With just a few months left of residency, I’ve started to pay a lot more attention to what is going on around me. I’m realizing what a unique perspective we have as housestaff physicians. The best way for me to explain what I mean is with this story of one particularly busy shift in the ER.
That night, I was distracted: on one side of me, a few PAs were having a heated conversation about various social determinants that seem to lead to early strokes among our patients; and on the other, a couple of the attendings were making clever jokes about the national discussion on health care reform. In that moment, both of those topics were more interesting to me than the tricky MKSAP question in front of me about hypertensive emergencies.
However, all of that was put aside as my attention shifted to the blinking light which indicated that the next patient had been triaged and roomed. I had noticed that the triage nurse initially labeled the case as “Possible Stroke,” and then changed it to “Blood Pressure Problem, no PCP.” As I saw this change, I looked at her and nodded, knowing that I made her proud by understanding what she was communicating.
The PA I was working with immediately stood up and said, “Hey, I’ll take this one.” I’m not sure if it was my version of “senioritis,” but I noticed the difference between us — she always seemed to step up to see patients with the sort of enthusiasm I had when I started training, and which I had not been able to muster up lately. And I really did admire her for this. We learned a lot about each other this month — growing up, we both loved Sherlock Holmes, we were both fascinated by science, and we both shared a social consciousness that inevitably brought us into this field. She has been working for quite a few more years than I had, and she always told me that remembering what got us into this field is how to stay resilient.
She came out of the patient’s room, ordered a CT head, started a nitro drip, called the admitting intern on the floor, and told him about this admission for accelerated hypertension. Almost an hour later, the intern came out of the room agonizing, “I think he is critically ill and I don’t know what to do. His blood pressure is 230/120.” I immediately started to reminisce…
In my intern year, I learned at the feet of my favorite attending, one who I like to describe as a modern-day version of Dr. William Osler. I remembered one afternoon when I walked out of a patient’s room in a similar panic and presented to him. In an attempt to emulate his style, I calmly said to the intern, “There is never a moment when a doctor should be more stressed than a patient. So, why did he come here?” He explained, “He checked his blood pressure at Walmart, noticed it was really high, and so he came here.” We then proceeded to painstakingly cover the expectedly negative review of systems. Then I asked him, “What’s the difference between hypertensive emergency and urgency?” He started to recite parameters of blood pressure goals and concepts of end-organ damage. And so I responded as I had been taught: “Hypertensive urgency is an outpatient problem.”
The PA, listening in, smiled and said, “It really is ‘elementary,’ isn’t it?” She then told me that she wishes that she got the sort of dedicated training that we receive as residents.
As I reflected on what she said, I started to realize what the real difference is between her and me. It really came down to this final leg of the training we receive as doctors — the period after we earn our coveted prefixes and suffixes — when we are taught how to think. During this crucial time, when we are devotedly mentored, when we are regularly challenged with arguments, inquiry, and Hippocratic discussions — during residency — we actually become physicians.
However, as it has once been said, “The philosophies of one age have become the absurdities of the next, and the foolishness of yesterday has become the wisdom of tomorrow.” And these days, it seems that a lot of people are questioning the need for this added deliberate practice. And I can understand why — our current medical system is very effective at putting out fires. The evidence-based guidelines that we have incorporated really do save lives. Our diagnostic tools allow us to reach the right answers quickly — a lot of detective work has already been done for us.
As I see it, this system is what “mid-levels” are trained well in. This role is necessary. But it is not sufficient. Nor is it even in direct competition with that of a doctor. Of course there is overlap, but when our patients are asking to be seen as more than the guidelines, when they are telling you that their version of events is different from what we have been taught in school, the listening ear of a well-trained doctor becomes crucial. As physicians, we are able to dig deeper, to think more critically. Our job is to understand the art of medicine so well that we really just need our advanced modalities as adjuncts to making diagnoses and plans. Our job is to communicate — we are supposed to take the most complicated science and translate it to the most basic form so we can educate our patients.
With such prominent national discussions around health care, we have been made painfully aware that the system is simply not working for large parts of society. The most likely to fall sick — the frail, the poor, the systematically disenfranchised — are the ones who are the least likely to have access to that well-oiled machine that we have set up. And when they do have access, our patients seem to still feel that they are not understood. This is profoundly sad. But it is a problem with a solution. By thinking the way that we are taught to think, we can see that patient who the intern saw and prevent him from suffering, for just about $8 a month at the very pharmacy where he checked his blood pressure. As doctors, we are equipped with enough ability — with primarily our mind and our touch — to put an end to this injustice.
Upon reflecting on this situation and in gearing up for the next phase in my life, I guess my enthusiasm is coming back. I’m realizing that if I stick to this concept, I could create an exciting career where such simple human connections will be appreciated, respected, and incentivized, even. I imagine this is what they mean on the national level when they discuss the value of physicians who provide valuable care without garnering fees for excessive services.
But more importantly, I am starting to understand that what we do is more than just a job. As Dr. Osler once said, “the practice of medicine is an art, not a trade; a calling, not a business…” It is a “way of life” — and I, for one, am starting to feel the hope that now is the right time to get started.
consci/o- [in medical terminology: a connection deep to a state of understanding]
All physicians are taught to communicate with a fundamental language of healing and justice. This column is a collection of reflections on how I learned this fundamental language and an homage to the teachers who taught me.