PS: Feel free to draw any inferences you must regarding my sense of humor.
PPS: Or help correct my clear lack of exposure to Real Humor with your own favorites. (Failure to do so will be construed as tacit acceptance of my version of reality, in which this is a funnier thing than anything else you’ve seen on the internet. Is that the kind of reality you’re willing to occupy? FOR THE REST OF YOUR LIFE?! Think carefully, friend.)
This article from The Lancet is a must-read for anyone who has a doctor.
And if that doesn’t apply to you, well, see previous thoughts on that topic, then get a doctor, and THEN read this article.
Every third sentence, I seriously had to keep myself from standing up and shouting, EXACTLY! (In my empty apartment.) You should hear my internal monologue when I’m talking to my patients.
I’d like to add: I’m getting a little sick of people talking about how doctors never have enough time for them because they’re evil money-grubbers who are more worried about the bottom line than the human being sitting in front of them; they push through as many patients as possible so they can fill their Olympic-sized backyard swimming pools with as much money as possible. Yes, some doctors are like that. But no matter how much you hear about them, my experience is that they’re the exception, rather than the rule, especially these days.
There are enormous pressures on a physician’s practice these days, and a lot of them are financial. The clinic where I did my Family Medicine rotation had to do Botox injections on the side, just to balance the books financially so they could keep taking Medicare patients without going bankrupt. And their schedule was PACKED. We saw patients every fifteen minutes. Which SUCKED, both for us AND (especially) the patients. But the only other option would be to close the clinic to Medicare patients. It was the only holdout in town; if we stopped taking low-reimbursement patients or went bankrupt, the Medicare patients in the area would have been SOL. (That stands for “surely out of luck,” Mom. 😀 )
I read comments on blogs and newspaper articles about health-related stuff a lot, and so far my favorite comment to illustrate this point was as follows: “I get reimbursed fourteen dollars for a physical. How much do you pay for a haircut?”
There’s not much awareness about where exactly medical dollars go. Yes, we’re pouring money into the medical system right now. Niagra-Falls-style. But I’ll tell you one thing: it sure ain’t going to the doctors on the front lines. It used to be that going into medicine was a sure first-class ticket on the gravy train. But that’s not always the case anymore, yet the perception survives the current reality. (Your typical medical resident starts out at least a quarter of a million dollars in debt, due to the absurd cost of a medical education. And no one ever bats an eye when doctors’ salaries are eroded.)
On a personal level, my patients often accuse me of being greedy and heartless when they’re upset with me for whatever reason. I get it; it’s what you say to your evil doctor when they’re being evil at you. Or you threaten to sue them. Whatever.
But it’s kind of hard not to take the prevailing cultural attitude personally. I did well enough in med school and on my Step exams that I could easily have gone into one of those super-cushy specialties that would pretty much set me for life. But you know what? I’m doing underserved internal medicine, in one of the most messed-up hospital systems in the country. I am not there for my health, or my pocketbook. Certainly not.
It was my first-choice program.
And you know what? I still have a see-x-number-of-patients-in-a-day schedule. Because there are a LOT of sick people. It sure doesn’t do my bank account any good.
But hey. Evil doctors are evil, and they evil the evil with their evil evilness of evil.
I get it. I swear I do. People who are scared and in pain lash out, and it’s often hard to remember not to attack your allies. (It’s understandable; it’s always safer to attack people who are on your side; they’re less likely to hurt you back.) But I can’t help getting irritated and ranty when I read stuff on the interwebzes.
Hoo.
I’ll end by saying, if I had the luxury of spending an hour with every one of my patients, I’d be the greatest doctor IN THE UNIVERSE. Not to mention the happiest. And so would your doctor.
But try finding someone that will pay us a living wage for that. Especially in this day and age.
A man goes to a mechanic.
“Hi,” says the mechanic. “What brings you here today?”
“There’s something wrong with my car,” the man says.
“What’s wrong with your car?”
“You’re the mechanic. You tell me.”
“Okay, what tells you there’s something wrong with your car?”
“It isn’t driving right.”
“When did you first notice this?”
“This morning.”
“Has this been developing gradually, or did it happen all of a sudden?”
“All of a sudden.”
“What were you doing at the time?”
“Driving.”
“Okay, but is there anything that happened right before your car stopped driving right?”
“Yeah, my car stopped suddenly.”
“Like the brakes went on suddenly?”
“You know, I’ve answered these same questions over and over to the other mechanics I’ve seen. I’m kinda sick of your questions.”
“This is the first time I’ve talked to you, though.”
“Just look in the computer.”
“We don’t have you in our….oh, never mind. Let’s look at your car.”
“It’s out there.”
“…..the hood is smashed in.”
“Wow, you’re such a great mechanic.”
“When your car stopped suddenly, was it because you crashed into something?”
“No. Just fix my car.”
“Okay, I’ll fix your car, but you need to be more careful when you’re driving.”
“Just fix my car.”
The mechanic fixes the man’s car, gives it a tune-up, and sends him on his way. Because that’s his job.
* * * * *
Three months later, the man comes back to the mechanic.
“My car’s not driving right again. You didn’t fix it like you said you would.”
“What’s wrong with it?”
“It’s the same problem as last time. You’re clearly incompetent.”
“Same problem as last time? It stopped suddenly, the hood is smashed in, and now it’s not driving right?”
“Yeah.”
“Did you crash it into something again?”
“What do you mean, ‘again’? I didn’t crash it the first time. What am I paying you for, anyway?”
“You never paid me for the last time I fixed your car.”
“Just fix my damned car.”
::sigh:: “Okay. It’s not like I can turn you away.”
“Damn straight. You’d better fix it for good this time.”
“The best way to make sure it’s fixed for good is for you to follow traffic laws, drive between the lines on the road, and not take risks or drive recklessly.”
“Just fix my car.”
The mechanic fixes the man’s car, gives it a tune-up, and sends him on his way. Because that’s his job.
* * * * *
Three months later, the man comes back to the mechanic.
“Let me guess,” says the mechanic. “Same problem.”
“Of course it is, you swindler. I’ve noticed you’ve got me coming back here every three months so you can take all of my money.”
“You still haven’t paid me.”
“And I’m not going to until you fix my car!”
“So you crashed it again?”
“Why do you keep saying that? I told you, I’ve never crashed my car!”
“Did you follow the traffic laws like I recommended? Did you drive inside the lines and avoid taking risks?”
“That has nothing to do with anything. My car doesn’t work. Why haven’t you fixed it yet?”
“I have fixed your car every time you brought it to me, but I can’t go home with you and keep you from crashing it.”
“Your job is to keep my car driving. You know, my uncle’s a lawyer. I’ll probably call him when I get home.”
“In your car, I suppose?”
“Damn straight. You’d better fix it. Now.”
The mechanic fixes the man’s car, gives it a tune-up, and sends him on his way. Because that’s his job.
* * * * *
Three months later, the man comes back to the mechanic. . . . .
Congestive Heart Failure
The two best actors acting in TV shows I’ve seen recently:
Aldis Hodge (Alec Hardison / Leverage)
Matt Smith (The Doctor / Doctor Who)
Discuss.
Hey, guys! My fave passel of punks is headed out on tour!
This is “It’s All Happening”, a pop-punk band headed by the unfairly-talented Mitch Vice:
Are you going to be anywhere near their large swath of destruction and awesomeness? You should go see them! (Or, you know, hide in your basement or something.)
July 14th- West End 2153- Ashtabula, OH w/ Setbacks
July 15th-American Legion – Branford, CT
July 16th-Mr. Beery’s- Long Island, NY
July 17th- Hangar 84- Vineland, NJ
July 18th- Boondocks Club- Harrisburg, PA
July 19th-Smiling Skull-Athens, OH
July 20th- Ann Arbor, MI
July 21st- Atlas- Hamtramck, MI w/ Break Anchor
July 22nd-Ft. Wayne, IN
July 23rd- Venue 42 @ Kidd Coffee-Lebanon, OH
Hope you can make it!
The lovely, amazing Margit had this wish for me:
For every sleepless night of angst, may you have two success stories, and an extra vacation day!
(I think Margit understands larval doctors PERFECTLY!)
To that, I add a wish for myself:
May I be the kind of person who is worthy of the friends who have chosen to add me to their lives.
I helped manage a post-surgical case a few months ago when I was working in the ICU. It was a messy case, and the guy’s abdomen was a catastrophe. (To be fair, the surgery is a type that’s very technically difficult, and it’s usually only done out of desperation, for a patient that’s pretty much dead anyway.)
But the surgery did not fix him. And there were complications. The man spent every day, all day, lying on his back in an ICU, depressed, in pain, with drainage tubes that later proved to be unremovable protruding from his abdomen, and barely ever speaking two words at a time.
Completely conscious. Completely aware.
He died a year later, under the care of the group that worked the month after I finished there.
I could feel nothing but relief.
I was out for drinks with a buddy of mine from the surgical program the other night, and I expressed disappointment that the surgery had been done at all.
“But it bought him a year he wouldn’t have had otherwise,” she said.
Which is true.
But you won’t be able to convince me that there was anything good about that.
We’re really bad at death in this country. Medical technology is just to the point that in some cases we can preserve life indefinitely….but not to the point where we can preserve the quality of life in all cases.
This puts doctors in a really, really tough position. The culture we’re in pressures us to fight, fight, FIGHT to preserve life AT ALL COSTS, and the flipside to that culture is the perception that death equals failure.
My religion teaches me to hold life as sacred above all other things. It’s one of the reasons I’ve stayed religious, even though I’m closer to agnostic when it comes to the whole guy-in-the-sky-with-skycake question. It’s one of the reasons I find medicine so fulfilling.
But practicing medicine often puts me in a position to see that sometimes standing in the way of death can lead to such desperately unnecessary suffering. That it’s a fine line between respecting the sanctity of life and accidentally twisting it into something truly horrifying.
Sometimes, the suffering just can’t be justified, even in the service of preserving life. And we’re not very good at admitting that. None of us are. Not patients, not families, not nurses, and certainly (especially?) not doctors.
When I was on Night Float a few weeks ago, I was notified by the nursing staff that one of the patients I was covering was dropping her blood pressure. She was 98 years old, and had been deteriorating in the hospital for a number of weeks. Her death was expected. One of her daughters signed a Do Not Resuscitate (DNR) order, releasing the medical team from the obligation to use all means available (CPR, intubation, etc) to extend her life as much as possible, at whatever cost (dignity, the privilege of dying peacefully, etc).
So I called the number in the patient’s chart to notify the family that she was decompensating. Whereupon I was informed that the patient had FOUR daughters, and three of them did NOT want the DNR order, there was NO advance directive or legally-designated surrogate decision-maker, and that they were on the way to the hospital RIGHT NOW, and that I had better do everything I could to keep her alive until they got there!
When they got there, they were distraught. They were angry. Understandably so; their mother was dying, and someone told the doctors not to do anything about it! And here I was, alone, the junior member of an overnight coverage team, knowing that this patient’s life was truly and honestly at its end.
So I found a conference room, and we all sat down. And I explained the situation to them. And I told them exactly what resuscitation entailed, and why I thought their sister had given the order.
You see, CPR isn’t what you see on TV. On TV, it’s this magical ritual that calls a dying soul back to life. Someone presses gently on an actor’s chest, yelling at them to live, LIVE! Paddles are rubbed together, actors twitch dramatically on tables, hearts restart like jumped car batteries, and people go back to their families, alive and whole, by the next commercial break. Fantasy CPR is quick, clean, and has an 85% success rate. And that’s what people expect, because that’s the only experience they’re exposed to. The stories we tell each other are so powerful and attractive that they end up shaping our realities.
Real-life CPR is ugly. It’s messy. Fluids spurt everywhere. Large needles are dug over and over into sensitive areas, desperately dowsing for access to a failing circulation. Ribs are cracked. Heads are cranked back for tubes to be shoved down throats. Doctors and nurses press around the bed in a nearly suffocating pack. The energy in a room like that is negative, and feels desperate.
And CPR is only successful about 15% of the time. Mostly on young, healthy patients.
That means 85% of people die, or suffer irreversible brain damage. Once I was talking to one of the chief residents about how I was nervous about messing up during a code. The chief told me that in a code, there isn’t really such a thing as messing up: the patient is already dead. No one expects anyone to be a miracle-worker; a true success is a pleasant surprise. (He also told me to review my protocols the night before a call, so I wouldn’t “mess up” in the sense of not knowing what to do when.)
For the family in the conference room, I demonstrated chest compressions on the table, exactly how I would have to do them on the 98-year-old lady who was dying in a room nearby. I’m a small person; I have to throw my entire weight on a person’s chest to get their heart to compress adequately.
I told the family that I would do that to their mother if they asked me to, and try to wring a few more minutes (or however long it turned out to be) out of the end of her life.
I also told them that if they asked me to, I would stand back and allow her to die at the age of 98, in a quiet room, surrounded by family instead of jabbering doctors.
They let the DNR order stand.
She died peacefully, in a quiet room, with her daughters holding her hands. And no doctors.
Which is probably what she would have wanted for herself, if she would have been able to tell us.
But I know the other side of it, too. Because when my family looked to me for guidance, I could not bring myself to request a DNR order for my grandfather.
This is hard stuff, guys. This is HARD.
It’s hard on patients. It’s hard on families. And it’s hard on medical staff.
And as a culture, we’re just not good at dealing with stuff like this. And we’re not good at talking honestly about it.
I love palliative care programs for this reason. This is a relatively new movement to try and take a more healthy, less desperate approach to death. It’s focused on alleviating suffering, not just extending life. It’s another tool in the toolbox of modern medicine: the ability to recognize that sometimes the blind preservation of life is not in the best interest of the patient, or not even what they might want for themselves if they had the ability to tell us.
Because that’s what it really comes down to.
We just have to figure out what is best for the patient.
There’s no one solution to this. No one has answers, no one knows what’s best. We just have to be able to talk about this, and trust each other, and blindly fumble our way into the dark.
Holding hands, if possible.
I found my first gray hair today.
Some people would be upset about this.
My first thought was actually, “Maybe people will start taking me seriously as a physician, now.”
Download some rockin’ awesomeness on iTunes: http://itunes.apple.com/us/album/home-sweet-home/id401584794 Or find them on Facebook: https://www.facebook.com/itsallhappening317 Or download a free three-song sampler at their Bandcamp page: http://itsallhappening.bandcamp.com/
How To Kill Your Imaginary Friends 