'f' the system.

In a recent desperate cry for help with my current existential career crisis, my sister pointed out an interesting and enlightening observation about my recent theme of processing with a statement to the nature of: I am boiling down all of my problems to a simple issue... the ethics of dying... when, in fact, most of my frustrations seem to reflect a much more complex systems flaw in a setting of deep personal discontent.

She suggests that remaining in an extended, artificial, structured, and underpaid academic environment (i.e. Fellowship) may not lend the complete answer that I am searching for.

When I think about it, she is probably correct. I suppose it is quite easy to boil down all your problems to something that you have an innate passionate feeling about. I see people doing this all the time. For an individual person, everything that is "wrong" or "right" in the world really comes down to a single thing that they feel very strongly about, for example, being PRO or CON to one of the following: the dollar. oil. alcohol. abortion. over-procreation. contraception. homosexuality. religion. the absolution of all pain. domestic violence. elder abuse. child abuse. smoking. freeing Tibet. saving extinct Quetzals. eating local food. running to ridiculous excess. music. self-rightous obesity. gender identity crises. universal health care. educating children.

This list goes on and on and on. And I see in my attitude and journaling that for me, this "cause" has become allowing people the right to die peacefully, free from the tense-fisted and white-knuckled grasp of our medical system.

I wonder why I have become so obsessed with this basic human right when there are so many other problems to obsess about?

I suppose, likely, that it is because it has been a continuous daily mind-rape throughout residency to see people suffering through this problem day in and day out.

To explain my perspective, let me start by stating the simple fact that I despise being in hospitals now more than anything else that I have experienced in my life. And that is largely because residency has been such a miserable experience for me. But also, because the things I value most in this world are: the freedom to choose a course of action and the independence to do this on my own.

Hospital medicine is, by nature, the antithesis of those innate characteristics. Not only that, but it is also a sterile pit of blood, shit, piss, tears, and sorrow. And it smells and feels and looks like all of those things. The weight of responsibility lays on your chest like a massive MI. Tiny, sparse windows reveal the glorious weather outside.. they put you in persistent, inescapable ICU psychosis, teasing you with the hallucination that you could be doing something nice somewhere far away from this place.... while you are stuck dealing with the cold dark underbelly of human nature in all its forms in a place that never closes and the work never ends... the only progress or change that ever occurs are via work shift changes, new admissions, transfers, and discharges..

In the hospital, you are initiated into the system by being forced to strip your clothes off and put on a gown that openly reveals your ass to the world. And that is a good example of what is to come. We want easy and un-consented access to every surface and orifice of your body. We want to pry into your blood and urine and sputum and stool, see your organs and measure their every move. We want to make sure your physiology is working precisely the way we learned it should, or else figure out what could possibly be causing such an insolent indiscretion. This all requires a network of co-dependence. To even check a simple lab, which we do repeatedly on every patient daily, it requires me to choose which lab should be done, a clerk to place the order, a phlebotomist to drain the blood from the patient's willing or unknowing vein, a lab technician to report, a functional EMR to find it, then back to the provider to interpret and act upon it. Meanwhile, I often wonder as I run around the hospital like a mad person for 14 hours a day, what the hell is the patient doing all this time?

Night float will often offer a window into that world... because on night float, there is no formal rounding. No SOAP notes, no discharge paperwork, no relentless pimping or chastising, no arrogant and accusatory, often personal insults about our "fund of knowledge" or our questionable level of dedication because we didn't stay late to hack away at the ever-growing list of delinquent duties (also known as: "Scut," (n., v., adj.) a form of work in which you can expect no reward, gain, or appreciation, but it still apparently has to be done by some worthless piece of shit out there).

On night float, we simply talk to people and take care of people, address problems as they arise, update families about the events of the day.. As an intern, I often got paged with something to the theme of, "Hey, Mr B's wife wants an update." I used to dread those calls because -- on night float -- I wasn't up to speed with all of the details from rounds. However, those "annoying requests" have consistently been the simplest and most satisfying requests of my whole day. And the specific details are fairly meaningless, they usually just kind of just want to know what the hell is going on. "Hey, remember when you shoved that camera up my colon yesterday, was everything OK?" I'm often amazed at their lack of knowledge, because while I am engrossed in the details of their problems from almost the moment I wake up, they often don't even understand the big picture. So I sit there and explain things, always amazed at how little they know or understand about their disease --- but it goes both ways, because at the same time, I have such an intimate understanding of the specifics of their physiology with almost no idea about who they actually are - or sometimes - even what they look like..

I learn, during these conversations, that people mostly just hang out during the day. Eat three square meals a day, often punctuated by sugar checks and insulin shots. PT helps them get out and move. They get their veins leached, pills divided and distributed, meds titrated into their bloodstream. They have x-rays and procedures. Get updates from their nurses. They often think and talk shit about their doctor... mainly things along the line of, "who the hell is my doctor anyway?" I overhear these conversations, and these sentiments always stab me to my core because I feel like my entire life has come to revolve around someone else's "problem list."

But really, their accusation is largely true. Quite often, I haven't found (or made) the time to go and chat with patients during the day after rounds. I grab my lunch when I get a minute and go hide in a little room to shove it down. I'm secretly relieved when I have a bunch of intubated patients to round on who can't talk and don't have anyone in the world who cares enough about them to repeatedly call me to the bedside to explain things. I'm tired. I just want to be alone with a book, my knitting, some exercise, my thoughts. I'm tired of talking to people and explaining everything to everyone. I don't want to defend my actions any more. I don't even care if anyone does what I suggest. In ten words, I am: burnt. out. wasted. overworked. underplayed. stressed. apathetic. tired. confused. lost.

Not surprisingly, my favorite attending is a guy that shadows many of my sentiments. I saw him yesterday morning in the doctors lounge getting coffee and said "Good Morning. How are ya?" He immediately replied, "I'd rather be anywhere but here." I laughed and nodded. On rounds, he is unconcerned about the details of the problems of a guy with terminal pancreatic cancer. He shrugs and tells us to do whatever we want. As long as the guy's comfortable. And, by the way, why is this dude in the hospital in the first place? I often feel a confused sense of understanding, relief, justification balanced by an overall feeling that he is not doing what he was trained and hired to do..

Ironically, someone recently told me they suppose I am getting everything I should be out of residency... And all I could think was, "Really? huh.."

Interestingly, I think I have translated all this pain to the notion that surely no one would ever voluntarily want to be in such a place. And especially, no one would want to end their life in such a place.

But as my sister points out, the patient's experience is different than my own. And also, patients who are having a terrible experience don't necessarily want to escape and die far far away from all of it, as I do.. Even more than that, often their terrible experience is something easily remediated. Take, for example, my old CHF woman who felt she was in hell because she hadn't gotten a shower... Why did that happen? Why didn't she have a shower? Is that a problem that is easy to remedy? I suppose it is.

So I admit, yes, there is a larger issue. And that is "f the system." Fix it. (someone with much more energy and perseverance than me, that is). Identify flow issues, patient concerns, medical mistakes. Derive solutions to address them. This is happening in a slow but steady undercurrent. Things are getting better than they used to be in this regard. It's always hard to see the stars when your drowning in mud.

I do believe the sanctity and dignity of death is still a very serious and prevalent issue in medicine.

But, I also recognize now that my feelings about the prying invasion and harsh depersonalization of hospital medicine is a separate and personal struggle for me that may not be shared by all...

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p.s. I'd still rather be shot in a lineup than to die in an ass-less gown - with an IV - bad coffee at my bedside - looking out a teasing window - in an alternating pressure-mattress hospital bed.

I. need. a. day. off. of. work.

Peace.