David Poon and the Road to Medical School: Bedside Manner

I would make a phenomenal nurse.

I mean, I've already been a cheerleader. That means I have experience being the sole male on a team of sexy uniformed girls. Fantasy stuff in the making.

Cept Canadian nurses don't have that outfit those Chinese nurses have. They wear scrubs. I mean, yeah, they usually suggest that the chick is going to get covered in body fluids, but um... not in the hot sexy kind…

And uh, high school's the limit for the sexy cheerleaders, and um, well – retirement is the limit for the nurses.

Totally opposite of sexy.

…

I don't want to be a nurse anymore.

But I was making a point somewhere along the way.

I think I'm phenomenally good at holding a patient's hand and asking them about their life.

But for actual doctor work? Wow, am I ever shitty.

I've reached the point in my medical training where I am called an intern, which is essentially playing doctor. Not playing doctor like that one time with that girl in kindergarten when I almost (almost!) got to touch her tummy but then her mom came in and then I didn't get to touch her tummy. But playing doctor in the sense that you do everything a doctor would do, and then a real doctor (a 'preceptor') checks out what you did. Points are accumulated in the form of the preceptor telling me you did a good job, bonuses if the nurses like you, and you should (literally) score everytime you tell a girl "I helped save a life today." Of course, like any game, I always end up losing.

Currently, I'm working in the cardiology ward, the area in the hospital where we deal with heart patients. Given my premed dating life, I should know broken hearts pretty well. I should be getting straight As, heck, even triple As… just not in my patients. (Med humour… a AAA, or abdominal aortic aneurism is a medical condition).

Maybe I would be lookin’ pretty good on the wards if I wasn’t posted with arguably the best medical student in my class. My preceptor would ask us…

“What can you tell me about the patient’s heart, Smartest Medical Student?”

“Well you see you’ve got ST elevation in leads V1-2 suggesting a septal myocardial infarction probably caused by the coronary artery disease affecting his left anterior descending coronary artery that…”

“Wow, very good Smartest Medical Student. How about you David? What can you tell me about the patient’s heart.”

“Um… his girlfriend dumped him. So he’s in a lot of pain. I talked to him earlier, he’s sad. Also he likes the colour green.”

“…”

Yeah, I really dropped the ball at the hospital.

There was one patient who had to go for a heart imaging study, a MIBI (properly 2-methoxy isobutyl isonitrile), which sees how much blood getting to your heart when you’re physically active. To paraphrase…

“Hello, my name’s David, I’m the medical student is supposed to take care of you. Can you get into the wheelchair so we can go to the test?”

“No no, I can walk. And you’re so nice, you’ll let me right?”

“Um, yeah. I’m a nice guy.”

“Oh I like you.”

(5 minutes later)

“David?”

“Yes Dr. Preceptor who is evaluating me and has the power to say whether or not I’ll be a doctor?”

“Did you not put your patient in a wheelchair?”

“Um, no.”

“You realize she could have a heart attack from walking.”

“But, she said she could!”

“You realize you’re the doctor, right David. She’s not.”

Sigh, sometimes I wish I were a nurse. If the patient disagrees, I can just say ‘Doctors orders, if it were up to me, I’d let you eat that fried chicken.”

One of the common complaints against physicians is that they simply don’t care. An example is that they “always” interrupt the patient. I think the stat is something like the patient will speak for a grand maximum of 15 seconds before the doctor interrupts with another question. It's also the notorious number 1 reason doctors are sued. An inability to communicate becomes big trouble. I should know since every time I shop in Chinatown I get ripped off. Love you longtime my ass.

Me? I never do that. I care about what the patient says.

Course I end up listening about their Mom’s knitting for Christmas for about an hour, but hey, I can study medicine some other time. No rush, not like they’re going to die.

Oh wait…

Bedside manner is a term used to describe a healthcare provider's ability to speak, relate, and communicate to patients. It comes from, I assume, the fact that doctors, nurses, pharmacists, and nutritionists typically speak with hospitalized patients at the bedside. The best bedside manner is likely a physician who makes the patient feel comfortable, understood, and human.

So really, the physician is like a friend who takes care of you.

Except we’re taught to keep a boundary between our patients and ourselves, called “professionalism” officially, but really personal distancing in practice. Probably has something to do with preventing us sleeping with patients, but if Grey’s Anatomy has taught us anything, it’s that the hospital is very much a burlesque house. I think we’ve all seen pretty terse, almost cold physicians who seem to only want to spend the bare minimum amount of time with the patient. Family physician billing codes actually reward doctors who see the most patients, not spend the most time with them. But really, why can’t we be our patient’s friends, why can’t we spend more time with them, what’s wrong with a little chit chat?

Why can’t we care about the person, not just the disease?

…

I saw someone die today.

It was a revelation.

Not only because it was the first person I had seen whose TOD (Time Of Death) was called before my eyes, though that was pretty important too.

Not only because it was the first time I had gone to a “code” (officially “Code Blue”, when someone’s heart stops, aka “cardiac arrest”) though that was pretty important too.

And not only because it was the first time I did chest compressions, and saw the patient’s unable to breathe, move, or close his eyes, though that was really important too.

It was because I saw how calm everyone was. One physician even pulled out his iPhone to show something to a colleague. A man’s life was in danger, and everyone seemed so… relaxed.

To summarize what happens when a code is called, first an announcement is made in the hospital. So “Code Blue, 5G4, Code Blue 5 Golf 4” s announced, where suddenly the closest available physicians, nurses, and emergency responders go quickly to the room. Students like myself are allowed too. Something affectionately called the ‘crash cart’ is brought in, that has medications, syringes, a defibrillator (that awesome machine that you see on TV that someone yells “CLEAR” before heroically electrocuting a heart back to life), among other tools. Cardiopulmonary resuscitation (CPR) is typically administered, which is that other TV friendly motion where you heroically press down repeatedly on a person’s chest to get blood flowing though the body.

Until today, I’d never done CPR on a real person. We have to keep a certain rhythm, which we taught was exactly that of the aptly named ‘Staying Alive” by the Bee Gees. Which (don’t tell anyone) I was singing in my head while doing CPR. It was actually really cool.

Until I looked at the patient’s face. The man’s face. A person’s face.

Head tilted, eye visible, open, empty, alone.

Under my hands.

Lifeless.

There’s a character on ‘Crime Scene Investigation (CSI): Miami,’ one of my favourite TV shows, who is what is called a forensic pathologist. This is essentially an MD who specializes in the laboratory examinations of the body, to assess criminal causes of harm. ‘Alex’ has a habit of saying something to the likes of…

“Oh Horatio, the victim was so young… so young… why do they die so young... young and innocent. (touches dead teenager’s face) The young are so beautiful, even when they die… which is sad… because they’re young…”

… effectively bleeding her proverbial heart out so much that she contaminates the entire damn crime scene. And for those who don’t watch ‘CSI: Miami,’ Lieutenant Horatio Caine is the main character, and the television equivalent of me – tortured complex inside, macho cool with the sniper aim awesome on the outside. On that note, anyone questioning my choice in TV shows should remember my taste for Latin women.

Actually, on that note, anyone questioning my sniper aim should see me on a date… I can show you.

But that kind of heartfelt compassion from a doctor is probably just on TV. Now, in the real world, my Mommy is the most compassionate doctor I have ever known. Admittedly, I’m biased cause I love her like a mother, but she honestly wholeheartedly feels for the patient with an empathy I can only admire. As a family doc, she earns money by the number of patients she has seen, not how long she has spent with them. Yet, I’ve seen her hold a patient’s hand for what seem like hours, comforting, listening, and most importantly caring. While professionalism standards today have effectively nullified this concept, she had always considered her patients her friends, more than just her billing codes. Yet even she scoffs at the character Alex, saying “I cannot stand her. So fake.”

Since the only time I’ve ever heard her say that was the last time I brought an Asian girl home (zing!), I admit this surprised me. The Alex character took the time out of her day to lament over the patient, talking about the cruelty, the indignity, and the horror of death. In the show, this tortured sentiment eventually led her to leave her job and medical career with the CSIs.

I saw someone die today.

It was a revelation.

Not because I cared, though that’s important that I do.

It’s because I’m still affected by it.

After the code ended, and the patients TOD was called, the emergency team wheeled the crash cart out of the room, and got straight to the debriefing and paperwork. My friend, talking about the excitement and detail of the events with a colleague, turns to me and says “Well, time to get back to work!”

Me? I reflected on what I saw.

The time of death was well before 17:00, when I was supposed to leave the wards, but I ended up leaving about 2 hours later, well after my preceptor and buddy finished up. Why? Because I had to catch up on my paperwork, physical exams, and seeing patients. The number of mistakes I made after the code ended was ridiculous, I’m surprised I didn’t cause one myself.

Wait a sec – sorry, I should mention that my last hurrah was that, by the end of my day, one of my patients I was attending to went into atrial fibrillation (‘afib’). That means a part of her heart stopped moving. Didn’t get to the point where she needed a code to be called, but certainly something I didn’t see coming. Certainly something I should have seen coming.

And I would have, if I wasn’t so damn busy spending my time caring.

Someone I knew very well during my premed days once said something very offhand, and very profound to me.

“David, do you want a doctor who’s a good leader, a nice guy, or do you want someone who knows what they’re doing.”

Of course there are many out there who do both with tact, grace, and humility. But in the end…

… the human body itself is unaffected whether or not a physician knows someone’s favourite colour, the bands they listen to, or how long it is given a hug. Independent of how much, or how little, small talk is had before the physical exam, the body lives, or the body dies. It is the doctor’s role to move that course one way or another. The disease remains unchanged if the patient is hated or loved.

The patient will not care if you said “hello,” as long as you prevent them from telling their families “goodbye.”

The emotional detachment between the patient and physician is likely deeply rooted in the basic medical principle that you would never treat your family members. At first, it seems ridiculous, as one would think, “Who better to treat someone that I love than myself? I care about them the most!”

And then you realize you don’t want them to be hurt. You withhold the scalpel. You don’t want to see them vomit, you stop the meds. You want to be nice, you let them take the stairs instead of the wheelchair.

Suddenly, you’ve stopped providing care. You just care too much to give it.

Of course there are happy mediums, and of course care and treatment do not always have to be dogmatically opposite. But chest compressions famously break peoples’ ribs, cancers stop with amputations, and a doctor must remain emotionally unattached before they too are dragged six feet under. A physician is of absolutely no use to a patient sulking, remorseful, and despondent. When a doctor didn’t ask what you studied at school, he or she was simply too busy diagnosing your disease.

I was a bit of a mess after the code. I actually ended up losing a patient’s file, when I remembered that I had actually brought it with me to the emergency, leaving it on a chair before I started chest compressions.

I went back to the room.

The body was still there.

Head tilted, eye visible, open, empty, alone.

He was dead.

And I got out of the room quick, when I saw a woman talking with some of the staff. She was about to cry as she began walking towards the room I just left. I stopped in my tracks. Would I tell her that her loved one wasn’t alone as he was surrounded by staff? Should I mention that the school trains their doctors to have at least 30 seconds of small talk before beginning asking their patient’s medical questions? I’m sure someone visited his room to sing Christmas Carols, that’s gotta count for something.

He was dead.

I didn’t say a word.

The staff saw how distraught I was, asked me how I was doing. I muttered something before I went back to work. I wasn’t really thinking, and that’s going to show when the staff go read my work later on.

I’d like to think that I hounoured the man who passed away today by keeping him in my thoughts. But instead of letting his memory inspire, I’ve let it impede. And by no means do I want to diminish the value of life, but I will see many, many more deaths in my career, with far more exposure to the person than the 20 minutes I saw the man today.

I guess in short, I gotta brush it off. Shit happens. Who cares?

Before he left today, my colleague stopped by, watching me franticly play catch up on paperwork, sitting in some hall writing away. After making sure the patients he was treating were stable, he asked me how I was doing, told me I could call him if I needed to.

In the end, he let me know that he cared.

And that’s when it mattered.

That’s a revelation.

- David