The rotation I'm doing now is an official "subinternship," which means I am to act as much like a real doctor as possible, clearing all my decisions with my resident, but writing all the orders, all the notes, and in general "carrying" the patient. I get paged by the nurses with questions and requests for clarification of orders. I talk to the subspecialists for consults.
I love it, I think. In part, what I do is just glorified secretarial work. I file papers, review papers, summarize papers. The fact that three years of med school is necessary to file these papers doesn't really seem to matter. It is here, in the headaches of paperwork, that the dehumanization begins. Patients become numbers, become diagnoses, because we see a stack of thirty pages about them more than we see them in person. In "The House Of God" the Fat Man comments that it is never necessary to actually see a patient, and in modern medicine, that's probably true. There are so many notes about the patient that it is possible to write about them, make decisions about them, and even cure them, without setting foot in their room.
That's the part I don't like.
So today, getting bogged down in phone calls and the elaborate system of documentation necessary to comply with the often whimsical requirements of HIPAA and JCAHO, I took a break and actually went to see my patient.
She's a wonderful woman, unfortunately without a bright future ahead of her. But she's come to terms with her poor prognosis and speaks quite frankly about her decisions. She doesn't want resuscitation, doesn't want surgery, and (a bit frustrating to the medical team) she doesn't even want a surgical biopsy of what we think is cancer, because she doesn't want to go through the treatment. She realizes she's old(er) and probably dying. Unlike Mr. Ashman, she doesn't have a family to support her, and after seeing her husband die of cancer a few years ago, doesn't want to go through treatment without support. All in all, a wise decision, if not an uplifting one. But we still managed to chat amicably for a half hour or so. She's from England originally, so (working from past experience) I got her talking about tea. Brits love talking tea, and she's no exception. It is a bittersweet conversation, since she has a nasogastric tube and can't drink tea right now. She may never again. For reasons much more aesthetic than mine her one wish now is to be able to drink coffee once more, "because though I do like tea, I fancy a spot of coffee now and then." It's maybe a bit odd that such a phrase can bring tears to my eyes listening, and now again while writing.
So then I went back to my papers, back to the headaches, back to the phone and pager. But now I'm not just trying to get my work done. I'm trying to help an old lady return to drinking tea, with a spot of coffee now and then.