Saturday, November 10, 2007

Don't let them change you

The past is the only dead thing that smells sweet,
The only sweet thing that is not also fleet.
I'm bound away for ever,
Away somewhere, away for ever.

The one piece of advice I got sick of hearing when friends/family/people I met on the street found out I was going to medical school was "don't let them change you." I think a lot of people see doctors as a bit disinterested, which is probably why my patients are so pleased when I actually sit down and listen to them. Don't let them change you, I heard, as if staying the same was possible and desirable.

I am finding out it is neither. Even during medical school I found myself picking up on the dark humor of my teachers, my attending, the residents I worked with. But it hasn't been until this last week or so that I've really started understanding it.

I walked into the intern work room yesterday when post call, having been awake and busy with mindless paperwork for the last 18 hours, and awake and seeing patients for 12 hours prior to that, and announced "I'm done even pretending to care any more." There were a few laughs, because we all say similar things occasionally, desperately clinging to humor as a defense against the rising tide of futility and anger and sleeplessness and frustration that is internship. But at that moment, I meant it.

The strain of maintaining insane attention to detail that has never come naturally to me is starting to tell. A few days ago I wrote up the plan for a patient, presented it to my attending, and enacted it. Now the patient is dying, intubated in the ICU, and though a relatively small change in my plan might not have made a difference, it also might have. He is 50 years old. Now despite the fact that it is my attending's responsibility, it is also still my fault. And while my resident was pretty nice in the way he pointed out the mistakes, my attending (perhaps to cover her own insecurities) has not been. I feel bad enough on my own, but her "teaching" of me now takes the tone of an owner-pet relationship. I want to remind her that "you signed off on the plan too, doc" but I value my future in this program.

I've changed, I know. I'm thinking maybe there is a finite amount of things we are able as humans to care about, and in the strain of this environment, having to deeply care about lab values, paperwork, physical exams, paperwork, research, paperwork, interpersonal dynamics, paperwork, the opinions of your superiors, and yes, paperwork, the pain of the patient gets bumped from the list, usually right after you bump your personal life from it as well. It becomes easy to see patients as intentionally causing you more work, even nice 80 old men with funny stories, because they are being admitted to your team for the third time this month. And that's mostly because they like the hospital more than home and are able to convince the ER that they need admission.

Probably part of residency is learning to deal with this strain and busy-ness while maintaining some compassion. But I'm finding that the teaching we got in medical school on implying compassion with body language and listening was some of the most important of all. At the time I thought that would come naturally, since I cared about patients. Now I'm finding that much of medicine is acting. Some patients are easy to like. But no one who is solely human has ever loved all mankind equally. And with tiredness and frustration and a tangible link between whining and hours spent in the hospital, an increasing segment of the population becomes difficult to love.

So yes, I've changed. Some of the compassion is acting. But the acting allows me to do my job, to be more dispassionate, to view a patient and their disease as I have to to treat it. Because I'm thinking maybe if I liked that guy less, he wouldn't be dying. But maybe I just need a vacation.