Wednesday, October 22, 2008

Commentary (thoughts related to the story Obsessed)

A physician I greatly admired once told me something I found quite sad and depressing. He said, "Jordan.....if you practice long enough, no matter how goood a physician you are, there will be a small graveyard with your name on it filled with people ." When I heard this I was at the begining of my career. And I did what most young physicians in my place would do....I laughed it off as an exageration.

Afterall....most of us became physicians to help our fellow man. Most of us took seriously the oath to "do no harm". And most of us would have trouble sleeping at night knowing that our actions could lead directly to someone's death.

As time goes on, however, I realize that as with most of life....things are not so simple. For instance what doe's it mean "to do no harm." Sounds pretty straight forwad doesn't it? But it's not. Almost everything I do as a physician has the possibility of doing harm. Every time I dole out an antibiotic for a respiratory tract infection I risk the possibility that the patient will have a life threatening reaction. It happens! Furthermore, often when the clinical situation is not clear I am forced to make decisions that will either benfit or harm the patient depending on whether I am right. Is the patient wet or dry? If I give fluids I could cause worsening heart failure and box the lungs. If I withhold and diurese I could box the kidneys. If I do nothing the patient could die.

And what about all those missed diagnosis. As Jerome Groupman talks about in his book How Doctor's think being a primary care physician can be a scary proposition. Like watching a train pass by with thousands of people and you have seconds to pick out through the windows the 1-2 who are desperately ill and need immediate action. How are you going to catch those? Is inaction that leads to harm the same as "doing no harm".

And lastly there is plain old human error. If you perform an operation enough times occasionally something will go wrong. Occasionally a hand slips. Occasionally a clinician misses the elephant in the room. The longer you practice.....the greater the consequences of your actions. It's a numbers game.

So how do we as physicians deal with this reality? Some leave medicine when the sadness becomes to great. Some become overly obsessive. Many try to protect themselves by becoming arrogant and considering the idea that they make mistakes blasphemy. Many cry...or write...or get started on antideppresants.

When it comes to me......I choose to hope. To hope that if somewhere there is a small graveyard with my name on it then next to that graveyard is a larger city of happy, healthy, thriving people also with my name on it. To hope that the sum total of my actions (like Lawrence's in the story) falls on the positive side.

Because no matter what we do, being a physician is just a magnified version of being human. We all effect the world around us. We all make decisions that have far reaching consequences. We just don't think about it as much.....should I drive home or stay at a friends house becuase I am too tired...should I spank my child or put them in time out.....should I eat that last piece of chocolate cake or should I stay on my diet.

We all make mistakes...

We all occasionally have blood on our hands...

It's just that being a physician makes it so much more painfully obvious.


tracy said...

Thank you, Dr. Jordan, for this, sometimes painful, look in to the life, your life, as a physican. i love books about the Patient-Doctor relationship and have read many (including the one you mentioned), but in your writings i have found something new and completely different and i love it. i hope you will write a book some day.
thank you,

Jordan Grumet said...

Tracy...thanks. I would really like to take my poetry and short stories and compile them in a book. The truth is I haven't had enough energy (emotional and otherwise) to get it done. The material is already written. I just need to compile it. And the truth is I am a little skiddish about rejection.

tracy said...

It is hard for me to imagine a p h y s i c i a n bring afraid of rejection. i guess it is because i admire you so much, i tend to forget you are also human...! i honestly see your writings on the same level as my absolute favorite, Dr. Gawande, just in a different gendre. i hope, when you get some time and emotional enery back, you will go for it...i will be first in line!
Be well, Dr. Jordan,