Monday, December 16, 2013

Healthcare as a Calling Across Generations

A young resident’s recent article in The Journal of the American Medical Association (JAMA) – as well as a more senior physician’s blog post, gives me hope that the calling of medicine lives on, and that professionalism by all those who care for others in need remains the key component in any healthcare system.   

The article by Dr. Diane Chang, entitled “Scut,” starts by defining scut work:  

“I want to talk about scut work, defined as trivial, unrewarding, tedious, dirty and disagreeable work; in other words, I want to talk about … the physical, backbreaking, day-to-day work of taking care of another person.” 

It often is not pretty to care for another human being who is sick.  It is filled with pain, and with sights and sounds that many would consider disgusting.  Dr. Chang rightly points out that the job of tending to the needs of a person are not a doctor or nurse issue, but a human issue that is the job of every person in a caring role: 

“I worked with an intern who, during her first month, took care of a 32-year-old patient with advanced HIV and intractable diarrhea.  One day my intern told me that she had, alongside the nursing aide, cleaned him up, as well as his bed and the floor. Why did you do that, I asked.  It’s not your job.  She answered that often, they did not clean him up right away and she did not want the patient to have to lie in his own excrement for a minute more than he had to. Amid writing orders and discharge summaries, relaying information from consults back to the team, and learning how to be a physician, my intern also made it her job to clean up poo.”

The intern understood that the nursing aide was, in that moment, even more important to the patient's care than the physician and the doctor's job at that point of time was to help that nursing aide.  To understand that simple fact is to have true passion for patient care.   It requires understanding that the “small” issues like cleaning up a soiled floor and bed, can be more impactful on a human scale than the “big” issues.
On the other side of the generational divide comes a blogpost entitled "Playing Doctor" from Dr. James Salwitz, an oncologist who has been in practice for more than 25 years. In that piece, he talks about the need to get past the personal issues that a physician (and this applies to all health professionals) has on any given day even if it means “playing doctor.”  Even when the passion wanes, the true professional understands the need to do whatever has to be done to help the patient. 

“However, there are times when it gets to be too much. When one is tired, the paperwork piled to the ceiling, you are missing irreplaceable personal events, then the quality of patient interactions seems to deteriorate to completing disability forms, rescheduling already delayed procedures, rethinking diagnostic ideas, salvaging failed therapies and running late in a chaos of myriad minor delays. Then it is very hard to summon the needed insight, compassion and focus which are vital to being the kind of doctor towards which each of us strives. Then, the best you can do is ‘play doctor'."

For the physician in practice for 25 years, the paperwork and the disability forms are even worse than cleaning up the poo.  But with the wisdom of experience, Dr. Salwitz understands that if you have the professionalism, you will act in the interests of the person in need. 

“Nonetheless, you are just human, so those tough moments will occur, when you cannot really ‘be a doctor’. …. On those days, you just ’do your job,’ be there for the patient and suppress the loss and weariness. Paradoxically, it is that commitment to the doctor’s role, when you are just playing, which marks the great doctors, because even on their weakest day they put the patient first and their own healing later.”

One day at an airport, after I had left practice and was a health policy consultant, an elderly woman collapsed near me in the baggage claim area. I immediately went over, checked her airway and checked for a pulse. In other words, I put my fingers in her mouth and my fingers on her neck. I then started CPR which, at that time, called for mouth-to--mouth resuscitation in addition to chest compression.  The consultant with me was impressed and said, “You really are a doctor!”  I knew I was “playing” doctor. The thoughts going through my mind, while they included a desire to help this woman, also included my own fear of infection and my own wish that I was not doing what I found myself doing. I just knew that of all the people standing there, I had the training and the calling to help this woman.

Dr. Chang and Dr. Salwitz both show caring, one with the passion of youth, and the other with the wisdom of age.  As I put together the passion of Dr. Chang and the wisdom of Dr. Salwitz, I see the wonder of medicine and the caring professions as a calling.  These two people at different points in their careers share the mission of helping those in need and thus suggest that the light of care in health will continue perhaps in spite of the politics and the policy debates.