Limits

Those of you that have read my previous communion meditation have heard me talk about limits. The stark reality of critical illness causes these limits to be displayed most prominently. There is no denying your limits when the patient worsens in front of you and you have no answers. It is undeniable.

The idea that we don't have limits in all other aspects of medicine is pervasive, however, and ridiculous. People are like that, though. We will always deny what we can't do until it becomes immediately obvious that we can't do it. Happens in all other aspects of life. Politics, business, all the same. "Sure, I can get that order done by tomorrow." "Read my lips, no new taxes." We've all heard it. We've all fallen for it, and yet medicine still gets away with it.

There are very practical implications to refusing to acknowledge our shortcomings as a profession. Our stubborness translates into real dollars and cents, real resources wasted in the delusional pursuit of ends that we claim to be able to reach yet lack the tools to reach them. 

End of life is the most obvious case study of this. What do you do if someone is dying but you view death as failure and merely a manifestation of some other lesser physician's previous mistakes? You burn through resources, that's what. You throw the kitchen sink at the "problem." And then? The patient dies. Every time. Without exception. 

It's an oversimplification of course. Some folks are critically ill and will recover wonderfully. We can't perfectly predict who will recover and who won't, but we certainly have a good idea sometimes. More importantly, and more central to what I want to say today, we often know who wants to use those resources and who doesn't.

Informed consent was initiated in the noble pursuit of joint decision making and patient autonomy. Why don't we tell the patient all the possibilities and let them decide? Sounds nice. It's imperfect, though. How do I adequately explain the risks and benefits of a procedure that it took years of school and training to master and understand? Explain that in ten minutes? Forget about it. Its a farce.

No matter how many forms you get patients to sign saying they understand everything and have made the decision all by themselves, physicians will always play a central role in making patients' medical decisions. Sadly, this is where physicians' refusal to acknowledge our limits most hampers, and dare I say harms, our patients. What do you do if a patient is wavering on a procedure that could prolong their life if you believe that death is failure and only happens if you allow it to happen? You push. You cajole. You tell them how they really want the procedure, how it will help them.

Patients will relent usually. They trust their physicians. However, they won't be better for it. Unlike physicians and their God complex, most of the patients that I have cared for do not view death as failure. They view death for what it is. Inevitable. If we are really acting as a medical fiduciary for our patients, then how should this affect our decision making? Should we make decisions based on our personal views of death or our patients?

If we accept that our patients views of death and disease are more important than our own, then this begins to have every day implications. Do you use low value tests and procedures that often result in much lower quality of life with minute quantity of life gain? Probably not. Out the window goes "routine" blood tests every three months, a lot of heart caths and CT scans. Costs come down. Patients receive care more in line with what we know works the best.

From an individual physician standpoint, the trade off comes in time. It will take serious time to explain to patients why they don't need a test. Much more time than to simply order the tests. As in all situations, inaction must be explained more than action, even when inaction is the correct action. That means a lot more of our day sitting in exam rooms simply talking to patients, learning their views and preferences. We must know the whole person if we are to consider the whole person in our decision making.

That should be no problem, though. Most physicians indicate that they got into medicine for the purpose of knowing and helping people. So spending large amounts of time talking to patients and not ordering tests that can make you more money should be second nature, right? Let's hope so...