With about a year’s worth of experience practicing medicine I can say with certainty that I've got a lot left to learn. I'm a medical student in my final year. In Estonia we cover all subjects by 5th year and in the 6th year we practice. I applied for medical license back home in Finland that allows me to practice medicine with a designated consultant. Having a consultant helped me learn clinical medicine quicker and avoid bigger medical errors. The lessons I've been learning the hard way are related to how I approach practicing medicine.
1. “Don’t blame the sick for being sick.”
That's the first piece of advice to doctors in the Oxford Handbook of Clinical Medicine. It really resonated with me because I realized I was judging some patients.
I started doctoring in a small hospital department. The department had a lot of multimorbid patients. I found patients with lifestyle diseases to be the most challenging. Lifestyle diseases are those with a clear link to harmful lifestyle, for example smoking is linked to COPD and overeating to obesity. Treating the exacerbation of COPD in a current smoker felt like plugging holes in a sinking ship. The patients didn't seem interested in helping themselves and that frustrated me.
The biopsychosocial etiology of disease is important. Let's take a smoker, for example. If they grew up poor, that increases their risk of becoming a smoker. Their parents might have smoked, maybe all their friends did. Maybe the smoker was prone to addiction from birth. This smoker could, because of all these factors end up smoking for their whole life and get COPD. Eventually their COPD would exacerbate, and they might need hospital care. While at the hospital that patient might go out to smoke regularly because they are addicted to nicotine. The revelation for me, semi-obvious in retrospect, was that it’s not that patient’s fault that they are sick.
It's easier to blame a patient than to help them with a sticky problem like nicotine addiction. The minute I blame a patient for a lifestyle disease I give up any responsibility for helping them with it. Blaming makes me cynical and unhappy. Understanding that disease is not a patient’s fault makes me optimistic and ready to look for solutions.
2. "You're not an inexhaustible resource."
Another gem from the Oxford Handbook that I often forget. There's a limitless supply of patients and I feel obligated to help as many as I can. Giving as many patients as possible the best possible care is a simplistic approach.
The problem is the law of diminishing returns. It's an theory in economics that I'll try to apply to medicine. In production there are inputs and outputs. Employees (input) create a product (output). If we increase the number of employees the relative return (product per employee) will increase because employees can work together to be more productive. Eventually, however if there are too many employees they'll be bumping into each other and the relative return or productiveness decreases.
In my medical version of the model my input is hours spent working and the output is the total care provided (no. of patients and quality of care). The more I work overtime, the less I'm able to connect with patients. My medical reasoning skills also take a dip after a full workday. So, for each additional hour I put in relatively less care is provided because I'm slower and the quality of care is worse. If I work say over 24 hours, I might start causing harm (negative returns).
While working in the ER I'm typically surrounded by a couple doctors dictating, nurses updating us changes in our patients' condition and occasionally a delirious person crying out in the background. My first night shift was tough. I was up all night treating patient after patient. Trying to look at an ECG or take a history at 4 AM was like trying to calculate an integral with severe brain fog. I was getting slower and slower. I didn’t want to listen to patients. I wanted to take a hot shower, sleep and forget about the whole thing.
Despite realizing diminishing returns I am often tempted to reserve more ER shifts. I feel useful in the ER and it pays well.
Hospitals and clinics will treat you like an inexhaustible resource if you let them. You might treat yourself like an inexhaustible resource. I do from time to time. Any extra hours you're willing to commit, your employer will be happy to accept. I try to keep this in mind and not overcommit myself when possible.
3. "Living with blood splattered armor."
I want enough time to thoroughly examine and talk with a patient, consider the diagnosis, the differential and treatment. It feels better to know I've handled one case thoroughly rather than five cases hastily. The problem is time.
In the internal medicine department I had anywhere from 10-13 patients. In the ER my list could have 5-10+ patients on it. In family medicine I would have plenty of appointments, nurse consultations and of follow-up phone calls throughout the day.
The Oxford Handbook authors share some good wisdom on the subject. They say when you start practicing, your metaphorical armor is shiny. After only a few weeks it is stained by the fallout of the decisions you make without sufficient consideration. They also point out that demanding perfectionism of yourself is like signing a death warrant for you and your patients.
There's clearly a time pressure in clinical medicine. Working like a perfectionist on each patient is potentially at the expense of other patients who may have a greater need of medical attention. It also means a lot of overtime. However, the cost of being fast is the possibility of missing something.
Having a consultant isn't a fool-proof means of avoiding all mistakes and their consequences. I remember a few cases when other physicians reprimanded me for not being thorough enough.
Accepting imperfection and knowing what level of diagnostics and care is thorough enough is the hardest lesson I've tried to learn. I used to spend a lot of my time after work worrying if I’d missed something when I'd had a hurried day. After work I try to practice acceptance of my worries and the circumstances in which I work. Acceptance helps me sleep better, which makes me a happier, healthy person willing to learn from my mistakes.
You don't have to be a jerk to get stuff done.
It's a great line that I'm paraphrasing from Patch Adams. Working in medicine can be nerve-racking. It helps me to relax and smile once in a while.