Gnosticism in the ED

When last I put pen to paper, we discussed the vexing problems of the complex code breaking we are obligated to teach our young colleagues. These codes of statistical mathematics, definitional precision, and societal interaction are still the core of what we give to residents, and are lessons that stay with them long after data about antibiotics and SSRIs have been forgotten. But there are also the specific truths (lest I say aphorisms) of the practice of emergency medicine they must also master if they are to long survive this most grueling of careers.

Are knowledge and science enough to bring meaning to the practice of medicine?

When last I put pen to paper, we discussed the vexing problems of the complex code breaking we are obligated to teach our young colleagues. These codes of statistical mathematics, definitional precision, and societal interaction are still the core of what we give to residents, and are lessons that stay with them long after data about antibiotics and SSRIs have been forgotten. But there are also the specific truths (lest I say aphorisms) of the practice of emergency medicine they must also master if they are to long survive this most grueling of careers.

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I claim no special insight beyond my own experience, the foundation for which was laid in the summer of 1968 when I saw my first emergency room case as a freshman medical student. I went to see a young child who had, during an automobile accident, gone from the back seat to the front, hitting the dash and lodging a radio knob into his frontal lobes. As I watched the futile resuscitation and the judgmental way in which the family was treated, my first general rules of emergency medicine were being formed. Namely, that I could not be a scientific Gnostic. Science alone could not bring me total fulfillment as a doctor, or provide final peace and solace to my patients.

When Cyrus entered Babylonia in 539 B.C. two great worlds of thought collided and syncretism of religion, philosophy and thought process began. The idea of the great struggles between good and evil, thought and scientific fact, contemplation and action came to a head. Judaism, Christianity and Islam – as well as many other pagan systems – held that the soul attains its proper end by obedience of mind and will to some supreme power (i.e. by faith and works). In the face of these beliefs – or in response – Gnosticism put forth that salvation (substitute fulfillment) is achieved only through knowledge. All of life’s answers, so they suggest, depend on our quasi-intuitive knowledge base. They also believed in the power of “ex opere and operato” – of names, sounds, gestures and actions which were known only to the insiders of the cult. Next time you watch a medical student doing a physical exam, remember the ancient world. To be a modern physician you must buy into at least the quasi-scientific basis of what we do. But to think that science alone will provide total fulfillment and peace is to be deluded beyond reason.

I hope to not slip the bounds of this earth intellectually intestate, so here I now share some social truths to go along with hard science that I feel we should be conveying to our young. I hope to find that intermediate space that integrates science with a set of observations on the human condition. We need to let the young in on the real secrets of a fulfilling career. We are in the business of throwing young men and women headfirst into the toughest job in medicine with nothing but honor, courage, commitment, and conscience as the safety net. If they don’t get some truths from us, who will they get them from? On to lesson one.

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Saint Augustine’s “Just War” theory (which is codified today in the American laws of war) includes principles on combatant behavior and instructions on the discrimination of targets. If we can be civil to our enemies, we can certainly be civil to our patients. The Paris Island Marine Base should be a more hostile place than the triage station in our emergency departments, but frequently it is not.

My next hard-learned lesson is to begin each shift with the declaration “Be Not Afraid.” I thought it was a two-bit platitude when it was first told to me. I likened it to, “brush after meals” and “eat more fiber” not as essential instructions for an emergency doctor. I was wrong. I was young when I first heard the words in John Paul II’s first papal address. I know biblical slogans are a dime a dozen, but this one grew on me. Just confront a world of imagined and unimaginable horrors from the ED of a single-covered city hospital and it comes into sharper focus. If you believe that the beaten children you care for have no eternal destiny, and therefore only this mediocre worldly end matters, then you don’t need a certain boldness of spirit to drive your soul. It’s just pro forma. I’m sorry. I’m not that strong. I need a belief structure and a purpose for going forward.

Lesson three. We all know physicians who are chronically unhappy with their life and their chosen profession. There is a particular sorrow which hovers over them. Their first words as they come onto the shift are always negative. They reflect an unhappiness, not only for the inevitable losses and grief which accompany all of us as we age, but more predominantly they express a settled conviction of the tendency of all things to be unsatisfactory. Everything fails to live up to their expectations. By both disposition and action, we must teach the young that this is unacceptable behavior. Enthusiasm is infectious. Get some. Share some. Find interesting cases and debate meaningful changes. In his master work, Novum Organum, Francis Bacon castigated such people for their “despair of life” and their “thinking things impossible,” thus obfuscating all reasons to try. Such people suck the very spirit from your marrow. 

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The next lesson – that much of medical care is a cultural/social event and not a scientific experience – comes very hard to the young. Medical students and residents don’t like the fact that most diseases go on their way with or without intervention. Managing a patient with a disease should not be confused with knowledge about the objective disease process. You will wind up doing some EKGs, chest X-rays and blood tests which are not needed. I try to convince patients why they are “lucky” they don’t need any “potentially dangerous testing,” but I don’t always win these debates. If you end up getting ten percent more studies than are truly necessary, don’t beat yourself up over it. You still have ordered 75 percent less than many of your colleagues. It’s not worth getting into a fight with a patient over minimal points. The movement of patients away from unnecessary tests, antibiotics, cough syrup and soft cervical collars will be a slow and painful societal journey. Do your best, but it’s not all on your shoulders. The concept of stewardship should be a central core training value in emergency medicine, but it just isn’t. I am open to suggestions on how to fix this black hole of expense. Great science and great savings can all be achieved, but the management of patients takes place one at a time.

Another important lesson for the list is: All families are dysfunctional. To paraphrase Chekhov: “All unhappy families are unhappy in their own way.” Who among us doesn’t have a strange Uncle Fred we’ve had to explain to our fiancé on their first meeting, or a 20-year-old family feud that erupts at the holiday dinner table? Just know that it is important that the family is part of the calculus as to whether a patient can go home, buy medications or needs involuntary commitment. The degree to which family dynamics influence care is staggering. Although I have yet to work out the final mathematical proof concerning this matter, it will at its completion include the number of relations in the waiting room divided by the total number of people in the patient’s room who don’t want those other people back. As I think about it, this total family dysfunction theorem may need to go higher up on my “must teach” list.

A cognate to the family dysfunction theorem is the personal dysfunction rule, which is: “They all lie a lot.” No resident should be surprised by this. More importantly, they should never be upset by it. Lying to ourselves is how most of us get through the day. Having just been in Las Vegas to teach, I’ve witnessed first hand the endless numbers of both men and women who have lied to themselves about how they look in spandex. The faster a young resident gets over the anger of being lied to, the faster he or she can deal with the real issues. There should be no lectures given to patients on the effect of lying on the immortal soul – no theoretical talks and no retaliation by withholding medication.  Just move on and realize that half the information you get is tainted and will need to be verified by some reasonable person. Now the tough part: How do you find a reasonable person to talk to?  

My time/space is running short. So I shall save other aphorisms for another column save a parting shot. Eat whenever possible. Just when you think the place is slow, you commit the mortal sin of ordering out. What you are all unaware of is that there is a conspiratorial group which has tapped the phone. As the delivery man shows up, they instruct at least 20 people with complaints which range from “I want to kill myself” to “I have run out of my seizure medication and antidepressants” to rush the door so you will never eat warm food. So eat when the eating is good! Some six months after I stopped seeing patients, I actually tasted warm pizza for the first time. A most unusual sensation.

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Sapere Aude
“Dare To Be Wise”