I'm on my last heavy-duty rotation of medical school, spending four weeks in a surgical ICU in Southern California. It's hard to believe that four years has passed. I know that I've changed throughout medical school, but I can't cleanly delineate how, or whether it's a positive change.
I remember worrying about changing in the beginning of medical school. I didn't want to become cut and dry, lacking in human spirit. I know so many physicians who treat their work like it's a day job, and that's not why I worked so hard to get into this field. I was reaching for something larger than life, some sort of zen or nirvana or self-actualization that I believed could only be achieved by dedicating my life to healing others. To doctors, I know now that this reasoning sounds insufferably common. To me, it just sounded true.
As part of my training in the SICU, one of our professors suggested we read a recent article in the New Yorker on death and dying, and the trillions of dollars spent on heroic measures at the end of one's life. I see this firsthand every day on our unit: for instance, there's the 60-year-old man with terminal lung cancer, sedated and paralyzed, on a ventilator forcing a measured volume of air with a measured content of oxygen at a measured volume of pressure through his chest to keep him alive because he can't breathe on his own. He and his family wanted us to do everything possible to keep him alive. Last week, the surgeons decided to put a permanent breathing tube in his throat to make him more comfortable. He came out of the procedure retching and nauseous, inexplicably more uncomfortable now than before. He died the next evening.
Dr. Gawande's article spells it out nicely, with similar heart-wrenching stories of people choosing the illusion of an ugly life over the inevitability of a "more" peaceful death. Interestingly, however, Gawande hints that the onus is at least in part on health care professionals to manage patients' expectations. After all, they are not as equipped as we are to make treatment decisions. Then again, who are we to decide the course of their lives?
At the heart of this struggle is, as my professor declared, America's unwillingness to accept death as an inevitable outcome. I'm sure our nation's litigious tendencies, particularly fearsome in the field of medicine, don't help. Sounds pretty hopeless.
So as a fourth-year medical student entering a system plagued with staggering costs, wasteful practices, and complex social injustice, is there a role for optimism?
I have asked myself this question about optimism many times and no matter what situation prompts me to question my natural tendency towards it, I always come out with the same answer. Whether it's building a clinic in South Sudan, bringing eco stoves to the Chiapan mountains, being there for an ailing family member, or petting a lame dog, the answer is always the same: you must act.
But why? Why should you intubate the terminally ill cancer patient who has essentially no physiologic reserve, sedating and paralyzing him so you can have a machine breathe for him in his last days of living, robbing him from any hope of interaction with his wife and daughter? For the preservation of life? For the preservation of dignity, if you define dignity as honoring your patients' wishes in their darkest moments of dying?
And why should you spend $2,000 risking your life and future to travel to a war-torn village in Africa the world has no use for, to bring health care to a place struggling with far more basic provisions like peace and water?
For that matter, why tell anyone to quit smoking?
I am convinced, more than ever, at the risk of sounding egotistical, that the job of physicians is to bring hope to their patients. This is not an unbridled brand of hope, whereby an 80-year-old patient can take up salsa lessons after her bilateral hip arthroplasties. No. It is a measured hope, where the physician essentially counsels his patient, "This is what you can expect if you do this, and that is what you can expect if you do that, and I will help you understand what your decisions entail, how they will affect your life, and how you can get where you want to go." We give people choices by giving them knowledge. If you don't tell your diabetic patient what can happen if she doesn't control her blood sugars, how can you expect her to care? She didn't go to medical school. YOU did.
I'm sure the situation is not as simple as I'm laying it out here. It is far more complex. But at the heart of the matter is still the patient's best interests, and far too often, health care professionals forget this. As Dr. Gawande puts it, we often get swept up in their whims, making ourselves salespeople and our patients consumers. After all, this is America, and the customer is always right.
At the end of the day, it IS the patient that calls the shots. The gentleman who passed away last week had every right to demand mechanical ventilation in his last days. Or did he?
My dad always used to say that when you live in a society, whether you like it or not, you have to conform to certain societal laws. As taxpayers, whether we like it or not, we pay for certain civil services that we ourselves may or may not make use of. One of these services is government-issued health insurance for the destitute and the elderly.
In America, we are at odds. We buy into this sense of shared existence, but we also defy it by protecting our personal rights to all kinds of things. End-of-life care is the perfect example. We spend billions of dollars on one person's last week of existence, fighting the inevitable and throwing quality of life to the dogs. Meanwhile, somewhere else in the country, whole neighborhoods of children with potentially bright futures go unvaccinated, undernourished, underdoctored. Where's the justice?
When will things change? If history is our guide, only when they get so bad there's no choice but to make it better. Some would say, hasn't that already happened? Isn't medical spending sufficiently out of control to warrant acute efforts? Isn't health care access abhorrent enough? I'm not sure. What I do know is that the new crop of doctors entering the workforce should grow enough cynicism to be hungry for change, and enough idealism to fight for it. If the most salient thing we provide is hope, there is no place for apathy in this profession.
