Teaser

I am nearing the end of this whirlwind tour through academic medicine. I have had the impulse to blog, flashes of thoughts I wanted to put into written form, but my desire to reflect is weak compared to my imperative need for sleep. And so this page has remained silent for almost 6 weeks. Which is funny, because I feel brim full of epiphanies had and stories witnessed. So as I wind down my time here and transition back into the slower world of winter in Alaska, I am hoping that my memory will hold and I will have time to sort through the jumble of emotions and thoughts brought on by my last 6 weeks.

For now, this:

Frequently I look at those of us who are training to be doctors, and those of us who are residents, and those of us who are attendings and I think, dear god, we are just children play acting. There are young children, like myself, who mimic and there are older children, like the attendings, who decide which games we will play, but we are all nothing more than children in a big, scary, chaotic world. We have information gleaned from good and bad studies that we use to make decisions, we have the experience of the way similar situations have gone in the past, we have a stethoscope, we have MRIs, and we have blood tests, but these are weak defenses against the uncertainty that fills the spaces created by the heterogeneity of patients. There is, over our shoulders, a constant question of uncertainty. Sometimes it looms large, sometimes it squeaks small. The latter are days of success, I think. This uncertainty is not what I find disconcerting. It is expected, it is why medicine is referred to as an art rather than a science. It is why so many of us are drawn to the field.

What I find disconcerting are the ways that we try and manage the uncertainty. There is the ridiculous paperwork that tries to minimize unnecessary uncertainty. Perhaps our best response to it is the collaboration that is the foundation of doctoring. And our worst, the one that would keep me up at night if anything could keep me up at night these days, is our collective approach to each patient as a game, a puzzle to be solved, a mystery to explore, a lesson to be learned.

I think of the pre-code we were called to several days ago on a post-call morning. In front of us was an unconscious, large middle aged man. His pillow was red from the blood drooling from his mouth. He grunted to pain, when we pulled his eyelids open, we could watch his eyes rove back and forth in a rhythmic pattern. One side to the other, one side to the other. His vitals were stable, his blood gases normal, nothing to indicate what was going on. And the three, maybe four of us in white coats stood at the foot of the bed nonchalantly discussing his case.

R3: What do you think is going on?
Other R3: I have no idea. . . maybe a seizure?
R3: Yeah, that's a good guess. Probably is what it is. I mean, it doesn't look exactly like a seizure, but, what else could it be?
Other R3: Yeah, I mean, his vitals are stable, ABG was good n' normal, normal sugars. . a seizure could look like this, I think.
R3: So should we give him some ativan?
Other R3: Maybe. Did you call Neuro (to the intern)
Intern: Yes. Couldn't get ahold of them.
R3: Hmm. . I guess we could just give him the ativan, it's not going to hurt him, right?
Other R3: I don't think so. Seems like it's something to do.
Silence
Nurse: So do you want me to go get the ativan?
R3: Yes, I guess. . I mean. . I think so. Yeah, sure.

And so on. . eventually no ativan was given, and we all backed away from the patient as his primary care team arrived. He was still seizing, or doing whatever he was doing. I was struck by how we stood at his bedside, fascinated by what he was doing, without any urgency to fix it. I felt like we were children – our white coats fit too large, our stethoscopes looked awkward. Our feet shuffled. .how can we make this more fun again?