the glory and the horror

It has become increasingly clear to me that any rotation can be fun if you have a good team – good residents, good attendings, good other med students. You can have hard-to-treat patients, demanding patients, patients who don’t speak english, whatever, and it’s all going to be ok if your team is a good team – not just medically competent, but fun, kind, caring, willing to teach and learn, wanting to make it a good experience for all, and not just seeing those lower on the totem pole as inferiors, but peers who are learning, and can take on more responsibility as time goes on. I think my medicine team has definitely been this way.

I just realized that, in medicine, the intern actually wields a lot of power and influence. How often do you say, “Let me check with the intern?” in other fields?

Sigh. I was given a serious tongue lashing by a patient’s daughter today, for something that I have no control over, and for apparently NOT treating the patient adequately. Never mind that I’m the lowest man on the totem pole, that I have no power to make any real decisions, and that anything I say or suggest goes through at least 2 other (real!) doctors before it happens. Never mind that we, the entire treatment team, all agreed on the course of treatment (3 MDs and 2 other med students), and we did our best. It was just frustrating because she somehow seemed to expect her elderly, demented, hemiplegic father to magically be able to get up and walk after an acute case of gout in his wrist and knee that was still resolving.

She even threatened to sue us. Sigh.

I know she’s probably stressed out, and I will be the first to admit that her father is a difficult patient, because of all the things that are going on. He’s a big guy, too, so it can’t be easy to move him around and stuff.

It just annoys and saddens me, on many levels, because this is exactly the sort of experience that jades medical students and residents. My resident, the leader of my team, essentially told me “This is why you don’t spend time with the family, because it’ll only come back and bite you in the ass.” And he’s a nice guy, competent, cares about his patients, wants to see them get well and be on their own, but he’s jaded. Some would call it realistic. He’s at the end of his residency and he’s seen crap. He’s been treated like crap. Nurses have paged him at 3 am for the most ridiculous things, waking him up. Patients and their families have threatened to sue him before. They’ve yelled at him, cursed at him, been racist towards him.

Perhaps (very likely) I’m still idealistic, but man, that just sucks, to have to say, “I won’t spend time with the family unless I have to, and even then, it’s get in and get out, because anything more than that invariably leads to trouble.”

Everyone finds a way to cope. Some compartmentalize. Some detach. Some just avoid those patients in the future. Some are able to love well, regardless of how they’re treated. But is there a time when you just cut the lines and wash your hands of the situation? When is that? How do you do that with grace and dignity, without bitterness and anger?

Welcome to the wonderful inside world of medicine. No wonder why people want to go into private practice in the suburbs with relatively more compliant and intelligent patients.

We got our first wedding present the other day from Jonathan H., a 4th year friend in med school. He kicked it off with a pair of rabbits from World Vision’s Gift Catalog. You don’t know how happy we were to see that.

Thank you, Jonathan.

I’ve been on my medicine rotation, and it’s been a pretty interesting time. One of my first patients, one I picked up on my 2nd round of call, I think, is now in the MICU. He’s an elderly gentleman, who was in decent shape, and just picked up a bad pneumonia. It was really tough to see him decline so quickly. He was only on our service for a day, and overnight, he took a turn for the worse with problems breathing, and his O2 sat dropping, and by the morning, they were shipping him off to the MICU, and by that afternoon, he was intubated. I’m still trying to keep track of him, and I hope to be able to visit him tomorrow.

Something I heard during a dinner with a visiting ethics grand rounds lecturer sticks with me. On average, he said, the dying patient spends 18 hours a day alone. A recent article in First Things regarding death and end-of-life issues makes a good point about 2 treatments that should never be withdrawn or withheld – pain control and human presence. I’m wondering more and more about the human presence thing, and whether or not medicine has a responsibility to dying patients in that respect such that quality time with fewer patients is better than seeing more patients, especially in end-of-life cases.

There are some killer mango milkshakes at the VA. Made from real Blue Bell ice cream and everything.