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How Medicine Is Broken

Discussion in 'Hospital' started by The Good Doctor, Dec 11, 2022.

  1. The Good Doctor

    The Good Doctor Golden Member

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    I read KevinMD regularly. I see a lot of stories about how broken medicine is: how doctors are retiring, leaving early because they are overworked or underappreciated, or being manipulated by corporate medicine. All these complaints are valid. There are also articles about how residency is brutal and causes mental distress to trainees, with the onerous hours and unrealistic expectations. That, too, is true. Medical training, at least in my experience, is like boot camp. They work you to the bone, and you either break or come through. Why the training has to be like that is unclear. Probably having to do with tradition and how things have always been done. Plus, the complaints about discrimination against women in medicine. That, too, is true. Having children carries many demerit points. That is if you are a female parent. No demerits for the male partner. It is assumed he has a wife to handle the home front. No such leeway is given to the doctor-mother.

    Anyway, having said all that, I want to add a few comments to the mix. What is worth salvaging from the experience of doctoring? What has been neglected in this barrage of unhappiness has been the one thing that drew us all to medicine in the first place: the privilege of taking care of sick people, the training that enables us to make tricky diagnoses and to help someone, or the patience that enables us to wade through the medley of minor complaints and still find an intervention, however minute, that gets a patient unstuck and helps them move on.

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    We are all smart people. We are selected for our mental agility. Heck, we can do physics and biochemistry; we can even memorize the 120 kinds of ovarian cancer, at least long enough to pass the test in pathology class.

    Being smart can be a good thing. We like challenges. We like solving puzzles. If we are not overwhelmed and asked to do more than is humanly possible — like working in the ER during the COVID pandemic — then there are many parts of medicine that are enjoyable. We seem to have lost track of what those parts are.

    Perhaps we should focus on what parts we like. And structure practices that enable us to reclaim the good bits.

    For example, a patient presents to the clinic with vague complaints. He is 27, generally healthy, but has been puny for the last week. Not wanting to get out of bed. On exam, he is afebrile albeit pale, His hands are shaky. His gait is unsteady. Has lost some weight and isn’t hungry. Denies cough, fever, nausea, vomiting, abdominal pain, urinary complaints, etc. But his blood pressure is on the low end, and his heart rate is fast, at 120. Standard labs are unrevealing. One would hope for a left shift on CBC, so you can blame some kind of infection. No such luck, If anything, his white blood cells are on the low end of normal. But — and this is the part a doctor cherishes — your instincts kick in. You say to yourself (or maybe out loud): “He looks sick. He looks unstable. I do not know what is wrong with him, but it scares me. To the ER with him!” And there he goes, off to the local ER that diagnoses sepsis from some occult infection. That makes for a very satisfying experience for the doctor who trusted her gut.

    This is true for all of us. We have all had to follow logic, tests, and physical exam findings and find our way through a maze of possible diagnoses. And then follow our instincts where they lead us. Send the patient home and spend the night worrying that he might die overnight. Not a good idea. Better to send them to the ER.

    Or the gentleman in the little rural hospital where you work. He is 78, dying of renal failure. He is under the care of hospice. You stop in to visit him. He is in conversation with his mother. Except that his mother died when he was born. There is no one in the room with him. He is looking forward to meeting her in heaven. You have seen similar scenes with other patients near the end of life. It is somehow comforting the ease with which this patient is confronting death.

    Our patients teach us lots of things about life and death and navigating the transition from one to the other. This is one of the privileges of being a doctor: We have insight into patients’ lives that no other profession has. Except maybe a priest or rabbi.

    I am hoping medicine in this country can regain its footing and find its way to allowing physicians and other providers to regain the autonomy they need to provide care to their charges. Corporate medicine is meddling more and more, forcing electric medical records on us to note every little factoid that will allow them to increase billing without enhancing the doctor-patient relationship. OK, that is my personal opinion.

    But nonetheless, there is a core to medicine that involves the relationship between doctor and patient. It is important that the relationship be cherished. Both sides profit. The patient needs someone to talk to, the doctor needs to feel needed. I am hoping that this core, this center, holds.

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