Life Between The Earpieces
Copyright 2001 by Author
Published by Sirius Publications
Copyright 2001 by Author. All rights reserved.
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This is a non-fiction work. Situations and names have been changed to protect confidentiality.
Printed in the United States of America
Table of Contents
"PHYSICIAN, n. One upon whom we set our hopes when ill and our dogs when well."
---The Devilís Dictionary, Ambrose Bierce
It was to have been a tranquil weekend, a retreat in the mountains of Western Massachusetts to meet new people and to explore new ideas. The setting was an idyllic forested haven in the Berkshires, and the tone of the gathering was one of brotherhood.
Ours was an eclectic group that featured both New Age devotees and champions of the scientific paradigm, yet we managed to find common ground. Initial meetings often began with answering the usual "what do you do?" sort of questions, and in this manner, the group discovered fairly quickly that I was a physician.
It took only until the second day for it to happen.
I was helping to clear the table and clean the dishes from our breakfast with one of our group, a gentleman I guessed to be in his sixties. He began lamenting the dismal state of health care in this country, and his certain belief that the root of all its troubles was the overwhelming greed of its physicians.
He made his case with misjudgments and factual errors. For a time, I attempted to educate him by providing an insiderís view of the situation. He remained steadfast in his position. Unable to rebut my arguments, he simply dismissed them. I attempted to diplomatically extricate myself from the debate, suggesting that we simply agree to disagree, but he would have none of it. He had one of his villains by the throat, and he wasnít about to let go. Finally, exasperated, I posed to him this question: How would you feel if, repeatedly, people who knew nothing about you save your profession accused you of being an avaricious swindler?
He was stunned, and, to his credit, instantly apologetic, insisting that his comments had not intended to offend, that I clearly was an exception to the rule. I did not want to accept his apology, for I had been truly hurt and angered by his comments. I tried to avoid him, but this proved difficult given the situation. At every opportunity, he expressed his regret for his words, until I finally yielded and grudgingly acknowledged his apology. But I did not forgive him, and we had no further association during the retreat.
Our encounter embodied the wounded relationship between Americans and their physicians, and it is exacting a heavy toll on both parties. Misunderstanding, our patients no longer trust us, and that trust is crucial to their healing. Misunderstood, our honest attempts to heal body and spirit met with suspicion, we are demoralized, many of us driven to consider other professions. There is a widening gap between ourselves and the very people we have taken an oath to help.
I now also regret my behavior that weekend. This gentlemanís words were born not out of malice, but of misconception. I wonder if the moment I accepted his apology, I had been transformed from that greedy uncaring doctor of his imagination into someone who could feel the pain of rejection, a human being just like him. He might then have been willing to cast aside his preconceptions and prejudices and hear my story. But I had been unwilling to forget that he had accused me of crimes of which I was innocent. I had been given the chance to be understood, but instead turned away. I am told that the word "doctor" issues from a Greek root that means Ďto teachí. I had missed out on an opportunity to educate, to explain in detail the life of a physician and to hopefully shed light on why things are as they are, and are not as they seem to be. He had proven to be a difficult pupil, but perhaps I should have persevered.
I will try to be more persistent with you.
On the following pages, you will find true accounts of real encounters with real patients. These are not unusual examples, but very typical "bread and butter" cases of the sort that daily populate physiciansí lives. Any distinguishing characteristics have been changed to protect the identities of those involved.
An old medical dictum states that the most important section of a stethoscope is the part between the earpieces, for there is objective data interpreted with human intuition to yield a diagnosis. It is also the residence of the hopes, frustrations, joys, disappointments, and passions of the person trying to heal. It is my hope that the following pages will allow you to understand a little of what it is like to live there.
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The mother had brought her seven-month old son to our clinic that evening because he had developed a fever that afternoon and she was concerned that he might have another ear infection. He had had several previously, and if this was another, she wanted him begun on antibiotics as quickly as possible.
He sat in his motherís lap, eyeing me warily, and, like most children his age, retreated deeply into his motherís arms when I approached to examine him, his cries an alarum. However, by moving slowly, and speaking gently and reassuringly to him, I was able to earn a sufficient portion of his trust to permit an examination without unduly agitating him.
The examination, save for his fever, was normal. The fragments of breath sounds heard between his sobs did not reveal a pneumonia, nor did the brief glimpses I was permitted of his throat suggest a tonsillitis. His abdomen, while tensed from his crying, did not seem tender. And his ears did not seem to be infected.
The mother was reassured. I was not.
American parents have an odd and at times unreasoning fear of ear infections. Much of this is understandable. Ear infections hurt. In my adult life, I have been granted the opportunity to compare the discomfort of an ear infection with that of a kidney stone, and Iíll take the kidney stone any day of the week.
But in the final analysis, ear infections, while painful, are not dangerous. Although it is certainly true that repeated and frequent infections can cause hearing difficulties, and rarely, if left untreated, can progress to involve the mastoid bone behind the ear or other structures, ear infections are for the most part a benign process. Indeed, European physicians do not invariably treat ear infections with antibiotics, since many are caused by viruses and resolve on their own. A Dutch or German child with an acute ear infection is often given only acetaminophen and a recheck appointment. By contrast, the average American mother or father of a child with an ear infection denied antibiotics becomes quite angry. Thus, American children routinely receive antibiotics for their infected ears, and American physicians often convince themselves that "his eardrum looks a little red" to justify prescribing antibiotics to a child with a viral illness rather than withholding them and enraging the parent.
I would have been delighted to have to have found this little tyke to have an ear infection. Without any abnormalities in his examination, he had a fever without apparent source. I was forced to consider the possibility that he had one of the sinister and potentially lethal illnesses that lurk out there amongst the myriad snots and sniffles that afflict little children.
Statistically, I knew that this young fellow most likely to have a self-limited viral illness. But it is exactly the relative rarity of the more serious illnesses that lulls the physician into relaxing his or her vigilance. Perhaps it is the dozen years I spent as an emergency department doctor that fuels my paranoia. Denied the familiarity with their patients and the opportunity for follow-up upon which family doctors and pediatricians depend, ED docs get only one chance to correctly diagnose their patients. But I suspect that this feeling is universal among physicians.
As doctors gain experience, they hear more and more tales of diseases that did not announce themselves in the standard fashion, causing their diagnosis to be delayed or missed entirely. Over lunch, we hear from one colleague of the heart attack that sounded like heartburn. In the elevator, another tells of the intracranial hemorrhage that seemed to be a migraine. And at a conference, the appendicitis that appeared for all the world to be an intestinal virus.
And we hear of the suffering, or worse, the demise, of these patients that perhaps could have been avoided.
The tales of others "getting burned" teaches us caution, lest we become ourselves another doctorís object lesson. As these anecdotes accumulate in our memory, our wariness grows. We look at each symptom, however benign appearing, as a potential harbinger of catastrophe. We look for the sinister in each complaint. We strive to see the phlebitis disguised as a pulled muscle, the ruptured abdominal aneurysm masquerading as a strained back, the congestive heart failure camouflaged as a bronchitis.
Or the child with meningitis with just a fever.
Meningitis is an infection of the lining of the brain and spinal cord. Potentially deadly if untreated, an early diagnosis offers the best chance of recovery. But the tools available to a physician often cannot readily distinguish children with benign illnesses from the one with meningitis.
The height of the fever is no help. Certainly, a fever of 106o hoists red flags in the mind of an examining doctor, but meningitis may not announce its presence with a high fever, or indeed, particularly in newborns and infants, with a fever at all.
A stiff neck, a sign of inflammation of the spinal cord characteristically found in victims of meningitis, may well be absent in young children, or appear too late in the course of the illness to be useful in diagnosing the condition at a treatable stage.
Laboratory tests likewise are not very helpful. An elevation of the white blood cell count may be found in many infections. Even if present, it may not be due to meningitis, and may be normal even in the presence of meningitis.
The diagnosis can be made with certainty only by examining spinal fluid obtained via a lumbar puncture, or Ďspinal tapí, the mere mention of which is usually sufficient to strike terror in the hearts of parents. While it is actually a very safe and easily performed procedure whose evil reputation is not justified, nonetheless, no physician wants to subject a child to a lumbar puncture unnecessarily.
So when do you do a spinal tap? Every medical student is taught to "do one whenever you think of one", the implication being that whenever a child is ill enough to make you entertain the diagnosis of this serious illness, you have prove to yourself that it isnít present.
This caveat worked for me a while, until I was present when the illness claimed a child.
When I was a resident, a child arrived in our Emergency Department one evening in full cardiac arrest, soon to die of meningitis. He had been seen that morning by a family physician that I knew to be competent, caring, and careful. "He looked fine," the distraught doctor explained to me in disbelief, punishing himself more than any malpractice jury ever could.
The lesson learned that night burned itself indelibly on my brain in a way that reading textbooks or journal articles could not. Sometimes, many times, you just donít know.
When that happened, the medical school admonition to "do one when you think of one" became useless, because I "think of one" in every child I see.
So how was I to decide if I should be worried enough about this child to subject him to a spinal tap?
Incredibly, in this technological age, the decision turns on the most subjective of data: how the child looks. More helpful than the physical examination, more helpful than laboratory tests is the opinion of one human, hoping to heal, judging the appearance of another hoping to be healed. All other things equal, the child who, in the eyes of an experienced observer, appears ill, is much more likely to harbor a significant illness than one who doesnít.
Thus, as I talked to the mother, I observed the child.
Children his age obviously cannot communicate verbally. They cannot tell us if they have a severe headache, or are nauseated, or simply feel terrible. They speak to us with the language of their behavior. We are taught to look for irritability, crankiness, and lethargy as indicators of serious illness. But these adjectives apply to a wide spectrum of emotions. Any cause of fever can cause a child to feel more lethargic and irritable than usual. Consider that the flu often makes people so tired that getting off the couch seems to require Herculean effort, and shortens the fuses on tempers.
How much irritability is too much? How much does a child have to nap before we label him excessively lethargic?
This young man cried when he was placed upon the examination table, but it was a lusty, full-bodied cry, and he calmed fairly quickly when held and consoled by the mother. Through teary eyes, he still took from me a tongue depressor with a smiley face drawn upon it and played with it.
I was reassured, at least to some degree. Whatever the cause of his fever, it seemed unlikely that he could be acting this way and still harbor a meningitis.
At least, not yet.
One of the most important observations that can be made is the change over time. A child who worsens over a day makes one worry more than a child who seems stable. This well-intentioned mother, by bringing her child in at the first sign of fever, had inadvertently made his diagnosis more difficult. Now, he would have to be observed closely over the next twenty-four hours, and the task of observing him fell to her.
I gave her instructions on what to look for, compressing paragraphs from pediatric texts into a few sentences. As is required in this litigious age, I had her sign written instructions indicating that she understood what to do and that she was return the child to medical care if he worsened overnight, and exacted from her a promise to bring him back the next day for a recheck.
She had come seeking reassurance, but left more anxious.
I felt somewhat guilty, but knew that I had done what was necessary and correct. This is the reality of medical care. Despite the publicís belief, physicians are not omniscient. We are not Marcus Welby, or his latter-day incarnations, the doctors of E.R., who can diagnose any malady, if not instantly, then at least by the next commercial break.
One learns to deal with the uncertainty that is part and parcel of a physicianís professional life, but the guilt remains.
Guilt that lurks behind the nagging thought that the uncertainty might be due to oneís incompetence; that if one were better read, or more experienced, or just plain smarter, things would seem less uncertain.
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Doctors make rotten bureaucrats. Most of us readily and proudly admit this deficiency, considering it evidence of character. Nonetheless, we find ourselves pressed into administrative service as members of hospital committees.
On this particular day, I was pinch-hitting for an absent colleague at such a meeting. Iím sure there existed somewhere in the by-laws an official description of our duties, although I couldnít quote it. It seemed little different than most other official get-togethers, the participants mired interminably in tedious affairs that seemed to have little or no consequence in the real world. Despite the hospitalís provision of strong coffee at this early morning meeting, many heads nodded and bobbed.
"Any new business?" the chair asked hopefully.
"Yes. I have a case to present," said the director of the Emergency Department.
He proceeded to relate that an eighty-six year old patient had been brought to our ED over the recent Thanksgiving holiday complaining of nausea, vomiting and just not feeling well. The ED physician on duty took a careful history, noting the absence of chest pain or other symptoms that would raise concern about a cardiac problem. Additionally, she recorded that the patient had three times in the past several months been hospitalized with similar symptoms, and that tests had failed to demonstrate any heart disease. Despite this history that strongly suggested a non-cardiac source for the patientís symptoms, the doctor ordered tests to again exclude that possibility. This was as it should be; heart disease in elderly patients often does not announce itself with the classic manifestations one expects in younger people. The physician was acting on a high index of suspicion in exemplary fashion.
The work-up was negative. Still, knowing that laboratory evidence of a heart attack may not appear for several hours after the onset of symptoms, the physician made arrangements for the patient to be admitted for observation. In the interim, she had prescribed the patient medication to allay his nausea.
The medication had worked well, and she was soon summoned to the bedside of the patient, who requested to be discharged. The family who accompanied him supported his request. He was, after all, eighty-six years old. It was distinctly possible that this was to be his last Thanksgiving, and he wished to spend it at home. After careful consideration and an explanation of the risks, the physician consented.
The patient was brought back by ambulance to the Emergency Department six hours later in cardiac arrest. Resuscitation was unsuccessful.
The heads that had previously nodded in near-slumber now shook in disbelief. Each knew they might very well have made an identical choice, had he or she been the treating physician.
"Iíve discussed the case with the doctor," the ED director said. "Sheís really upset. Sheís beating herself up about it." He read a note she had written to the committee about the case. I could hear the anguish and self-doubt in her words.
I knew her well. She was one of the finest emergency department physicians I have had the pleasure to work with, a woman I would literally entrust with my life. It disturbed me profoundly to hear her pillory herself.
It was a decision like many in medicine, made in real time on the fly by a single human being. There is no opportunity for lengthy consideration, or referral to committee for discussion. Objective evidence weighs heavily in the process, but the human body is so complex and variable, and our means of probing it so imperfect, that conclusions based solely upon such evidence are notoriously inaccurate. The doctor must also factor in intangibles such as the patientís wishes and understanding of their predicament.
The manner in which a physician makes decisions defies simple description. It cannot be catalogued, classified or indexed. Attempts to reduce it to an algorithmic method that spits out cook-book-like guidelines invariably fail. The current trend in medicine that favors the proliferation of such guidelines demeans both physicians and patients. Bureaucrats, lawyers, politicians and insurance adjusters, lacking any concept of the art of medicine, imagine that there exists a "standard of care", a template against which they might measure any case to determine the quality of the care provided.
There exists, however, no such standard of care, at least not in the form they conceive of it. There is no massive volume of reference that delineates what is appropriate medical care in all situations. The rules of the road for drivers provide an analogy. It is a regulation that at a red light, the driver must stop until the light turns green before proceeding. It is also a regulation that at a stop sign, the driver must halt until, in his judgment, it is safe to proceed.
The medical "standard of care" is far more often a rule of the latter type. Despite the marvelous advances in medical technology, the practice of medicine at the bedside remains a human art. It requires human perception, human intuition and human insight to treat human beings, and, more often than not, turns on a gut feeling. It is astonishing how often that feeling is correct.
"Iíve reviewed the case, and I feel the care was appropriate," continued the ED director, "but given the outcome, I thought I should present it here,"
"I believe this should be reported," a woman said. She was the head of Quality Assurance. She explained that the State required self-reporting of any serious complications occurring shortly after a patientís discharge from the hospital. "They require as well a Plan of Correction," she added.
I struggled to maintain my composure, and for a few minutes, I was able to remain silent. Finally, I felt compelled to speak.
"There does not need to be a plan of correction. That implies that something was done wrong, and that isnít the case."
"State regulations require it," she shrugged. "Weíll have to comply." She spoke cautiously, aware she was being placed in the unenviable position of speaking on behalf of a government bureaucracy most physicians view with a justified suspicion.
"He probably would have died anyway," a family physician said. "Even if he had been admitted, thereís a real good chance that the same thing would have happened." There were mumbles of agreement.
"Why do we have to report it at all?" another asked. "The care given was appropriate. Why call attention to ourselves by reporting it?"
All eyes turned to the QA director. "If we donít report it and the family complains to the State, it would trigger an inspection."
"Howís the family taking this?" the chair asked.
"I spoke to them afterwards," said a family physician, who doubled as the county coroner. "They seemed to have accepted it."
"For now," another reflected. "Time may change their minds."
"Itís too big a risk. If it surfaces later and we havenít reported it, the Department of Health would be on us like a pack of dogs," an internist said. "Theyíd go through us with a fine tooth comb, and you know theyíd find something.
The big problem with bureaucracies is their need to justify their existence. The Department of Health has been assigned the responsibility of ferreting out medical incompetence. They have to be able to put a few heads on spikes each year to display at budget allocation time, even if those heads belong to great doctors. The internist was right: it wasnít in our best interest to give the DOH an excuse to inspect us.
So it was agreed that the case would be reported. Though the physician in question had provided excellent medical care, and, lacking clairvoyance, could not have prevented the outcome, we would notify the State that the care provided by one of our finest colleagues left room for improvement. Though we deemed nothing in need of correction, we would manufacture a plan for correcting it. A new guideline, policy or protocol would be written and filed in a policy book already bigger than a Manhattan phone book. It would lie there, useless and unread.
And we would thump our chests, chant mea culpa, and hope that Big Brother would prey on another institution.
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