“Don’t look at me! Save yourself!”
Andrew* was a 25 year old with an imposing build that was mollified only by his despair and terror. Andrew was losing his mind. I didn’t have to see Andrew and I somewhat wish I never did. I had received a call late at night from Andrew’s nurse. “You gotta give him something man, I mean, he’s freaking out and I feel really bad.”
I knew nothing about Andrew, and as the patient was not on the psychiatric service, it was bizarre that the nurse should be calling me, as I was not responsible for his care. Something bothered Andrew’s nurse enough that he called me and so I went to see Andrew. When I arrived, he was pacing in his room, chattering to his tormentors, his mind racing, his body unable to stop moving. He was, he told me, the worst person in the world, he would contaminate me with his evil if I dared to enter his room. He covered his eyes so that he would not destroy me with his gaze. I told him I would take my chances, convinced him to sit down, and to let me sit next to him. It was not possible to be with Andrew without wanting to cry. In his despair he believed he was dead and soon to be tortured, he was a Promethean figure being punished for his grandiosity, castigated by nameless voices that had hounded him for days. To know Andrew was to know despair. It was also to discover why the nurse had wanted me to knock Andrew out. As he said, “I feel really bad.” He didn’t say Andrew felt really bad, which of course he did. Whether aware of it or not, the nurse was not asking for an elixir for Andrew’s pain, he was asking me to treat his own.
The art of prescribing
The defining act of the physician is the ability to prescribe. This has shifted in recent years as prescribing privileges have shifted to other providers, but prescribing remains a central practice of a physician’s identity. We prescribe because it’s expected, sometimes because it’s necessary, always because it’s what we do. Prescribing goes beyond drugs and to any intervention used to cure or control symptoms. Sometimes the act of prescribing includes ordering investigations for the aim of assuaging the anxiety of a patient, fending off the threat of litigation, or even palliating our own anxiety that we have missed something. Whether a prescription is necessary or not, it is more often also a self-prescription. The maxim that sometimes the best medicine is no medicine at all has become anathema. We intervene because to not confronts us with the pain of living, the experience of suffering, the reality of death, and most of all our own helplessness. Such is the hidden curriculum of medical school that death (and by extension suffering) is failure means that the physician who has a patient who dies, or who suffers means that we have failed. Failure is unacceptable. Intervention, and prescription as the fundamental medical intervention suppresses feelings of failure.
Prescribing as Identity
I always half-joke with my medical students that they were far more empathic before they ever started medical school. Some nod their heads knowingly, others pretend to agree with me, a few openly scoff at me. All usually tell me by the end of their time with me they didn’t realize just how right I was, they are far less empathic now and they never even realized it. Two years of endless lectures of every aspect of the body in health and disease had changed the way they saw the world, but incrementally so they didn’t quite realize it was happening. The systematic gutting of humanity that occurs is implicit, deliberate, and unspoken. It occurs because it makes the practice of medicine more tolerable. It is but one more defense against the pain of living that we are confronted with on a daily basis.
In the same way, prescribing is not implicitly taught as a defensive maneuver that can be employed as a way of avoiding engaging with the patient or to assuage one’s own feelings of helplessness. Prescribing is instead the therapeutic act that defines the identity of the physician. This is how my students are introduced to it.
I remember one of my students was assigned a patient who had attempted suicide and was doing therapeutic work with him. I told him that as it was his patient he could use whatever treatment he wanted. My student was keen to treat his ‘depression’ with both interpersonal therapy and an antidepressant. He had discussed with the patient at great length different medications and they had agreed on an SSRI. My own understanding for the patient was that he was lonely and I did not think that an antidepressant would be beneficial. I asked my keen student whether he still wanted to use a medication. He told me “Well I’ve never prescribed anything before, so I would [like to]!” The act of prescribing was not to treat the patient’s loneliness, it was part of the student’s transition to becoming a doctor.
Unfortunately, he had not mastered the basic concepts of pharmacology and when I reminded him that these agents are not benign and rattled off the long list of side effects as well the possible psychological complications of antidepressants, he seemed a lot less confident in his identity as a manqué-physician.
The denial of death
5 years ago, when I was still a medical student I remember being constantly confronted with the institutional denial of death in clinical medicine. It was during my emergency medicine rotation, which I enjoyed immensely, but also began to think about quitting medical school altogether. I remember the mute patients with advance dementia who we referred for surgical evaluation, but more than that I remember the patients who were already dead that we wouldn’t let go. There is something brutally demoralizing about resuscitation. Most people don’t know how many times we frantically stab patients with needles trying to get a line in. Or the way the body writhes when it is defibrillated. Most people don’t know what osteoporotic ribs sound or feel like when they crack under the pressure of chest compressions. In physiology, death is the endpoint of life. In clinical practice, it is the failure to prolong life. Once, it was only the physician who felt this sense of failure or humiliation, an alien feeling to someone who is used to succeeding. Today, intervention, and successful intervention is expected.
The Expectation to Intervene
We have a religious faith in the capacity of modern medicine to cure and to regenerate. Medicine is the Philosopher’s Stone of our age. We are asked to imagine a world without pain, without suffering, without sickness, and without death. In the US, where medicine is a multibillion dollar profit-driven complex, we have cultivated an image of the promise of cure. For those conditions where no cure exists, it is on the horizon. America no longer only promises the pursuit of happiness, but the pursuit of immortality. With this pursuit comes the expectation from the public for the physician to intervene. A clinic or ER visit that does not result in a prescription is a disappointment, and leads to a disgruntled “the doctor didn’t do anything.” Even at the very end of life, I am troubled by just how many patients and their families insist on futile interventions including resuscitation, and the institutional reluctance to discuss the inevitability of death.
The Archetypal Overreacher
As I sat with Andrew, he told me how he had believed he could be better than God, and push the limits of human capability. It was this belief that was his downfall. Now he was tormented, and there was no escape because he was already dead and this was his hell. I couldn’t help but feel that as a physician I had been trained to be an archetypal overreacher like Andrew, to fly too close to the sun, to steal fire from the Gods to help my patient’s cheat death, to fight the realities of existence. The price was an intolerable enduring sense of failure. My training was supposed to have deadened the visceral human response to Andrew’s suffering. It was supposed to have taught me to intervene with a prescription to deftly avoid engaging with Andrew on an emotional level and contemporaneously retain feelings of mastery and omnipotence over his suffering. My training had failed me. I knew he needed a prescription to sleep. But he also needed something that was not available on prescription. He needed a hug. This simple act of human connection and kindness is one of the few things proscribed in medical institutions. Instead I put my arm on his shoulder. I realized why we often prescribe without listening, we often engaging in doing to the patient rather than being with. It is because to do so is to be confronted with failure.
*For confidentiality reasons, Andrew is not a single patient but represents a composite of a number of patients