In the last two episodes of Butterfly Arose we looked at our medical system's gifts and challenges from the patient point of view. But this system is, indeed, complex. To gain a better understanding of it, we need to get a sense of what it looks like from the point of view of nurses, doctors and other practitioners.
For this episode I draw from five books written by four people. They are:
Finding Joy in Medicine by Reza Manesh, MD, in which he relates both the story of how he became a doctor and teacher of other doctors, as well as the ways in which the experience of becoming a doctor helped both his medical skills and sense of humility to blossom. Doctor Manesh's parents immigrated from Iran when he was two years old. After starting school to study neuroscience, he changed to getting a degree in medicine and becoming a doctor in internal medicine.
What Patients Say, What Doctors Hear, and When We Do Harm, by Danielle Ofri, MD, who takes us through the challenges of responding to the different way her patients have communicated their needs and the complex levels at which mistakes can happen in medicine. Doctor Ofri is an attending physician who works in primary care and also teaches other doctors. In addition to writing books and articles and doing TED talks, she "is a founder and Editor-in-Chief of Bellevue Literary Review, the first literary journal to arise from a medical setting, now an award-winning, independent nonprofit literary arts organization." as her website says.
The Shift by Theresa Brown, RN, where she tells a story, as the subtitle says, of One Nurse, Twelve Hours, Four Patient's Lives, and through this gives us a gut level sense of what it is like to walk in her shoes. Theresa grew up in Springfield, Missouri and originally earned a bachelor’s and then doctorate in English, which she taught in college for several years. She then went through an accelerated course in nursing and became a registered nurse and works on a cancer ward of a major hospital.
And Complications, A Surgeon's Notes on an Imperfect Science, by Atul Gawande MD who also has a master’s degree in public health. This book, through telling stories of challenges he has faced, leads to philosophical questions that underlie the practice of medicine. Doctor Gawande was born in Brooklyn to parents who immigrated from India. According to an article on Wikipedia, his education and degrees took him from a BA in biology and political science, to a masters in philosophy, politics and economics, to a doctor of medicine and finally completing a residency as a surgeon.
I chose these four because they represent medical professionals who come from a variety of backgrounds and who do different types of work in medicine. They do not, of course, represent all medical professionals, but I found their books helpful in beginning to see medical system complexity through their eyes.
One theme I found is the contrasting roles of book learning and practical experience.
Doctor Manesh, for example, in relating his experiences in medical school talks about how the emphasis was more on memorizing large amounts of data quickly rather than the “problem-solving and critical thinking" he had experienced in a class on neuroscience before entering medical school.
Like many other medical students, he says, he struggled with depression and even, in his case, thoughts of suicide. The cause was the long hours of memorization and frequent tests of their memories, with little time to sleep. It was in his third year of medical school when he was finally able to interact with patients again, that he gained practical skills and learned about the importance of human connection from their actual disease experiences. Knowing the facts of what science knows about our human bodies is vital for doctors and nurses to give us excellent care. But so are things like empathy and building trust with a patient.
Or take another example, which I spoke about in episode 12 of Butterfly Arose. I recounted how Doctor Ofri, in her book When We Do Harm, goes into detail about the challenge of figuring out what is causing a patient's problems when their symptoms might be caused by a variety of problems. In that case, it turned out that the patient had an incurable form of multiple myeloma. Doctor Ofri had missed the diagnosis in part because of the fuzzy way in which the patient presented her medical problems, and in part because Doctor Ofri missed seeing two blood test results that might have clued her in to the problem. The tests had been done in other departments or hospitals or far enough in the past and were thus not easily viewable to her. She could not come up with the right diagnosis without having the full information about the patient's history.
But even a simple seeming medical problem can hide complications. What if a patient comes into the emergency room with a bone in their leg sticking through the skin? On the surface it seems simple to know what the problem is, and if the patient was hit by a car of fell off a ladder at 20 feet, it might be simple, indeed. But what if they stumbled down a few stairs? Many people could survive that without any broken bones. Was this a fluke? Or could it be caused by osteoporosis?
An article I found from the Mayo Clinic says osteoporosis can be caused by age, low levels of testosterone in men or estrogen in women, thyroid gland problems, low calcium intake, eating disorders, and excessive alcohol intake among other factors. In this case, after treating the break itself an emergency room doctor should at least refer the patient to a primary care clinic for follow up.
If the patient is elderly, it might seem easy to understand the cause of the broken bone. But what if they are in their 40's or 50's? When the primary care doctor learns about this incident, they will need to combine their book knowledge of the possible causes with what they know about the patients' history. What among eating disorders, alcohol use, hormone imbalance or the condition of the patient's thyroid apply to this patient? Does the patient even have a primary care physician with knowledge of their history, and to what extent does the patient trust the doctor? Trust, after all, can be important in whether a doctor knows if a patient is suffering from alcohol abuse to use just one example.
On pages 23-24 of his book, Doctor Manesh says something I found important in confronting this dilemma. It was something he read by renowned Canadian physician Dr. William Oster.
"To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all."
Doctors and nurses must navigate this intersection every day. And as doctor Gawande says, in his book Complications, on page 7, "We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line. There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. The gap between what we know and what we aim for persists. And this gap complicates everything we do."
Another theme I found in these books is the complications of busy workdays with many patients and little time allowed for each person.
In chapter 3 of The Shift, titled Hitting the Floor, nurse Theresa Brown gives an excellent example.
As nurse Brown starts her day she is asked by another nurse, Susie, to validate the numbers on a bag of platelets with the patient's identification information. This is to make sure the platelets are given to the right patient in the right amount.
The patient needs this bag of liquid because their chemotherapy treatment has reduced the level of platelets in their blood stream. They are scheduled for surgery, and without the surgeon inserting an intravenous line to get the platelets into their blood before surgery, they could bleed to death on the operating table.
There is a vital series of steps here. Record the number on the bag of platelet liquid in the computer and make sure they are going to the right patient.
Have a second nurse make sure you have entered the correct information.
Notify the surgeon so they can insert an intravenous line into the patient's body, so the platelets get in their blood with enough time to be successful before their scheduled surgery. And the doctor is waiting to hear from Susie so he can insert the intravenous line.
But as Susie and Theresa head toward the computer to enter and validate the numbers, Susie is asked by the wife of another patient to disconnect his intravenous lines so he can take a shower. Theresa offers to do that job so Susie can enter the number on the computer; getting the platelets to the right patient is more urgent than someone needing a shower but having to wait to get a shower can feel very inconvenient to the other patient and their wife. Theresa removes the line, for Susie’s patient, and later verifies that Susie entered the numbers accurately in the computer. All this before she gets a chance to work with her own patients.
This kind of interruption can and does can happen at any time in any day, especially in hospitals.
Another common theme in these books is the complications of understanding what your patient needs as you navigate communication challenges.
Doctor Ofri opens her book What Patients Say, What Doctors Hear by telling the story of a patient who annoyed her with his demands for care. At times he just shows up at her clinic, including when she is not there. He leaves because he only wants to see her, then annoys her by leaving repeated voice mail messages and by calling to get an immediate appointment. In that phone conversation, when he says why he wants to see her, it doesn't sound urgent to her. She offers him the choice of either to go to urgent care or make an appointment, but he asks again to see her immediately. Over a week, they exchange phone messages, with her repeating the scheduling choices and him just saying, "I need to see you," in different ways. He then shows up at the clinic without making an appointment, which annoys her, but she reluctantly agrees to see him. This in spite of having a full load of patients who do have appointments. She asks her assistant to take him to an exam room to check his vitals, and he collapses before he can take a step. He ends up in the emergency room.
In retrospect, Dr. Ofri describes her patient this way. "For all his annoying mannerisms and pushiness, Mr. Amadou was fundamentally trying to say, 'Help me.' Deep down, no doubt, he was terrified that his heart could give out at any moment. This fear informed all of his actions. Seen in this light, his relentlessness was understandable--his life hung in the balance--so he could never take no for an answer."
She'd reacted to his annoying demands for her time by drawing a boundary. There were alternative appointments he could make. In her self-defense in the face of the way he expressed his fear of heart failure, she didn't take a moment to really get the message underneath the surface presentation. His falling to the floor was, in her words, "that stomach churning moment" when it becomes clear that what seemed an ordinary problem was in reality an emergency.
As she writes about this incident, she uses it to highlight what she sees as a critical truth about medicine. As she says, on page 5, "For all the sophisticated diagnostic tools of modern medicine, the conversation between doctor and patient remains the primary diagnostic tool. Even in the fields that are visually based, such as dermatology, or procedurally based, such as surgery, the patient's verbal description of the problem and the doctor’s questions about it are crucial to an accurate diagnosis."
Like all primary care doctors, she has a packed schedule every day and only has so much time to see and talk with each patient. Someone who frequently insists on getting immediately scheduled for an appointment can make it harder to give a doctors' full attention to other patients.
Speaking of communications challenges, in Chapter 13 of his book Finding Joy in Medicine, Doctor Manesh recalls how he missed a diagnosis in his mother's case. She was complaining about her left eyebrow feeling numb and tingly when she is stressed. Because of the circumstances, and because she is his mother and he knows her that way, he tells her it is okay, and she should relax, maybe take up meditation. She sees other doctors who say the same thing, likely just going along with Doctor Manesh’s diagnosis when she tells them what he said. This doesn't seem urgent to any of them.
But five years later she meets a neurosurgeon at a dinner party. She tells him about the problem, and he does a quick diagnosis. As doctor Manesh says, on page 58, "He took his napkin, folded the edge and touched her eye. She didn't blink as she should have." He asks her to come into his office, does an MRI, and discovers a thankfully benign tumor. Removal of the tumor solves the problem.
It is a challenge to really understand your patients’ needs when you don't know them well but knowing them well can create a certain blindness of its own.
I was tempted to use another example from these books, but as I read over the three examples, I've already given I noticed something I think is important. As I read these books I tried to focus on one aspect of the life of a doctor or nurse in each story. But in each story they told, other factors played a role as well. One of those factors is the cultural ethos in which medicine exists.
I took this up in episode 12. Because of the success of checklists in preventing accidents in the airline industry, in 2001, one doctor developed a checklist to prevent infections caused by errors when a central line was inserted into a patient in the intensive care unit, or ICU.
His list of steps was exhaustive and resulted in such infections essentially dropping to zero in his hospital. "And," as Doctor Ofri says on page 10 of her book When We Do Harm, "when the checklist was tried with nearly one hundred ICUs in seventy different hospitals in Michigan, infection rates also plummeted to near zero within three months."
But when the authorities in Ontario, Canada told their hospitals to adopt checklists, there was no improvement in infection rates. This was because successfully implementing this protocol required a change in the hospital's culture. Doctors were not used to being corrected by nurses until there was a conversation about why everyone's eyes needed to be focused on making sure the checklist was followed accurately, including nurses. And that meant the hospital administration needed to react if a doctor got angry at a nurse for pointing out a missed step. Without those changes to the culture, the checklist was a failure.
We need to be able to trust our doctors and nurses, both for their medical knowledge and to trust that they will treat us in a way we feel respected as human beings. And each of these four professionals exhibited qualities in their books that I admire.
Like Doctor Manesh, in his 15th chapter, embracing the mantra "I don't know," which motivates him to often engage his whole team in making sure they are working with the right diagnosis for a specific patient.
Or Doctor Ofri who uses examples of her own mistakes to help us understand how she learns and the challenges of navigating medical complexity.
Or nurse Theresa Brown in the way she takes us through a 12-hour shift weaving in the times she is not sure of what to do in a specific circumstance, how she asks for help, and her commitment to helping other nurses and doctors even when her day is very busy.
Or Doctor Gawande who uses real world dilemmas to illustrate thorny philosophical issues. For example, every surgeon must go through a learning curve. It is not possible for a human being to learn a new skill without trial and error. Our own experience of making mistakes is what we learn from, and they are learning on human bodies that are not anything close to exact copies of each other.
Now, legally and morally every patient has the right to have a say in who does things to their body. But in the operating room, for complex procedures, there is always a team and that includes both experienced surgeons and those in training. As he says, on page 24,
"This is the uncomfortable truth about teaching. By traditional ethics and public insurance (not to mention court rulings), a patient's right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden, behind drapes and anesthesia and the elisions of language."
If an experienced doctor is being operated on, and needs a central line inserted, it won't be done by a first-time doctor in training because that type of patient and their family know about how this training happens. But Doctor Gawande goes on to say, "the ward services and clinics where the residents (meaning doctors still in the learning phase) have the most responsibility are populated by the poor, the uninsured, the drunk, and the demented." Doctor Gawande says that it is on these populations where residents often get to practice on their own, after the initial times when they are directly supervised by the attending, or experienced surgeons. To me this is an example of an intersection between the practical problem of training doctors and cultural questions where some people may be more likely to experience medical mistakes.
I will do an episode for my Sacred Gyre podcast on my own experiences in learning, using examples from both my youth and as an adult. This will be partly to illustrate an example from my own life, and partly to be honest about why I approach this topic the way I do.
For now, let me say that these four authors helped me deepen my appreciation for the complex world of medicine that we all traverse in one way or another in our lives. In the next episode of Butterfly Arose I will go into more detail about how patients, doctors and medical systems are attempting to improve the medical world they inhabit. In particular, I want to talk about what is this thing called Person and Family Centered Care that I introduced in episode 14?
Thank you for listening. Remember that you can find links to books and articles I reference by clicking on Bolded text in the written version of my podcast episodes. And please send me your thoughts on what you enjoy about my work, or ways I could make it more interesting or useful from your point of view.
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