The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn’t, someone who understood that the damage is greatest if all you do is fight to the bitter end.
I want cupcakes like these!
Compassion is not a sloppy, sentimental feeling for people who are underprivileged or sick…it is an absolutely practical belief that, regardless of a person’s background, ability or ability to pay, he should be provided with the best that society has to offer.
Neil Kinnock, b.1942, Welsh Labour politician, from his maiden speech in 1970
Source: kt-lately
To most physicians, my illness is a routine incident in their rounds, while for me it’s the crisis of my life. I would feel better if I had a doctor who at least perceived this incongruity.
Veterinarians and Pediatricians (and Pediatric ER Physicians too)
I’ve always thought that veterinarians have it tough. They see patients who cannot communicate. Their patients don’t speak or complain of symptoms. So veterinarians have to go by what owners have observed and by the physical exam for most of their data.
It’s kind of like a pediatrician or even a Pediatric ER physician. Little kids might not be able to complain. And when they do, they may be very vague, unable to give a good description of what they are feeling.
I recently worked a Pediatric ER shift where I saw a 4 year old patient who was transferred from another facility. The other hospital wanted us to rule out appendicitis because the patient had abdominal pain and a CT scan that was equivocal.
I went in to see this little patient who appeared to be lying comfortably in the gurney watching the TV hanging on the wall. The patient, who I’ll call Joe, didn’t seem to be in pain. So I asked his parents what the problem was. It turns out that Joe had been vomiting — up to 10 times over night — and that was why he was brought in to the ED. I asked if Joe was communicative at home. His parents told me he was.
Was Joe a child who would normally complain of pain like a stomach ache? Yes, they told me. Did Joe ever complain that his stomach was hurting? No, he didn’t.
At this point appendicitis was getting knocked down lower on my differential (list of possible diagnoses). I proceeded to sit down next to Joe and say hello. He stared back at me. I told him I was going to just take a look at his stomach and started to pull back the hospital sheet that was covering his belly.
Almost immediately he pulled it back. Apparently, this kid liked his stomach covered up. I pulled back a little and pressed on his stomach. He started crying. I tried to observe how he was crying — to see if he was just being fussy or if it was really painful. I started pressing on the left side and worked my way to the right lower area of his abdomen (where appendicitis typically presents with pain) and tried to see if his crying intensified as I neared that spot.
I finally gave up and let him cover up his stomach. But I tried one more time. This time, I pressed on his stomach through the sheet. This time Joe did not cry. I was able to press fairly deep all over his stomach without eliciting any cries of pain.
That pretty much did it for me. And, after more discussion with the parents about Joe’s symptoms at home prior to coming in to the hospital, I concluded that appendicitis was not likely in this little patient.
In the adult world, most patients are able to communicate. Sure, I’ve had adults who were unable to communicate with me, but the proportion of patients who can’t communicate is much, much less. I don’t plan on going into pediatrics or emergency medicine. But I can appreciate how difficult it can be at times. And I am thankful that there are people who choose to do it.
Source: jeffreymd.com
The Complexity of Informed Medical Decisions
sarainthought replied to your post: What the heck?
I agree its a poor example, as you say. But on a big picture, as an MD, where is the line on your beliefs & your practice? Not performing or not explaining the option? The issue comes up with birth control and it makes it quite an ethical issue.
It is a complex issue. But I do side with the majority that say it is not an obligation for an OB/GYN to perform a procedure he knows how to do if he is opposed to it and it is not an emergent situation. The OB/GYN should make a good faith effort to help the patient get in touch with a physician who is willing.
You do make a good point about explaining options, though.
I think it is very difficult, if not impossible, for most physicians to explain an issue and ALL the options without bias. We’re human. We do have a preference. And often, that preference will direct how we present information. It is what it is.
For example, an otherwise healthy patient has abdominal pain that the surgeon decides is due to gallstone. He would like to operate and remove the gallbladder. But prior to any procedure the physician must explain the risks and benefits to the patient. The benefit is that the pain could be resolved. The main risks of the procedure include bleeding, perforation of adjacent structures, and infection of the surgical site.
Now, how the surgeon frames the risks is key to selling any procedure. Most, if not all, will casually mention them and say that it’s possible but it hardly ever happens. The throw in statistics about how very few of these complications actually arise due to the procedure. For this fairly typical surgery in an otherwise healthy patient, no one is going to sit there and emphasize the risks.
It’s all how you sell it.
But often we have to sell it. Because we know it’s the best option a patient has. And we push for procedures because the numbers — the evidence — say it will offer the best outcome.
In the end, I think it is our duty to provide a patient with as much information about the options. But I also feel that it is our duty to care for the patient and to explain what we think should be done. To me, providing all the options without any guidance whatsoever is just as bad as holding back some options.
This is, I suppose, a shift in the practice of medicine. Fifty years ago, the decisions in medical care were very one-sided. The physician knew best. And He or she made the decision and the patient accepted it.
Today we have this this notion of informed consent — that the patient should be informed about his or her treatment and the available options. And this, overall, is a good thing.
We’re trying to change with the times. And I think we’re headed in the right direction.
What the heck?
The following quote has been circulating around tumblr. People have been quoting this passage and re-blogging it. I went to the actual article from which this statement was taken and I can’t figure out who wrote the article. But it’s on Jezebel.com (link to post).
Doctors in emergency rooms have no right to refuse to provide medical care to someone who overdosed on heroin, even though heroin is illegal and many people are morally opposed to its recreational use. They have to care for drunk drivers, even though driving drunk is both illegal and a pretty universally assy thing to do. Why, then, should a hospital be forced to bend over backwards to accommodate people’s religious beliefs surrounding abortion, a legal medical procedure protected by the Constitution?
Apparently, a group of nurses are fighting for the right to refuse to be involved in abortions because of their personal objection to the procedure.
Ok, I won’t get in on the argument of Life vs Choice. That’s not the problem I have with the quote above. The problem I have with that quote is the author somehow equating refusing to provide an abortion with refusing to treat a patient who has overdosed on heroin or drunk drivers (who I assume were involved in some sort of life-threatening accident, because why else would one “treat” a drunk driver in the ED if not for an injury ? Ok, maybe you could treat a drunk for alcohol poisoning, but then he/she would just be a drunk and not necessarily a driver.).
Unless a woman is dying because of her unborn child, this argument is flawed. A woman seeking a legal abortion must do so before the age of (fetal) viability. This is usually a normal pregnancy. There aren’t life-threatening circumstances. The woman has usually thought about this.
A patient who has overdosed on heroin can DIE. A drunk driver in a car accident can DIE.
What about the woman seeking a legal abortion? She can go and find a physician and nursing staff who are willing to perform the procedure! A guy who overdosed can’t do that. Neither can the drunk driver who is unconscious and bleeding internally.
Absolutely ridiculous. Maybe I shouldn’t be reading things from Jezebel.com in the first place.
Again, this is not meant to be a Life vs Choice issue I am grrr’d about.
And most clinical ethicists will agree that a physician is not required to perform whatever procedure is requested of him or her. A physician only has the moral obligation to treat emergencies as best as he or she can. And the ethical thing to do, if a physician is unwilling to perform a procedure in a non-emergent case, is to make a good-faith effort to help the patient find a willing physician.
Seems like today has been a day full of health-related relationship advice!
A clip from the 1954 film Doctor In The House.
I bet patients are glad that morning rounds don’t proceed like this anymore. Well, not quite like this.
Source: approachingsignificance
