Stop Treating Your Patients Like Things
I'm in a hospital room on a random Thursday afternoon. It's sunny outside, but the tightly drawn shades mixed with the glow of the muted TV (playing a friggin Joel Osteen infomercial of all things) gave the room an eerie mood. There's a familiar "stale and musty" smell that's common to any hospital room which has been occupied for a few days.
In the room with me is a pharmacy student, a medical resident, and an attending heme/onc physician.
There's also a 42-year-old single mother of two girls. We had just told her that the breast cancer she thought was "cured" had come back with a vengeance and spread to several parts of her body. She needed to start second-line chemotherapy as soon as possible.
She was crying. A lot. Worried about who would take care of her daughters. Of course, she was going to do the chemotherapy. She had to, for her girls. But she was afraid and worried. She wasn't sure how to tell them. The attending sat on the bed and rubbed her knee over top of the thin hospital blanket. Trying to console her and give her strength. To reassure her that her prognosis still had hope.
A few minutes later, we were in someone else's room. His bilirubin had increased 3x over the past couple of months. His skin was yellow and bloated. We told him that a recent scan confirmed that he had new liver mets. His family was in the room; some of them fighting back tears, others openly sobbing. He sank back into his bed as if completely exhausted. He looked defeated.
Next, there was another room. This person's lung cancer had spread so much throughout his body that a scan of any particular region of it lit up like a Christmas tree. You might say it was "PharmD positive," because if a pharmacist can interpret a CT scan then something is seriously out of whack. Outside of the room, the person's brother frantically pleaded with the doctor for radiation. “Anything that could help.” The doctor tried to explain to deaf ears that radiation would not work here and that it was time to let his brother go peacefully.
Alright, end scene.
Sorry to lead off with a down note. But these people and their stories have been on my mind recently. And they’ve had me thinking about some things.
As healthcare workers, we toe a gray, fuzzy, and contradictory line.
On the one hand, we give our all day in and day out to care for people (like the ones described above). We strive to improve their health and well-being. We empathize with them.
We sacrifice a lot of ourselves in school and residency to build up the knowledge to be able to care for these people. It's a lifelong pursuit of service. Many of us have known that we wanted to be a doctor/nurse/pharmacist since we were little kids.
On the other hand, there's a part of every single one of us that treats these people (the same ones we've dedicated our lives to serving) like things.
Let me 'splain.
In order to comply with HIPAA laws (and for logistical reasons), we call the people we take care of "patients." There are some variations of this, of course. In the operating room, we call them "cases." On the inpatient side, we may call them "467" for their room number. In a dialysis or infusion center, they're called "Chair 16." And finally, we may just call the person by their medical diagnosis, such as "The uterine prolapse on the 7th floor."
These monikers make it easier for health care professionals to talk to each other clearly. It’s especially useful for differentiating patients with similar names on the same floor. It also is a HIPAA requirement, as we can't go around yelling about "Mr. Smith's new diagnosis of HIV."
This all is practical and makes sense. I am not arguing that we should stop. Privacy matters in our world, and we are entrusted with a great deal of secret and personal information about the people we take care of. We need to keep it safe.
That's not what has been bothering me. What has been nagging at me (like an itch on the bottom of the foot) is what happens inside of our own heads when we think about our patients this way.
Quite frankly, we strip them of their identity. They stop becoming “Mrs. Thompson, the retired high school teacher from Wisconsin whose favorite joy in life is playing with her 2 grandsons.” Instead, Mrs. Thompson becomes “the laparoscopic cholecystectomy on the 5th floor that developed an abscess post-op.”
In our mind, even if only subconsciously, Mrs. Thompson just became a little bit less of a human being. We ignored all of the life experiences and trials and tribulations that made her who she is. We forgot about the family that loves her and looks to her as the matriarch of their clan.
I think this is especially prevalent with difficult cancer or psych diagnoses. Have you ever engaged in water cooler talk with the social workers and doctors about the terminal 28 year old with glioblastoma whose parents just need to let go?
“We’re not doing anything for her medically…she’s been here for weeks.”
Or about the homeless drug addict whose here yet again with another round of MRSA cellulitis?
“Ooh! Maybe he’s got osteo this time and we’ll have to amputate!”
How about the alcoholic bipolar patient who just came in with another failed suicide attempt?
“Doesn’t she just need to end it for real already?”
All of these people have families (even if broken ones). They have interests and hobbies. There are things that make them unique. There was a time when that 28-year-old glioblastoma patient was her parent’s greatest source of hope and inspiration. She was their gift to the world. How can they just “give up” on her and let her die…even if every treatment option has been exhausted?
These are difficult scenarios to work with as health care workers. In a way, identifying the person only by their medical diagnosis or room number creates a sort of psychological barrier between them and us. It keeps us from getting too attached. It allows us to do our jobs without breaking down into tears.
What I worry about is that it also makes us care less about the person.
And if we care less about the person, we’re going to be a little bit less attentive to their needs. We’ll be more likely to see them as a “collection of lab values and a list of drugs” instead of “a father of 3 girls and sole financial provider for his family.” We might even see them as an inconvenience that throws our workday off track.
Paul Sax, MD, author of the fantastic blog HIV and ID Observations (I totally recommend subscribing to that), once wrote about working 28-hour shifts as a medical intern. He expressed a similar sentiment:
“…the long hours and fatigue could made us look at the patients not as the human beings we should be trying to help, but as components of assembly line work.
It's this last point that, as an intern, bothered me the most. One mid-winter night — I was already a six-month "seasoned" intern — I'd finally had some time to sleep in the hospital call room. Then at 2 a.m., my beeper awakened me, indicating I had another admission waiting for me in the Emergency Room.
It was a man in his 60s with metastatic lung cancer, brought in by his daughter because he was having seizures. The oncologists had already told him that there was no more therapy available. It promised to be a very challenging admission, one filled with both difficult medical decisions and tough discussions about death and dying.
And my first thought? Not, "how can I help this poor man?" Not, "how can I console his daughter?" who was crying in a chair beside his bed. It was, "why did he have to get sick during my call night?"
Whatever stage of training you are in as a pharmacist (or whatever field of healthcare you work in), have you ever been a patient? Or have you ever been the family member of a patient? What did you notice?
I once went through a pretty terrible experience as the family member of a patient. Here's what happened...
A couple of years ago, my mother passed away in a MICU after about a week of progressively worsening organ dysfunction. It was the first time I noticed that there are two different versions of me. And both of them were present in that "state of the art" hospital room.
Pharmacist Brandon was looking at the numbers. I stepped in and listened when the team rounded every day. I looked at “the patient’s” blood pressure and thought “Oh no! They had to increase the rate on her Levophed drip last night.” When she started going in and out of afib, Pharmacist Brandon knew the battle was lost and it was just a matter of time. Even if she ever got out of this hospital room, her life would forever be altered by the medical care she’d need.
Pharmacist Brandon wasn’t happy, but he knew that “it is what it is” and that nothing else could be done.
Also present in the MICU room was Loving Son Brandon. Pharmacist Brandon tried to keep him away (I had to “be strong” and supportive for my brother and my mom’s SO), but Loving Son Brandon would show up just the same.
This is the woman that birthed me (she went into labor with me on her birthday, no less). She raised me. She provided for me. She helped me navigate my way through this crazy maze called life and made her mark on who I am today.
Loving Son Brandon didn’t know the battle was lost. Loving Son Brandon just wanted his mom to go back home and for things to be like they used to be. He didn’t want to let go, and he didn’t want to say goodbye.
Loving Son Brandon had a very shitty week filled with a lot of tears.
It took an earth-shattering experience like that for me to realize how much control I let Pharmacist Brandon have when I’m at work. Before that week, I didn’t even know there were 2 versions of me.
But awareness is the first step to remedy.
It’s not that Pharmacist Brandon no longer exists. He needs to. And your version of “Pharmacist You” or “Nurse You” or “Doctor You” needs to exist too. The people you take care of every day need an objective mind not clouded by emotion to make the best possible medical decisions. You need to be sharp to notice the early signs of sepsis or the potentially harmful drug interaction before dispensing the new prescription for amiodarone. Plus HIPAA. Don’t forget about HIPAA.
But the “Loving Son/Daughter” version of you also needs to exist (and needs to come to work with you from time to time).
Make sure a part of you remembers that the obnoxious and rude person in your waiting room is much more than the “guy waiting on the Klonopin” (yes, even if he’s trying to refill it a week early because the cops stole it and he’s going out of the country for a month and his flight leaves in 2 hours).
The person with lung cancer who still won’t stop smoking (because who the hell are these people to tell me what to do?!) has a family that loves her. She has a job and a life outside of her medical diagnosis. She likes to garden. She loves going out to the bar with her girlfriends to grab a beer and some wings and watch the Browns game.
I’m just kidding. No one likes to watch the Cleveland Browns.
To put all this another way, you are better at your job when you let the human side of you have some presence in your working life. Remembering that each patient has their own story will make you review their med list for drug interactions and renal adjustments just a little bit harder. You’ll care a little more and act with a little bit more urgency. You’ll be just a little more accommodating.
Professional You still needs to predominate, but make sure to save some room for Human You. The people you’re taking care of (and their families) will thank you for it.