The Religion of Medicine

Spirituality is a nebulous term and I’m not sure I think of it the same way everybody else does. If it’s the same as faith, how does it differ from religion? If it’s just a set of values or a belief system, how does it differ from culture? Like religion, I think of medicine as a faith system instead of a factbook. Every time we prescribe a medication or send a slide to pathology we are secretly hoping and praying that we are in the 95% confidence interval. We use p-values and percentages to reassure ourselves that we know what we’re doing despite the inherent uncertainty of the scientific method. And if all else fails we can always seek comfort in describing a presentation as atypical.

But our patients often expect us to have the answers. We live in a world that highly values the tenets of science and technology; we live in a world that places empiric data and experimental reproducibility on a pedestal. Patients want the definitive diagnosis. We search for the pathognomonic feature believing that if we find it, we cannot be wrong. It didn’t surprise me to find a mother throwing stimulant drugs at her 4-year-old misbehaving son for a criteria-based diagnosis of ADHD, but it was quite a shock to find a patient who accepted the response, “We just don’t know.” But we practice medicine with the faith that we are doing our best, and there are times when our beliefs butts heads with other religions.

I come from a Christian household and a Chinese heritage. I think it is Asian culture that has convinced my mom that herbs are good and synthetic medications are bad. She views the body as a tumultuous entity constantly fighting to balance positive and negative chi. Disease occurs when one side wins out. She believes that, instead of restoring that balance, most drugs disrupt it further and cause side effects. But I think it is religion that has convinced her that, if she were diagnosed with a terminal disease, she would refuse life-prolonging non-curative therapy. She feels she has led a full and complete life, and she will be ready to die if and when God makes it clear that it is her time to go. Unfortunately, hypothetical situations can only reveal how we think, not how we act. I tried to take it out of the theoretical realm to find out what she would really do. Would she really refuse chemotherapy to prolong a prognosis from 1 year to 10 years so that she could see her son graduate medical school, get married, and have children? She didn’t answer, but her silence was a far more illuminating response. She didn’t know.

As far as religion goes, I have yet to encounter one of the “classic” confrontations between religion and medicine on my rotations. I haven’t seen any Jehovah’s Witnesses hemorrhage out and refuse blood. I haven’t seen any devout Christian family refuse to take a permanently unconscious family member off life support. What I have seen is a great many people confused about the role of medicine, searching for its place in their lives. I am always humbled when our patients realize that medicine is as much a faith as their religion is, but even more so when they believe in its power to help as strongly as I do.

My Hippocratic Oath

On admission as a member of the medical profession, I solemnly pledge:

• To keep the health of my patient as my first priority, understanding that treating the disease is not the same as healing the patient;
• To treat patients with dignity and respect, regardless of their social group or status, and keep in confidence their private histories;
• To work collaboratively with other medical professionals, community and religious leaders, and family members and friends;
• To commit myself to lifelong learning and recognize when I become unable to care for patients due to personal handicap;
• To encourage healthy behavior within communities, remembering that preventing disease is preferable to curing it;
• To maintain my own physical, emotional, and spiritual health so that I am able to effectively serve my patients.

 

JUSTIFICATION:

My intent with this pledge is to address the patient first. The biopsychosocial model of health teaches us that patients are more than pathologic processes. I address this fact in the first line and again in the third line, as it pertains to collaboration with other important people in the patients’ lives. The second line addresses the importance of the patient’s trust in the doctor. They must feel accepted regardless of age, sex, race, or religion and must feel comfortable revealing private facts that are necessary for us to diagnose and treat the disease. In the fourth line I discuss the fact that medical knowledge is not static, but constantly growing and changing. In order to be effective physicians, we need to keep up with this expansion. We also must be aware of our physical, emotional, and intellectual limits so we do not hurt our patients. In the fifth and sixth lines, I wanted to step back and remind everyone of a duty to our community health and a duty to our own health, which seems neglected in many similar oaths.

I removed some of the lines in the Declaration of Geneva because they seemed self-evident or common to all professions (e.g., treat colleagues as siblings, respect teachers, practice with conscience) and not unique to the medical profession.

Stress

I started third year on triple block. On psych consult I worked 8am-6pm and on inpatient psych I worked 8:30am-3pm. On primary care I worked 10am-4pm three days per week, I went to lecture once a week with similar hours, and had three-day weekends. Neurology was the most time-consuming of the three, starting at 7:30am and ending around 4pm. I had plenty of time after I got home to study, hang out, and watch movies. Third year seemed manageable. But after triple block I started ob/gyn.

Most days this past month I have woken up at 5am and have gotten home around 7pm. Occasionally I would leave before 6pm and consider it a good day. On one lucky day I got to leave at 5pm. I relished the days we had 8 hours of straight lecture (including a lunch lecture) because it meant that I could go home at 5pm and study. Unfortunately, the lecture days weren’t quite the godsend I’ve made them out to be: even though the lectures started at 9am, I had to round on my post-op patients at 5:30am, write notes on them by 6:15am, and attend M&M conference at 7am followed by grand rounds at 8am. I also had to work a Sunday shift, meaning I only had Saturday to relax and recharge (i.e., study) followed by six more grueling days of work.

When I got home at 7pm, I would eat dinner and read up on the next day’s cases (the patient’s history, the disease process, the surgical procedure, and the relevant anatomy). I tried to get 6 hours of sleep each night, but it was never enough. As the clerkship went on, I found myself too tired to keep up with my studying. I would literally fall asleep at my desk with my head bent over my book. Before ob/gyn I thought people were just exaggerating when they said stuff like that.

For me, the most stressful part of medical school is how constant and unrelenting the workload is. I no longer have time to be the good boyfriend, the good listener, or the good son. I no longer have time to make my own breakfast or lunch. I no longer have time to exercise (no, speed-walking and retracting don’t count). I no longer have the time to enjoy my life in the carefree manner I used to. Every decision I make to take a break by watching TV or meeting up for dinner directly impacts the time I have to study and how well I do in the rotation. But that is precisely what I need to do to ensure my mental and spiritual wellbeing. I simply have to accept the fact that I cannot be the best medical student I can be while simultaneously being the best person I can be.

It’s not the amount of information we need to learn that is so overwhelming, although that certainly contributes. It’s not the fact that we’re being thrown from team to team every 2 weeks as soon as we start to feel comfortable with and confident in our fund of knowledge, interviewing efficiency, and clinical reasoning. It’s not the uncertainty we feel from learning every new attending’s special way of doing things. It’s not the isolation we experience from never seeing our friends unless they’re on the same rotation. It’s the fact that we have to do all of this while working 60+ hours each week, with fewer and fewer days to catch our breath and re-evaluate and reassess our situation. It’s the fact that we’re on an unyielding, terrifyingly fast treadmill without the safety cord to stop it if we falter or fall off. At some point, we all need to take our feet off the machine and rest for a little while. And we need to take control of the treadmill instead of letting it control us.

Dying

During my psychiatry rotation, I was consulted to see a woman for depression. Four months prior to admission she received a liver transplant for accidental acetaminophen overdose. She began feeling depressed after the surgery because of poor body image related to the surgical scar. She believed she had gotten to the point where she needed to be taken to an inpatient psychiatry ward to take a break from her life and reorient herself to her situation. One week prior to admission, she came into the ED complaining of depression, requesting to be admitted. The attending informed her that the inpatient ward was for very sick people and it did not seem appropriate based on the information she was telling us. The attending further informed her that there was insufficient reason to commit her because she did not pose a risk of harm to herself or others. She left with the impression that she needed to be actively suicidal to be admitted. One day prior to admission, she ingested a bottle of acetaminophen while sitting in her car in a garage, with her husband and two kids in the house. The husband saw her and asked if she wanted to be taken to the hospital, but she said no. The next morning her father came and took her to the hospital.

In the hospital she denied suicidal ideation, saying that she never wanted to hurt herself and currently doesn’t want to either, but felt that she needed to get admitted to psychiatry at any cost. Because of her actions and despite her denial of suicidal ideation, she was admitted. She clearly had a number of psychiatric problems, including a personality disorder that impaired her insight and judgment. I thought that she would realize that inpatient psych wasn’t really the place for the therapy she needed and that she would eventually find appropriate help. I was wrong.

Two months later I overheard her being discussed during my neurology rotation. She was in the hospital for altered mental status. Imaging of her brain showed diffuse cortical changes consistent with carbon monoxide poisoning. My initial reaction was that she attempted to kill herself again, but she was found at a residence without a garage. The story of what exactly happened has not been fully explained, but it is not hard to imagine what will happen next. We have heard of three potential suicide attempts (two acetaminophen overdoses and one carbon monoxide overdose). One of these days she will succeed.

I’m writing about depression because most of us do not consider it a terminal illness, although 35,000 Americans die from it yearly. Eleven times that amount attempt suicide. Because of risk assessment, looking at various demographic data and emotional/support factors, we can convince ourselves that we are doing our best to prevent their deaths. But suicide is wholly unpredictable. Imagine a cancer that vacillates between indolent growth and aggressive symptomatic expansion. How will you ever know if you’ve treated it? I believe this woman will likely kill herself. She is on the verge of doing it already and has exhibited repeated worrisome behaviors. She is dying from her disease and traditional therapies have not been successful. She is a dying patient and there is nothing medicine can do. She is my dying patient and there is nothing I can do.

Medical Hierarchy

As everyone knows, medicine is hierarchical. On the bottom is the third year medical student who sees the patient first (and sees the glare in the eyes of the grumpy entitled ones who don’t want anything to do with anybody but the attending) and makes all the mistakes of forgetting to ask about pertinent re­view of systems or failing to perform all the relevant special exam skills. Next up is the intern or PGY-2 resident, who guides the student along and gives them advice. They ask you the questions you forgot to ask the patient, and only after your one hundredth time responding with, “I don’t know,” do you finally remember to ask the one hundred and first patient that question. But the residents are often strung out from overnight call or getting dumped five new patients in an hour and don’t always have the time to teach you in a forgiving manner. They can be blunt. They can ignore you. Both suck. Above them are the senior residents, above them are the fellows, and above them are the attendings. They have even less time for you.

That’s how it works for the hospital anyway. In the outpatient setting, it’s completely different. It’s just you and the physician and he has himself overbooked in order to see 20 patients per day. You go in, do a focused exam, report your findings, explain what you think it is, and define a treatment plan. All in 10 minutes; after that, the physician makes sure everything you said is correct, writes the prescriptions, and sends them off on their merry way just in time for you to see the next patient. If they’re running late, you end up shadowing the physician until he catches up, which may take the rest of the day. Then he has to write his notes for the day, but he doesn’t want to keep you around doing nothing, so he kicks you out quickly. It’s almost impossible to find the time to get constructive criticism and feedback.

From the patient’s point of view, I’m sure it can be exasperating. They wait in the room for fifteen mi­nutes (outpatient) or half a day (inpatient), and the person they see peek their head behind that door is very different from the person they expected to see—and usually much younger. The medical student isn’t as skilled at determining what parts of the history and physical are important. They ask questions out of order, they fumble with how to frame the question correctly, and they make the patient stand up and sit down and stand up again because they haven’t yet gotten fluid with the exam. Then the student leaves, the patient doesn’t know what the diagnosis or management plans are, and is left waiting another ten minutes (outpatient) or three hours (inpatient). The attending finally comes in, the patient corrects any mistakes in their story (embarrassing the poor med student in the meantime), and wonders why the physician is doing all these weird things to his body that the student never did. That’s how it goes for a mediocre student (I would know). For an excellent student, the patient may just experience déjà vu: the physician asks the same exact questions the student did and performs the same exact exam maneuvers.

But I wouldn’t have it any other way. Going in there and making mistakes is the best way to learn. It’s in correcting your mistakes that you learn best, and it gives you that innate, unshakeable knowledge of disease, of diagnosis, and of patient care. That’s what you need to be a doctor.

New blog attempt.

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The Noble Profession

In general, I find primary care to be a rather noble specialty to go into. While the hours are fairly lax, the pay isn’t particularly good and the procedures aren’t particularly sexy (probably because they consist of the physical exam and blood draws). The physicians who enter primary care aren’t always the noblest of people either: some people are forced into it because of less competitive scores or because of financial incentives (debt forgiveness for setting up practice in a rural area). But my heart is warmed whenever I see a physician practicing primary care because he believes in long-lasting relationships with patients, preventive medicine, and public health measures. Sometimes it is their faith and dedication to what they believe is the heart of medicine that makes their behavior so inspiring.

Dr. Vaccaro and I recently saw a patient named Jessica Rose. She was a young woman who presented with paresthesias along her hands and feet. She had been worked up by her prior primary care doctor and had been brushed off as crazy, meaning there was no physiologic reason he could find to explain her symptoms. She decided to find a new primary care doctor; she searched on Yelp and found Dr. Vaccaro. Before her appointment, she went to see a neurologist at Northwestern and had a few more blood tests that showed low vitamin B12. While B12 deficiency can cause a neuropathy, the neurologist wasn’t sure that it explained her symptoms. Regardless, he started her on B12 supplementation.

When Dr. Vaccaro and I saw her, she came off as genuinely concerned with her symptoms. But at the same time she did seem to exhibit some hypochondriasis (she was extremely precise in describing what was going on and had searched on WebMD for possible diagnoses). It was unclear how to interpret the patient’s actions and behavior. After performing some physical exam techniques, Dr. Vaccaro was also not convinced that the low B12 was causing her symptoms. He ran some blood to check on her B12 and her copper and iron as well. Since it would take a day or two to get the results back, he had to go back in and talk to Jessica about what he thought she should do in the meantime.

He decided to tell her that there was a high probability that the symptoms she was experiencing were not physiological. He believed there was a 50% chance she would blow up and scream about not being taken seriously, threaten to find another doctor, and storm off to write a negative review on Yelp. He was willing to take that chance because he believed she really needed to know what his medical opinion was on the situation. So he went in and said exactly that. Jessica was actually relieved. She told us that she just wanted to make sure there was nothing that could hurt or kill her that she was missing. She said she was okay with her symptoms being a result of anxiety, because that would be easier to manage than some unknown and undiagnosed disease. (As it turns out, her blood work came back with some concerning copper and iron levels, but that’s a story for another time.)

While it turned out to be a (relatively) happy ending, Dr. Vaccaro took a risk that could have damaged his reputation and relationship with patients. He did it for the same noble reason he entered primary care: he believed it was the right thing to do for the patient.