The ‘superhero’ mantra physicians would love most to tout when asked what our work entails would likely be, “Saving lives and stamping out disease!” At the very least, that’s how the primetime dramas would like to portray it, and what we’d like to tell children on Career Days.
But when you strip away the glitz and glamour to see what life is like at the daily grindstone for an average doctor at work, how often do we really feel like we are saving lives? Especially with the population’s advancing age, if you “save the life” of a 97-year-old whose heart has stopped by performing chest compressions, applying electric shocks, throwing a tube in his/her throat and sending him/her to the ICU on a ventilator, have you really saved a life? …Or simply delayed death by a few more days? What if instead of 97, this individual is 85, and they manage to come off the ventilator but have to spend the next several weeks in rehab, during which time they actually bounce back and forth between the rehab and the hospital with complications like pneumonia, or medication side effects like dizziness, leading to falls, leading to broken hips…? I can tell you that as a Hospitalist, neither of these scenarios were ever exceptional, but rather are examples of the bread and butter of my regular work life: situations where as a physician you honestly find yourself asking whether you are adding anything of meaning to these patients’ lives other than a little bit of extra time to inhale and exhale, all too often with pain or discomfort that is put upon us to treat… also with side-effect-riddled medications. Tell me whether you’ve seen that situation on ER or Grey’s Anatomy?
I would like to think that as a Primary Care doc, I would have the opportunity to head this off at the pass, to get to patients before they are deathly ill, and get a better handle on their disease processes so they need the hospital less. But I had to stop and ask myself whether the goal of “slowing disease” is really any different from averting death? When we as evidence-based medical care providers focus on metrics like longevity (age at death, basically) or “QOLY” (quality of life years – which is a measure of how many more years of life patients with a particular condition live if rendered a treatment that is considered to be beneficial), the goal is still time driven. But truly, does it matter how much time we have if the time is spent in pain and suffering?
So with this in mind, I have come up with the Number One question I intend to ask every patient for whom I am responsible for managing any chronic medical condition: “What does it mean for you… to live?”
If anyone tells me that it means having a beating heart and lungs that draw in oxygen while expelling carbon dioxide, they will get redirected. But I do think the average person has a different understanding of what “life” is really all about, as opposed to the biological definition of the word. The thing is that when they visit their doctor, they are all too often met with scientific-speak, a/k/a “medical-ese”. Meanwhile, all they really want to know is whether they will be able to continue playing golf or crocheting afghans, playing Twister with their grandchildren, or even just living in their own homes instead of having to move to a facility. If we start with the question of what “life” really means for a patient then design a management plan focused on making “life” possible, we could probably save a ton of time wading through medical jargon where I would be trying to convince a person to follow my advice that really is only focused on drawing out a few more days or months of time; only to have that extra time be wasted trying to juggle pill boxes and battling insurance companies for treatments with limited access. It’s probably much more important, and valuable, to know up front whether or not a person feels all of that is worth it, or if they’d rather fill the time they have left with something that is more worthwhile. And these questions are not unique to the geriatric population. It is no secret that we are all terminal.
So what does it mean for you to live?