Category Archives: Doctorhood Quest

She Must Be Just a Number to You

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“You see so many patients, she must be just a number to you,” the patient’s son said as he watched me perform the official exam declaring his mother dead.

“We care about all our patients and take the best care of them we can. Of course, I haven’t known your mother for as long as you have. You’ve known her your whole life,” I said. I finished my exam. I stated the time of death, gave my condolences, and left the room.

I had pronounced a patient dead almost daily that week. During this patient’s exam my emotions were not the emotions of a son who had just lost his mother without much warning. My emotions as the patient’s physician could not be the same as her son’s. I was sad, of course, but I also knew we had done everything we could for her. As a physician I must balance being emotional and being clear-headed so that I can make objective decisions about how to help patients with their medical challenges.

In medicine we push to the edge of current scientific knowledge, yet we are not capable of magic or miracles. We cannot predict the future and we cannot stop the inevitable. Death is part of life. Since medicine in the science of life it inherently involves death.

As a physician my mission is to prevent and cure disease and reduce suffering. A lot of suffering can happen when a person is gravely ill. Part of my job is to recognize when the fight for life is futile. Once the fight becomes futile, anything we do to prolong life also prolongs suffering. It is at the time of futility that I can offer a path that leads to greater comfort and death with dignity. This path requires a shift from a goal of prolonging life to one of promoting comfort. To stop fighting death is not a decision to take lightly. Further, the decision must be made by the patient or their appointed decision-maker (when the patient is too sick to decide). I can only offer guidance as part of the patient’s care team.

This patient, the mother of this son, had fought for her life. She had maxed out every treatment we could offer. She had failed other treatments. When she was worsening, we called the family to come into the hospital. When everyone who needed to be there was at her side, we turned off the medications and interventions that were keeping her alive. We did this because to keep those medications and interventions going would not save her. She would die regardless. She was suffering. Most importantly, she had made it clear when she was well that she would not have wanted to keep going in these circumstances.

When we turned off the medications and interventions keeping her alive, we gave the patient medications to treat her discomfort. She had pain, shortness of breath, and anxiety. She died shortly after we changed our approach from treatment to comfort. She died peacefully and surrounded by the people most important to her. None of this struggle made her a number. She was a person who had fought bravely and died with dignity. And, sometimes, that is all we can offer in medicine – a place that illuminates a person’s intrinsic bravery and permission to stop struggling.   

I have seen and will see many people die. My role in these circumstances is not a counting role. As a physician I ensure my patients get the best treatment available when there is a fight to have and the most comfort possible when there is no fight left. My role is to adhere to their wishes regarding their life and death as best as I can within the constraints of medicine. These are serious responsibilities that are both rewarding and harrowing. Rewarding because I know my patients receive the best care we can offer and a death as close as possible to what they would want if they had a choice. Harrowing because it is hard to lose someone I cared for and because I feel each patient’s loss, not as a friend or family member, but as a partner in the patient’s battle against death.

Being a physician has made me realize exactly how people aren’t numbers. It is my job to learn my patients’ stories and to partner with my patients to tackle their health goals. What happens to my patients is partially a reflection of how well I did my job and partially a reflection of the complexity of being human. The depth of the patient-physician relationship is part of the reason I chose medicine. My patients’ stories are sometimes tragedies and my relationship with my patients is sometimes difficult, but the opportunity to heal, cure, and reduce suffering is enough to make those challenges worth it. I am grateful for the opportunity to take part in my patients’ lives. Grateful even if we meet under extremely unfortunate circumstances. Grateful even if we meet at the end of their life.

Lost to Follow Up

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Two different cancer screening tests came back positive. The patient needed additional testing to see if they had these cancers, but the threat was real and could be life changing. As the months went on, the referrals I had put in for the follow up tests came back – “unable to reach patient,” “failed scheduling effort,” and finally “referral canceled as unable to reach patient, reorder if still clinically indicated.” The patient missed their follow up appointments with me. I saw, however, the ongoing social work notes in the chart. Half of these notes stated they couldn’t reach the patient and half suggested contact. Perhaps it made sense that this patient wasn’t attending to their cancer diagnosis/rule out follow up appointments. This patient had big fish to fry without cancer. They were struggling with drug addiction, didn’t have secure housing, and weren’t sure where they’d get their next meal. The electronic chart, filled with short notes attempting objectivity written in the same font used in 1980s faxes, told a story. The story was both an epic and a tragedy.

This patient was lost to follow up. Would we ever find out if they had cancer? Did it matter? Would they die before medicine could help them? Was medicine really what they needed? As I watched the story unfold, Maslow’s Hierarchy of Needs surfaced in my mind. This patient’s basic needs weren’t met – food, safety, and a place to stay. Cancer was so high up the pyramid of needs it seemed silly to discuss. Though, was it really that high up the pyramid? I know what cancer can do.

Health is multifactorial. Only one piece of health is access to quality healthcare. This patient was focusing on several nonhealthcare pieces of health – safety and security of the physical body. Perhaps they were also focusing on finding their next meal. Perhaps the recreational drugs they used were treating demons of a past filled with trauma. This patient was part of a healthcare system with robust social services to help with social problems like housing and food insecurity. Interestingly, the social services this patient could access are exceedingly rare in the US. Most health systems don’t provide these services and most insurances don’t cover them.

I hoped the patient’s basic needs would be met. I hoped that when those needs were met, they’d return to clinic so we could start the cancer investigation process. I hoped it wouldn’t be too late. Even as a physician I don’t get to write the story of other people’s lives. As the story in the chart unfolded, I was grateful that the patient was receiving social services. I was frustrated that in most other US healthcare systems a different patient in the same situation would receive no help of any kind.

“Lost to follow up” is the phrase we use for patients who disappear from healthcare. It’s a term that provides a label, but it doesn’t explain where these patients go and why they disappear. The label can have negative connotations because it’s easy to be frustrated when patients don’t want to take our (their doctors’) advice and follow our carefully designed plans. It’s easy to forget our patients (just like us) are products of the social determinants of health. It’s easy to forget (just like us) they have lives filled with complex situations regardless of their use of healthcare.  

I’ve found that it’s worth stepping back and trying to see why patients decide to become lost to follow up. When I do this, I often discover that they aren’t lost at all. Rather, they are fighting for the most important things in their lives at that time. And the important things they see are usually different than the important things I see. Since patients are the experts in their own lives, they are often right about what’s most important. Frequently nonmedical things have a greater influence on patients’ decisions than their health needs as dictated by their doctor.

As the alerts came to my inbox for missed tests, I thought about the patient the first (and only) time I met them. They had answered all my questions thoroughly and without hesitation. I wondered if I’d see them again. I hoped they returned to clinic before anything devastating related to their maybe cancers happened. I cleared the alerts. The patient would write their own story; I’d be here if they invited me to partake in another chapter of it. Even tragedies sometimes have plot twists and happy endings. I always (and unwaveringly) root for happy endings no matter how stormy the story becomes. 

References:

Wikipedia on Maslow’s Hierarchy of Needs: https://en.wikipedia.org/wiki/Maslow%27s_hierarchy_of_needs

Article on the importance of the different determinants of health: https://pubmed.ncbi.nlm.nih.gov/26526164/

HHS overview of the social determinants of health: https://health.gov/healthypeople/priority-areas/social-determinants-health

WHO overview on the determinants of health: https://www.who.int/news-room/questions-and-answers/item/determinants-of-health

The Doctor’s Dilemma

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Being a physician is a career that can become one’s life. There are many reasons for this including the 24/7 need for healthcare, the pressure from healthcare business for productivity, the need for advocacy to improve the system and increase health equity, and the desire to help others. There is also the added stress that medicine literally deals with people’s lives and wellbeing. Given these career features, being a physician historically was a way of life, not just a job.

Despite the historical trend that being a physician was a way of life and an identity that trumped all others, there has been a shift in recent years. This shift started some time ago and was, perhaps, expedited by the COVID-19 pandemic and the severe toll it took on all healthcare workers. The shift is that newer ages of physicians don’t just seek to be doctors – they seek to be partners, parents, athletes, cooks, travelers, readers, vacationers, relaxers, and gardeners to name a few identities they claim beyond the physician identity.

As a member of the newest generation of physicians I find myself caught between the old dogma that to be a physician is to prioritize it above all other aspects of life with the newer view that to be a physician is to be a person with a serious career. I think of these completing identities of “way of life” vs “profession” as the “doctor’s dilemma.”

Sometimes self-imposed and sometimes externally-imposed the training physician (and all physicians really) are driven to do more. More reading and learning, more shifts, more leadership roles, and more research. It’s hard to balance the forces urging me to do more with the desire to also do nonmedical things like spend time with my husband, hike, and write. My medical training has taught me to hustle, be efficient, and work for long durations of time with high focus. As my training continues, I’m also learning how to say “no” and pump the break. Of course, these learnings are contradictory. The pendulum falls sometimes more on the hustle side and sometimes more on the relax side.

As I finish my 1st year of residency, I’ve been thinking about the doctor’s dilemma because in the remaining years of residency I’ll make decisions about my post-residency career path. While I contemplate my career’s trajectory, I also find myself thinking about other things in life. For example, living in a city apartment has made me miss walking barefoot on grass. I don’t suspect I’ll own a house anytime soon, but missing grass has made me think about homeownership more than ever before.

What do I put on hold and what do I pursue? What opportunities if not taken now will disappear? Where do I want to be in 5 years?

While wellness preaches “live in the moment” heavy careers, like doctorhood, require forward thought. Doctorhood requires the balance and blend of one’s professional dreams and identity with one’s personal dreams and identity. During my 2nd year of residency, I’ll become a team leader and gain more independence. With this greater responsibility doctorhood feels more serious than it did as a new resident when I had more people guiding me. As my training continues, it is my turn to step up with the answers. Patients will depend on me. Each choice, like whether to study or run, has a ripple effect on my future and (perhaps) on my patients’ futures. There simply isn’t enough time to “do it all” at the same time. Choices must be made along the way. The choice options are what pose the dilemma.

A Letter to My Intern Self

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Dear About-To-Be-Intern Self,

Intern year (as the first year of residency is called) is going to be tough. At times, in fact, it’s going to be downright awful. There will be stretches where you don’t see the sun and can’t remember the last time you felt anything but exhausted. The trend you noticed in medical school, in which current physicians and administrators don’t value your time (and waste it) and then wonder why your mental health is poor, will persist. You will be told by some to do more because “you’re a doctor now” and you’ll be belittled by others because you’re new and you don’t know what they think you should know.

You will be impressed by how your health deteriorates intern year. You are welcome to take some of the blame for your decline if you’d like, but the truth is that everything about intern year is the opposite of the wellness advice we give our patients. From your sleep schedule to your stress level, or from the food the residency program gives you to your work hours, there is very little healthy about intern year. It would be misleading to ignore these negative things that will unfold, one way or another, as they have for every intern. They manifest a bit differently for each person, but their occurrence is a guarantee.

Like all things in life, the negative of intern year is paired with the positive of these 12 months. First off, you’re paid – a huge victory after 4 years as a medical student. Your salary will be meager compared to your future salary (and it will be poop if you calculate the hourly rate) but remember that the intern salary is higher than the average annual income of Americans. Second, you are a doctor now. A real doctor. This title, alone, allows you to meet the most extraordinary people and hear their amazing stories. People will tell you things they never told anyone else. Your kind patients and your brave patients will be beacons helping you through intern year.  Focus on remembering the kind and brave patients more than the hard and mean patients; it’s the opposite of what your mind will want to do. I assure you that remembering the kind and the brave will help you more than you realize.

There will be difficult senior residents and supervising physicians; there will also be amazing ones. Take a moment to appreciate the inspiring senior residents and supervising physicians and reflect on why you respect them. You’ll be in their shoes before you know it and you can learn from them. Let the degrading and unkind supervising physicians and residents bounce off you; let them be a lesson of what you do not wish to become. The same goes for the nurses and other staff in the hospital. Nurses will be your biggest nightmare and your biggest savior throughout intern year. A knowledgeable and respectful nurse is gold. Thank the hard working and thoughtful nurses. Learn how to navigate the mean and not patient-focused nurses. You’re a doctor now and, once intern year is over, you’re going to be a team leader. Intern year is about getting ready to be a leader.

No one is good at being an intern when they start. Every intern gets better at medicine, navigating the healthcare system, and working with the interdisciplinary teams of healthcare. You won’t notice how much you’re learning at first. The days will pass slowly and the weeks quickly – before you know it, you’ll wake up and realize that you are a new version of you. You’ll blink and a new July 1st will be just around the corner. Then, intern year will be behind you…forever. I’m not delusional enough to say, “enjoy it while it lasts.” I am delusional enough to say fight for your health (because you’ll need to) during this year and soak up as much knowledge as you can. In the end, intern year exists to help you get closer to becoming the best doctor you can be. Intern year will force you to grow. It will challenge and push you to a new level. Always remember that intern year is finite and only one small phase of the Doctorhood Quest. It will pass.

You go this. I know you got it. At the end, you’ll know you got it too.

Yours truly,

Jett

Space

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I often think about space, specifically taking up/claiming space. My most conscious ponderings about space are while I’m running in the park near my house. I’ve observed that people are more likely to step aside for a male runner than me, a female runner. It’s so blatant that when my husband and I are running or walking together we strategically put him on the outside because people move over for him and not me. It’s an annoyance. I’ve started to run strong and serious. I’ve learned that a confident stride and a squared shoulder do help remind people that women also deserve to run without stride interruptions.

Guarding my lane while running is a newer claim of space for me. The first time I claimed space was changing how I sat. Changing my sitting stance was a project that took the better part of my twenties. For some reason women in my culture are taught to sit small and closed. I’ve found that sitting small is counterproductive. It has (perhaps) made it easier for males to harass me on public transportation and (definitely) made it easier for my colleagues in healthcare to ignore me. These days I try to sit large and open, just like my culture teaches their boys to sit. I don’t take the inside seat on the train/bus (that’s more for safety as I’ve learned the hard way) and I take up my whole seat even when it’s wider than I am broad. If there’s a seat at the table in a conference room, I take it. Which brings me to medicine, my most recent occupation (both meanings of occupation, wink, wink).

I have a very distinct memory from medical school related to being a female in medicine. I was mid-sentence presenting my section of a group presentation when a male member of my team cut me off, talked over me, and started his section of the presentation without letting me finish. It was so rude that several females in the class texted me in solidarity. The experience made me think about why seats at the table are not enough on their own. Seats must be claimed and, sometimes, defended.

Being a first-year resident brought with it a whole host of interesting space claiming challenges, many simply related to being a new doctor and some related to being a female physician. Filling the role of physician involved learning how to defend and explain my medical decisions, striving to take the high road and set boundaries when other members of my interdisciplinary team did not, and observing how physicians I admired conducted their doctoring and led their teams so I could model their techniques.

The challenge of being a new doctor exists for all new doctors. But filling the role of a female physician comes with its own occupational hazards. Here are some concrete examples from the past year of times I was reminded that I was female while at work:

  • I frequently must remind my patients that I am not their nurse — a challenge that my male counterparts don’t have.
  • My name is gender neutral, so nurses often think I’m male when communicating electronically with me before they meet me in person. (We have a secure chat in our electronic health record system that we use in the hospital). It is interesting to see how nurses’ tones change after they discover I’m female when they originally thought I was male. At times the tone change is dramatic and frustrating because I get more pushback as a female than as a male physician.
  • I have been lectured by a male supervising doctor about what clothes a doctor should wear. The lecture was somewhat confusing given that all the female residents wear exactly what all the male residents wear… scrubs of similar fits, styles, and colors. I doubt any male resident teams have been subject to such a lecture, but my all-female resident team was.
  • Several times I have found myself uncomfortable on rounds (that time of day when you talk about all your patients with the supervising doctor) because the male supervising doctor was very good at looking at my chest but never made eye contact.

The above situations illustrate that there are additional features of the medical terrain that female physicians must navigate that their male counterparts don’t experience.

As my second year of residency approaches (starts July 1), I’ll soon find myself no longer a first-year resident. In my second year of residency, I’ll start to be a team leader and I won’t be the new kid on the block anymore. I’m excited about this next step in my training. I feel ready to take on the challenge knowing I’ve learned a ton already and have a ton more to learn as a physician. I continue to have much opportunity for growth on my journey to lead with humility and excellence. As I wait for my second year to begin, I’m curious what the phase of “senior resident” (my title during my second and third (last) years in residency) will be like and the space challenges it will present. All adventures have space challenges however they present themselves in different ways.

I Don’t Let Anyone Die Alone

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I saw the nurse sitting calmly at bedside. I knew she was the night nurse; it was shift change. Usually, the end of a nursing shift is busy with finishing tasks and telling the next nurse about the patients they’re taking over. I got up to check on the nurse and the patient. We’d just transitioned the patient from full code to comfort care. “Comfort care” means no life-prolonging measures – just medications and other interventions to help people be comfortable as they die. Minutes earlier I had put in the comfort care orders.

“Hey, do you need anything else?” I asked the nurse. “I only put in a few orders and just wanted to make sure I wasn’t missing anything you need.” The nurse was holding the patient’s hand.

“No. They’re dying now,” the nurse said. She was looking at the vitals monitor; I shifted my gaze from her to the monitor too. The blood pressure was 15/0 (recall that normal is 120/80). The heart electrical line (usually a dramatic up and down) was flat. The patient was taking agonal breaths (the last gasps a person takes as they die; they aren’t true breaths). The patient’s eyes were blank. I had known that the patient would die that day but it was happening faster than I expected.

“We let the patient’s pastor know, but she won’t make it for another half hour or so,” I said. The patient didn’t have any family. They had listed their pastor as their emergency contact and the person who would make decisions for them when they couldn’t make decisions for themself.

“I know,” the nurse said. “That’s why I’m here. I’ll be here. I don’t let anyone die alone.”

The nurse sat quietly on a chair next to the patient holding their hand. I stood with her and the patient for a little while watching the monitor. Eventually I left the room and got my stethoscope. When everything on the vitals monitor was zero, the nurse closed the patient’s eyes gently. I did my exam and determined the time of death. Next time I looked at the room there was a picture of a butterfly on the closed door (alerting people that the patient inside had passed).

When I looked at the room later in the day the bed was empty and made with new linens. It was as though the patient from the morning had never been there. Yet, I remembered the nurse and patient holding hands as the patient’s heart stopped forever. I did not know what the patient did when they were alive but, at least, I knew they hadn’t died alone. I was reminded that small acts change lives. I was reminded that heroes only wear capes in movies. I wondered how many people die alone – I was grateful that this patient wasn’t one of them.

Code Status

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“Would you want us to do compressions if your heart were to stop?” I asked.  

“Of course!” the patient said.

“Would you want a breathing tube if you needed help breathing?” I asked.

“Yes, do everything you can,” the patient said.

“Ok, we call that ‘full code.’ If your heart were to stop, we will do what we can to bring you back,” I said.

“To my surprise, I recently learned that there are people who don’t want that,” the patient said.

“Correct,” I said. It was a busy day and given that the patient’s personal goals regarding code status were quite clear I avoided further discussion. 

~

Code status is the first decision people make regarding their goals of care. “Code” is medical slang for a heart attack (which is when the heart stops causing death). “Goals of care” is an umbrella title for the objectives patients have when they interact with the health system. Goals of care exist because patient autonomy is a key ethical principle in medicine. “Patient autonomy” is the idea that patients have the right to information about their care options (the risks and benefits of all the options) and have the right to decline any medical intervention they wish even if declining can result in a sooner death. 

We always ask code status when patients are admitted to the hospital so that we know what the patient would want if the unexpected happens. There are 3 code status options:

  • “Full code” means that a person would like compressions and a breathing tube if their heart stops.
  • “DNR/otherwise full interventions” means a person does not want compressions if their heart stops but would want other interventions (like a breathing tube) if they needed them for some other reason.
  • “DNR/DNI” means that a person does not want compressions or a breathing tube at any time.

Unlike what the patient above believed, picking a code status is not an easy decision for many individuals. There are zillions of reasons why one’s heart might stop; the likelihood increases the older a person gets and the more medical problems they have. There are also multiple situations that might cause young, healthy people to code. A common trajectory (but by no means the only one) for code status is that young people choose to be full code and as people get older (like in their 70s or older) and/or sicker they decide to change to DNR/DNI. If a person doesn’t pick a code status, the default is always full code.

If you ever find yourself in the situation where you are very old and frail and/or very sick your medical team might encourage you to consider changing your code status from full code to DNR/DNI. Some individuals and families are against the idea of DNR/DNI and that is their right. However, let me explain why your healthcare team might recommend DNR/DNI and why the decision is more delicate than it might first appear.

When someone codes it means that their heart stopped; they are dead. The chance of coming back to life after someone’s heart stops is zero if nothing is done. If efforts are made to restart their heart (like compressions, possible shocks, possible breathing tube) then they might come back to life or they might remain dead. The chance of coming back to life if something is done depends on many, many factors. And, even if we can get someone’s heart to restart after it stops, we can’t guarantee that the person will wake up or have brain function again. Medicine is imperfect; we can “save life” and “prolong life” but the nature of that life ranges from fully functional to a vegetative state (dependent on a ventilator and unable to communicate).

The likelihood of someone fully recovering from a code after we get them back depends on how strong and healthy they were before their heart stopped and the reason they coded. It also depends on how long it took us to restart their heart. For example, returning to normal function after coding is more likely in an otherwise healthy person who coded because they had an abnormal heart rhythm and whose heart restarted rapidly after initiating compressions. A full recovery is less likely in a person who has multiple medical conditions and required an hour of compressions before their heart restarted.

Compressions and post-code recovery are invasive medical interventions. For example, compressions often cause rib fractures. Many people require at least several days with a breathing tube and on a ventilator after their heart restarts. This is why, as you may have noticed in the above code status options, there is no option to have compressions without accepting a breathing tube (while you can have the reverse). The reasoning is that there is no point in doing compressions if a person does not want the interventions required to keep them alive after we restart their heart.

An important reason that people choose DNR/DNI over full code is because they believe their chance of surviving and returning to a functional state after a code is low. Often people who choose to stay full code no matter how sick they are do so because they believe any life is worth living. To complicate matters further, a person (or their appointed medical decision maker) can change their code status at any time. The fluidity of code status is why we ask code status every time a person comes to the hospital. Like most things in medicine, there is no “one-size-fits-all” for code status. Choosing a code status is a very personal decision with no right or wrong answer. The decision often depends on an individual’s values about life, beliefs about what happens after death, and baseline state of health.

The State of Being Human

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Being human is an uncomfortable affair at times. No one, perhaps, knows the state of being human better than the internist (internal medicine, my residency) who passes between managing patients in the primary care setting and the hospital setting.  As I gallop toward the end of my first year of residency, I can say with growing certainty exactly what the normal state of being human is.

Being human involves hemorrhoids, knee pain, and back pain. It involves debates (whether internal or external) about what to eat throughout every day and whether to exercise. And if exercise is on the menu, the question becomes: What kind of exercise should one do? Being human involves the occasional-to-frequent stuffy nose and nonspecific ache. It involves external stress such as work, family, and accidents as well as internal stresses like low mood (all the way to depression), anxiety, and difficulty sleeping. Being human involves getting older day by day, grumbling about this certainty, and knowing that the only alternative is death.

One role of internists (and emergency medicine doctors) is helping people sort out if their current uncomfortable state is on the normal spectrum of the human experiences or is out-of-the-ordinary enough to be life-threatening or to cause lasting impairment/injury. Take the classic question, “is my chest pain because my heart is injured?”

The answer is “maybe.” Moving the maybe to “unlikely” or “likely” a heart attack is where medical training and medical tests come in.

If you’re 20 years old and two days ago lifted the heaviest weights you’ve ever lifted and come to me with chest pain, I’ll start by pushing on your chest. If you then tell me that pushing on your chest makes the pain worse that’s enough information for me to say that your pain is likely soreness in the muscles that you worked out and does not involve your heart. To be safe, I could order some tests to confirm my hypothesis. I might not need the tests but if I see you in the emergency room, I’ll probably order them.

If you’re 60 years old and you don’t really have chest pain but, rather, mid-chest pressure as if someone is sitting on your chest…you’ve caught my attention. And if you then tell me that this chest pressure used to only occur when you mowed the lawn but now also occurs when you walk from the couch to the bathroom my concern for a blockage in the vessels that feed your heart is high. I will most definitely order some tests to explore my hypothesis.

I’ve heard hundreds of chest pain stories. With a story I can sort chest pain into categories including “likely normal life chest pain” and “likely heart chest pain.” I have exams and tests to further help me determine if the chest pain is directly related to heart injury. If I’m still concerned even after my first tests are negative, there are additional tests I can order.

One of the most satisfying aspects of being a doctor is helping people move past the uncomfortable affair of humanness so that they can maximize the joyful aspects of being human. Because being human also involves doing well. It also involves getting promoted at work and having kids. It also involves traveling and parties. It also involves loved friends and family. Being human also involves adventures and creative undertakings. It also involves feeling good and achieving goals. It also involves sitting on the pouch relaxing and glorious naps. It also involves conversations while sitting on the couch or at a café. It also involves sipping favorite beverages in favorite places on perfect evenings.

The state of being human is one of contrasts. Medicine occupies the space between the uncomfortable and joy of being a human with the aim to tip the scale back toward joy when things go awry. Medicine doesn’t have all the answers, but it outlines a system for exploring physical and mental discomforts and offers possible solutions. Part of what makes a good doctor is knowing exactly what the normal states of being human are so that we can quickly identify situations that deviate from the range of normal and intervene.

Moral Injury: Taking care of Sam

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Moral Injury

When I Googled “moral injury” the first definition that populated was, “Moral injury refers to the psychological, social and spiritual impact of events involving betrayal or transgression of one’s own deeply held moral beliefs and values occurring in high stakes situations.” The definition came from the site Open Arms which provides mental health services to Australian veterans.

You may have heard the term “moral injury” in the context of the military. However, moral injury is also common in other professions, not the least of which is medicine. The 3 reasons that are most prominent in my mind for moral injury in medicine are:

  • Our (the US) healthcare system is limited. Without universal healthcare our healthcare system is a commercial business where those with more money have access to care that those who are poor don’t. It means that the rich get better care overall than the poor regardless of the attempts of individuals working in medicine to deliver just care. The injustice comes because insurance and personal finances have the last word on any person’s access to medications, equipment, home health services, procedures, and surgeries. Without money in the US, you do not get full access to any of these health services.
  • Health is essential to wellbeing. Those who seek medical attention often have serious injury, life changing illnesses, and may be imminently dying. In medicine, we often take care of people at the worst time of their lives. We often deliver terrible news. We don’t always have good outcomes.
  • Healthcare is about people and every individual has their own beliefs and values. The doctors, nurses, and others taking care of a patient have different beliefs/values than the patient and each other. I’ve never had an experience in healthcare where every member of the healthcare team and the patient all had the same beliefs and values. And, in truth, I don’t think it’s possible.

I’ve experienced moral injury multiple times in my medical career. Sam’s case illustrates how my questions related to wellbeing and differing beliefs/values while caring for a patient opened the door to my moral injury. The injustice of commercial healthcare I’ll leave for another day. I’ve modified the details of Sam’s case (including the patient’s name) for patient privacy.

Taking Care of Sam

Sam came to the hospital because they believed their nursing home was abusing them. They were bedbound. They could feed themselves (if someone brought them food); yet they didn’t eat much. Were they refusing to eat because they didn’t want to or because it was uncomfortable to eat for some medical reason? They ate just enough to stay alive but not enough to thrive. In the time I cared for Sam, they became weaker and more confused partly from malnutrition. They also refused their medications. Did they have the right to refuse to eat and to refuse their medications even if it would hasten death and worsen their condition?

It was possible that Sam could live for 40 years more. Given their condition, would they want to live for 40 more years? Sam had days in which they understood what was going on. Yet, they often forgot things. Sam sometimes answered questions correctly and sometimes their thoughts trailed off to a land that was only barely understandable. How confused was Sam? Eventually it was decided that Sam couldn’t make their own decisions because they were too confused. The only person in the world who knew Sam outside of their healthcare team was an ex-partner. The ex-partner was designated as their legal decision maker because there was no one else.  Was an ex-partner the right person to decide what Sam’s medical treatment should be? Did this ex-partner have any idea what Sam would want in complex situations they had never talked about?

Sam was full code and full interventions per their ex-partner’s decision. This meant that every intervention Sam needed for their multiple medical conditions was to be pursued even if it caused discomfort. To do this Sam needed an IV. Sam pulled out every IV we placed (so they pulled one out about daily).They also pulled out multiple more permanent lines (basically deeper IVs that access bigger veins and are often held in place by stitches). We kept replacing the IVs. Was Sam pulling out the IVs because they were confused or because they didn’t want them?

As Sam’s nutritional status worsened and they missed more medications, my team suggested placing a tube in Sam’s stomach so that they could get proper nutrition and medications even if they refused to eat and didn’t have an IV.  Most days when I talked about this feeding tube with Sam, Sam said they didn’t want it. Did Sam know what they wanted? The ex-partner decided that Sam should get the feeding tube in case it helped improve their condition. They got the feeding tube. Did we know what was best for Sam?

Not long after Sam got the feeding tube, they went to the intensive care unit because their blood pressure was too low. They were placed in medical restraints (basically tied to the bed) so they wouldn’t pull out the IV through which they received a medication to help increase their blood pressure. Without that blood pressure medication, they might have died. That medication had to be given through an IV. Were the medical interventions we did for Sam helping or hurting?

Sam hated the restraints. They screamed, pleaded, and cried for us to take off the restraints. Were the restraints doing more harm than good? They screamed and yelled that they didn’t want any of the interventions that we were doing. Was Sam aware enough to know what they did and didn’t want? Sam could tell you their name and where they were; they’d lost track of why they were in the hospital, the month, and the year.

Sam survived and eventually returned to the regular hospital floor before being discharged to a nursing home. Sam’s hospitalization lasted months before a nursing facility accepted them. Did Sam want to prolong their life even though that meant going to a new nursing home? Would they have preferred to be made as comfortable as possible without medications and without being forced to eat? Would anyone ever truly know what Sam wanted? Would Sam’s right to make their own decisions ever be regranted?

Despite doing everything medicine could do for Sam, I’m still not sure if any of it is what Sam wanted. I’m still not sure if we did the right thing. And because of these uncertainties, I’m not sure if Sam’s case broke several of the most important principles of medical ethics: patient autonomy, do no harm, and beneficence.

The Sorting Hat of Medicine

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Recently, I was back in the emergency department (ED). Not as an EMT this time but as a doctor. It’s different as a doctor. In the years leading up to medical school, I worked as an EMT in the ED and volunteered on an ambulance. Being an EMT was my first patient care experience. It was eye-opening in many ways. Among the things I learned as an EMT is that I did not wish to become an emergency medicine doctor. My residency program (internal medicine) has us do a month in the ED as part of our first year of training to get a different experience and a different perspective.

The ED is like no other place in healthcare or in the world. There are few places where the staff have as much camaraderie. There are few places in the hospital where the staff laugh so much and the adrenaline runs so high. The ED also, perhaps, provides as many reasons to cry as to laugh – which is why those who work in the ED find ways to pick laughter over sorrow.

The ED is the sorting hat of medicine. My rotation as a doctor in the ED showed me that ED doctors are the gatekeeps to the hospital and the safety net for everyone who can’t access healthcare anywhere else. The doctor’s role in the ED is different than that of the EMT. As an EMT my day was filled with tasks – placing IVs, performing EKGs, getting snacks for patients, and so on. As an ED doctor there are fewer tasks than as an EMT but the tasks that remain are heavy. ED doctors make big decisions about which tests a patient needs and where they should go next – home, surgery, a regular medical floor, or an intensive care unit. ED doctors stabilize patients before they are shuttled off to other parts of the hospital. ED doctors reassure patients that they are okay before sending them home. ED doctors are the last contact for many people as they leave this world for what comes after death.

Some days in the ED are hectic and some are slow. ED doctors connect with every other specialty in the hospital. They consult specialists and convince other doctors to accept ED patients so that the patients can be admitted into the hospital. As much as ED doctors are the gatekeepers, they are also the connectors.

The ED runs at a blistering pace but when things are running well no patient stays there for long. Hours, yes, but not for days. Yet, some patients become known to the ED. They’re called “frequent fliers.” Frequent fliers are known by their ED doctors much like primary care doctors know their patients. Often frequent fliers don’t have a primary care doctor. And, so, when ED doctors take care of a frequent flier they may be the only doctor that patient has. The only doctor standing between that patient and no medical care at all.

The ED is the sorting hat of the hospital. As the leaders of the sorting hat, ED doctors have many roles. They are gatekeepers. They are also connectors and, for some, the only option. The ED is the bridge between the outside world and the hospital. I’m grateful for the folks (doctors and all the others) who choose to work in the ED because being the sorting hat is no small feat.