Friday, May 15, 2009

the heart of medicine

i am reading a fascinating book that was written in the 70s called 'the house of god'. it's "fictional" but was written by an MD at harvard and follows the internship year of 5 medical students. it's riveting, horrifying, disgusting, disturbing, compelling, and utterly familiar - the human aspect aside.

a particular passage stood out to me - after the intern has aggressively treated a fellow doctor's cancer, everything has failed, and the doctor is dying - he sits with him. and the doctor explains to the intern the heart of medicine.

"no, we don't cure. i never bought that either. i went through the same cynicism - all that training, and then this helplessness. and yet, in spite of all our doubt, we can give something. not cure, no. what sustains us is when we find a way to be compassionate, to love. and the most loving thing we do is to be with a patient..."

i like to think that i see through to the heart of my profession - that i understand my place and my function. i've seen others that don't -who keep hanging on -forcing their patients to hang on - for just one more day - for a cure that is never coming. who confuse optimism with refusal to accept that we are just human - not gods. not capable of fixing everything, every ill, every wronged organ.

i am reminded of an intensive care patient that i handled for 4 days. he was diagnosed with hepatitis and had lived TWO years with this condition (most dogs are dead within 6 months). at the end, his liver completely and predictably failed. he couldn't make clotting factors, he couldn't make proteins, and his glucose was low without constant supplementation. his owners refused to euthanize him, and i had to be party to his slow torturous decline. he was admitted for frank hemorrhage from his rectum. my attending thought he had a coagulation problem or a GI bleed. i wasn't so sure. further, he couldn't have ANY pain medications because his liver couldn't metabolize them. giving a small dose of sedative knocked him out for 12 hours at a time. his owners latched onto the idea that a novel therapy would save him, and the doctor working with me fed this idea. i was party to his demise, and it made me sick - to see this loyal, sweet dog forced to lie in a cage with tubes coming out of him, hooked up to machines, with no hope of ever being normal again. when his owners FINALLY assented to his euthanasia, we found on necropsy that an 8 inch section of his GI tract was dead (leading to the bleeding). he had lain, in a cage, without pain medications, for 5 days like that. with a dead, rotting piece of intestine probably hurting like nothing you or i could imagine.

but it isn't always that cut and dried. and reading that story makes me sound judgmental and harsh. the doctor i worked with loved that dog, and she wanted the best for him. it's not always easy to know when to stop, to say enough is enough, and to let our pets go. there are times when i honestly don't know if one more day will make the difference. that is what makes my job the hardest. looking at a patient and knowing it is time. sometimes it is easy, and sometimes, i have no idea, and i still have to help the owners make that decision. while it is a hard one, i still feel it is a gift that i - as an animal doctor - can give my patients. human doctors (and patients) aren't so lucky.

in the end, medicine isn't just knowing what to treat and how to treat it, but when to stop treating and allow our patients a measure of peace at the end.

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