In a sense, then, the physician's dodge is inevitable. Learning must be stolen, taken as a kind of bodily eminent domain. And it was, during Walker's stay - on many occasions, now that I think back on it. A resident intubated him. A surgical trainee scrubbled in for his operation. The cardiology fellow put in one of his central lines. None of them asked me if they could. If offered the option to have someone more experienced, I certianly would have taken it. But that was simply how the system worked - no such choices were offered - adn so I went along. What else could I do/
The advantage of this coldhearted machinery is not merely that it gets the learning done. If learning is necessary but causes harm, then above all it ought to apply to everyone alike. Given a choice, people wriggle out, and those choices are not offered equally. They belong to the connected and the knowledgeable, to insiders over outsiders, to the doctor's child but not the truck driver's. If choice cannot go to everyone, maybe it is better when it is not allowed at all.
This is, I suppose, what the public relations professionals would call networking. But the word misses the essential hungriness of the doctors on those buses, and throughout the convention, for contact and belong. We may have each had good practical reasons for coming here: the new ideas, the stuff to learn, the gizmos to try, the chasing of status, the break from the grind of unending responsibilities. But in the end, I came to think, there was also something more vital and, in a certain way, poignant drawing us in.
Doctors belong to an insular world - one of hemorrhages and lab tests and people sliced open. We are for the moment the healthy few who live among the sick. And it is easy to become alien to the experiences and sometimes the values of the rest of civilization. Ours is a world even our families do not grasp. This is, in certain respects, the experience of athletes and soliders and professional musicians. Unlike them, however, we are not only removed, we are also alone. Once residency is over and you've settled in Sleepy Eye or the northern peninsula of Michigan or, for the matter, Manhattan, the slew of patients and isolation of practice take you away from anyone who really knows what it is like to cut a stomach cancer from a patient or lose her to a pneumonia afterward or answer the family's accusing questions or fight with insurers to get paid.
Once a year, however, there is a place full of people who do know. They are everywhere you look. They come and sit right next to you.
Neff recognizes at least four types of behavioral sentinel events:
1. There is persistent, poor anger control or abusive behavior.
2. There is bizarre or erratic behavior.
3. There is transgression of proper professional boundaries.
4. And there is the more familiar marker of incurring a disproportionate number of lawsuits or complaints.
The explanation of pain that has dominated much of medical history originated with Rene Descartes, more than three centuries ago. Descartes proposed that pain is a purely physical phenomenon - that tissue injury stimulates specific nerves that transmit an impulse to the brain, causing the mind to perceive pain. The phenomenon, is like pulling on a rope to ring a bell in the brain. It is hard to overstate how ingrained this account has become. Twentieth-century research on pain has been devoted largely to the search for and discovery of pain-specific nerve fibers and pathways. In everyday medicine, doctors see pain in Cartesian terms - as a physical process, a sign of tissue injury. We look for a ruptured disk, a fracture, an infection, or a tumor, and we try to fix what's wrong.
The degree of injury ought to determine the degree of pain, rather like a dial controlling volume. Pain was becoming recoginzied as far more complext than a one-way transmission from injury to "ouch."
All pain is "in the head" - and further that sometimes, no physical injury of any kind is needed to make the pain system to go haywire.
We should stop thinking that pain or any other sensation is a signal passively "felt" in the brain. Yes, injury produces nerve signals that travel through a spinal-cord gate, but it is the brain that generates the pain experience, and it can do even in the absence of external stimuli.
Pain and other sensations are conceived as "neuromodules" in the brain - something akin to individual computer programs on a hard drive, or to tracks on a compact disc. When you feel pain, it's your brain running a neuromodule that produces the pain experience, as if someone pressed the PLAY button on a CD player. And a great many things can press the button. A pain neuromodule is not a discrete anatomical entity but a network, linking components from virtually every region of the brain. Input is gathered from sensory nerves, memory, mood, and other centers, like members of some committee in charge of whether the music will play. If the signals reach a certain threshold, they trigger the neuromodule. And then what plays is no one-note melody. Pain is a symphony - a complex response that includes not just a distinct sesation but also motor activity, a change in emotion, a focusing of attention, a brand-new memory.
These drugs do: they tune brain cells to modulate their excitability.
Motion sickness occurs when there is a conflict between the motion we experience and teh motion we expect to experience.
The nausea and vomiting that comes with motion sickness may be a modern by-product of our standard system for expelling poisons and nutrturing avoidance of them.
Whether with living patients or dead, however, we cannot know until we look. Even in the case of Mr. Sykes, I now wonder whether we put our stitches in correctly, or whether the bleeding had come from somewhere else entirely. Doctors are no longer asking such questions. Equally troubling, people seem happy to let us off the hook.
From what I've learned looking inside people, I've decided human beings are somehwere between a hurricane and an ice cube: in some respects, permanently mysterious, but in others - with enough science and careful probing - entirely scrutable. It would be as foolish to think we have reached the limits of human knowledge as it is to think we could ever know everything. There is still room enough to get better, to ask questions of even the dead, to learn from knowing when our simple certainties are wrong.
Now, kindness will often involve respecting patients' autonomy, assuring that they have control over vital decisions. But it may also mean taking on burdensome decisions when patients don't want to make them, or guiding patients in the right direction when they do. Even when patients do want to make their own decisons, there are times when the compassionate thing to do is to press hard: to steer them to accept an operation or treatment that they fear, or forgo one that they'd pinned their hopes on. Many ethicists find this line of reasoning disturbing, and medicine will continue to struggle with how patients and doctors ought to make decisions. But, as the field grows ever more complex and technological, the real task isn't to banish paternalism; the real task is to preserve kindness.
The core predicament of medicine - the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of a society that pays the bills they run up so vexing - is uncertainty. With all that we know nowadays about people and diseases and how to diagnose and treat them, it can be hard to see this, hard to grasp how deeply uncertainty runs. As a doctor, you come to find, however, that the struggle in caring for people is more often with what you do not know than what you do. Medicine's ground state is uncertainty. And widsom - for both patients and doctors - is defined by how one copes with it.
Decisions in medicine are supposed to rest on concrete observations and hard evidence.
Another approach to decision making, one advocated by a small and struggling coterie in medicine. The startegy, long used in business and the military, is called decisoin analysis, and the principles are stargihtforward. On a piece of paper, you lay out all your options, and all the possbile outcomes of those options, in a decision tree. You make a numeric estimate of probability of outcome, using hard data when you ahve it and a rough prediction when you don't. You weight each outcome according to its relative desirability (or "utility") to the patient. Then you multiply out the numbers fro each option and choose the one with the highest calculated "expeccted utility." The goal is to use explicit, logical, statistical thinking instead of just your gut.
Human beings have an ability to simply recognize the right thing to do sometimes. Judgement, is rarely a calculated weighing of all options, which we are not good at anyway, but instead an unconscious form of pattern recognition.
How can this be justified? The people who pay for the care certainly do not see how. Nor might the people who receive it. People have proposed two strategies for change. One is to shrink the amount of uncertainty in medicine - with research, not on new drugs or operations but on the small but critical everyday decisions that patients and doctors make. Everyone understands, that a great deal of uncertainty about what to do for people will always remian. So it has also been argued, not unreasonably, that doctors must agree in advance on what should be done in the uncertain situations that arise - spell out our actions ahead of time to take the guesswork out and get some advantage of group decision.