized for bounce backs, which is where a patient is readmitted within a month. So, we need to get people out earlier and ensure they don't come back. Our A1c's are too high. We are not keeping diabetes well enough in check. Our blood pressures are not well enough controlled. We are not getting enough yearly mammograms.

Quality improvement can be frustrating at times, because there are so many places where a quality standard is being imposed, either now or in the future, and many of these standards have no evidence whatsoever that they actually improve patient outcomes.

So let's be honest here. These goals are not to improve quality. They are to save cost. There's nothing wrong with that. We waste a lot of money in health care and trimming our expenditures is reasonable for any business. But I resent the idea that I am not delivering quality care because I don't hit some arbitrary target, or document something so some quality maven can review it.

A few years ago, I had a patient with HTN and diabetes who was passing out frequently. So I changed his meds so SBP was >140 and A1c was >8.0, and he hasn't passed out since. I think he would say that he's getting quality care.