Monthly Archives: February 2007

For some time, I’ve thought that the relatively high prevalence of excellent health and relatively low prevalence of illness among physicians and physicians-in-training is reflective of socioeconomic origin. As much as my liberal instincts might wish that this weren’t the case, there are many reasons why physicians should be the healthiest members of any population.

At the very least, physicians should be as healthy as possible because it is our responsibility to take care of other people in poor health. Physicians and other medical personnel are exposed to infectious agents and pathogens on a daily basis, and this exposure begins as soon as students enter medical school or nursing school. All measures taken to resist the spread of infection are imperfect and rely on the assumption that health care personnel are not immunocompromised (hence, complications and limitations for HIV-positive medical personnel). As such, all medical personnel should take the “buck stops here approach” and pledge to do their best not to spread infections, to the best of their ability. This effort should include optimizing one’s own health and immunity.

Another less obvious reason why physicians should strive to be as healthy as possible is that the training of a physician requires an immense investment in energy, financial resources, stress, and risk on the part of the student, the student’s family, and the health care system. Physicians can have very long careers, and unlike in some other careers, physicians may continue to contribute to their field long after their primary skills have diminished: physicians and surgeons can teach, continue to conduct research, and also turn their attention to advocacy and leadership. To get the most bang for the buck and maximize cost-effectiveness of our training, it makes sense that we should keep ourselves in good health so that we can live longer and healthier and contribute to our field throughout a longer life span.

Lastly, being in poor health when we have the choice not to be impairs our ability to serve as good leaders for our patients and to serve as effective healers. Not only does one’s health status affects one’s ability to lead patients, colleagues, and the general public by example, but it also has profound effects on one’s ability to devote one’s full attention, energy, and wealth of spirit and strength to caring for one’s patients. The more we let ourselves be weak by letting sickness take its toll, the more we feel sorry for ourselves and become self-absorbed – at the expense of our patients, who need us to be strong and focused for them.

I believe this is a controversial view because it challenges notions of strength and the ways in which we deal with adversity, those related to the curse of poor health and others. On the one hand, we celebrate those who deal with adversity and achieve great success despite their trials. We also sometimes believe what doesn’t kill us makes us stronger. As such, we refuse to overmedicate or pamper ourselves – we believe that a little pain, a little discomfort, a little sickness is ok, because we’ll just come back stronger the next time. However tempting these notions may be (and may have been to me previously), I believe they are absolutely wrong with respect to health and disease. I personally feel that I have gone through a great deal of adversity and fought poor circumstances and bad luck to get to where I am today, but as much as I try to believe that, there’s always someone else out there who has had worse – someone who might need my help. Chances are, that person is someone I see everyday, whether he or she is a fellow classmate, a neighbor, a patient, or the person holding up a cardboard sign on the side of the road. While it is admirable to deal with adversity, even pain, with a degree of bravery and stubborness, it’s not worth trying to “deal with it” when one has the opportunity to prevent it. Why fight a fight that could have been avoided? No one respects the underdog who constantly picks unnecessary fights. Disease is not a fair contestant in the ring, and I believe that people lose no honor or integrity by seeking treatment for pain and illness without holding back. We may not be able to control the diseases, eccentricities, and inconveniences that we are born with, but we can control how we handle them (when we have the means to do so). For the most part, we have the means; it is up to us, too, to provide those means to those who need it. For the sake of all those who need us to be more than our vulnerable and selfish selves, we need to maximize our energy, our strength, and our ability to devote ourselves entirely to our patients and their care when we’re wearing our white coats. How can we do this when our energy and strength are depleted from fighting our own illnesses and pain? It might manifest as a curt reply, or a slip of the lancet, or a mistake in writing a prescription, or words left unsaid that might otherwise help soften the pain and trauma of losing a loved one. We must do the best we can to take care of others, and in order to do that, we must also take care of ourselves.

Today I had a wonderful experience working with a group of anesthesiologists in the Operating Room preparing patients for surgery. Although I spent a fair amount of time waiting for the anesthesiologists and surgeons to arrive, I had the opportunity to bag and ventilate a patient, perform an intubation, and insert an intravenous catheter.

One interesting notion came up when I was talking to one of the anesthesiologists after I intubated a patient. He mentioned to me that he was bothered by something: that another physician asked him, in front of his patient and his patient’s family, whether it would be ok if this first year medical student (pointing to me) could help intubate the patient. While an appropriate question to ask, the anesthesiologist felt that it would have been better for the other physician to ask him the question out of the range of hearing of the patient and the patient’s family. Instead, the open question could have made the patient and the patient’s family members very uncomfortable or excessively worried. Should they be letting this medical student intubate their family member? Is this medical student properly trained in intubation? What if something bad happens?

In his opinion, these are reasonable concerns. However, if one has those considerations, then one should explicitly state these concerns at the beginning of the patient-doctor interaction. One might think, “Doctor, I’m here to see you, and I only want you to treat me.” On the other hand, this hospital is a teaching hospital, and there is an implicit disclosure in the name of the hospital as a medical training facility that there will be students and residents assisting with the procedures and learning the techniques. Furthermore, if patients and their families are concerned about having students assist in their treatments, why not complain about the trainee scrub techs (who assist at the surgical table), nurses, and circulators (who retrieve supplies in demand in the OR)? These trainees can just as easily make mistakes that may cost the lives of the patients, or at least substantially influence their health outcomes. Why, then, are some people so hard on medical students?

Taking that extra step of further exposing patients and their families to the reality of training physicians and their participation in treatments almost seems to suggest that they should be worried about an increased risk of negative outcomes, even if they weren’t worried before. Should they be? While there are some medical students who are cocky and overconfident, my impression is that most are relatively humble and underappreciative of their own abilities and skills as related to medicine. This is understandable since it seems like we have such a long way to go before we are “real doctors,” and we might expect some rite of passage to psychologically change our self perceptions. However, taking this morning’s example alone: I successfully performed the ventilation, intubation, and IV placement. This is not to say that I didn’t have any difficulty (I did have difficulty), but I succeeded without too much difficulty because I frequently consulted the physicians for advice and correction of my technique. At the end of the day, I acquired many important pointers and gained new first-time experiences, at no expense or discomfort to the patient. The physicians would not have let me do these procedures if they believed they would be too difficult for a student at my level. If the physicians are confident in the ability of trainees, why not patients and their families?

I’m inclined to agree with the anesthesiologist: why bother the patients and families with information that won’t provide them with beneficial knowledge? How much is too much information? Although medicine is moving away from a paternalistic stance to an approach emphasizing patient autonomy and informed consent, there still seems to be the possibility of overkill and of overtreating the problem.

As a closing note, it’s important for physicians, residents, and students to be sensitive and aware of how patients and their families feel: not all discussions and decisions need to be made with them as witnesses, especially those for which they are not offered roles as participants in the decision-making process. The needs of patients for maximizing positive health outcomes and the need of the field of medicine for experiential training of physicians do not need to be achieved at the expense of the other.

Advice to fellow medical students: As suggested by the anesthesiologist, don’t go up to the physician in front of the patient and the patient’s family and say with unbridled enthusiasm, “Doctor (insert name here), I’m (insert name here), a (number-year) medical student. Can I (insert procedure here) this patient?” Be professional and make requests under the right circumstances, not when they might make the patient and patient’s family uncomfortable or excessively worried.


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