Two Young Fish

As many of you know, I like to retreat to my asylum of books and articles regularly. If you’ve had a conversation with me for more than ten minutes, you’ve probably heard one of my tangents on healthcare, child psychology, or my favorite books. Most of you know that my favorite authors are Hemingway, Oliver Sacks, and David Foster Wallace.

My favorite speech is David Foster Wallace’s 2005 commencement address to Kenyon College. It’s a common favorite, particularly among students who attend liberal arts colleges. It serves as a nice meditation on the truths and “Truth” we experience in life – a meditation on avoiding self-absorption and arrogance, a reminder to employ conscientiousness in daily living.

I’ve been thinking a lot about two fish.

Wallace opens his address:

“There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says ‘Morning, boys. How’s the water?’ And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes ‘What the hell is water?'”

Wallace asking "What the hell is water?" maybe. Unlikely. Steve Rhodes - Wikimedia Commons

David Foster Wallace
Steve Rhodes – Wikimedia Commons

I spend a lot of time thinking about death and dying. I don’t mean that in a morbid way, but rather, I am simply hyper-aware of the fact that my future career exists because of death and dying, specifically.

All of the students here are dealing with issues in bioethics, a topic that frequently presents emotional challenges. I think that all of us, to some degree, think about and are affected by these topics.

It’s tough listening to patients grappling with a surgical procedure, trying to measure the benefits of surgery with intense risks. It’s even harder when you don’t know if that patient has full mental faculties and has no family to contact to make an informed decision.

It’s difficult looking at photos of face transplant transitions. Many of these people have horrific stories – bear attacks, shrapnel from war, or chemical burns. They have been stripped of markers of personal identity. Hand and face transplants are new, emerging practices, and these forms of transplants are unheard of with children.

Biomedical ethics must shape the best policies, but the field is venturing into unknown territory. I’ve had the privilege of getting to know Adam and the other students more this summer, and while Adam may be insufferable to grocery shop with, I admire everyone’s ability in remaining conscientious in approaching these tough topics.

I’m not uncomfortable with my projects. I’m excited by them, really.

But one thing that I have thinking about is the fact that once these papers are published and my name is on them – once I have that new line to put on my résumé – some physicians may use this information to change their practice. I see this particularly with my systematic review on risk prediction on acute kidney injury and end-stage renal disease.

I’m not saying that as an undergrad that I have some huge, lofty power. I am, however, given a great deal of independence here to work and pursue my interests comfortably and on my own terms.

I am trying to convey the fact that my name will be on a paper that may cause physicians to change their care practices. The aim of this paper is to explore outcomes in mortality, quality of life, and economic aspects of dialysis treatment vs. no dialysis treatment.

I hope that I have had enough qualifiers and supporting statements before I lead into this next thought.

If those physicians do indeed change care practice, they may not recommend dialysis treatment for a patient. They may communicate with the family that they can’t expect good outcomes. This review may make clinicians pause before recommending dialysis.

The academic-looking-at-schools-after-Davidson-freaking-out-about-grade-deflation student in me is pleased that I will be contributing to a paper of this much depth and influence. I don’t even disagree with the end-goal of the paper; I support its larger ideological backing on an “uncomfortable” topic (that maybe we should consider how prolonging life can lead to severe decreases in quality of life). But the fact that my name will be on a paper that clinicians may use to recommend or not recommend life-sustaining treatment?

That’s heavy.

This is a new area for me. It’s not one I expected to be in at 20 years old.

I want to make it clear that I am fully committed to my projects and am willing to take on any associated challenges. Today, I read 800 titles of articles relating to absolute mortality for acute kidney injury, chronic kidney disease, and end-stage renal disease. I’m simply writing this tonight because I think that in order for me to go into this field, I need to be able to balance handling this information while still not being “too caught up” with it.

6292 articles on the wall..

At the end of the day, 800 titles on death and dying later, it can be hard to remember the end-goal. I have to remember that these study participants are real people in real hospitals with real pain. I can’t just sort these studies into “Include,” “Exclude,” or “Maybe” (group criteria for the review) without giving them proper thought and care.

And so this brings us to “the art of medicine”.

I talk a lot about evidenced-based medicine, yet I am more deeply concerned with the art of medicine. The practice of medicine, and the rest of the health care disciplines, is deeply rooted in the scientific method, in systems, and in theories. We now see an emergence of “checklists” (come on, we’ve all used WebMD before) in attempt to standardize medical care, despite the rapidly changing profiles and needs of patients.

If the goal of health care is to provide the best care (“the needs of the patient come first”), is it not, perhaps, odd that we have standardized patients and condensed backgrounds and experiences into a checklist?

We demand physicians to provide effective and efficient care. We demand for them to have answers, as if they are infallible. We want structure and competence.

But what about the individuality of each patient? What happens when you leave the lab and step into the waiting room?

I’m in the weird lobby, somewhere nestled between the two.

In a study published by Family Practicethe authors note that patients’ dissatisfaction with consultation lengths with their physicians can actually be managed by making consultations longer. You would think that patients simply want to be in and out of the office with a prescription slip, but patients value a doctor who listens and tries to understand them. In addition, patients are more likely to follow recommendations from an attentive doctor.

Patients want to be treated as an individual and not as an insurance billing opportunity. Patients can feel neglected in strive for a medical standardization.

People want others to care about their problems.

Dr. Brian Yeaman, CMIO, of Norman Regional Health System writes for Nuance:

“The art of medicine has always been just that: an art.  It’s about listening to your patients, bridging questions, answers and observations with clinical knowledge to form a diagnosis, and developing a treatment plan that is then documented in a progress note… For someone who has dedicated his or her life to practicing the art of medicine, being asked to distill a patient visit into a series of check boxes can seem reductive, administrative and, at times, irrelevant to the most important aspect of healthcare — the capture and sharing of the patient’s story across the care continuum.”

Healthcare change is looming and we, as a collective society, are about to be thrown into a massive overhaul. Perhaps, with those changes, we lose some of the artistry of medicine. In a pursuit of checklists, reimbursement forms, and standardization, we deviate from the heart of medicine itself. The patient-physician relationship is complicated.

We view the patient as a number with a checklist of symptoms.

As I’m swimming around in my cubicle asking myself, “What the hell is hypocalcemia and hyperphosphatemia with secondary hyper-parathyroidism?” understand that I’m still asking, “What the hell is water?”.

Tomorrow, I’ll try to read another 800 titles, and I hope that I am able to employ the necessary attention and professionalism when thinking about others. I hope that I’m able to find a balance between the artistry and science.

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2 thoughts on “Two Young Fish

  1. When you said “massive overall, ” did you mean “massive overhaul'”? And why do you think that’s “looming” and not already here?

    • Good catch – I’ll fix that now!

      I suppose that I say looming because I feel that, in the future, the ACA will be accepted into American society the same way FDR’s Social Security Act was. We still have political debates every year regarding social insurance, social welfare, retirement age, spousal benefits, etc., and so we do see changes made every year (Medicaid and Medicare, in particular). Yet, overall, I think that you’d be hard-pressed to find to find someone who was totally opposed to some form of social insurance at every level.

      I think that the ACA will go the same way. I think that it’s also difficult to find someone who is totally opposed to providing public insurance for needy individuals. Sure, we may debate to what extent, what fines should happen, what it means for healthcare regulators, premiums, pre-existing conditions, etc., but when it boils down to the “spirit” of the law, people are beginning to agree more with its principle. Yes, the ACA is in effect, but it’s going to be a point of debate for years with new changes, additions, and provisions.

      Courts will, inevitably, have to debate questions on provisions for some time (contraceptive court challenges started in 2010, as you know), much the same way we see insurance challenges every year. I think more could be said about possible conflicts with EMTALA, Federal Employees Health Benefits Program, federal deficit, undocumented immigrants, and we’ll have to see policies in the future with supportive physician language.

      Completely unrelated, but isn’t in interesting how Sebelius’ resignation is going quietly? Burwell was President of Walmart, involved with the Bill and Melinda Gates Foundation, and the director of MetLife. Looks like we’ll be seeing her name in the case dockets now!

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