Tuesday, February 27, 2007

Every accidental crack

There, on the mountain and the sky,
On all the tragic scene they stare.

Mr. Smith has recovered from the acute phase of his illness, but has been left mentally scarred by the ordeal. Part of that may be a reaction to a stressful situation, but part of it is, according to the rheumatology consultant, one of the manifestations of lupus cerebritis. Systemic lupus erythematosus is an autoimmune disease, and as it has begun to affect this man's brain, essentially his body is attacking the very cells which make him uniquely him. So though he has returned to making cell phone calls and texting from his bed (prompting a transfer out of the ICU to an intermediate care ward) he is not firing up a lap top and running Sudoku 3D. He probably never will. And I am left, as the med student following and learning, questioning where this leaves his wife and her son, now that her twenty-something husband has lost his mental acuity.

Across the hall, back in the ICU, my newest patient lies recovering from an aborted surgery. Upon exploring a thoracic mass, the surgeons determined they could not remove the tumor without killing the patient. And so this man, in his mid forties, excited to finally be starting a family, with his pregnant girlfriend in the waiting area, learns that his life is likely over, just as it has begun.

I don't speak Spanish, but one of the nurses does. And she just let our team know that the apparently very supportive and ever-present mother of one of our spinal cord injury patients is telling him, in Spanish, that because he can't walk and has lost his sexual function, he'll never be a man again. No wonder he is stressed out and not improving.

Just another day in the ICU.

One of the difficulties of going to medical school and growing up at the same time is the lack of comparison. I have no reference point outside medicine when it comes to conceiving "normal" in workplace environment.

That's a bit of overstatement, but the point is, as I mature as a person, coming more to terms with who I am, and with what life is, and how those two concepts fit together, both of them are dramatically affected by an environment which alternates between euphoria and desolation. Sometimes I wonder, as I'm giving an order to a nurse or respiratory tech, if my developing ability to make decisions and follow through is separable from my environment. I wonder, as I hold the hand of a dying patient, if other people, people who work in office buildings and go home during rush hour, develop responsibility and care for people in a similar way.

I am beginning to drift into medical conceit. But that's another aspect of what I'm developing. I wonder if other professions have the tacit assumption that what they do is so vital, it probably is more important than most jobs. Even if doctors don't admit it, most of them feel that, somewhere inside. It isn't just the environment which draws us here. I've heard more than once the quip that "I would have been a nurse if it weren't for my ego." The hours are certainly better, and the pay is comparable in many settings. But a desire for prestige and power, (which likely includes two or three mortal sins, good thing I'm not Catholic :) ) is part of why I'm here, and part of why every other medical student is where they are, if they are honest. If it was only altruism, there would be a lot more general practitioners around.

Probably everyone develops an ability to get along with others, to care for others, and to make and accept their place in the world. Probably most struggle with humility and with despair created by their workplace. I guess it's just the way I'm doing it that has got me thinking.


Alice said...

On the other hand, if we don't know what 'normal' is, we can't miss it so much, right?

I've realized that I can't even ask friends at church how they're feeling without my language being tinged by all the training on "medical interviewing," and their answers are usually colored by the knowledge that I'm almost a doctor.

How do normal people think about life and death and sickness and health? It must be funny not to have all the pathology, prognoses, and side effects of treatment attached to every statement.

The Peanut Gallery said...

Great post. I wonder who I'd be if it weren't for all the exposure to the extremes of good and bad on a daily basis in the hospital.

Nathan said...

alice - wow, that is cold comfort :) I know what you mean though. Though the novelty has still not worn off for me, I find myself offering minor bits of advice to friends who ask me about illness and such, but I still notice the change in the way I talk when I do.

t p g - thanks!

I should add, for anyone who reads this far, that I don't mean to disparage other professions in the above post. It just seems to be an implicit attitude in many doctors that there really is no more important profession. I want to maintain some sense of perspective, but perspective is exactly what it is most difficult to acheive in this environment.

MrStandfast said...

Pastors, charged as they are with the nurture of immortal souls, have perhaps more right to conceit than any profession. Curious then that they are ideally humble to their calling.
Or mothers...or garbage men...

I'm certainly not denegrating what you do. I think it's among the most selfless and vital things in society. I admire you.

But it's not you and the rest of the race race. Jobs are jobs. They aren't glamorous, they're real, and each is filled with the same everyday morality. For my part I actually see tragedy and joy, suffering and relief and so do policemen and firemen, and doctors.

"One of the difficulties of going to medical school and growing up at the same time is the lack of comparison. I have no reference point outside medicine when it comes to conceiving "normal" in workplace environment."

very few people do have any other reference points. I grew up and had my first job in a national disaster area. It took me almost two years and a finishing my 200 pages worth of manuscript for my book to realize that there is not "normal" workplace environment any more than there are "normal" people. There are liars, and scoundrels, and heroes, and saints and fools. And they deliver your mail, and prepare your food, and process your tax forms.

I'm sorry to say so but if you desire prestige and power get out of medicine. That isn't to say you won't get it, quite the contrary.

You hold the hands of the dying. Thank God for you and what you do. I am the accountant of loss, and destruction. We're both in the restoration business.

I'll say there's something particularly visceral (literally) and human about what you do, but it seems to me that you ought to be able to say with some sincerity that it's just your job, just your calling in this world, and for all its sublimity, it's a plain business, and as normal as anyone else's. Which is to say not normal at all.

When I was 23 a woman called me "an f#$%ing incompetant little @#$%." She further advised me that if I was willing, I could go to hell. At 23 I told a 40 year old woman that we would continue our conversation once she was able to speak in a civil manner, and I hung up the phone. Later the same week I told a drunk contractor and his ex convict employee "don't count on it buddy,". Everyone comes of age in their own milieu. It's like tom waits says, "we're chained to the world, and we all gotta pull."

also the elephant is soft and mushy. remember that

Nathan said...

MrStandfast - Medicine is not plain business. It can't be. Plain business conceptions of medicine lead to checklists, insurance organizations, and socialized medicine, impersonal and unfeeling. There may be good in all those, but the good is in how much they preserve the human, sublime character of medicine. In other businessses, attention to civility, decorum, and all the sundry details of interpersonal interaction contributes to getting the job done by helping everyone to work smoothly together. In medicine, they are the job.

But medicine is not a job, it is a life. And it is perhaps in that that the conflict I see arises. Quite literally, almost everything I do in life will revolve around the fact that I am a doctor. If I'm on vacation, away from my pager even (should that ever happen) and I see a medical emergency, I must respond, as a human, as a private citizen, and as a doctor. Now a garbage man might respond too, he might even be an EMT (and therefore better equipped for an emergency outside the hospital), but the difference is that my licence is on the line. It's the same every minute of every day.

Maybe that's just a societal construct. But doctors, for all their personal calling and responsibility, cannot exist outside of society. None of them would want to.

All that said, I like your line "everyone comes of age in their own milieu." This I cannot argue with. However, like Frost contemplating the untraveled road, I cannot help but wonder what another millieu would have been like.

Nathan said...

MrStandfast - But I should add, I think you are right about pastors. It's like that quote I posted a while back: the son of the family who winds up in medical school is the guy too weak to work a plow, too stupid for law, and too immoral for the clergy.

I guess, through all of my comments, runs a rather romantic conception of the profession of physician, but I think ideals are important, and important to keep straight. That's what I'm trying to do.