Friday Reflection 7: Eavesdropping in Medical Education
AS was a 95-year-old-woman with COPD admitted with pneumococcal pneumonia.
In medicine, as in life, we learn in myriad ways. Medicine is taught didactically: through lectures; gleaned from assigned texts; absorbed from seasoned physicians. We also learn it independently so that we stay “up to date”: reading journals; studying our patients’ diseases; observing how people react to their doctors and their illnesses; questioning the things we don’t understand.
Another rich source of knowledge are the conversations that are part of clinical care. You might eavesdrop on them, or you might be privy to them as a bit player in a clinical drama. Either way, these exchanges often convey information that is never otherwise taught as clearly or as memorably.
AS was a patient I admitted during my internship. She was a stoic 95-year-old woman accompanied by her two elderly daughters who doted on her while deferring to her with what seemed like a mixture of respect and fear. AS came to the hospital with fever, fatigue, a productive cough and shortness of breath. Her chest X-ray showed a lobar pneumonia and her sputum gram stain (which I did in the emergency room – yes, this was a long time ago) revealed the gram positive cocci in pairs and chains diagnostic of pneumococcus.
Although I knew almost nothing about medicine at the time, I did know that pneumococcal pneumonia in a 95-year-old was serious business. William Osler referred to pneumococcal pneumonia (or at least lobar pneumonia) as “the friend of the aged” because it was a common, painless, fatal illness for elderly patients.[i] I incorrectly learned that the term he used was “the old man’s best friend.” I’ve always liked that.
At the time of her admission, AC wasn’t critically ill. She had a fever, was tachypneic and tachycardic, but her blood pressure was normal and her oxygenation was fine. Because I knew there was the possibility that her condition would worsen, perhaps rapidly, it was important to discuss her advanced directives. I launched into a discussion of her DNR (do not resuscitate) status, channeling residents I had watched as a medical student. If my memory is at all accurate, my effort was cringeworthy at best. I stood next to the bed, failed to explain why we were having this conversation, and then launched into my spiel:
“Before I let you rest, I want to cover one more thing. If you get worse, I want to know if you want us to try to keep you alive with a machine. This would mean putting a tube down your throat and putting you on a respirator. If your heart stopped, we would need to do CPR. This means pounding on your chest, probably breaking ribs. If you would rather not go through this, which would be reasonable given your age, the alternative would be for us to concentrate on your comfort and allow you to pass away peacefully.”
Or something like that.
The utter failure of the conversation was exacerbated by the fact that the patient spoke only Italian, my Italian was elementary, and my translators were her increasingly distraught daughters. Oh, and my pager was going off incessantly. I headed back to my call room leaving behind a patient and family fretting about the hospitalization (and an unsigned DNR form).
Daylight brought the usual post call clarity.
AS was little changed from the night before – a good sign. She was resting comfortably requiring only 2 liters per minute of oxygen. I met up with her primary care physician. I told her how frustrated I was by our discussion the night before. I said, with some assumed superiority, that a 95-year-old-woman with pneumococcal pneumonia should be treated aggressively but if she does poorly, we should let her go. Wasn’t that obvious? Dr. Z invited me to come along with her to see the patient.
After warmly greeting (hugging actually) AS, Dr. Z sat down next to the bed.
Mrs. S, you have a very serious illness. Dr. Cifu here did an excellent job caring for you last night and I think you will be OK but if your heart stops or you are unable to breath on your own, we will let you die naturally. Given your age and health, I think that is the correct way to proceed. Is that alright? Do you have any questions?
While watching the family nod and thank Dr. Z I remember thinking: Wait, what just happened? She’s not supposed to tell the patient what to do! Is this even alright?
Only with time did I understand the interaction. Dr. Z knew her patient well. She knew the right thing to do medically and knew what her patient wanted – not only what kind of care she did (and did not) want but also what kind of doctor she wanted at that moment.
This conversation was a turning point for me. I had sat through a dozen or so lectures on clinical medical ethics. I had read about paternalism (anathema in the early ‘90s), patient autonomy (which had, for a time, been accepted in the extreme) and shared decision-making, in which the doctor outlines what medical care can be expected to achieve and how harm can be avoided[ii] while the patient articulates his or her values, treatment preferences and image of a future self.[iii] A successfully collaborative plan of care incorporates medical realities, uncertainties and patient preferences.
The conversation between Dr. Z and AS was an ethics textbook coming to life. I had tried to present facts and demand that “my” patient incorporate these facts with her values and tell me how to care for her. What I failed to appreciate could have filled another book.
Medical facts are seldom facts. They are likelihoods, often drawn from flawed data, applied to the infinite variety of patients and their situations.
A patient, dealing with illness, in a completely foreign situation, often needs assistance articulating and applying his or her values and wishes.
And sometimes paternalism or pure patient autonomy aren’t so bad. There are situations, usually desperate ones, where a doctor who understands the intricacies of the medical situation, knows the patient well, and is truly working in her patient’s interest will make the best decisions. There are other times where only a patient really knows what he wants and why. He may not be able to express himself clearly, certainly not in a way that makes sense to the medical team, but a competent decision maker sometimes needs to make the “crazy” but correct, decision.
Not every conversation that you learn from comes with an epic life and death story. My best continuing medical education continues to be eavesdropping on my colleagues as they teach their students. Not only do I learn medicine, I also see which teaching approaches work and which don’t. It is much easier to be an actual third person, listening in on a conversation, than to be a virtual third person, mindfully observing your own mentoring.
When mindfulness does work, it is when I can use an interaction with a patient as a memorization aid. As every medical educator has said, it is easiest to remember the facts about a disease when it is associated with a human being (rather than when it is associated with a page in Harrison‘s or UpToDate). When I read about a disease, I try to apply every fact to the case that sent me to the literature. What is it that I need to know for this patient? What would need to be different about this case for the factoid I just read about to apply? Hepatitis C, Pott’s disease, multiple system atrophy, risk-reducing oophorectomies and almost every disease in my “diseases just learned” thread immediately brings to mind an actual human being, a person for whom I was fortunate enough to care.
AS survived her hospitalization. It was a more complicated stay than I expected. I still thought the outcomes of a hospitalization were black or white, dead or alive. After seven days in a hospital room with urinary retention, antibiotic associated diarrhea and atrial fibrillation, she spent another 2 weeks in a rehabilitation hospital trying to regain her independence. At her post hospitalization visit with Dr. Z she was clear, “Never again.” Actually, “Non lo farò mai più.”
AS died 6 months later, at home, with her daughters, of an undiagnosed infection. It was not even necessary for Dr. Z to be involved in her care. Her daughters called, explained that their mother had a fever, was confused and hard to arouse. They were certain that the correct thing to do was to keep her at home where they could assure her comfort and dignity.
Lifelong learning demands energy and curiosity. It also demands good hearing and a willingness to eavesdrop on your colleagues as they care for patients and teach tomorrow’s doctors.
[i] The authors of the text cited above, Osler’s Textbook Revisited, point out that Osler’s own view of pneumonia changed over his life. He initially referred to it as “the special enemy of old age” and only later, as he was aging, did he begin referring to it as “the friend of the aged.” William Osler died of pneumonia at the age of 70.
[ii] These days, increasingly educated patients bring information on these topics.
[iii] For those decisions analysis aficionados, I often see this balance as the physician providing the probabilities while the patient provides the utilities.