Archive for January, 2009

Strength in Adversity

January 23, 2009

Once upon a time, I was a pre-med volunteer at the Harborview Medical Center Emergency Department (pink scrubs and everything; those of you who’ve been there know the pain of which I speak).  Sometime between collecting ED beds from around the hospital and re-stocking the soft restraints, I found myself listening to a conversation between one of the physicians and a patient who had amputated four fingers off his right hand in a skilsaw accident.  The doctor asked how he was doing and such, but what ultimately piqued my attention was when he asked which was his dominant hand.  “Right,” the patient said.  He continued lightly, “But I swear to God, after filling out all these damn forms you’ve set in front of me, I’ll be walking out of here a lefty.”  Perhaps my inadequate writing trivializes his words, but sitting there re-stocking some cabinet in the room, I was so struck by this individual’s courage in facing what was sure to be a difficult recovery.  This gentleman had woken up with ten fingers and the ability to button his shirts.  He’d be going to bed tonight with neither, and yet lying in his hospital bed he could summon the strength to crack a joke.  Melodramatic I know, but I don’t know if I’ll ever forget that.

I bring that up because lately our oncology and psychiatry courses have been inviting patients to speak to us medical students about their diseases.  They are all different, ranging from schizophrenia to alcoholism to prostate cancer, but to a person, they have all impressed me with their cool and collected attitudes towards their illnesses.  The most recent panel was a group of men living with prostate cancer, all of them I believe long past the stage where they can hope for a cure.  They spoke to us about their orchiectomies (castrations), how they went home and cried with their wives, and how they need to fight with their fatigue to get up and go about their lives.  I don’t know if I can imagine discussing something so personal with such humor and introspection.

I’ve seen this courage in other places too, in cancer patients with bilateral mastectomies learning of the return of their cancer and in heroin addicts relating their stories of addiction.  I was giving a Hepatitis vaccination to a patient at clinic (which serves mostly heroin users and sex workers) and going through the usual checklist I asked her do you have any allergies, any problems with shots in the past, etc etc.   Then I asked her, do you have any problems with needles, and she looks at me and she says “Honey, if I had a problem with needles, I wouldn’t be here right now.”  It never fails to amaze me, how these normal people who find that strength from somewhere to confront their illnesses.  These things that will kill, or seriously and irreparably debilitate them, they confront with a joke.

I can feel some of you shaking your heads and thinking perhaps that I’ve drank too much of the med-school kool aid.  That for every patient that makes it onto a panel or into my memories there are dozens who fight it badly, denying their illness and lashing out, unable to muster some personal grace.  Perhaps that is so; I am only a second year, and have yet to see that full measure of human adversity.  But I can only write about what I have seen, and I have seen some truly remarkable people who have shown me (corny as it sounds) just how strong people can be.

I think that patients spend a lot of time (whether worthy of it or not) respecting their doctors.  I am not sure how much time physicians spend respecting their patients.  So yeah, if only for a little bit here, I feel I can give some recognition to the strength of some of the people I’ve had the opportunity to meet in the last two years.

All For One, and One For All?

January 1, 2009

I was watching an episode in the first season of House the other day, where Dr. House’s patient is this Type-A personality executive, who ends up with heart failure secondary to her bulimia.  She needs a heart transplant, but House knows that because of her psychiatric history, she will likely be assigned a very low priority on the heart transplant list.  He lies to the transplant board reviewing her case, and she gets the transplant.  When he was asked why he lied, he states simply that she was his patient.

I found that to be an extremely compelling answer, and representative of a central tension (in my opinion) in medicine.  Ideally, doctors are charged with the welfare of their patients; getting the best for the individual that sits in front of them.  But in many cases, what is best for the individual is not what is best for the group.  Like Dr. House’s patient, she DID have a psychiatric problem, and she ruined her heart because of it.  There are many other patients out there with failing hearts and otherwise spotless medical records who would be much better candidates for a transplant.  With a limited supply of donor hearts, as a society you want to make sure that those that do get it have the least chance of squandering that resource.

And therein I feel lies something of a tension in medicine.  On one level there is the doctor who is compelled to do everything he or she can for their patient, and on the other, there are the policy makers who must make those hard utilitarian decisions that reduce the beneifit to some in order maximize the benefit to many.  What sane doctor wouldn’t want to lie, cheat and steal to get their patient a life saving treatment?  It isn’t their responsibility (not directly anyway) to care about another patient in a hospital down the street; their charge is the man or woman in the bed in front of them.

And so I wonder to myself, was Dr. House wrong to lie to get his patient a new heart?  I don’t know.  I was told once that if you wanted to save the world, you shouldn’t be a doctor.  And to a large extent, that is true.  There are over six billion people in the world, and over 300 million in the United States.  Physicians help individuals; it is the policy makers of the world that will save millions.  And yet, there is something important in doing what is best for the individual, even if it does inconvenience the masses.  The Americans With Disabilities Act and our nation’s staunch support of minority rights being just two of the many ways we all stick up for the individual even if it means less benefit for the many.  I grant you that spending money on a wheelchair ramp isn’t the same thing as ranking a heart transplant list, but surely they are related on some level.

Anyway.  This wasn’t meant to be a full-fledged entry, more just a chance to think about something that maybe hadn’t occurred to you before.  Best wishes for the coming year to all of you!