I glanced at my watch before responding to the pager. It was almost 2 a.m., with the end of my 24-hour call as the in-house surgery resident still dangerously far away. The page was for a new consult from the medical service, on a patient with necrotizing pancreatitis. Apparently, she had been in the hospital for over a month, in and out of the ICU with multiple drain placements, and had finally started to improve in the last week. Tonight, though, she suddenly developed new left-sided abdominal pain and tachycardia. The medical intern covering her overnight was calling for backup. I could hear the fear in her voice as she finished the story:
“So, I guess I’m wondering, is there anything you would recommend?”
“Get some labs,” I told her, “and get an abdominal x-ray, I’ll be there in a few minutes.”
“She won’t want an x-ray,” the intern told me, “she doesn’t want to be re-positioned, it hurts her to move.”
I was flipping through the electronic chart, trying to understand the patient’s course and anatomy, and said casually- “Tell her she needs it. I’ll meet you there.”
Ten minutes later, I walked into the patient’s hospital room in time to hear the intern’s attempts to convince her to undergo the portable x-ray: “Ma’am, you have a very serious condition. If you don’t get this x-ray, you could die!”
I rushed in to change the tone of the conversation, but the patient responded before I could. “Doc,” she said, “You people tell me that every time you want me to do something. If I don’t get the drain placed, I’ll die. If I don’t let you intubate me, I’ll die. Well, I’ve been to hell and back, but I haven’t died yet.”
As trainees, our introduction to mortality can be overwhelming. I will never forget the moment when, as an intern, I walked out of an unsuccessful code and into the family waiting room. The details of that room are etched in my memory: the sound of his wife’s scream, the smell of his mother’s perfume. So too are the times when I have explained on consent forms that death is a possible or even probable outcome. These are moments that help define us as physicians. Moments when we stand guard while a patient gazes on the unobscured face of his own mortality, and we know his life will never be the same. Our lives — in a smaller way — are also changed forever. This is painful, and profound, and necessary. As physicians, we work in a world where life and death linger close to one another, and we need the courage to face that intersection.
The specter of mortality was also present in the room of my pancreatitis patient at two in the morning, but it was wielded like a weapon to convince her to obtain a test. The intern, when I pulled her out of the room to talk, did not know why I wanted an x-ray. She knew only that the patient was sick, she was not sure how to help, and she had been given a task to accomplish. Her ultimate goal was to help her patient: But in her single-minded pursuit of accomplishing the specific task (obtain an x-ray!), the patient ceased to be her partner or even her beneficiary, and became an obstruction. In her single-minded pursuit of her immediate aim, she threatened death as a consequence for disobedience.
This intern’s reaction is not an outlier; rather, it reveals a greater problem. I can remember moments in my own intern year when I fought similarly uneducated fights. Sometimes the opponent was another physician: I remember being told by my chief to transfer a patient to the medical service. I fought with the medical intern who, I later found, had been told by his chief not to accept any more transfer patients that day. We argued, becoming increasingly irate, determined to accomplish a task we didn’t fully understand. The situation was resolved in minutes when a more experienced physician — someone with the clinical knowledge and moral authority to accept a compromise — took over the debate. It was no longer about winning and losing and became, finally, about the patient.
In the middle of the night, with an acute change in status that the covering intern did not understand, the opponent became the patient herself. Internship involves following orders. It teaches obedience and efficiency. For surgical interns, team rounds occur at 6 a.m., and when the chief resident leaves for the operating room an hour later, she leaves behind a task list. The expectation is that when the team comes back together in the evening, all tasks will be accomplished. Interns become single-minded in their desire to “check the box,” completing each item on the to-do list. It becomes a matter of pride, and the standard by which we judge good interns. When a patient refuses a test, or a medication, or a treatment, the patient becomes an obstacle.
We have created a system where our interns are mindlessly following dictates: “Theirs not to make reply, theirs not to reason why, theirs but to do and die.” These are not secretaries, and they are not students any longer. They are physicians, taking first tentative steps towards a career, and creating habits that will define them and shape their future patients. How, then, can we perpetuate a system that forbids discussion, forbids objection, and forbids uncertainty?
For those of us in training: Can you think of a moment when you ignored a patient’s requests, strong-armed a consultant, or fought without understanding why? For our attendings: Look at your interns now. How many of their tasks do they understand? When a consultant pushes back, or a patient disagrees, what do they do? Do your interns engage honestly, seeking the best possible solution? Or do they fight an enemy they didn’t choose, over a cause they don’t fully understand?
Laura Mazer is a surgery resident.
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