Volume 8, Issue 5: Medicus
We sat, birdlike, hunched over his tray with a thin gray stream of mucus draining from his nose into the bowl of partially eaten oatmeal resting on the tray. The five of us, four residents and one attending doctor, huddled around his bed as though he were a football. As one of the resident doctors, my fear level was on par with the patient. Somehow I had to impress the attending doctor that I knew what was going on here, and I wondered if he was also listening to a tiny Voice in the back of his head that was saying, "Assuredly, I say to you, inasmuch as you did it to one of the least of these My brethren, you did it to Me" (Matt. 25:40). The patient's most pressing problem, a never-ending bowl of oatmeal, was the farthest thing from our minds as we probed into his family tree, identifying problems known to be passed from family of origin. Next we explored his social situation, family history, employment, health habits, including the good ones like whether he wore his seat belt, and whether he exercised and ho
w much, as well as the bad ones like how much he smoked and what and for how long, and how much he drank and what and for how long. And here we launched into a long discussion of how his family history affected his social history, since his having one alcoholic parent would make him forty times more likely to be an alcoholic and having both alcoholic parents would make it four hundred times more likely that he would be an alcoholic. Here the tiny Voice was saying something about blessings and curses being to generation after generation. We covered his dietary habits including how much fat, cholesterol, coffee, tea, and pop passed his lips, as well as whether he had a satisfying relationship with his wife. His past medical history provided the usual array of previous surgeries, hospitalizations, allergies, and current medications. From there we pursued a review of his current signs and symptoms. We were interested in any symptom he had experienced from
the top of his head to the bottom of his toe. Then, after a thorough physical exam, we were armed to generate a problem list that might explain how this guy ended up at the fountain of oatmeal.
This is where we tried to think of every conceivable disease process which might contribute to this clinical situation. The emphasis here is on "every conceivable." The tautology that common things occur commonly is nowhere more apparent than in the practice of medicine. However, the pathway in the brain where common things are stored must be very near where the boring things are stored. No self-respecting physician wants to diagnose a common cold. It is much more interesting to come up with something like Legionnaires' disease. The search for the "every conceivable" traverses the unlikely to the just plain impossible. But, after the list is made and coddled, tests are planned to "rule-out" the various possibilities. This process can be done in a hurry if the situation is pressing, or it can be done over weeks if there is no urgency. The characteristic which does not vary is the cost. The onus for the medical team is to find an adequate explanation for
the clinical situation, prove it through the use of laboratory, and/or radiological tests, and launch an arsenal of therapeutic modalities designed to restore health, whatever that is. Often patients find themselves fighting problems they didn't know they had with solutions they don't want--all to the tune of a health care budget that is waxing much faster than the problems addressed are waning.
Complicating the scenario above is the legal field, whose motto is "leave no stone unturned." Armed with weapons like "current standard of care" and "what would a reasonable physician of your training and experience in this part of the country do in this situation," they have invaded the practice and psyche of physicians to insure that whatever can be imagined is done. Physicians' lounges echo with the words "I have never known of a physician sued for doing X, Y, or Z, but I have known someone who was sued for not doing X, Y, or Z." The inertia of the medical establishment, goaded by the legal profession, is action-oriented. Diagnose, test, and treat are the options, and the more the better. Too much is acceptable, not enough is culpable.
As our huddle disbanded and we prepared to leave the patient's room, the family of the old gentleman arrived to give us their charge: "Do everything possible. We just want Grandpa back." Unstated, but clear, was the instruction that we want grandpa back like he was, i.e. taking care of himself or in a nursing home. But not interrupting our busy, (read hectic) lives. So the family echoed the inertia of the medical and legal professions. Too much is acceptable, not enough is culpable.
Somewhere in the back of my head the still small Voice was saying, "Do not lay up for yourselves treasures on earth, where moth and rust destroy and where thieves break in and steal; but lay up for yourselves treasures in heaven, where neither moth nor rust destroys and where thieves do not break in and steal. For where your treasure is, there your heart will be also" (Matt. 6:19-21); "For our citizenship is in heaven, from which we also eagerly wait for the Savior, the Lord Jesus Christ, who will transform our lowly body that it may be conformed to His glorious body, according to the working by which He is able even to subdue all things to Himself" (Phil. 3:20, 21). Oh, and by the way, read Psalm 91 before you go to bed tonight.
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