Friday Reflection 46: The Best of Days

A Thanksgiving Post: Giving Thanks for My Job

PR is an 82-year-old woman who is brought to the emergency room after “an episode.” During her first 12 hours in the hospital, she saw an emergency medicine resident and attending, a neurology resident and attending, and finally an internal medicine intern and resident who were covering the “night-float” shift. By the time these last two met her, she was pretty well wiped out, so the case they presented to us, her admitting team, was mostly cobbled together from the other doctors’ notes. The diagnoses that had been considered, and treated, included a transient ischemic attack; syncope; a seizure; delirium.  

On Sensible Medicine, we tend toward critical appraisal, argument, and skepticism.¹ I worry that means we don’t communicate the wonder and absolute joy that is part of the practice of medicine frequently enough. That might be for the best; I am not sure how interesting it would be to constantly read people “wax poetic” about clinical care. Occasionally, though, it is worth stressing that even with all the flawed studies, overuse, conflicts of interest, and other messes we cover, medicine remains the only job I could imagine doing.²

The day my team admitted PR was a day I experienced how good it can feel to practice medicine. I returned to my office after morning rounds practically beaming. I ran into Mindy Schwartz, a long-time colleague, and recounted my bliss. I told her maybe I had just had too much coffee. She said, “Some days are the best of days, it’s good to recognize them.” 

What made the day so good? First, there was PR.  

When we went to see her in her hospital room, she was sitting up in bed, well rested, and enjoying a hospital breakfast. The room was quiet and bright; we had closed the door to the hallway and the shades were up, allowing in a bright autumn sun. The resident, intern, and I sat next to her bed and got a complete history -- not just of what led to her coming to the hospital but of her last three months. After about 15 minutes, we had a good idea of what was going on. There was mild cognitive impairment, orthostatic hypotension from an unnecessary medication, and previously undiagnosed seizures.  

Soon after leaving her room, I rounded on an elderly woman who’d been admitted days before, OTBOD – a medical abbreviation meaning “on the brink of death.” She had pneumonia, hypotension, and acute kidney injury. She went from the ER directly to the ICU and spent the next few days on a ventilator, getting antibiotics, pressors, and hemodialysis. Once off the ventilator, she was transferred to our team. The first two days she was on our service, I wondered what had been the point. She was barely responsive, and our ministrations were aimed only at supporting her blood pressure and nudging her labs toward normal.  

This morning, she was wide-awake and sitting up in bed. I introduced myself, as she had not registered my presence the previous days. Her face lit up with a radiant smile I could not have imagined 24 hours earlier. I recounted what she had been through, and the challenges that lay ahead. She asked a few remarkably appropriate questions, told me she had faith she’d get better, and thanked me for the care she’d received. 

Probably buoyed by these patients, I was strangely alert to the colleagues I passed in the hall: nurses, CNAs, chaplains, phlebotomists, physical therapists. All these people are professionals who chose a career, a difficult one, that requires unpleasant tasks, without hope of great riches, but whose goal is noble. In today’s cynical world, it is hard to admit that the shared task of all these people is to care for the suffering.  

Back with my team, we ran through the rest of our patients.³ This is when I most appreciate my people. These doctors get the same nerdy delight from the intellectual challenge of puzzling through a case. On good days, we get the satisfaction of finding a solution, but unlike Wordle or Connections, the problem has evolved naturally and its solution benefits someone. The discussions we have about our patients are more satisfying than they have ever been. We work at a time when so many of our questions are answerable with the device in our pockets.  

On this day one of the questions was, what are the test characteristics of Fungitell? We found our answer easily using OpenEvidence. Sensitivity about 80%, specificity 63-75%, but you need to be aware of which fungi the test covers.  

Another question -- would a prolactin level be useful in diagnosing PR’s seizure? This led to a great discussion of critical appraisal as we looked at the references turned up on PubMed. We realized that the studies available could not be generalized to our current clinical situation – or probably to clinical situations we would ever find ourselves in.  

I walked back to the elevator with a pulmonologist who was on the consult service, seeing a couple of our patients. I asked how she was thinking through the case of a woman with bilateral lobar infiltrates. Listening to this experienced expert talk through a difficult and puzzling case was like a chapter out of Harrison’s or Symptom to Diagnosis come to life. I was reminded that, no matter how much longer I do this job, I will always learn from my colleagues.  

Not every day is like this. Some days, nobody gets better, nobody thanks you, your colleagues are in a rush, and you clash with a nurse even though you are both trying to do right by the patient. And then there are the days when you don’t notice how good you have it because your coffee was cold, or you are worried about afternoon clinic, or you are thinking about how to negotiate where you’ll spend Christmas.  

I am happy that, occasionally, I can appreciate the privilege of doing the job I do.  

I’ll try to highlight that on Sensible Medicine now and then. 

1. Sounds like a fun place, right?

2. On a recent “Ask Us Anything” podcast episodes, Vinay and John said pretty much the same thing (12:45 at this link).

3. I call this card flipping because I carry an index card for each patient. The residents call it running the list since they are looking at a list on a workstation. Last year, when a new intern asked, “what is card-flipping?” the resident replied, “That is what old people call running the list.”

Photo Credit: Gabriel Garcia Marengo