A Wake-Up Call From Under Anesthesia
A patient undergoing colonoscopy accidentally recorded the procedure on his smartphone. When he reviewed the tape after surgery, he was shocked to hear what was said by the anesthesiologist and gastroenterologist during the procedure. So upset, he sued the anesthesiologist.1 The case made national news—mostly because of the insensitive and inflammatory comments made by the two physicians.2
The Fairfax County, Virginia jury awarded the patient $100,000 for defamation, $200,000 for medical malpractice, and $200,000 for punitive damages. The $500,000.00 jury award was apparently a compromise. One juror wanted to award the patient nothing and others wanted to give him much more. As the media reported, some of the jurors wanted to send a wake-up call so that it wouldn’t happen again.
Compassionate Physician Versus Combat Soldiers
I am grateful to them. Now let’s make sure we all get the right message from this case—it isn’t simply keep one’s mouth shut during procedures and keep mocking, homophobic, hateful comments to oneself. (And if your moral compass doesn’t help you in this effort, maybe the realization that even the OR isn’t off limits to Little Brother might).
The media coverage undoubtedly brought tremendous attention to this sordid episode, exploiting the voyeuristic aspect of catching “doctors behaving badly” and our deepest fears of being mocked while defenseless, asleep, disrobed, and vulnerable.
This is unfortunate. Some people might find in this story yet another reason to avoid a colonoscopy—an essential and much less onerous procedure than many in the public fear and, therefore, avoid.
But I believe the dialogue between the physicians belies the real story. For what I hear in this video is not just crass and completely unprofessional talk; I hear the kind of trash talking that goes on in locker rooms and all kinds of settings where it is meant to generate esprit de corps and unite “us against them.”
I have heard “trash talk” myself in certain high-stress treatment environments, such as emergency departments in inner city hospitals, some of which have been widely disclosed through published accounts of, for example, the inner workings of residency training. Terms like GOMER, and worse, that I won’t dignify by spelling out what the acronym stands for, are often used.
Many medical schools and residency programs have changed how they train physicians to be empathic and caring by reducing the physical/mental exhaustion and high-stress components of training in favor of incorporating activities such as shadowing patients as they experience the health care system. The hope is that we churn out compassionate physicians rather than loyal combat soldiers.
But this incident didn’t occur in a busy emergency department. And what was this poor man’s offense? He asked too many questions? He needed more time? He was fearful and clingy? He might have been a (chronic) pain patient (I am taking liberties with accounts that he was given gabapentin for the rash on his genitals, thinking he might have had neuropathic symptoms).
Therein, find your wake-up call: are you taking the time to examine what the pressures of the health care system in general and your day to day practice is doing to you? Is—as the doctor in this incident put it—the constantly spinning “wheel of annoying patients” killing off all your best instincts to be caring and burning you out?
It is best that you not think that the doctor involved in this incident was some kind of monster—I doubt she wanted to become a doctor, and specifically an anesthesiologist, so that she could render people vulnerable and then mock them to satisfy some deep-seated need to feel superior. We all risk losing our empathy and caring due to the simple daily pressures and demands of the sheer magnitude of human need that crosses our paths every day.
I know that after 25 years of seeing patients with cancer and non-cancer pain and addiction, I needed to do something else. I used to joke that my tombstone would not read RIP, it would read RVU (relative value units). “Here is Dr. Passik, fulfilling his RVU quota for all eternity.”
Chronic Pain Colleagues Take Note
Colleagues in the world of chronic pain treatment please pay particular attention. The stresses you all face both inside and outside the consulting room are perhaps some of the greatest in medicine today. If you are burning out, and the very need that a patient presents makes you consciously or unconsciously hateful and avoidant, your work will be robbed of its richness and its most rewarding aspects, and it will be rendered less effective.
“Us against them” doesn’t work in healing, particularly not in pain management. Learn strategies to care for yourself, take time for yourself, and dissipate any residue of hate that might be festering in you, not only to avoid burnout but because patients can sense it. If that, in turn, affects their trust and they can’t effectively engage with you and it somehow prolongs their struggle, the unending need that was burning you out in the first place will only burn further out of control in this vicious cycle.
If you don’t think that such unconscious transmission of your fatigue or dislike is possible, I would point you in the direction of studies of how a doctor’s fear of movement (kinesiophobia) can be unconsciously adopted by their patients.3 If fear of movement can be communicated in this way, I think it quite possible that an even more primal set of feelings can be as well.
In pain management, you often have to use tools that can easily be construed by patients as alienating—state-run databases, urine drug testing, pill counting, and the like. All of these are essential to patient safety and in the patient’s best interest. But think of the challenge here: how does one introduce and use these aspects of a treatment plan, presenting and administering them artfully and in a way that doesn’t undermine trust?
It seems to me that the communication that surrounds their use is the essential element, and it must come from the right place inside all of us. “You and I working together, pulling out all the stops to help and not harm you,” not “I am mainly invested in protecting myself and my practice against you who may do something to harm me.”
James P. (Pat) Murphy, MD, had it right earlier this year when he established a day to honor and nurture the pain practitioner (National Pain Care Providers Day, March 20, 2015).4 Nuturing yourself allows you to honor and nurture the suffering souls you see every day. The sentiment that led Pat to establish that day needs to be embodied daily. A healthy esprit de corps can emerge as we celebrate one another and care for ourselves and the people who need us.
Wake-up call received.