It doesn't really matter

"Is anyone running this code?"

There were two residents in the room, one administering chest compressions, and one getting an arterial blood sample. Neither of them answered me; in response to my question, there was only the binging and bonging of various monitors ably detecting a dead man.

"OK, so, I guess I'm running this code."

Although I'd been looking forward to this moment for a long time, it was acutely uncomfortable in the way that being onstage in one's underpants might be. As fifteen people watched and waited for my decisions, I bumbled through the algorithms, alternately talking to myself, staring at my ACLS cards, and shouting when an inside voice would've been adequate.

I had a more experienced resident there to make sure I didn't do anything dumb. Once it was all over, with the patient packing off to the MICU to die noisily of an overwhelming sepsis, I asked my senior how he thought I'd done.

"Does it matter?" he said. "You had the cojones to step up and do it. That's great."

It was a disquieting answer; no one likes to think that just showing up is as good as their best intellectual effort. But in taking the long view of academic internal medicine, there's a homogeneity to sick patients' outcomes that's equally disquieting.

Since the start of residency, I've been having some circular discussions with a friend--also a resident--about whether anything we do in internal medicine really matters. If I back up and squint at all the patients I've cared for on the medicine wards and in my clinic, a huge proportion of them are so sick that they're going to die in the next 10 years, no matter what I do. Some will die sooner. If I'm great at choosing the right combination of anti-hypertensives for a guy with twenty other medical problems, does it matter?

Perhaps--but probably more to my future patients than to my current ones. I might not change the course of a very sick patient's health while I'm a resident, but I'm beginning to think that's not really the point of residency. It makes more sense to see these sick patients as substrate on which to hone skills that I'll use when they matter, like when I take care of a guy who has only hypertension and diabetes. (This will happen eventually, I am told.) It seems a little heartless when I see the concept in writing, but please believe me when I say that it actually gives me some hope. It makes me feel less like I am wasting my time when I perform otherwise meaningless, time-consuming interventions mandated by one's functioning in an academic medical center setting.

There may be occasional patients for whom my interventions and my knowledge base really make a difference, of course. I welcome those patients, and seek out interactions that predispose to those occasions. In between, at least for now, it doesn't really matter if what I do matters.


More like this

I'm willing to bet that many a fine medical resident has had the same discussions, I know I have. Sometimes, only sometimes mind you, I envy the surgeons for the almost instant gratification they can provide their patients. On the other hand following a patient throughout their life provides a unique opportunity to make a difference. Although the results are not instantaneous, helping a patient to quit smoking, or providing the encouragement for a patient to exercise and diet can be a life changing experience for some. In addition just taking the time to explain to a patient about their disease can make a world of difference.

Well, the chaplain in me has to weigh in. Remember that giving someone a few extra years, months, days or hours may not seem meaningful or perhaps it seems cruel at times (aside from the learning involved), but it could be very meaningful to your patients and/or their families. Working in hospice has made me realize that a lot of sacred moments take place in those final days of a patient's life, even if the patient is non-verbal or non-responsive. I've attended many deaths and performed many memorial services/funerals and witnessed significant emotional healing and closure take place. In addition to the learning involved when you practice medicine with your best efforts, you may be preparing and/or providing additional precious moments that allow people to exit life in peace. I continue to be so grateful for what you do...


By Anonymous (not verified) on 09 Nov 2007 #permalink

I've just graduated university and have started teaching high school science. I've been put in some ethically challenging situations even already, having it put on my shoulders to push students through a program that they aren't prepared to do the necessary work for, simply because their parents paid a lot of money to get them into it. It's been not so subtly suggested that I need to make things easier, fudge the numbers, whatever, and that's depressing.

It made me wonder, does anything in my job really matter? Intellectual honesty, respect for the educational process, professional ethics. I think your unpleasant epiphany has helped put my own situation in a different perspective (though, don't get me wrong, I'm still not happy about my situation).

This code piece is a reminder of the ups and downs of many professions. There are moments of despair, or just plain vaccum, but there are also times of elation. The very supportive comments are so refreshing.
Sometimes letting ourselves wallow in those down moments give us the energy and motivation to eject ourselves out of it and see things in a new and positive way.

I think people differ greatly on this issue. For example, if it were completely unidentifiable as my own, I would have no problem with a picture of my naked ass being posted on the Internet. Others would be absolutely horrified by the prospect.

Signout reader named Benjamin Langer, who himself has a very nice critical piece on intelligent design in the current edition of SCQ.