Thank you for the inquiries, the orders, and the pleading tones. I swear, I’m alive; medicine is still interesting and worth writing about; and although Scienceblogs.com may eventually lose patience with the intermittent nature of my writing, I haven’t yet lost interest in writing intermittently.

Soon, I’ll tell you about the things that have happened since November. (November! I’m going to blogger hell.) I’ll tell you about running codes by myself; about coming as close as I’ve ever come to saving someone’s life; about the thrill of contemplating a specialty. I might even publish a picture of something delicious.

It might be next week. It might be next year. Who can predict these sorts of things?

I hope you are all well and–in the northern hemisphere, anyway–enjoying the anticipation of spring. More as it comes.

As you might remember from my days as an intern, I used to love the ICU. That love is no longer: doing procedures to people whose fate is inevitable isn’t as much fun as it used to be, and I feel powerless in the face of a culture that doesn’t exactly embrace the avoidance of unnecessary intervention.

This most recent time in the ICU, I worked with an intern who seemed to me less eager than some to take on the burden of her responsibility. About three days into the rotation, she–let’s call her Dawanna–remarked to me with some irritation that “all I ever do is put in orders.”

“Yes,” I replied. “That’s kind of your job.”

Of course, that’s not her entire job–she is also meant to evaluate patients, make plans (or try to) for their care, and learn about their disease processes and our interventions. However, the intern is meant to be the first line for nursing concerns, and a large part of her job is therefore to write orders.

I was annoyed by her implication that this was a waste of her time, and that there was nothing to learn from this exercise. After all, I told her, when she is an upper level and her intern asks how to do things, how will she provide instruction if she hasn’t ever done those things, herself?

Only a year and a half ago, I was an intern. I remember feeling demoralized at the paperwork–especially that involved in discharging patients. But the lists of orders carried with them a certain amount of satisfaction in their doing. I felt like the engine that made the hospital run, writing hundreds of action verbs every day: admit, administer, place, remove, flush, drain, call. While others ruminated, I did.

I remember cursing at computers, printers, and occasionally, behind their backs, other people–but I never questioned whether the job was mine to do. I was astounded that Dawanna did.

One of the things Dawanna didn’t want to deal with was patient deaths. I know this because she remarked repeatedly that she hoped patients wouldn’t die while we were on call. In my irritation with her, I related this to her lack of enthusiasm: patient deaths require an exam for pronouncement of death and a small stack of paperwork, which can be time-consuming. Not wishing to hear more about her distaste for her job description, I did not inquire further.

Today, I woke up and started reading “Final Exam,” by Pauline Chen, a liver transplant surgeon. In it, Chen writes about the ways in which doctors are trained to deal with death, or not, and uses as illustration vivid tales from her own training. Early in the book, she captures quite beautifully what disturbs her most the first time she pronounces a patient dead:

I had insinuated my hand into that mysterious nexus of stars and fate and destiny, and I had reduced that great passing of life into an arbitrarily calculated moment in time.

Until I read this, it hadn’t occurred to me that in Dawanna’s anxiety over patient deaths was more than mere laziness–that there was fear of what it might mean and what it might feel like to be the pronouncer of a person’s passing.

Only a year and a half ago, I was an intern. I feared this, too.

In retrospect, I really should have asked what she dreaded about the pronouncement, and should’ve given her some space to talk about what it means when someone dies, or what it feels like to be present at a death. Even if it was just the paperwork she didn’t want to do, it would have been good for her to feel able to explore her feelings around other–especially senior–residents.

Who thought I’d ever feel guilty about not being touchy-feely enough?

Last year, I set what I thought was an ambitious fundraising goal for Signout’s readership, and you guys absolutely blew it out of the water. This year, there are more of you–and with you all being so fabulously wealthy (and devastatingly attractive), I figure we can aim even higher. Watch the graphic to your left to see how we’re doing.

If you click on that graphic (or here), you’ll get taken to a page that lists some projects I found especially worthy. You may note that some projects are depressingly basic–again, one asks for pencils and pens for students who can’t afford them. Others are less basic, but perhaps bring back memories of some of the things that sparked fires in your teensy brains back before they became so massively overloaded with YouTube clip addresses and the names of smelly Italian sheep’s milk cheeses.

Wouldn’t you like to help create that spark for a kid with potential? Or at least, give her a pencil?

Even if you’re not sure you want to donate, I urge you to browse the projects available. It’ll make you righteously angry at the state of education in this country–and if it makes you angry enough to donate, so much the better. (I especially urge you to look at the essential lower-cost projects in the schools with the highest poverty levels.) I’ve got a few projects picked out on the Signout 2008 Campaign for Smart Kids page, but don’t let that limit you; you can search by tons of different variables to advance whatever agenda you hold most dear–even to help fund schools in your neighborhood.

I hope you’ll consider making even a small donation. Don’t forget–smart kids turn into smart grown-ups, and smart grown-ups vote.

Issues around patient confidentiality fall under the umbrella of the ethical principle of autonomy. In the Belmont Report–the manifesto on which much of the regulation of human subjects research is based–that principle is tied to self-determination. Anyone respecting self-determination is called on by the report’s writers to “give weight to autonomous persons’ considered opinions and choices.” In practical terms, that means that you determine how–and whether–you’re represented when your medical record is published for public consumption.

But what if you can’t be identified by the information published? If anonymity is ensured, is consent even an issue?

The short answer is, yes, in large part due to the fact that anonymity isn’t what it used to be.

In an editorial in the British Medical Journal published in the mid-1990′s, Richard Smith gives a nice chronology of the discussion around this issue. He notes that the medical literature used to be the exclusive domain of medical professionals. Back then, even if a patient could be identified by features of a photograph or a case report, they were identified by other doctors in the context of what was arguably an academic discussion–even if it was a very broad one. No more anonymity was needed than the minimum allotted in casual conversations among colleagues.

What’s changed, Smith notes, are the readers. In the age of the Internets, medical literature can now be read by anyone, including patients. In this climate, the entire definition of anonymity changes: it’s not so much about whether we can identify a patient, but rather, whether patients can identify themselves. (Smith suggests that it’s also about whether curious journalists can identify patients, although I don’t know of any cases where this has been a problem.)

In a later article, different authors suggest routinely obtaining consent for use of patients’ images in publications, regardless of the certainty of true anonymity associated with their publication. They also suggest that inasmuch as photos constitute part of a patient’s medical record, and inasmuch as the medical record theoretically belongs to the patient, there may also be “rights akin to ownership” associated with medical photographs. This means that patients would potentially be compelled to give consent for their photographs to be published, more because of rights of ownership than because of a right to anonymity.

In many institutions, medical photography is now routinely accompanied by a consent process. Even in cases when it seems highly improbable that a patient could be recognized from a photograph, their written consent is obtained before that photograph is taken. Obtaining consent is less routine, but still common, before publishing case reports or small case series about patients. It doesn’t seem that a lawsuit alleging breach of confidentiality would go far in the case of a patient who has found themselves described in a case report; however, it’s exactly that kind of event (although it was a complaint rather than a lawsuit, and one that seems to have been highly avoidable) that started much of the discussion, to begin with.

It sounds a little crazy, I know. But the goal is to protect patients from what many of them consider to be a pretty unpleasant scenario: seeing a depiction of their diseased or dysmorphic selves in a place they didn’t plan to.

Although I don’t know the details of the UNMH case, it seems that in an area where the ethics are a little blurry, firing the employees for what they did might have been hasty. It’s hard to say for sure without knowing what exactly happened.

Naturally, issues like this provoke some introspection: I’m not sure how good I am at hiding the identities of the patients whose stories I share here. Sure, I change many details about each patient’s story–but do I change enough? The test, in my case, would be a patient reading a story about themselves and, knowing my identity, being unable to recognize that the story was about them. I hope I’ve achieved that kind of true anonymity in each case, but it’s hard to be certain.

In several cases, if I wanted to provide true anonymity, I’d have to change so many details that most of the meaning would be lost. I suppose that’s a small price to pay to avoid giving someone the sense that they’ve lost control over the telling of their own story.

P.S. For the latest in great nurse/other medical blogging, check out this week’s Change of Shift. Mmmm, piratey!

Among behaviors rated as most unprofessional by the participating interns were: discussing patient information in public spaces (yeah, that’s a no-brainer); falsification of patient records (illegal, and bad medicine); reporting patient information as normal when uncertain of true results (dumb); not alerting the patient that the individual [made] an error (not always helpful, especially if it didn’t result in harm, but certainly ethically reasonable); making fun of patients to colleagues (poor form, indee–wait, what?).

I mean, WHAT?

In my most recent encounter with “unprofessionalism,” the word seemed to be usable interchangeably with “being human.” The JAMA survey only confirms my sense that professionalism in medicine has come to represent a romantic fantasy–and worse, that we’ve invented that fantasy, ourselves.

The Accreditation Council for Graduate Medical Education–the people who accredit residency programs–now has requirements for residency programs based around six “core competencies,” one of which is professionalism. In this competency, they mandate, residents should be able to demonstrate the following:

1) compassion, integrity, and respect for others;

2) responsiveness to patient needs that supersedes self-interest;

3) respect for patient privacy and autonomy;

4) accountability to patients, society and the profession; and,

5) sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.

Sounds mostly reasonable, right? Except for that pesky item two, which suggests that to be a good doctor, I need to routinely prioritize patients’ needs above my own. With this as our model, is it any wonder physician burnout is a problem? What other profession–other than maybe the priesthood–would willfully submit to this?

After my unfortunate experience a month ago, I felt certain that the unrealistic model of medical professionalism was the responsibility of several vocal, unreasonably demanding patient advocates. As customers, I was certain, they felt they were always right–and since no one ever told them otherwise, they became right by default.

On the fringes of the JAMA study lurks a different story, however: we have unreasonable expectations of ourselves. Perhaps we even enter the medical profession because of those unreasonable expectations: if we become everything we dream of being, after all, we will be suprahuman–we will be gods.

The truth is, it’s hard, and not much fun, to be suprahuman while still being an actual human. Actual human residents see a patient population that is incredibly dysfunctional and often abusive of the medical system and its employees. At times, there is only one way to really unpack the madness that accumulates after taking a few blows: judging harshly, while snickering, over beers. The day I am told that’s unprofessional by anyone who’s been in practice longer than three months is the day I poke a motherfucker in the eye.

Venting about the people that make-a you crazy is part of being a functional person. So is prioritizing your own needs over those of a patient. It is possible to be a compassionate, meticulous, attentive doctor while doing those things, but I’m not sure how possible it is to be a functional human without doing them.

Also, my heart goes out to those memorializing loved ones lost on this day in 2001.

I promise, content is coming. Ayyy, it is so hard to write in complete sentences when I am working the night shift!

Speaking of which, this daily-plus blogging thing is exhausting. I need a vacation.

You think I’m kidding?

John McCain has repeatedly voted against legislation that would have prevented unwanted pregnancy by providing insurance coverage for birth control, programs to increase access to and awareness of emergency contraception, and biologically-based sex education.

He has repeatedly voted in support of abstinence-only sex-education programs, which don’t work to prevent teen pregnancy. He also voted against laws requiring that they be vetted as medically accurate before being used.

He voted to earmark a chunk of U.S. aid for HIV/AIDS prevention in the developing world (PEPFAR) for abstinence-until-marriage programs, which don’t work–especially not for women.

In general, when it comes to women’s reproductive rights, John McCain has voted and spoken publicly in favor of programs that get–and keep–women pregnant, whether they like it or not.

The New York Times today quoted Barack Obama as urging that “people back off these kinds of stories.” While I certainly hope we avoid publicly judging Palin’s kid for this, I think it’s very reasonable for us to judge the programs that got her into this pickle to begin with, and the people who promote them. Moreover, I think it’s very reasonable for the press to use this episode as an example of the conservative movement’s hypocrisy and total ignorance of the truth. May their teeth gnash until the McCain campaign is chewed up and spit out.

Palin is quoted as saying her daughter has grown up “much faster than [she] would have ever planned.”

No shit. Blame John McCain, blame your party, and blame your ideology. I do.

Dear Dr. Signout*,

I was supposed to start medical school last week, but [I've deferred for a year to figure things out.]

I guess the thing is, I like living so much, and medicine seems both incredibly in line and at odds with that–you give up everything you’ve ever been passionate about to live, to the extreme, one particular passion.

I know that what-ifs are horrible exercises of futility, and that denial and self-rationalization are crucial elements of happiness, but I was wondering anyway: would you do it over again knowing what you know now?

---

*This email has been edited to preserve the writer’s anonymity and enforce the use of Standard English.

For starters, “what I know now” is merely medical school and residency. I haven’t even tasted independent medical practice yet, so that limits my perspective. I’ve asked for some more experienced practitioners to add their thoughts in the comments section.

I had a hard time choosing to do medicine. The idea was never mine to begin with–it came from my parents, along with a lot of pressure to quit dreaming and do something. In part to get away from that, I took a substantial amount of time off in between my undergraduate time and medical school. By the time I started medical school, it seemed that my exhaustion from prolonged directionlessness had landed me there as much as anything else had.

A few things kept me from being really enthused about medicine, among them my lack of talent for science and my preference for creative efforts over academic ones. I desperately wanted to make one of those creative efforts into a career, and did some work in different sectors, but there was something that routinely needled me: every time I encountered someone disabled, dysmorphic, homeless, or otherwise disadvantaged, I felt impotent. My impulse was to face those people, talk to them, and give them comfort, and I had very little context in which I could do that appropriately and constructively. I ultimately didn’t feel I’d satisfy that impulse in any of the creative fields, so I started to look elsewhere.

After applying to medical school and getting in, I had the same problems with what-ifs that you do. The unsuitability of other career paths did not make medicine feel like a better fit. Once made, the decision did not settle easily: I spent most of my first year of medical school pretty depressed, and felt a great sense of loss that took a long, long time to go away.

What makes it OK now, eight years later, is the mix. I am fundamentally the same person: I still need to have creative outlets and people in my life, and I still have an impulse to offer something to disadvantaged people. When I’m able to satisfy both desires in one day, that’s a good day. Happily, I’ve also discovered a real joy and fulfillment in things I never thought I’d like much, like teaching and research. This only expands the list of things I can do when I’m done with my training (not to mention, while I’m in it).

As I mentioned already, I haven’t reached my own career nirvana yet. There are definitely times when I feel that medicine has taken over my life, but as I work my way slowly upward, some of the things that were squeezed out are getting squeezed back in. The symbiosis of my medical practice and my writing is one that I’m not sure would’ve evolved out of any other career choice, which helps make me feel pretty good about things. My point is, although there are parts of the training where medicine certainly dominates, it’s not that way forever, and the variety in your life depends largely on you.

There’s still a part of me that wonders how things could’ve been if I’d had more faith in my ability to make another career path work, but that’s the kind of person I am–I look back. Still, one thing I know for sure is that if I were doing anything but this, I’d still feel a catch in my throat every time I saw someone in need. It’s nice not to have that any more.

I’m not a huge fan of inspirational quotes, but I like this one from Howard Thurman: “Don’t ask what the world needs. Ask what makes you come alive, and go do it. Because what the world needs is people who have come alive.”

Others’ thoughts?