All posts by Stephanie S.

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?

What is healing?

//Because I have a short attention span, I assume others do, too, so I try to use a different color text for “main ideas.

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It’s probably a bit strange that after four years of medical school, I’m not sure what “healing” actually means, or that medicine (as a field) is even about healing. Treating a disease or pathology is not the same as healing a person. The absence of disease is…well, the absence of disease, not necessarily health. We don’t cure cancer– we usually just cut off the offending organ or treat it with radiation/chemo and hope it doesn’t come back elsewhere. Many, if not most, diseases can’t be cured (think of chronic conditions like COPD, heart failure, schizophrenia, diabetes, etc.) – even with the best medical treatments, their effects can only be slowed or minimized, though they all eventually result in the inevitable progression of disease. Even if the best medicine can “cure,” I would venture to say that only the mildest of infections can probably be “cured” completely, and that “curing” just means returning you to baseline.

Which makes it that much more astounding that Jesus healed the sick and in turn commanded his disciples in Matthew 10:8 to heal the sick.

What does it mean that He healed, that we are supposed to heal and be healers?

Though he was addressing seminary students in the excerpts below, Paul Tillich’s thoughts have also been helpful for me as a soon-to-be physician, as his reflections on health and sickness appropriately grasp the comprehensiveness and complexity inherent in disease and health.

1) Health is about unity – the wholeness and integration of body, mind, and spirit – and shalom (this comprehensive flourishing) is the ideal. Let’s not mistake the absence of disease for health, because its absence could just mean we’ve discarded the parts of us that have the potential for disease, which are also the parts of us that have the greatest potential for life. I see this as particularly true in mental health, when the best treatment can get rid of the problem without having addressed the root of the issue (e.g. antidepressants that make you not depressed, but is to the point to blunt emotions so that one is non-suicidal, or to work with the patient to understand how to deal with pain in a meaningful way and still find joy?)

Health is not the lack of divergent trends in our bodily or mental or spiritual life, but the power to keep them united. And healing is the act of reuniting them after the disruption of their unity. “Heal the sick” means — help them to regain their lost unity without depriving them of their abundance, without throwing them into a poverty of life perhaps by their own consent.

2) People in medicine often talk about how increasing specialization (to keep up with unmanageable amounts of information) creates “siloes” that compartmentalize providers into only being able to treat very specific problems.

Take, for example, diabetes, one of the most common problems in the US. If you have diabetes, you probably have an endocrinologist to manage your insulin schedule, an ophthalmologist to check out potential diabetic retinopathy, a nephrologist to make sure your kidneys aren’t failing, and a cardiologist and/or neurologist if you’ve experienced any heart attacks or strokes as a result of that diabetes. And a PCP (primary care provider) to coordinate all of that. Our very training implies that we are to stay within our areas of “expertise,” and that expertise is limited to only certain organs, which in turn can cause us to reduce our patients to organs.

But health means wholeness, and shalom is about individuals, communities, and systems – even (or especially) in medicine. And that ultimately sickness has a spiritual component in that all illness is a reflection of sin, or separation (maybe the sin of nature, but sin nonetheless.) That is why in the stories of healing in the Word, it is never just an individual’s physical healing alone, but a restoration to one’s community (as in Matthew 8, when the fever leaves, she prepares a meal for others) and spiritual healing (e.g. in Luke 5, when Jesus heals the paralytic, spiritual healing (“your sins are forgiven”) is closely linked with physical healing (“rise and walk”), and the response of the paralytic is not just physical (“he rose up before them and picked up what he had been lying on and went home,”) but also notably spiritual (“he went home glorifying God”)).

And you have learned that disease that seems bodily may be mental at root, and that a disease that seems individual may be social at the same time, and that you cannot heal individuals without liberating them from the social demons that have contributed to their sickness. Beyond this, you may have become aware of the fact that both physical and mental, individual and social, illness is a consequence of the estrangement of man’s spirit from the divine Spirit, and that no sickness can be healed nor any demon cast out without the reunion of the human spirit with the divine Spirit.

3) Though health and healing are huge concepts, ones that I still don’t fully understand, this at least is true: we know that our God is Jehovah-Rophi, the Lord who heals (Exodus 15:26), and that the real illness and diseases that we ought to fear (i.e. not the bodily ones) have been borne by Christ, who took them upon Himself.

 You have a glimpse of what can heal ultimately, of him in Whom God made manifest His power over demons and disease, of him who represents the healing power that is in the world, and sustains the world and lifts it up to God.

 

Shalom in medicine

Hello! My name is Stephanie; I graduated Princeton in 2010 with a WWS degree and am now a fourth-year medical student going into psychiatry residency (i.e. more years of training to become a psychiatrist) starting this July. I recently married my wonderful husband, who is also a fourth-year medical school student.

One (of the many) joys of being in medicine with my husband is that he is able to also think through and provide a different perspective about the field – all of the posts I will be writing on this blog are the product of and/or influenced by conversations I have with him, so I wanted to explicitly acknowledge (and thank!) him from the beginning.

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When I went to medical school, it seemed like a fairly straightforward decision because there seemed to be such an explicit link to promoting shalom, which is perhaps just another way of saying “you get to help people.” The book of Revelation makes clear that in heaven there will be no more mourning, crying, or pain, so from my then-cursory understanding of medicine, of course becoming a doctor was a legitimate endeavor.

In medical school, psychiatry in particular captivated my attention because while the body was interesting intellectually, psychiatry deals with the profound mystery of patients’ minds and spirits, the restoration of shalom in situations where ultimate things are at stake. In friends and acquaintances who have struggled with eating disorders, depression, PTSD, schizophrenia, and bipolar disorder (to name a few), I have seen how necessary a foundation mental health is for establishing shalom, for “a man’s spirit sustains him in sickness, but a crushed spirit who can bear?” (Proverbs 18:14).

// as a side note, i feel like there’s a WORLD of redemption that needs to happen in the church’s understanding of psychiatry and mental illness; those who suffer from mental illnesses are unnecessarily shamed and hurt by the church’s ignorance of the realities of mental illness and casual dismissal of those who suffer as “needing to have more faith in God” etc.//

The journey through medical school has been one of the most challenging experiences of my life (academically, personally, spiritually etc) — and having a gospel worldview in medical school itself is probably worth 1000 posts (or rants) — but my journey has given me a glimpse into a more nuanced reality of the gospel worldview when applied to the practice of medicine. My hope is that those who are seeking to be in the medical profession (or even just want to understand it) will find this a useful adjunct to their own journeys.

A few things that come to mind and that I hope to address in future posts (although on some of these I may have more questions than answers):

  • How should a gospel worldview impact the attitude of a physician when treating patients?
  • What is medicine prepared to do, and where are its boundaries? (i.e. what are the expectations we can rightly have of medicine?)
  • How does promoting shalom translate into how a doctor practices? Beyond treating the individual’s disease, this includes (but is not limited to): 
    • addressing systems and policies that prevent patients from receiving proper treatment
    • addressing the patient’s context and community
  • In psychiatry:
    • How can a psychiatrist respond to both the organic and inorganic needs of the mind?
    • How does an understanding of sin and the fall help us conceptualize mental illness?

Not sure where I’ll start, but I’m glad this blog exists, as it encourages me to think a little more systematically through some of these issues (the unexamined life etcetc).

I’m always open for suggestions for topics, so let me know!