Insights on Residency Training

Although this clip is from a movie about a sports agent trying to negotiate a new contract for an entitled egotistical football player, every time I see it, it reminds me of work. Put a white coat on Tom Cruise, and transplant them from a shower room to an exam room, and it becomes a pretty accurate portrait of my daily conversations with patients.

In fact, when I was on Medicine call the other night, I had this exact conversation with two patients. The first was a 33-year-old male who overdosed on Rohypnol, went into cardiac arrest, and was resuscitated, intubated, and taken to the ICU for monitoring; the other was a 65-year-old end-stage renal disease patient on chronic dialysis with a fever and a 10 cm x 10 cm abscess overlying his AV shunt.

Briefly, my conversations went something like this…

The overdose patient awoke in the ICU, was extubated, and said, “I am leaving. Give me the papers.” When I explained to him that we would like to monitor him for a little longer (especially since his heart had stopped less than 12 hrs ago!!!) and get him the social help that he needed, he refused, and began pulling out all his IVs to leave.

“Help me help you,” I said. “You died last night. Next time it might be for good.”

He replied, “I don’t want your help.” Then he signed his Against Medical Advice (AMA) papers and walked out of the room and down the hallway in nothing but his boxers and no-slide hospital socks — to go and get his next high, I’m sure.

The older gentleman with the abscess was even more disappointing. After claiming to be very “in tune” with his health and aware of his infection, he refused admission to the hospital because, “I don’t like the dialysis machines, and the food is bad.” When I told him that it was my medical opinion that he be admitted and treated with IV antibiotics and a probable surgical I&D, he said, “I know medicine. I read the internet, and this is no big deal. Just give me some pain meds, and I’ll be fine.”

“Sir, you have an abscess at a very dangerous location. It can ruin your graft, but more importantly, you’re febrile and may be on your way to bacterial sepsis,” I emphasized.

After gaining no ground with my reasoning, I gave him the AMA paperwork. “I’m not signing that unless you treat my pain,” he said. “I need hydrocodone 7.5/500. That is the ONLY thing that works.”

To which I replied, “This is not a trade-off. Help me help you. You could get very sick from your infection. Let me treat you.”

Needless to say, he left without treatment or pain meds.

Patient autonomy is one of the cornerstones of medical ethics. It is defined as giving patients the right to make decisions about their own care without the influence of a physician. The twist is that it is the physician’s responsibility to provide all the information to that patient about their condition so that they can make an informed choice, but not to decide for them.

However, as I experienced the other night, sometimes you want to throw ethics out the window, lock the patient down, and do what you know is “right” for them. Other times you want to beg and plead, “Help me help you” as Jerry Maguire did in the clip. But, alas, we do not. We hold true to the ethics of medicine and allow patients to make, in some instances, very poor decisions.

The Hippocratic Oath states, “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone … But I will preserve the purity of my life and my arts.”

There are two parts of this oath that strike me in these particular situations. The first is primum non nocere. I have to remind myself that what might be beneficial to me, might be harmful to others. Meaning, no matter how much schooling or studying or experience I have in medicine, it holds no weight to what my patients are experiencing in life. To some, my helping prolong their life or heal their wounds might be, in one way or another, harmful to them. Often, the choices that patients make that seem absurd to me, are calculated and well thought out to them.

The other is “preserving the purity of my arts.” No matter how I feel personally or professionally about a patient or their condition, as soon as I impart my frustrations and biases on that patient, my “art” becomes tarnished. I respect medicine and the forefathers of the profession too much to bring shame on it. So I stick to the facts and hope that my patients make the right medical choice for them.

As long as we practice medicine, we will be faced with difficult patients — those who feel entitled, those who don’t take their medications, those that skip appointments, and those that refuse treatment. However, our responsibility is to continue to do our jobs well by providing our patients with all the resources and information that they need to make informed choices, good or bad, even if they express no appreciation or interest. And when they make poor choices, our job is to be there for them, without bias, when they return.

We took an oath on it.

“If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.”