Friday, November 5, 2010

Internal Medicine-Waiting For Godot?

She was like....Superwoman. A strapping medical visionary probably in her forties. Gray long coat falling below the knees. She strode confidently down the hallway towards the elevator, a father hurrying beside her with his young lanky daughter cradled in his arms. The girl's head nuzzled into her father's shoulder. She was old enough to walk by herself...but clearly she was sick. Unable.

Undoubtedly they were headed from the medical complex to the ER which was a few hundred feet away. As I walked past them towards my own office door one clear thought leaped into mind. Boy....I wish I was a doctor. Then I froze. Wait...I am...I am a doctor. But maybe I no longer feel like that kind of Doctor. You know, the one with a capital D. As in MD. The one who throws caution to the wind and runs out of a full office of patients to escort an ailing person and family member to the ER. The one who rushes out of a crowd to perform CPR on the elderly lady who collapses in the shopping mall.

Unfortunately most of us in Internal Medicine have found our jobs and lives deranged to the extent that we no longer feel the strength and surge of emotion that brought us into the profession in the first place. Most of us have lost our inner Superman. And our patients have grown tired of waiting.

It's been going on for years now. The devaluation of primary care and especially Internal Medicine. It started with the loss of technical abilities. Over the years Internists have given up most of the manual labor. We no longer perform biopsies, place central lines, lumbar punctures, or manage ventilators. We have ceded these skills to specialists.

This loss of technical prowess has had far reaching implications. For one...our patients, as well as our specialist colleagues, no longer see us as doers....they only see us as thinkers.

And this by itself is no big deal. If you need your car fixed you go to a mechanic. And we don't want to be mechanics. So we embrace our new vision as thinkers. We are warm, kind physicians, who a patient can talk to. We use manual dexterity through physical exam and pure wit to solve medical problems.

Except....that over the years physical exam has been undervalued. Medical training has moved to lab and radiology based evaluations. The Internist no longer prides himself on exam skills. Who needs to know the ins and outs of heart murmurs when you are going to order an echo anyway.

So Internal Medicine lost its concentration on manual dexterity...and turned towards mental gymnastics. I am reminded of Rodin's Thinking Man sculpture. We are now the astronomers and philosophers. Physicists and scientists. We can live with that!

Now take the Thinking Man and remove hand from chin and place squarely on mouse. Take other hand from knee and fill with preprinted checklists and practice guidelines. Tell Thinking Man he has 7.5 minutes till his next patient appears and he will have to strike the same pose in the next exam room with a new patient.

What you get is a thoughtless, hurried physician, who feels impotent. He is isolated from his patients emotionally. He is boxed in by a computer that doesn't allow eye contact. He is isolated physically by a loss of manual dexterity and an overwhelmingly belief by both patient and physician that tests are more important than human touch. And lastly he is isolated mentally by rules and regulations, check lists, and inadequate time to fulfill his role as a thinking man.

Our patients are figuring this out. They are leaving our practices and going to minute clinics, specialists, emergency rooms, and alternative medicine practitioners. They are taking on cute names and becoming epatients and creating their own empowerment movement.

They are sick and tired and frustrated by us supposed supermen who are enslaved in straight jackets of cryptonite. They have been here before.

Our patients know what happens when you're waiting for Godot....

You sit around an awful long time....

But ultimately...ultimately..

no one comes!

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