At this point, I have spent one month on pediatric surgery, one month on trauma surgery (a service that deals mainly with adults who need emergency general surgical procedures), and one month on general pediatrics. It’s clear already that physicians treat pediatric and adult patients very differently. Children need high levels of protein and calories in their diets, and pediatricians need to have a higher index of suspicion for congenital abnormalities, or genetic diseases. Children also swallow small objects, and stick objects up their noses, which can cause infections, shortness of breath, or scarring of tissue; this happens much less with adults. But beyond this, there is also a clear difference in the way one reacts to treating these two different patient populations.
With children, the world, from a healthcare perspective, is almost always black and white. One cannot blame a newborn child for soiling a diaper or for
crying when being examined. A baby is always innocent — poor parenting or an unlucky genetic lottery pick is usually to blame for sickness. One too many
children on the pediatric service fall into these categories. Some parents beat their children so badly that a portion of the intestine ruptures. One
infant had multiple broken bones, some of which were considered “old” fractures. I imagine just reading that sentence induces the kinds of horrific shivers
I felt upon seeing this child on the service. Who do we blame when multiple tubes need to drain out different colored liquids from the intestines because
of child abuse or premature birth? Anyone but the patient. The innocence of children is inviolable and, as such, one cannot help but feel an unrelenting
sympathy for them.
With adults, however, gray areas abound. Many older patients have chronic illnesses like diabetes, high blood pressure, obesity, high cholesterol, and
cancers. Undoubtedly genetics play a role, but we also hold adults responsible for their own well-being. Smoking, poor diet, refused medications: these are
just some of the life choices that invite those chronic illnesses.
Smoking leads to lung cancer. A poor diet leads to diabetes or heart disease. Taking medications regularly for Crohn’s Disease or Ulcerative Colitis can prevent the need for
massive abdominal surgeries in which portions of the intestine need to be resected. And if the piece of colon resected was necessary for the patient to be
able to defecate voluntarily, he or she needs an ostomy, a procedure in which part of the intestine is
connected to a bag on the outside of the abdomen, where stool collects; the patient then empties the bag manually. How easy it is to dump sympathy by the
wayside! When we know who the guilty party is, how can we behave impartially? The enervation of seeing patient after patient in a similarly preventable
situation on the adult floors eases one into cynicism despite the sympathy and empathy that brought us into medicine.
And this is where the question of physician burnout also comes up. Burnout is defined as loss of enthusiasm for work, feelings of cynicism, and a low sense of accomplishment. In one Medscape survey, physicians
of all different specialties were asked whether they experienced at least one symptom of burnout. Pediatricians experienced one of the lowest levels of
burnout. Another study, published in JAMA Internal Medicine, found general pediatricians ranked lower on burnout than every other specialty except dermatology and preventive, occupational, and environmental medicine.
Many, many factors account for physician burnout and cynicism in different specialties, including lifestyle, geographic area of practice,
private versus hospital practice, and so forth, and I will continue to write about this because it can affect patient care. But among the many factors involved, I do think that the
patient population one deals with affects the feelings a physician has toward the patient. After all, it is much harder to sympathize with those who have
made mistakes and poor decisions than with those who are only a victim of circumstance.
The job of the physician, and the art of medicine, involves trying to put aside the idea of the culpable adult or the blameless child and to treat the
person as he or she stands before the doctor. This is incredibly difficult, but I suspect this push and pull is integral to the imperfect system that we
have — a system that deals with human beings and human relationships as well as with science.
A neurology resident’s blog about the inner workings of the field of medicine and its theoretical, practical, and ethical complexities. [More]
Science, Medicine, and Healthcare
- MedCity News
- The Apothecary (Forbes)
- The New Republic on Obamacare
- The Atlantic, Top Stories in Health
- Unofficial Prognosis (Scientific American) [archived]
- This May Hurt a Bit (PLOS)
- Science Daily
- Nature news
- MIT Technology Review on Biomedicine
- Health Blog (Wall Street Journal)
- Well blog (New York Times)
1984 ABC abscess ADHD Affordable Care Act agonal breathing agonist airway albumin albuterol alcohol aldosterone Algis Valiunas ALS Alzheimer’s disease American Scholar amphetamines amygdala Andrew Cuomo Andrew Solomon antagonist anti-vaccination movement anxiety arteries arteriovenous fistula Arthur Conan Doyle asthma attending physician autonomy Avicenna Avik Roy battle benzodiazepene beta-1 receptor beta-2 receptor bias birth blood blood pressure blush Bordetella Pertussis Boston Review botox British Medical Journal burnout cancer capillaries carbidopa-levodopa carbon dioxide cardiac output cardiovascular system Case Files CDC cerebrospinal fluid chemotherapy chlorpromazine Christopher Tollefsen Civil War CNN code combatants Commentary Magazine compressions computers confounding bias contact precaution controlled COPD CPR CT scan cupping cynical cynicism Danielle Ofri death Death with dignity deep brain stimulation defibrillation dehydration delirium delivery delusions dementia depression detachment diabetes dialysis diastole differential diagnosis dilation Doctor and Doll dopamine dopamine agonists doppler double-blinded Dr. Watson DSM Duke University Dylan Thomas dyskinesia ECMO Edward Rothstein EEG EKG electroconvulsive therapy electrolytes Emblems of Mind emergency department emergency medical technician emergency physician emergency room empathy EMTALA epinephrine euthanasia evidence-based medicine expletives face facial expression family febrile seizures fetal station field hospital fighting death Forbes free will Fyodor Dostoyevsky Galen Gaza Geneva Convention George Orwell glia glidescope glucose Google hallucinations Hamas Hamlet health heart heart rate Henri Dunant hepatitis c heroin high blood pressure hippocampus Hippocratic Oath HIV Holocaust Hopital X hospice hospital gown hospitals How the Poor Die How We Die human humor hyperkalemia hyperosmolar hyperglycemic state hypertension hyperthermia hypoglycemia hypophonia hypotension ICU imaging inoculation inpatient insulin resistance intensive care unit introduction intubation iPhone Israel J. M. Peebles jaded JAMA James Parkinson Jean-Jacques Rousseau Jenny McCarthy Jim Carrey John Adams John Donne John Locke jokes Joseph Bell Julia Joffe Kaplan Kay Hymowitz kidney stones kidney transplant kidneys labor labs language of medicine lead-time bias Lenox Leo Tolstoy Leon Kass leukemia Lou Gehrig's Disease Louisa May Alcott lower motor neuron lungs mathematics medical school medical student medicine Medscape Memories and Adventures memory mental illness micrographia monoamine oxidase inhibitors morphine MRI multigravid music Musicophilia naloxone narcan neonate neurology New England New England Journal of Medicine New Jersey New York City newborn night shift NMDA No Joke nonadherence nonadherent Norman Rockwell nurse NYU olanzapine Oliver Sacks operating room opioid organ transplant orthopedic surgeon osmotic pressure otolaryngologist outpatient overdose pain Palestinian palliative care paralytic paramedics Parkinson's disease pathology patient plan patient presentation patient satisfaction Paul Bloom Paul McHugh PCP pediatrician pediatrics Peter Singer pharmacist phencyclidine physical exam physician physician-assisted suicide placenta platelets pneumonia Polio politics postpartum potassium practicing medicine pregnancy pregnant prenatal testing pressure ulcer PreTest preventive medicine prostate cancer pseudoseizure psychiatry Public Discourse pulmonary artery randomized red blood cells reflex renin residency resident rhabdomyolysis riluzole risperidone Robert Louis Stevenson Robert P. George Robert Youngson Robitussin romanticization Ronald Reagan Rounds Ruth Wisse Samuel Shem Saturday Evening Post schizophrenia seizure Sherlock Holmes Sherwin Nuland shoulder dystocia shuckling Smallpox smell smirk smoking social worker sodium specialty specimen spinal cord spleen splenomegaly SSRI status epilepticus STEP 2 CK Stephen Bergman Stephen Hawking stroke Sudden Infant Death Syndrome surgery systole tachycardia TechCrunch The Brothers Karamazov The Death of Ivan Ilyich The House of God The New Atlantis The New Republic The New York Times The Public Interest The Sign of the Four third year Thomas Szaz Toward a More Natural Science tracheotomy trauma trauma surgeon trial tumor umbilical cord uniform UNRWA upper motor neuron uterine contraction uterus UWorld vaccine criticism Vaccines vascular surgeon veins ventricles ventricular assist device Vinod Khosla vital signs Wall Street Journal war war crime warfarin Whooping Cough William Osler
- ► 2015 (13)
This blog will contain frequent references to patients and their illnesses. In order to protect patient and hospital privacy and obey the law, I will not mention any significant identifiers for patients or hospital staff. I will ensure their privacy by altering age and gender when necessary, and by describing events only when sufficient time has passed, so that it is impossible for readers to know when a patient appeared at the hospital. I will, however, remain loyal to the facts relevant to these vignettes when they do not come in conflict with the privacy of the people involved.
By way of a warning, some of these posts contain graphic descriptions of medical conditions and procedures. These descriptions may be troubling to some readers, but they contribute an essential component to the full picture of how medicine works.