Friday, January 29, 2016

Becoming Cynical, Part 4

I have written quite a bit about why physicians become cynical (see herehere, and here). What follows are some more thoughts on this topic that relate to my previous post on Parkinson’s Disease (PD).

Recently, a sixty-three-year-old patient came to the neurology clinic for a left-handed tremor that had become worse. He and his wife gave a classic history of the onset of PD. His tremor occurred only at rest. He felt his left arm was weaker than his right arm — this was evident in some sessions with his personal trainer. He noticed his handwriting had become slightly smaller. And his wife said she couldn’t hear him well anymore. She initially thought it was due to her own hearing loss, but her friends also found that his voice had become harder to hear. The attending physician and I asked other questions regarding sleep (sometimes PD patients act out their dreams), drooling, and cognitive status. After a physical exam, a cognitive test, and some more questioning, the attending physician concluded that the patient had PD.

At this point in my short career I had seen multiple patients with PD, some in its early stages, some advanced, and some in-between. I was at least superficially familiar with the course of the disease. So when we broke the news to the patient and his wife, it felt slightly banal: another PD patient, another diagnosis, and another prescription for PD drugs.

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But this patient’s reaction took me by surprise. Most people are upset, ask for some information about the disease, take their prescriptions and leave. But in this case, the patient’s questions were far more detailed than I was used to (the attending, given the extent of his experience and knowledge knew exactly what to say). The conversation eventually led to a discussion about the advanced stage of the disease. We explained that medications and deep brain stimulation would become less and less effective. Ultimately, he would get dyskinesias and end up in a wheelchair.

We all know we’re going to die — that is one of the few things in medicine that one can say is 100 percent certain. But there is something eerie about hearing exactly how you’re guaranteed to deteriorate. The attending was telling the patient in a very diplomatic way that his life would look just so in about twenty years. It was said gently, but the patient understood the meaning well. His wife began to cry and he teared up, too. His movements, his hobbies, and control would slowly peter out and vanish.

After I told this story to someone with experience in the medical field, the person responded with, “I don’t know what they’re so upset about — it’s just Parkinson’s Disease.” This probably seems callous and insensitive. Just PD? Think of the horrible symptoms, the side effects of the medications, the creeping debilitation. Imagine, eventually, being locked-in, frozen and unable to move, relying on a pill that becomes less and less effective for allowing such simple functions as turning around or walking. It is indeed a terrible disease.

But for a physician who has seen far worse — such as ALSCreutzfelt-Jakob diseasetrauma, Sudden Infant Death Syndrome (SIDS), all of which involve rapid debilitation and death — PD can seem preferable, with its long course and all the available treatments, however limited they may be.

This tendency to compare the severity of varying illnesses is perhaps one of the greatest traps in practicing medicine. Physicians see so much that diseases that are serious to most patients seem mild relative to the more horrifying ones. I have found myself falling into this pit more than once. I remember doing CPR on a patient who had burst a pulmonary artery (a major artery in her lungs) as a complication of her lung cancer. As I did chest compressions, blood poured out of her mouth and onto my pants, soaking my shoes and scrubs. While this was going on, I got a call from a nurse about a patient with a history of drug abuse who wanted more pain medication. He may very well have been in serious pain. But compare his needs to this woman’s death. Clearly, one was much more affecting, disconcerting, and significant than the other, and it was a while before I could address the drug patient’s pain appropriately. It can be all too easy to dismiss as a “mild” disease or complaint the sorts of conditions against which our exposure has hardened us.

Thus, with experience, our expectations change; it takes more to move us. We shrug off the majority of hospital cases as “not that bad” or “benign.” I think all this is inevitable in a career in medicine. One must pinch oneself every day, at the very least, to recognize it.

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