Stand Up And Deliver

I never considered becoming a surgeon.  I knew that I didn't posses the three dimensional sense to perform at the highest levels. I would have been mediocre at best. And, in general, I don't regret this decision. There are times, however, when I feel unbridled jealousy.  When the abdomen quivers with acute appendicitis, I so wish I could wield the scalpel and with a few trusty thrusts rid the body of the diseased organ.  Or when the breast is invaded by misguided cells, I could extirpate the cancer with strong arm and unrepentant soul. 

It's not that surgery is easy, un-messy, or for the weak of mind.  We all know that it is actually a thinking mans sport.  But there are times when the answer is actionable and the pathway is clean and decisive.  Did I go into the wrong field?

General Internal medicine (like surgery in general) is anything but straight forward.  The common cold can turn into life threatening influenza, the tingling of pain in the chest can be a heart attack or the first signs of a perforated esophagus.  You never know what's lurking behind the exam room door and complacency of the routine can be shattered at any moment.

Yet, strangely enough, the certainty I crave has become more apparent as I delve further into end of life care.  Unlike many of my colleagues, it mostly seems quite obvious when a patient is dying.  Maybe its the weakness of voice, durability of diagnosis, or just a hunch.  Usually I can tell when the time is coming and help prepare as best as possible.

Once all parties accept that death is the realistic outcome, I become like the surgeon operating on a fiery appendix.  The dance becomes much more choreographed, the decision tree much less complex.  This is where I thrive. 

And maybe this is why we are failing in medicine.  The dizzying myriad of treatments and options sometimes clouds our minds to the obvious reality.  If we could just foretell death better we could surely save a world of suffering and unnecessary treatments.

I think the knowledge is out there.  Like the surgeon, we need to learn to stand our ground.

We need to deliver in both life and death.