Hospital- Questions of Being a Good Doctor

Julie Salamon's ethnographic account of her year observing relationships, bureaucracy, and patient care at Maimonides provides an unusually candid view into the world of hospitals and doctoring. There are no attempts to veil disagreements or feuds, in fact Salamon brings them into light (or rather print). The passages and dynamics that I found most interesting were those between doctors and patients, particularly when delivering difficult diagnoses.

We hare already broached the topic of how difficult it is for doctors to face mortality and to have discussions about it with patients.This is evident from the satirical writings of Samuel Shem (as Roy struggles to accept Dr. Sanders terminal cancer) and the serious musings of Atul Gawande who talks about the discomfort doctors feel around a co-workers illness/death.

Many of the patient encounters in Salamon's book deal with doctors discussing the implications of a cancer diagnosis with patients. The prevalence of "cancer stories" is likely a result of the prominent feud between the two doctors Kopel and Bashekvkin and the new cancer wing that takes center stage in many of the writings. While none of the doctors in the cancer stories prove to be insensitive or anything short of concerned individuals practicing in a very difficult field of medicine, there is a great degree of variance in the honesty and candidness used when talking to patients.

One of the stories Salamon recounts is that of Dr. Rubin treating a 24 year old mother with Stage IV lung cancer. The patient is so weak and debilitated at the time of diagnosis that it is clear to the reader and the doctors that the patient's death is imminent. The hospital staff urge her doctors to discuss the direness of the situation with the mother so she can consider who will care for her children and how she wants to be remembered by them. However, when Dr. Rubin meets with the patient he frames everything in an overwhelmingly optimistic light. Rubin is described as having "a desire to cure so fervent that it compelled him to put a positive spin on the direst situations" (278). As he meets with the patient and her family he arbitrates great hope to the chemotherapy she is receiving and even provides the possibility of adding months or years to the young mother's life- she is to die days after this conversation.

Dr. Astrow, the associate director of medical oncology, is treating a patient named Marie, a 45 year old patient with metastatic gastric cancer. When Salamon discusses talking to patients Astrow identifies himself as a doctor who believes in telling the truth, while also not telling patients what they don't want to hear. Marie remains in denial of her prognoses and Dr. Astrow walks the fine line of being honest and acknowledging that some patients aren't prepared to face their mortality. He is described as beginning conversations telling patients about how he sees things and asking them how they see their condition. While Marie is never frankly told her diagnosis, at the request of her family, Astrow is very honest with the family when describing the inefficacy of treatment for solid tumors.

Both Astrow and Rubin desire the same thing, to provide their patients with a cure, and when a cure is impossible, they hope to comfort. The innate ability to care about patients feelings and how they are treated are the hallmarks of a good person. However, the same blind optimism that doctors deliver news with may reflect good intentions but not be in the patient's best interest. There are logistical issues that end-of-life discussions require. I think that patients ought to have their prognosis described in a caring empathetic way but the important of candidness can not be undervalued. In the case of the young mother she was indicated to have much more time than was realistic; this is problematic since patients need to have a realistic amount of time to deal with the spiritual and familial aspects of their impending death.

I don't think there is an easy solution to discussing end-of-life issues with patients, particularly when patients are in denial. However, I do think that the doctors need to be better trained and briefed about the importance of these issues and how they are best discussed. The evaluations that doctors receive throughout med school and residency are largely a reflection of academic knowledge, but in a field where human interaction is tantamount there ought to be a greater emphasis placed on conversations and humanity.