I've got a pile of other emails to process but it's hard not to click on writing that is just so good and honest like this. Makes me proud to be part of this profession. Keep raising the bar for all of us to remain human and kind.
I'm presuming the med student's response to shifting the car was an incredulous/rude tone? If it was me, I could say exactly what that student did, and it simply be a confirmation that yes, you do want me to shift the car, perhaps slightly surprised, but I could say those exact words with no disrespect intended whatsoever! I'm assuming there's some history/background to your taking offense to that response. Not just sleep deprivation.
Thank you for sharing these remarkable and touching stories.
As an aside, as the parent of a (now) adult son with T1 diabetes, we have realized just how little training many health professionals have when it comes to T1 diabetes. My son sadly developed gastroparesis and spent 2 months on and off in the hospital last year. We were so thankful for the doctors and nurses who listened to him and advocated for his diabetes management system (he uses contemporary insulins most people haven't heard of). He had amazing doctors, including a very tired but smart and kind resident.
Thank you for sharing these stories, Adam. Brought back so many memories from my days on the VA wards, where I volunteered to take as many rotations as possible because I loved the veterans. I don't know that I remember the names like you do (if I could find my green cloth books with the silky labels, I would be on a major trip down memory lane), but I certainly remember the stories. So many of them and so many hours worked doing everything from transporting patients, to using the ancient EKF machine and giving respiratory treatments in the middle of the night with my pockets full of tools and a pilfered vacutainer sleeve attached with adhesive tape and a safety pin to my lab coat (since the VA never had any). So many lessons learned...a good life in medicine lived as I approach the end of my career.
Dang - English muffins and ketchup! That was and remains one of my favorite combos that continually makes my bride gag! Sometimes I add a little mustard. Thanks for sharing your very hard working human memories.
I love the last one about the med student. I'm a 4th year med student and am still blown away by what some of my classmates get bothered by. Recently I had a classmate upset we had to wait for a lecture that was scheduled for 3pm to start instead at 3:30pm. The attending giving the lecture was a nephrologist consulting on our ICU patients that were getting put on CRRT. My classmate ended up leaving the hospital at 3:15pm because she thought the doctor was "wasting our time". It's always a good reminder no matter what position we're in to remember your point, our job is to care for patients, and no one is having a worse day than the patients. Entitlement makes you insufferable to be around, and no one is more entitled than the modern day med student. Thanks for sharing these stories Dr. Cifu
As a mid-stage trainee, now in fellowship training, I love it when older physicians share these stories because we see how our "learn by doing" training really impacts how we practice medicine. I hope to remember my patients and their stories as well as you do. Thanks for the great work. I also went to BIDMC for IM training and remember my time very fondly.
The story about AS is not euthanasia, it was palliative care. You were not aiming for his death, you were aiming for discharge, which unfortunately was impossible. If you had sent him home with hospice without that trial, he would have suffered all night and died anyway and his family would have been traumatized. Instead you asked him his goal of care and he gave it to you, and you tried. I had a similar experience trying bipap on a lady who wanted to live but didn’t want intubation for a bad pneumonia. She didn’t make it. She wasn’t going to make it, she just couldn’t face it without trying one more thing.
I know the goal was home... But if the mechanism involves cranking up the meds to lethal levels... It's a physician assisted death. I don't know the technical definition of euthanasia, in my country legally it's suicide, and if getting your drs to prescribe you meds that you know are likely to kill you (as this patient did) is not legally suicide, I'm not sure what else is? The Double intention doctrine doesn't invalidate the fact that the actions caused death.
I'm absolutely with the physician for giving the patient a peaceful death, but the "I'm just relieving suffering" sugar coating is specious. Try it with a patient who's not terminally ill: even if they'd rather die than suffer, you won't comply. Because you know that relieving suffering isn't a good enough excuse for killing the patient; at least not as medical ethics currently stand.
It’s not that simple when you’re dealing with someone in pain or respiratory distress. There’s no line that says “this dosage is symptom relieving” and “this dosage is lethal.” The patient was dying of his disease and couldn’t maintain oxygen levels high enough to survive anyway, that’s the cause of death. Not accepting every treatment offered doesn’t mean you’re committing suicide.
When I was still working as a staff nurse and going to graduate school, I worked crazy hours and was assigned to patients that the regular staff didn't want. I would get angry because I felt abused but never opened up about it. I noticed something interesting. I would feel so guilty for not wanting the assignments that I would compensate by lavishing attention on the patients. They would then respond to this by loving me and it is hard to not love someone back. The patients I resented most became my favorites.
I would characterize my residency as fabulous and yet I feel such sadness as I read your memories and my version of each story stirs inside me. All those stories and patients. I feel gratitude and shame and pride and so many other feelings. I was so young, so clueless, worked so hard, hoped so deeply. And now I'm on the other end of my career. Fortunately for me, the intensity has been dialed down. I don't think my 60 year old heart could handle it.
The stories of medicine are human stories. Thanks for humanizing these patients of yours and being willing to remember that you don’t know everything.
I've got a pile of other emails to process but it's hard not to click on writing that is just so good and honest like this. Makes me proud to be part of this profession. Keep raising the bar for all of us to remain human and kind.
So real, so authentic, so on point. Thank you for sharing.
I'm presuming the med student's response to shifting the car was an incredulous/rude tone? If it was me, I could say exactly what that student did, and it simply be a confirmation that yes, you do want me to shift the car, perhaps slightly surprised, but I could say those exact words with no disrespect intended whatsoever! I'm assuming there's some history/background to your taking offense to that response. Not just sleep deprivation.
Thank you for sharing these remarkable and touching stories.
As an aside, as the parent of a (now) adult son with T1 diabetes, we have realized just how little training many health professionals have when it comes to T1 diabetes. My son sadly developed gastroparesis and spent 2 months on and off in the hospital last year. We were so thankful for the doctors and nurses who listened to him and advocated for his diabetes management system (he uses contemporary insulins most people haven't heard of). He had amazing doctors, including a very tired but smart and kind resident.
Thank you for all you do.
Thank you for sharing these stories, Adam. Brought back so many memories from my days on the VA wards, where I volunteered to take as many rotations as possible because I loved the veterans. I don't know that I remember the names like you do (if I could find my green cloth books with the silky labels, I would be on a major trip down memory lane), but I certainly remember the stories. So many of them and so many hours worked doing everything from transporting patients, to using the ancient EKF machine and giving respiratory treatments in the middle of the night with my pockets full of tools and a pilfered vacutainer sleeve attached with adhesive tape and a safety pin to my lab coat (since the VA never had any). So many lessons learned...a good life in medicine lived as I approach the end of my career.
Dang - English muffins and ketchup! That was and remains one of my favorite combos that continually makes my bride gag! Sometimes I add a little mustard. Thanks for sharing your very hard working human memories.
I love the last one about the med student. I'm a 4th year med student and am still blown away by what some of my classmates get bothered by. Recently I had a classmate upset we had to wait for a lecture that was scheduled for 3pm to start instead at 3:30pm. The attending giving the lecture was a nephrologist consulting on our ICU patients that were getting put on CRRT. My classmate ended up leaving the hospital at 3:15pm because she thought the doctor was "wasting our time". It's always a good reminder no matter what position we're in to remember your point, our job is to care for patients, and no one is having a worse day than the patients. Entitlement makes you insufferable to be around, and no one is more entitled than the modern day med student. Thanks for sharing these stories Dr. Cifu
As a past patient on Reisman 12 I am forever grateful for all of the hardworking men and women who have taken such good care of and many others
What a beautiful piece of writing. Thank you for sharing it.
As a mid-stage trainee, now in fellowship training, I love it when older physicians share these stories because we see how our "learn by doing" training really impacts how we practice medicine. I hope to remember my patients and their stories as well as you do. Thanks for the great work. I also went to BIDMC for IM training and remember my time very fondly.
The story about AS is not euthanasia, it was palliative care. You were not aiming for his death, you were aiming for discharge, which unfortunately was impossible. If you had sent him home with hospice without that trial, he would have suffered all night and died anyway and his family would have been traumatized. Instead you asked him his goal of care and he gave it to you, and you tried. I had a similar experience trying bipap on a lady who wanted to live but didn’t want intubation for a bad pneumonia. She didn’t make it. She wasn’t going to make it, she just couldn’t face it without trying one more thing.
I know the goal was home... But if the mechanism involves cranking up the meds to lethal levels... It's a physician assisted death. I don't know the technical definition of euthanasia, in my country legally it's suicide, and if getting your drs to prescribe you meds that you know are likely to kill you (as this patient did) is not legally suicide, I'm not sure what else is? The Double intention doctrine doesn't invalidate the fact that the actions caused death.
I'm absolutely with the physician for giving the patient a peaceful death, but the "I'm just relieving suffering" sugar coating is specious. Try it with a patient who's not terminally ill: even if they'd rather die than suffer, you won't comply. Because you know that relieving suffering isn't a good enough excuse for killing the patient; at least not as medical ethics currently stand.
It’s not that simple when you’re dealing with someone in pain or respiratory distress. There’s no line that says “this dosage is symptom relieving” and “this dosage is lethal.” The patient was dying of his disease and couldn’t maintain oxygen levels high enough to survive anyway, that’s the cause of death. Not accepting every treatment offered doesn’t mean you’re committing suicide.
Well said and thank you.
What was the "miss" DX from the first patient, just curious.
I don't think we missed anything. It was just her disease that killed her. Everyone wanted a better explanation than that.
After reading this essay, “I laughed, I cried” just about sums it up.
When I was still working as a staff nurse and going to graduate school, I worked crazy hours and was assigned to patients that the regular staff didn't want. I would get angry because I felt abused but never opened up about it. I noticed something interesting. I would feel so guilty for not wanting the assignments that I would compensate by lavishing attention on the patients. They would then respond to this by loving me and it is hard to not love someone back. The patients I resented most became my favorites.
That deserves an essay.
I would characterize my residency as fabulous and yet I feel such sadness as I read your memories and my version of each story stirs inside me. All those stories and patients. I feel gratitude and shame and pride and so many other feelings. I was so young, so clueless, worked so hard, hoped so deeply. And now I'm on the other end of my career. Fortunately for me, the intensity has been dialed down. I don't think my 60 year old heart could handle it.
Beautifully said.