Tuesday, April 22, 2014

Becoming Cynical, Part 2

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.

Wednesday, April 16, 2014

Becoming Cynical, Part 1

One of the things I hope to accomplish in this blog is to document my change in perspective as third year progresses. Part of this means addressing the topic of cynicism in medicine, which refers to an unhealthy skepticism towards patient complaints, callous detachment from death and sickness and even, perhaps, nastiness in situations when kindness is most needed. When, during a physician’s education, can this cynicism take root? In the third year of medical school, argues Danielle Ofri, an associate professor of medicine at NYU School of Medicine. As she writes, “Many of the qualities that students entered medical school with — altruism, empathy, generosity of spirit, love of learning, high ethical standards — are eroded by the end of medical training. Newly minted doctors can begin their careers jaded, self-doubting, even embittered (not to mention six figures in debt).” I think Dr. Ofri is absolutely right.

The first of many contributory factors to this change is the way the third year of medical school is set up. Medical students spend weeks or a month in different specialties and subspecialties, also known as services. In surgery, this may mean spending a month on vascular surgery and then a month on pediatric surgery. In internal medicine, this may mean spending a month in the Intensive Care Unit and then a month on the Infectious Disease service. Throughout our training we switch rapidly between different areas of medicine in order to gain a broad understanding of medical pathology. This is a clear educational advantage. There is, however, a downside.

As students we seemingly establish a deep relationship with the attending physicians and residents, a natural result of spending twelve hours a day together. We become comfortable with each other’s habits, musical tastes, food preferences, and career ambitions. And then, two weeks later we leave and a new group of students arrives. Despite the intimate knowledge we have of each other, the goodbyes we say are polite and brief. Next week we have a whole new group of residents to meet, and we don’t linger. Similarly, the residents will have a new set of students with them. We all learn to avoid the kind of human attachments which colleagues normally form in the workplace because we probably won’t see each other again.

But it is not just with coworkers where we learn this rapid emotional release tactic. It happens with patients as well. In multiple instances, I switched services before discovering a patient’s diagnosis or witnessing the effects of a newly proposed treatment. I saw a one-year-old boy in pediatric surgery clinic with an embryological disorder that required corrective surgery. But the next week I moved to a different surgical service and never saw him again. On a separate occasion, a newborn child had a kidney problem that needed surgical management. I went into the patient’s room for nearly seven days in a row, got to know her parents and followed her course closely. But I left for a different hospital floor and never found out what happened to her. A patient with a psychiatric disorder refractory to many different medications began a new medication. I knew the patient’s story and saw him every day for nearly two weeks. And then I moved to a new service and have no idea what happened to him.

I find an apt comparison in starting a fascinating and powerfully moving novel and suddenly having the book taken away as I approach its resolution. Each new story has an equally elusive conclusion as each month or week comes to an end. Thus, medical students assimilate the need to form loose attachments. We care when we are on a service but let it go when we switch. A patient becomes a transient learning experience. Though not everything can tie neatly together with a beginning, middle, and end, unquestionably something is lost in this hurried change. How can any relationship begin when its end is so near and a new one looms so soon?

Dr. Ofri endorses this explanation: “Every four to eight weeks, the students are whisked through a new world: surgery, internal medicine, obstetrics-gynecology, psychiatry, neurology, pediatrics, and outpatient medicine. This ensures that students have a good grounding in the broad field of medicine, but it also ensures that any relationships formed — with patients, nurses, senior physicians, or mentors — are serially disrupted. It’s no wonder that so many students spend the year in a daze.”

It certainly can feel like a daze — more on this in Part 2.

Monday, April 7, 2014

Losing a Sense of Self

In the hospital, older patients frequently go through a process called sundowning or delirium, where they see and imagine things that don’t exist. The etiology of this has to do with an aberrant sleep-wake cycle. Nurses and doctors constantly check in on patients throughout the night and wake them up to get blood tests, check blood pressures, and monitor health status. This disrupts sleep quality, eventually leading to an acute but reversible state of altered mentation. These patients sometimes see dead loved ones reincarnated, believe they are in a foreign country, or see doors and windows where there are none. After a good night’s sleep, however, they regain awareness of what is and what is not real. This process is different from dementia, a chronic and deleterious pathology unhindered by peaceful repose. The classic example of dementia is Alzheimer’s Disease, which leads to progressive memory loss, incapacitation, and eventually death.

On a night shift during my surgery rotation, I was instructed by a resident to start an intravenous line on a patient with advanced Alzheimer’s to deliver medications. He was an older gentleman with graying hair, wrinkled and tan skin, and yellowed nails. His hands and feet were swollen and edematous from fluids that had leaked out of the blood vessels into various compartments of the extremities. He had restraints on — his hands and feet were tied down to the bed — because he occasionally got violent. His forehead glistening from sweat, a full head of white hair, and in a hospital gown, he was outwardly similar to other elderly hospital patients. But while other elderly and delirious patients eventually understand why they are in the hospital and who their family members are, this patient did not have such a prognosis. His dementia irreversibly ate away at the fundamental qualities that once made him a unique and identifiable individual to his friends and family.

He looked up at me as I approached the bed clutching the needle, alcohol swab, and gauze pads necessary for starting the IV and asked me a question that I could not understand. The nurse standing at the bedside told me that he thought I was his wife and that he frequently confused people he met with his spouse. I shook the patient’s hand and introduced myself but he responded merely by reaching out to me, sitting up in the bed and staring at me, eyes glazed over seemingly in another world. I hesitated: Was he cognizant in any way of his surroundings, of who he was, of what his life was like? Before Alzheimer’s set in, what kind of active life did he lead? I did my duty, started the IV, and left, allowing the patient to get back to sleep.

Later that evening, I met a patient even further away from our world. He was in his sixties and had drunk so much liquor that his brain had completely atrophied, or shrunk. Tall and burly, he maintained his physical build but could not recognize anyone, converse, or understand what was said. He got up and walked around, faced the corner of the room, stared at the wall, lightly touched it, mumbled gibberish and about-faced. He neither saw nor heard me. His aimless sauntering demonstrated some retained primal instinct, purposeless beyond a need to keep the muscles of his legs from withering away. His wife, whom he didn’t recognize, cared for him as she would a baby: bathing him, clothing him, feeding him, and fearing the moments when he became aggressive and violent with her. Who was he before he began to drink? Who was he before dementia set in and removed the man his wife once knew?

These encounters during the graveyard shift, disturbing and brief though they were, raise some larger questions about patients who are so demented that they lose a sense of self and the world that surrounds them. What makes them human? They solely retain the need to eat and sleep, the kind of primitive qualities, necessary only to live, characteristic to all beings. Are they in some purgatorial state between human and beast, between life and death, merely waiting for the day when they will shuffle off this mortal coil?

The debate about what makes us human is voluminous, and relevant to the medical profession, which frequently confronts patients with end-stage dementia. John Locke’s Essay Concerning Human Understanding, published in 1690, touches on this issue. Locke writes that a person is “a thinking intelligent being, that has reason and reflection, and can consider itself as itself, the same thinking thing, in different times and places; which it does only by that consciousness which is inseparable from thinking, and, as it seems to me, essential to it: it being impossible for any one to perceive without perceiving that he does perceive.... Consciousness makes personal identity.” Thus, those so demented that they lose awareness of themselves or the ability to think are no longer persons. But this definition seems incomplete. After all, are not infants living, breathing human beings? And yet, they initially lack the kind of reason and reflection to which Locke refers. In EmbryoRobert P. George and Christopher Tollefsen address Locke’s argument and the question of what makes us human.

Professors George and Tollefsen point to an even more absurd example than a newborn: “human beings who are in a dreamless sleep, or in a deep coma, seem not to possess the relevant properties [that make them human].” The same might be said of the transiently delirious hospital patients, who lose the ability to perceive the world accurately. And, indeed, these people, like the patients I encountered that evening, lack “immediately exercisable capacities for mental functions characteristically carried out by most human beings,” as George and Tollefsen write of immature human life. But “we must,” they continue, “distinguish two senses of the capacity (or, as it is sometimes called, the potentiality) for mental functions, psychological states, and so on: an immediately exercisable one, and a basic natural capacity, which develops over time.” Because infants and humans in a deep sleep or delirium have a capacity for mental function that eventually develops when they grow up or awake, they too are human beings.

Perhaps a similar line of argument ought to be applied to those with end-stage dementia. They don’t have the potential to become fully conscious and reasoning beings — but they once had that capacity. They once had memories, perceptions, and feelings. They once socialized with friends. They once worked. They once raised children. And because of that, we owe them the kind of care and decency that we provide to those newborns not yet conscious of reason and thought.

I realize that this is merely a brief post about a topic that is worth its weight in thousands of pages, and thus I’m acutely aware of how insufficient this is. But it is an issue that continues to come up during third year and an issue which I will try to write about further as the year goes on.

Wednesday, April 2, 2014

Olfactory Adjustments

There’s no question that one of the most difficult things to get used to about the hospital is the smell — or, rather, the smells. This is especially true on a surgery service where many patients undergo multiple operations. Some need a leg or foot amputated. Others need open abdominal surgery and can’t control their bowel movements afterwards. Some patients’ intestines cannot absorb fat, leading to oily stools which give off their own distinct and foul odor. And still others have abscesses, or deep bacterial infections, which need to be cut and drained. It’s impossible to know how to react to the offending smell. Mostly, in the presence of these stenches, I control my desire to run from the room and, stoically, attempt to breathe through my mouth. But the smells are potent and dehumanizing. Empathy for these patients is difficult to find when one’s visceral desire is to sever the olfactory nerve which transmits smells to the brain. One encounter in particular is burned into my memory.

The Emergency Department had called the surgical team to see a patient who had a deep abscess. An abscess initially develops with some kind of break in the skin: an insect bite or a cut. And these infections are usually caused by specific bacteria called Staphylococcus aureus, though other bacteria can be involved. Our body’s immune cells wall off the infection, thus creating a pocket of pus and inflammation. Because it is walled off, antibiotics can’t reach the site of infection, so the only treatment in most cases is an incision of the abscess, draining of the pus, and allowing the incision to heal. If the abscess goes untreated, the infection, despite being walled off, can still spread. Some of these bacteria infect and consume flesh and produce gas as they disseminate.

The patient in the Emergency Room had a severe abscess that was far advanced. He had noticed a fever and some tenderness and redness in his lower abdominal area a week earlier but had not thought much of it. As the week went on, however, this area of redness grew and he decided to come to the ER. I felt awful for this young man who had assumed whatever this was would go away.

On entering his room, the smell hit me. There is nothing comparable to it. It took every effort to restrain myself from coughing — my sympathetic flight response had been turned on: my heart began to beat faster, I began to sweat, and I wanted to run. Never in my life would I have guessed that such an uncontrollable visceral reaction could occur because of a smell.

Alas, this seems to be a common theme throughout the history of medicine. Louisa May Alcott, author of Little Women, volunteered as a nurse during the American Civil War and wrote Hospital Sketches, a compilation of reflections on her time in the hospitals. She explains exactly how it feels to deal with the potent smells: “The first thing I met was a regiment of the vilest odors that ever assaulted the human nose, and took it by storm. Cologne, with its seven and seventy evil savors, was a posy-bed to it; and the worst of this affliction was, every one had assured me that it was a chronic weakness of all hospitals, and I must bear it.”

Our patient’s skin in the affected area was lucid. I could peer through into his body and I watched as air bubbles and pus percolated in the tissue. Because of the diffuse infection, he had to be taken to the operating room immediately in order for the dead tissue to be cut out. This was the only possible treatment — even with the medical miracles we possess, the scalpel is often still the best treatment.

In the operating room (OR), we put our masks and gowns on and the nurses coated the front of our masks with Starburst-scented cream to overpower the stench. We were like Alcott: “...armed with lavender water, with which I so besprinkled myself and premises.” Four of us — two medical students and two upper-level surgical residents — huddled over the patient’s body, cutting away skin and fat and flesh as warm pus poured out of the infected area, which overpowered the smell of Starburst, rendering our substitute for lavender water completely useless. But, there was no “out” here, no excuse to leave the OR. It had to be done, as the situation, in Alcott’s words, “admonished me that I was there to work, not to wonder or weep; so I corked up my feelings, and returned to the path of duty, which was rather ‘a hard road to travel’ just then.”

Thankfully, the patient ended up being ok — no vital organs were touched by us or by the bacteria. We had come very, very close to the inside of the pelvis with its reproductive organs, but all was safe and well. However, the smell lingers in my memory. Now, whenever I encounter an unpleasant smell in the hospital I compare it to the abscess. No smell is quite as awful and dehumanizing as the shock of the first one. Perhaps it was the unexpectedness of it that caught me. And, of course, I remember Alcott and what she must have faced in an understaffed, overburdened Union Army hospital in 1862. Her words admonish me that I am here to learn and help where I can and not to wonder or weep.