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.


Thainamu said...

I'll like you better after you've had a good sleep.

Anonymous said...

Nathan, we appreciate your honesty. And there isn't ANYONE in the medical field who doesn't feel like this at some time. The jerkiness of that attending was partly her own feelings of guilt, failure, wretchedness, tiredness, and maybe a power trip.

You are exhausted – physically, emotionally, spiritually. Do not let this snapshot frame your image of who you are or what kind of doctor you are or are going to be. Elijah, Jonah, Paul, and even Jesus were exhausted and wanted to give up at some point.

You are right in that part of the training is for you to learn to still feel some compassion while attending to all these details. Think of how far you have come from internship … when even the idea of having to go draw blood or drop a line was overwhelming. Now you can do those things without thinking, allowing you to concentrate on higher skills. There will come a time when the myriad details and differential diagnoses will become more automatic, allowing you to revert to more normal and natural (not acting) feelings of compassion.

it’s ok and human to have these feelings, and it’s not ok in God’s eyes to acting inhumanely towards someone. Medical/ gallows humor in the break room? Yes! It’s how we cope. Rudeness, shortness, disrespect of patients or staff, even to those who are acting patently stupid or exasperating? No.

And there will still be times of failure: you will overlook something, and not have the attending to blame or catch you or back you up. In those times, remember the cliché – you’re only human. We who know who the God of the universe is must remember we are not the same as He is. We also remember His example of servant leadership: “Even the Son of Man did not come to be served, but to serve, and to give His life as a ransom for many” (Mark 10: 45).

As a doctor who is a follower of Christ, you have additional lessons to learn. You have passed the internship phase of your Christian life, too, and now are moving on to learning higher skills. You will learn to use these times to lean on Jesus in a way that brings glory to Him, by keeping your mind focused on the goal: to serve these patients (and the other staff members) by using your skills to provide for their needs. Our pastor preached on Isaiah 6: as he saw the glory of the Lord, Isaiah could only collapse in anguish: “Woe to me, for I am a man of unclean lips!” Yet God in His great mercy cleansed him of his guilt and commissioned him for great service.

This reminder is not just for you – daily and even hourly I have to remind myself of these truths, as I go about on seemingly endless efforts for my patients and feeling so inadequate. You are not alone in these feelings. For each of us in the medical field, we need to keep the goal constantly in our mind.

Are you changed? Yes. And let the Lord change you more.


Anonymous said...

PS. "Now may the Lord of peace Himself continually grant you peace in every circumstance..."

2 Thessalonians 3:16


medstudentitis said...

I am glad you're still blogging. This post was very human.

Anonymous said...

"Something of more permanent worth. That’s what medicine was to me. …It’s all rubbish. Transplants, antibodies, we’ve manufactured genes, we can produce birth ectogenetically, we can practically clone people like carrots! And the kids in the ghetto haven’t even been immunized for polio! We’ve established the most enormous medical entity ever conceived, and people suffer more than ever! We cure nothing! We heal nothing! The whole goddamn wretched world is strangulating before our very eyes. …That’s what I mean when I say impotent.”

Anonymous said...

i think that last statement is much too pessimistic and short-sighted.
yes, we need to do MUCH better on preventive care. But the discoveries and recoveries have been stupendous. People from all over the world come to the US for care.


Nathan said...

thainamu - give me five or six years.

tmu - thank you, sincerely, for your comments. They've given me a lot to think about.

mestudentitis - thanks for dropping by, and for the comment. One of my hesitations in posting this was that it was a lot darker, emotionally, for me than most of what I've written here. But I felt I had to be honest, if I was going to write at all.

anon - I'd prefer a name attached to comments. But I am actually about 95% sure I know who you are, so I'll post it anyway. I'm not sure George C. Scott is a great role model for a physician, and anyway, as long as I'm talking preferences, I'll prefer you post your own thoughts, rather than extended, obscure, dreary quotations. Bro.

Matthew said...

My patients think I'm tough. I am NOT tough. I must have changed. It happens.

Ryann said...

tmu - your insights are encouraging to all (not just those in the medical field).
And while I don't take Newsweek as authoritative on any subject, they did have an interesting (and short)article here:
What I'll draw out from tmu's comments and Newsweek's comments about doctors is thus: I think it's safe to say that you are called to be where you are. Your gifts, talents, intellect and passions are put to use for His glory, and He will always use where He's placed us to conform us more to His likeness. Part of equpping us to serve Him in our vocations is how He's wired us individually. You are caring for your patients when you logically use your education and reason to treat them, even when you're too tired to sit and hold their hand or muster the appearance of compassion. And ultimately, we all have to remember that He's in control...
"That Good Physician liveth yet,
Thy friend and guide to be;
The Healer by Gennesaret,
Shall walk the rounds with thee."

Jen said...

As a fellow IM intern, I can say that you pretty well summed up where I find myself these days (despite my lofty proclaimations throughout medical school that I'd NEVER get to this point). I think it might be the time of year. All of the enthusiasm for starting something new is beginning to fade, the days are getting shorter, the work hours are getting longer, and the futility of 99% of what we do is finally starting to gnaw at my psyche. But talking to my fellow interns and some upper level residents has left me with the impression that this is just par for the course. Thankfully, God gave us humor to use as a defense mechanism, because I don't know how I'd otherwise get through some days if all I focused on were the depressing details and pointless piles of paperwork. Sharing that dark humor with people who understand it (our colleagues who also live it EVERY SINGLE DAY) has become a therapy for all of us, and I'm actually pretty thankful for the opportunity to share it with them. Life in the hospital is just so...abnormal.

medstudentitis said...

Thanks for the comment today. I hope you're going to get some time off to enjoy this holiday season.