Physicians: too busy for patient care?

David Foster Wallace opened up his rather memorable 2005 commencement speech at Kenyon with the following story:

Two young fish are swimming along and they happen to meet an older fish swimming the other way, who nods at them and says, “Morning, boys. How’s the water?”
The two young fish swim on for a bit, and then eventually one of them looks over at the other and goes “What the hell is water?”

That is, the reality and culture in which we’re immersed can be quite hidden to us if we don’t continuously work to remind ourselves to stay aware.

There are parts of medical culture that I’ve come to take for granted; narratives I’ve rehearsed and excuses I automatically give for why things are the way they are, even when they seem at odds of serving the patient’s good.

It’s unsurprising that pride underlies a lot of these non-ideal realities, but being aware of how exactly we’ve let ourselves be gradually puffed up is harder because this is our reality.

A typical day in the hospital starts with pre-rounding, i.e. seeing the patient for 2-3 minutes in the morning to see if anything “acute” has happened overnight (i.e. is it something worth mentioning to the attending?) and then spending the rest of the hour pulling up “objective data” (i.e. labs, vitals, imaging) to present during rounds. In rounds, depending on the attending, you might sit in one room and discuss the patients without ever going to see them; you’ll maybe spend 10 seconds talking about the patients themselves; much longer presenting the objective data and discussing the consults you’re going to call and tests you’re going to run that day. Then the rest of the day you’re going to run around following through on these, fielding phone calls, checking the EMR (electronic medical record) often for updated information, and at the end of the day, what you’ve taken care of is more the data about a patient rather than the patient himself.

And this is in the more “humanistic” parts of medicine – during my surgical rotations, how often did we (half-)joke that patient “looks good from door” and write from day-to-day: “ambulating, urinating without catheter, positive for bowel movements,” as if that were the sum of the patients?

We grumble to one another about our lack of sleep and that there’s never enough time to take care of things in the hospital; we get impatient when a patient has a “complaint” (literally, that’s what the medical jargon calls it) or has something to tell us that “doesn’t change medical management.”

Inwardly we ask, “Why are you wasting my precious time?” right before we spend 20, 30 minutes chatting to our peers, holed up in the residents’ room. We always have more than enough time if another physician wants to talk to us about what recommendations they may have or even if a more senior physician wants to pontificate on some random tangent; we try hard not to give in to the urge to check our watches or restlessly tap our feet when a family member or a patient stops us and has something “important” to tell us. “Sorry, we have to go,” we say as soon as they pause to take a breath.

We make huge life-altering decisions within the confines of the physicians’ room and then ask the nurse to let the patient know as we scurry away to take care of something else.

I get it, we’re sleep-deprived and busy, but are we so busy we’ve forgotten to take care of our patients? Or are we justifying ourselves out of a misguided sense of self-importance ?

Anyway, I’m part of the problem, and recently I’ve been convicted, as James has some pretty harsh words about the sin of partiality (with some insertions of my own):

Show no partiality as you hold the faith in our Lord Jesus Christ, the Lord of glory. For if a man wearing a [white coat] comes into your assembly, and a [malodorous homeless patient in disheveled clothing] also comes in, and if you pay attention to the [one in the white coat] and say, “You sit here in a good place,” while you say to the poor man, “You stand over there,” or, “Sit down at my feet,” have you not then made distinctions among yourselves and become judges with evil thoughts? Listen, my beloved brothers, has not God chosen those who are poor in the world to be rich in faith and heirs of the kingdom, which he has promised to those who love him…

If you really fulfill the royal law according to the Scripture, “You shall love your neighbor as yourself,” you are doing well. But if you show partiality, you are committing sin and are convicted by the law as transgressors.

And elsewhere in the Bible we see Jesus going out of his way to bless the unimportant, those that wouldn’t have necessarily “changed his ministry” or in any way made him “more efficient” in proving his divinity.

Then children were brought to him that he might lay his hands on them and pray. The disciples rebuked the people, but Jesus said, “Let the little children come to me and do not hinder them, for to such belongs the kingdom of heaven.” And he laid his hands on them and went away.

So now that I’m aware of parts of the medical “water” — how, then, shall we live?