Seeing patients as 'gold nuggets in a muddy stream'

October 22, 2010

When this physician remembers to focus on the patient, on the person with a serious need, time stands still, money issues fade onto the horizon, and things are as they were when he graduated a number of years ago.

Two years ago, I felt betrayed by medicine. I was practicing in a busy emergency department (ED) that sees more than 70,000 patients a year, and the reality of the job I was doing looked nothing like the dream of a profession I had envisioned a quarter of a century earlier when I took the Hippocratic Oath at graduation. That was when I wore a cap and gown, the dream of becoming a doctor tinged with thoughts of dignity, autonomy, collegiality, and, most importantly, compassion. A picture of Sir Luke Filde's "The Doctor" surely would hang in my office to reflect my ideals.

In a scrub suit a few decades later, the reality was much different. Instead of appreciating the dignity of being a physician, I was privy to a conversation around the main desk in which 3 physicians said that they no longer tell people they are an emergency physician. One of them, when asked why he hesitated to be forthright, responded, "Well, just look at the press we receive."

Instead of autonomy, most physicians agreed that, now, we operate with our hands cuffed behind us while having a sense that someone with a clipboard is hovering over our shoulders, recording our decisions and outcomes.

Instead of compassion, probably the most important trait of any fine physician, I unwittingly had adopted the detached and slightly cool demeanor that most physicians around me had learned to display when approaching patients.

And instead of Sir Luke Filde's timeless portrayal of a physician at a sick child's bedside hanging in our office, we had a bulletin board filled with articles about failed tort reform, decreasing enrollment in our state ob/gyn residency programs, and the effect of undocumented workers and the uninsured on healthcare costs.

EPIPHANY AT THE LOTTERY COUNTER

One day, about that same time, I found myself buying a lottery ticket on the slim chance that I could change my life's circumstances. Standing at the counter, I abruptly realized 2 things: my job satisfaction should not revolve around a lottery ticket's success, and something had to change.

After a few days of thinking about things, I realized that although we live in a society in which we want fast, top-quality, and cheap medical care without realizing-as former Surgeon General C. Everett Koop Jr., MD, once said-that we can only ever have 2 of these things at one time, patients are unlikely to mutate into the Marcus Welby patient caricatures I want them to become.

Patients' expectations about medicine changed from the 18th century to the 19th century, from just the 1940s to the '80s, and no doubt they will continue to evolve as time goes on. So perhaps my approach to patients also could change, I reasoned.

One thing that had not changed among patients was their desire to be heard and treated as individuals. Nothing was evolving away from this paradigm, so far as I could see, so maybe this was something I could hang my hat on. Maybe instead of feeling like a doormat and a drone in a hive of busybodies, I could search for the wheat among the chaff, the occasional patient truly in need of the services I dreamed I could provide when I graduated from medical school.