seven days at the VA

Much can happen in small spaces of days, rooms, a smattering of people and conversations, a flow of observations and semi-blurred details. I've loved my first week on my medicine rotation at the VA, where the patients are generally older males with one shared experience that's as widely varied as the fingerprints they made us give in order to work in a government hospital.

There's a lot about this place that suggests a bit more space in a profession that can often feel limiting, restrictive. My first patient from day one was still here at the end of my first week. An elderly man with blue eyes and the charm to match, he gives me recipes, flirts every other line, does a little dance when we walk him on unsteady feet, and worries about his wife while he's the one in the hospital. The pace of the VA makes it so I can talk to him several times everyday, and so I remember he likes 2% milk and hates his oxygen, and he begins to know me as the one with cold hands and notices before I do a new scratch on my face.

He's been worked up and treated for four separate problems, one of which brought him here and three that have arisen or noticed since, covering his lungs, his liver, and his joints. He let me learn about so many different things in one person, and reminded us that care is continuous and multifaceted. We treat the cough and sometimes its persistent presence smothers the pain of a swollen leg; his pleasantness we enjoy disguises the weakness of his muscles after illness. I'm amazed at how my medical team considers all of these, amazed that openness can require so much more learning on my part, amazed that this comes not as a disappointing realization but as a worthy goal.

It's been a hard argument to sell, but I generally counter worries about the negatives of medicine by pointing out the appeal of a challenge. A geriatrician made mention of things worthy of fight, during a conference about how to talk to patients about end-of-life care, noting that often patients don't see their difficult treatments as burdensome, but as a measure of how much they're willing to struggle for their lives. She made many, many good points during this talk, that will contribute to concrete changes to how I'll approach this in the future. Key terms include outcome, uncertainty, and decision. Patients make decisions based on outcome, not on treatment, but doctors often present their options in terms of treatment ("would you want to be intubated?"). It isn't whether they want to have their chest compressed, but whether they want to live afterwards with 10% of the quality of the life they had before, or 20, or 50, or 75, or 100.

But even as we offer possible outcomes of the different options, we have to relay the degree of uncertainty we have. Because we want to be and because we want to make it easier on everyone, we seem more sure of our words than we can be. And patients need both what we know and what we don't know, because as the speaker noted, decisions change as the possible outcomes become more or less nebulous, more or less likely, more or less intense. It's hard, because people do seek something definitive; we have to remember that no one wants to make these decisions; we get so caught up in asking for their preferences that we forget they need to figure it out too. This isn't too hard to appreciate for someone who finds it difficult to choose a flavor of steamed milk, but this brings up again the need for continuous care, to which I haven't given as much conscious thought. As things go one way or the other, degrees of certainty change and so do how people feel, so this is an ongoing, organic conversation. The speaker also gave objective advice: have families hear from the patients themselves what they want; studies have shown that patient and family preferences often diverge in significant ways, and it's hard for families, amidst so much emotion and uncertainty, to make distinctions between their wishes and those of their loved ones. Ask patients not how they want to be treated, but what outcome could they live with and then how much they would be willing to endure to get there. Begin with their subjective goals, and fill in the technical details for them about how they could get there objectively.

This goes back to the fact that patients don't want to make these decisions, and the speaker made an excellent point about how we can share the burden. This point is very hard to conceive in our minds, and then very hard to articulate, and I respected her very much for forming the thought and then conveying it. I won't be able to do it quite as well, but essentially--she told us that we don't have to make people feel as though they're deciding about every possible intervention or treatment. Instead, they can focus on the parameters for how they want to live. This is something people often feel rather than rationalize, and the hardest part can often be trying to rationalize how we feel. Our role is to implement the rational, while leaving them full control of the emotional, with our rationale only taking reign after being guided by their feelings. We let them know that we understand that end goals for quality and quantity of life are individual, but we can design our options and path to lead to their goals, and once we know how they feel we can steer them to those goals, allowing them to feel both empowered and taken care of.

I started this post and didn't have time to finish, and it's now the end of my second week. I can't quite remember what else I wanted to say, and since then much more has accumulated, so instead of trying to backtrack I'll let it be.