Give me residents who are more than their CVs, doctors who base their practice on actual beliefs and values
To the left, you see Dorothea Lange’s iconic photo, “The Migrant Mother,” which became the unforgettable symbol of both The Depression and The Dust Bowl. I would say there are no educated physicians who have not seen this likeness a dozen times. The woman in the photo, Florence Owens Thompson, became a national symbol of what existed in America in 1936 and what an inexplicable and poorly understood Evil Empire had done. The photo is emotional lightning, like the raising of the flag on Mt. Suribachi and Gehrig’s farewell to the Yankees, the images encapsulate the entire range of our emotions. They are stop action film noir.
Color photographs are real. Black and white photos are surreal.
They cover the extremes of form but not reflection. Blisters of a hand, the angulated face showing the soul bleeding through are what we remember. People viewing sense the poverty of our secular culture, which has systematically robbed us of a moral vocabulary to talk about fundamental human desires for stability, for contact, for tenderness, for hope. Anyone who thinks tweeting or texting is human contact is a fool.
So what does this have to do with medicine? It has everything to do with medicine, especially emergency medicine. For if there is no meaning, no base, no principle, why are we going through the motions? In the past month, I have visited four residency programs and had the chance to discuss with the young some uneasy questions, like why they do what they do. This is not always a popular question. It can even be painful. They want to hear about the HINTS exam and multiple interpretations of pronator drift testing. No value judgments please. Don’t challenge how we think or what we feel. It’s not right. It’s unfair. I like the way they deny the fact that their souls weep every day and they are totally unaware of it.
Are these kids smart? They are thoroughbreds. They are the product of the current script for a fabulous life. Since as science people we need a formula, here it is. Unbelievable amounts of trumped up extracurricular activities, plus unbelievable grades (that in the old days would have been B’s), plus great SAT scores, equals the Ivies, equals success.
The “higher” in higher education tends to refer to complexity and cost, not purpose. College was once a young person’s opportunity to stand apart from the real world for a few years between the pressures of family and the exigencies of the work-a-day world, to discover self and life’s directions. Those times are gone. Now it is a cut-throat path to building a medical school application instead of a self.
So once they have clawed their way up all of these achievement mountains, what’s next? Is the salary you get from being a doctor the only goal? Are we just technicians or are we professors of a trade requiring moral philosophy?
What we are lacking in this narrative is candor about the proper goal and end of learning. Why did you go to school? Your education is what’s left when most everything you’ve learned has been forgotten. How do we know that we’re serving “the truth”? Please define for me. Next, where do we find a shared concept of reason? Because it certainly can’t be just assumed at this moment in time.
Back to the reason that I’m now showing this picture and asking questions which have no “right answer.” Emergency doctors are at best applied scientists. We are the engineers of humanity who take a small number of scientific fact and theories and apply them to make the lives of unfortunate people a little bit better. We are health advisors, not dictators. We don’t tell patients what’s right but help the patient come to an understanding of the situation with which they have to deal and the possible solutions. But to do this requires a value structure. Oh, heaven forbid I’ve mentioned values which might have something to do with morals, which must then state boundaries for right and wrong.
All systems of thought must be based on a set of beliefs. In America we tend to be paid for doing stuff. Your RVUs per hour determine whether you drive a Focus or a Ferrari. So if there is no moral base, why not keep billing? If you get paid more for running a code, why ask questions? The shock and bill theory of healthcare predominates. Never make the mistake of thinking you don’t use some nonscientific beliefs to make scientific decisions.
As I probe some of these more unsettling questions with residents, it is very clear they are smart, talented and driven to success . . . but have no idea what success actually looks like. And they pay dearly for this. Learning is not about the answer but how you take in new information and decide its volition and whether it will really change your practice. To one group of residents I suggested that the PAs I trained can sew up wounds, apply splints and do spinal taps as well as they can. They were not only infuriated but wanted my blood. I said doing one of those procedures was not exactly the Queen of Sciences. What I quickly added was that I felt that the physician’s job was to not only to do the procedure but understand the procedure and be able to evaluate its real use and benefits to the patient and our needs to alter practices to suit the individual.
All the paramedics can give epinephrine. It’s the physician’s job to transfer the knowledge that it doesn’t work. I pray I do not need to read another high dose epinephrine study in which the entire circulating blood volume has been replaced with alpha and beta stimulators. I wonder if zombies are actually created this way now that we are back to believing in the living dead.
The Oxford biologist Richard Dawkins continually told us that the cosmos is pointless. Our universe, as he explains: “Has precisely the properties we should expect if there is at the bottom no design, no purpose, no evil, no good, just pitiless indifference.” I respect Dr. Dawkins as a scientist but I would never want him as my physician. I don’t want him taking a family in to see their just deceased 18-year-old son killed in a motorcycle crash. I don’t want him presenting a young couple with their baby after a SIDS death.
Without resorting to defense of Pascal’s Wager, I reject Dawkins’ sense of nothingness. By the way, I don’t believe that Dawkins really believed his own message. Why would you work so hard, write so many books to denounce the concept of a creator if it was pointless? If human life is pointless then our place in the universe must be pointless too. Pass the hemlock and the razor blades.
I want newly minted doctors to have a value system. I want them to read the great thinkers and find meaning of some kind somewhere and in something. The older I get the more I appreciate the writings and insights of Oscar Wilde. When asked to comment on life’s purpose, Wilde retorted: “To realize one’s nature perfectly – that is what each of us is here for.” Take that, Dawkins. I agree with Emerson that the purpose of life is not just simply happiness but to receive joy through being useful . . . honorable . . . compassionate and to have it make some difference that you have lived and lived well.”
I am a child of the Baby Boomer 60’s when we invaded the culture. To be an American teen in the 60’s was to be optimistic, to have dreams of a decent life and the thought that our government was just and had a true goal of helping me obtain self-fulfillment. It now seems there is a subtle malaise abroad in the land. I am from a “can do” era. This is an era of “we should find a program or get the government to start one that can do that”.
I want our residents to feel as well as process data. Notice I didn’t say think. I honestly care that residents have helped someone with making their life better. If you’re like me, you have gone home from the department on occasion wondering whether anyone is any better off because you showed up to work that day. Sure, I got paid, but did I really make a difference?
A quick story. One evening about 15 years ago, the afternoon shift had turned to stool. I grabbed a chart and headed into a room to see a four-year-old child with a two-inch laceration on his right arm, caused by a fender as he fell off his bike. Mother and father and another man – who I was later to learn was a visiting uncle – were in the room and clearly distraught. I’ve never been much for inflicting unnecessary pain on children, so after playing with the child for a few seconds I gave oral Versed, some topical anesthetics, then went out of the door to start another case.
I came back in. The nurse gave me the needle with the Marcaine, but it was unnecessary as the child was resting comfortably as the wound was cleansed, closed and dressed. Goodbyes were said and instructions given and I rushed off to see the next case. Twenty minutes later, the nurse told me the uncle was at the front desk and requested to see me and was quite emphatic.
I went in, assuming the uncle to be upset. Instead, he gave me a hug and placed a bottle of Chateau Lafitte on the counter. This uncle – who happened to be a wine importer – couldn’t stand to see his nephew in pain and was obviously grateful. Did I do much? Not really. I used eighth grade level science and a few years of experience to solve a simple problem. In emergency medicine, you take small victories where you can. And damn it, at that moment, to these people, I made a difference. I wish for all the residents I teach to have such joy and have pride in what they do for a living.
Mary Shelley said: “Surely something resides in the heart that is not perishable and life is more than just a dream.” If you ever feel hopeless, all you need to cure it is to help someone else. The purpose of life is to kindle a light in the darkness of “mere being”. Now go ahead and look at the photograph again. If the world is pointless, why do we feel such misery and pain for this simple woman and her children?
Me iudice – in my judgment.
5 Comments
Love your columns as always. What I remember of my career (longer than yours I think) are those moments when I made someone feel better not the codes not the central lines the big rvu days but the days I “connected” with a patient or family. It get so depressed at another meeting devoted to how are charting can “drive up the bills of those least able to pay” oops I mean improve our coding.
Thanks for reminding us of why we are here.
Making a difference? I used to feel that I did. I went into emergency medicine to do just that. I did not want to be a cog in the wheel. I wanted to treat patients as a physician, not a technician. Almost anyone can learn a procedure. It is knowing when and how to apply that procedure in the proper circumstance that elevates a physician. Taking care of patients in the oft chaotic emergency department was a challenge I enjoyed. I love procedures and making the right call. But those procedures and critical actions are quickly over and most of the shift revolved around talking to patients. As a physician, you are supposed to be teacher of patients and that requires some hard conversations. Sometimes those conversations could be painful, awkward and moralistic. But at least once a day I had a meaningful conversation with a patient or their family. I could do that. I was not in fear of a poor patient satisfaction score from upsetting a patient through my advice, or not getting to the frequent flyer back pain within the metrically mandated 15 minutes.
Fast forward to the present. It is about not stepping on the land minds. It is no longer about practicing good medicine, with compassion it is about the metrics. Metrics finally gave the business and non-clinical suits an upper hand over physicians. Isolated individually a single metric is not that big a deal, but when combined the weight is staggering. What we say no longer matters. Pure and simple. Did you meet the door to doctor time, disposition time, departmental protocol time, approved antibiotic… the list is nearly endless. Of course antibiotics are beneficial in bacteremia, but I cannot for the life of me see how they work for a septic patient with ebola. But God forbid that you did not give the antibiotics as dictated by the sepsis protocol. We are training the current generation of physicians to react to protocols and metrics the way a street performer grinds an organ for a monkey.
When you spend the entire shift in fear of falling afoul a marker that has nothing to do with the patient in front of you, it is soul sucking. Fall to far afoul and watch your ability to get shifts disappear. Not to mention spending 75% of the shift plugged into a desktop computer clicking in data that will never be used in a meaningful fashion, except to assign blame if something goes wrong. Metrics do not care if you spent an extra 20 minutes with the family of a dying patient, or giving a new diagnosis of cancer. Compassion in medicine is dying, because medicine is transitioning from being about individual people to a mass of numbers plugged mindlessly into machines.
So Dr Henry, I would like to remind you of a column you wrote some years ago about patient satisfaction scores. You talked about teaching to the test to be successful; “In short, when your job depends on it, it becomes important.” Well, because we as a profession did not refuse to cooperate with each of the incursions into our profession as they occurred, they accrued into a seemingly unstoppable landslide where compassionate physicians are becoming irrelevant. Success depends on meeting the metrics. It is no wonder the residents respond as they do. They learn to the test.
Like the parrot in the Monty Python skit, Medicice in the US is simply dead. Does not matter how “good” or well trained a physician is because the system, the context of the work, has itself failed making individual contributions essentially irrelevant. This is at least vaguely understood by the professionals involved, but actual critical thought and speech about it is like speaking ill of the deceased at the wake. We are collectively involved in the first stages of grief. I don’t expect rational responses by the grieving. So very, very sad.
Herb Ruhs, CWRU ’79
Someone please take away this man’s soap box. One can look at the state of medicine today (and the rest of society) and know the Baby Boomers largely are to blame. Like most from your generation Dr. Henry instead you choose to scold the younger generation who continues to choose this career path despite its current state, meanwhile talking about how much better/stronger/tougher/smarter everyone was back in your day. And like most baby boomers you criticize young people for wanting more government programs (is there any evidence this is actually true?) while your generation will slowly bankrupt the nation with your Medicare and SS benefits, which you will draw down far more than you ever paid in.
This is the best essay I’ve read from Greg Henry. Thanks for your unique insights.