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Monthly Archives: October 2006

One of the best aspects of my medical school’s preclinical curriculum is the use of Standardized Patients for our clinical skills course. This aspect of training provides students with a relatively stress-free learning environment (instead of training them on real patients first), and it gives students a chance to get direct feedback from the patient-actors and faculty. (Fortunately for us, we also have a lot of clinical extracurriculars such as patient care at free clinics and in emergency rooms where we get to provide care to patients under supervision of the attending physicians and residents.) While some might still think that it’s better to just jump right into the deep end and start with real patients, there are some situations that the vast majority of medical students wouldn’t be prepared for.

Today, I was presented with one of those: telling your patient that he or she is going to die. During this problem-based learning session for Gross Anatomy, I served the role as the “moderator” and as the physician caring for the patient (whose role was played by a Standardized Patient, an actor that is trained to simulate an actual patient based on a real patient’s history, diagnosis, and treatment). In this case, I had the opportunity to take the history, make a differential diagnosis, and perform an abdominal exam (with the help of my other eight group members). We quite smoothly came to the right diagnosis, but the news was bad, and it was my job to deliver it. I don’t think my group members envied my position, and as soon as I figured out what the correct diagnosis was, I felt depressed with the prospect of explaining the prognosis (the likely course of the disease) to the patient.

Our faculty facilitator, a former surgeon, gave us a lot of good advice and framed the situation in the context of our development as doctors: for most of us, our first inclination was to shield ourselves from the emotional trauma of having to deliver the bad news. While not unexpected as a reaction, as doctors, we are expected to do better. For me, I had no choice on whether or not to deliver the news, and some part of me that aspires to care for very sick patients (those hovering between life and death) was telling me that I was ready for the task at hand. Another part of me, knowing that I have been a sick patient and that I had also experienced the trauma of the death of my mom (i.e. a prolonged period knowing that she was going to die soon), compelled me to believe that I have some sort of mettle that most medical students don’t (because so many have never been so close to death before entering the anatomy labs).

Nonetheless, despite these notions of confidence, as I sat down on the table next to the patient, it didn’t come naturally, and though I didn’t stutter or blank, I felt that the words were heavy as they came out of my mouth. I first tried to provide a little context, and then I delivered the news simply. But when he asked, “But you told me it would work?” in reference to the treatment, I knew that although I might have done better than others in this situation, I had lost sight of what it means to be a doctor. For a moment, I was wrapped up in my own feelings, focused on my own sadness for my patient, my inability to cure him of his disease, and my inability to know what to say to help him find some peace from the anguish. For me, one of my aspirations in becoming a doctor is to be able to stand beside those standing on the edge between life and death and help lead them back to the light. Now, though, I realize more than ever that revitalizing patients is only half of what we do – the other half is being there for patients when they are dying.  However, that doesn’t mean that our job is over, or that there’s nothing we can do. For a second, I wondered if I should leave him alone to let him deal with the news in private (which some of my group members also thought), but something in my gut told me that I shouldn’t – that I should stay and talk to him, say anything to him, until he asked me to leave. Nothing that I thought was meaningful came to mind, though, so I asked if I could help him get in touch with his family, or if there was anything I could do for him right now.

Later, the faculty facilitator helped me figure out exactly what was behind that gut instinct of mine: it’s that people, when they’re going to die, are most afraid of being abandoned. They’re afraid that they’ll die alone and in great pain. As doctors, one thing we can do is tell them that we will be there for them, that we will be able to provide them with palliative (pain relief) treatment so that they won’t suffer, and that we will do everything in our power to help them (i.e. talk to the family for them if they prefer, provide them with hospital/hospice care, etc.). He said that I did well. I know I can do better – be there more for my patients rather than for me. Medicine is as much about death as it is about life, and it would be a shame if doctors, of all people, cannot deal with death in a compassionate and composed manner. Everybody dies: you can say that they “die alone,” but they don’t have to feel abandoned when they die. Though “human nature” often carries a negative connotation, one of the best and more admirable parts of human nature is that we don’t abandon our sick and injured – we protect and care for them. Let’s be human.

I recently shadowed an intervention cardiologist and scrubbed in for two angioplasties for two heart attack patients. This experience reminded me about something which has been troubling me for some time: I think one of the most disheartening parts about being a doctor is listening to some people say that they don’t need doctors. They have a lot of ways of saying this: that doctors are “no better than mechanics,” that doctors don’t do anything that can’t be substituted or done better by a robot or an advanced computer system, and perhaps worst of all, that they don’t intend or plan to get sick (ranging from contempt and jealousy to ignorance to, for lack of a better word since “self-neglect” doesn’t quite cover it, stupidity). This is not to say that people shouldn’t be unhappy with the way that health care is provided – at great cost and inconvenience to almost everyone. However, I think that a lot of these critics fail to understand the reality of the situation:

1. People get sick. No matter how healthy you try to be or how much preventative medicine you take part in as a patient, you will, at some point or another, get sick or injured. Avoiding health care is a terrible decision to make, because it will only hasten your death, or perhaps worse, severe disability and pain. The cardiologist explained to his patients in the trauma center: “time is muscle”, and the longer the patients take in making a decision on whether or not to get an angioplasty (as opposed to intravenous medications which are effective but take longer to start working), the more the muscle tissue in their hearts dies (note: a myocardial infarction, or heart attack, results from a blockage of the supply of blood to the heart’s own tissue. If too much heart muscle dies, the heart fails to pump blood throughout the body, and most importantly, to the brain, which results in death.). One of the patients, a man in his early 40’s suffering from an anxiety disorder, was uncertain whether his chest pain and nausea was caused by a heart attack or his anxiety. Nonetheless, it was fortunate for him that he made the decision to go to the hospital. Much in life is unexpected and unpredictable, and as much as we might try to reduce the risk, there will always be risk because there will always be accidents and we will always have blind spots that we failed to cover.

2. You want a person to take care of you, not a machine or yourself. I personally believe in the utility of technology and the power of knowledge. I admit to using websites like WebMD and eMedicine to look up medical information related to my own health, and I think they’re a good thing. However, I go to the doctor and appreciate them for what they do and provide, even if I think I can come to the same conclusions based on my own research. Furthermore, actual doctors go to see doctors all the time. It’s not that they’re not smart enough to figure out what’s going on in their bodies. It’s just not possible to know everything you need to know to make the most educated judgment possible about what is wrong and how to deal with it without the help of an expert.

This argument is most supportive of specialists, but I have something to say on behalf of generalists (like family practitioners, pediatricians, and primary care physicians) too. I agree: doctors can be like mechanics, except for the human body. But what do you value more, a car or your life? You can live without a car, but you can’t live without your body. Furthermore, as much as it might be frustrating to have a car that gives you trouble, it’s much worse to have a body that isn’t working.
As for me, I was feeling tired of studying and in need of a pick-up when I went into the hospital to shadow the cardiologist. As soon as I walked in the door, he spotted me in the hallway and grabbed me as he was headed to the trauma center. Four hours later, having watched the saving of two lives, I went home, energized and with a smile on my face. If it feels this good standing beside the doctor and the patient’s bed and watching lives be saved, how much better will it feel to actually do the saving?

Talking to two individuals close to me, my girlfriend and my friend Serene (who is the current Editor-in-Chief of the Next Generation), I discovered two notions that I feel strongly about regarding the experience of first year medical students.

1) Cadaver donors give their gift to our future patients, not to us (the medical students).

My girlfriend, also a first-year medical student, is starting her Anatomy class tomorrow and asked me for advice about her plan to perform a small ceremony with a group of her fellow students prior to their first day of cadaver dissections. Traditionally, there is usually a memorial service at the end of each Anatomy course to honor and show gratitude toward those who donated their bodies to the cause of medical education. In reflecting on my own experiences and those of my classmates, however, I realized that people don’t donate their bodies for the sake of the students: instead, they donate their bodies so that other patients like themselves will have good doctors taking care of them. In a sense, we (as medical students and future doctors) are vessels or conduits for this gift, and in engaging in this anatomical education with the unique experience of being face-to-face with death and the dead on a daily, intimate basis for a time, we are silently pledging to carry this gift to those who will need it in the future. Although this experience may set us apart from others (and some may let it go to their heads), it only has meaning if we give it to others in the form of better medical care.

2) Medical students, before entering medical school, would best prepare themselves by making sure that they know how to connect with other people and be happy people.

Serene recently asked me what advice I would give to medical school applicants now that I’m in medical school but still have fresh memories of my entrance into this training and profession. My answer’s origins were in my reply to an early question of hers: what have I found most challenging about medical school thus far? While the academic coursework is obviously very challenging and demanding, I find that the greatest challenges for me involve reconciling all the other aspects of life with the substantial psychological, physical, and emotional commitment required for this training. We all bring with us things that we can’t leave behind, and all of those things we hold dear to us either compete with medical school for our time and energy or keep us healthy and replenished. In that respect, it’s important for incoming medical students to have healthy relationships: this gives them a strong ability to stay grounded, form new relationships, and be happy. Although medical schools probably try to select for good people, I suspect that they find a harder time selecting for happy people (or at least people who can make the best of a bad situation and stay optimistic). In my eyes, I think being happy (or at least satisfied) is an equal requirement to being a good person for becoming an effective and well-liked doctor.

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