Healthy Death

I was surprised when Dr. A brought up what the 50-year-old patient would want if he were to be placed on a ventilator. He was scheduled for a colonoscopy to screen for colon cancer, and I didn’t think there was much risk for complications in this routine procedure. The guy appeared generally healthy apart from a history of high blood pressure and a little anxiety. By the look on the man’s face, both of us were surprised. “Even he should have an advanced directive,” the doc continued as he gestured in my direction. The man’s face relaxed a little as he and I realized that this was a routine discussion to be had with all patients, even those in their twenties and thirties.

It was not the first-time end-of-life care had been brought to my attention in medical school. During one of the first-year electives, a doctor recommended we all write an advanced directive and give it to our loved ones. The idea seemed excessive, but I could understand why this person thought it was so important. She had probably seen numerous accidents involving young and old patients alike who had been placed on ventilators or undergone aggressive resuscitation efforts. She had watched while the family struggled with both the pain of their tragedy, and the uncertainty of what to do next. A written declaration of the patient’s desires would have avoided half their strife in the unlikely event they were incapable of making decisions. Sure, she was making a lot of sense in the crowded lecture hall, but at 24, I wasn’t too keen on facing my own mortality. I’m still not.

Sometimes the doctor visit is the intervention.

As I continued with my family medicine clerkship, we saw several other patients where Dr. A again brought up end-of-life discussion. One man was 80 with aches and pains from arthritis and new onset depression that he was facing at the prospects of his death. Dr. A had discussed advanced directives with him the previous month, and he had brought him a copy during this visit. But the lingering thoughts of his demise were weighing on him. I thought this was normal, and I was surprised when Dr. A probed further into his symptoms. The patient was not interested in taking any antidepressants, denied any suicidal ideations and left with a feeble reassurance and a three-week follow-up appointment. In our discussion after the patient left, Dr. A explained that men over 50 have the highest risk of successful suicide attempts. Although the man lived with his husband and had no history of depression, both good protective factors, he still had a real risk of suicide if his depression remained untreated. I asked why he scheduled a follow appointment so soon for an otherwise healthy patient. “Sometimes the doctor visit is the intervention.”

Another day a 70-year-old male and his wife came in after she realized his skin had tinged yellow and become jaundiced. They had already visited a gastroenterologist, who had scheduled an ERCP procedure for the next week. They had come to Dr. A because he had been their primary care provider for over a decade, and they felt it was important to update him. The patient was jovial, and didn’t seemed amused by his change in complexion. But his wife was a nurse practitioner. She was the one that first noticed the yellow tinge in his eyes. She was hyper-focused on the details of his lab results and the nuances of his care plan. Dr. A calmly addressed each of her issues while her husband interjected with light hearted jokes and validation of his wife’s statements. At the end of the interrogation, Dr. A asked him what he would want if he did not recover from the ERCP procedure. “No heroics” he said with a smile, oblivious to the scowl and furrowed brow that came across his spouse’s face behind him.

After they left, Dr. A debriefed me. “What’s the prognosis for new onset, painless jaundice in the elderly?” I admitted I didn’t know, and he explained it likely indicated biliary cancer that has a poor 5-year survival rate. The ERCP was a relatively low risk operation, but the real value in bringing up an advanced directive was that he would likely be needing one in the next few months. He further explained that although these discussions may be off-putting for the patient and their families now, it has the potential to prevent unneeded suffering down the line. And he knew how that looked first hand.

No heroics.

Dr. A spends three of his afternoons each week in the case management department of the hospital adjacent to his office. A list of patients is printed for each of the meeting’s attendees. The list includes patients who have Medicare insurance that have been in the hospital for longer than 5 days. The team talks about skilled nursing facilities that could take stable patients, and hospice care for those nearing their death. At first these meetings seemed like a calloused business strategy to preserve limited hospital resources; the government cuts funding for these patients after 5 days, forcing the hospital to pick up the rest of the tab. But I soon realized that many of the patients on the list did not have a medical reason to be in the hospital any longer.

During these meetings the case managers, nurses, and social workers present each patient on the list to Dr. A. Often the family is insisting the patient remain in the hospital to receive every treatment option possible; they cannot accept that it is the end of their loved-one’s time. The blame appeared to fall on the relatives. But after the first meeting Dr. A explained that this situation often occurred because no physician was stepping up to have the end-of-life discussion with the patient and their family. Sometimes this was because the internist shirked this unpleasant part of his or her responsibilities. Other times it was because the patient had never had a primary care physician before being admitted to the hospital; no one had prepared them for the end of their life, and it was too frightening for them and their families this late in the game.

The worst case I saw at these meetings was a 70-year-old man who lost consciousness while being treated for lung cancer at the hospital. He had shown up on the list during my first week; it was the sixth day of his hospital stay. The radiographs showed multiple metastasis to his brain. There was a brain surgery that could potentially bring him back to consciousness and increase his quality of life, but the odds of success were low. Normally this discussion would be had with the family, but this man was completely alone. The case was deferred to the medical ethics committee, a team of physicians, lawyers, and other hospital personnel who collectively decide on the most ethical course of action for patients in these types of situations. The committee had decided to move forward with the surgery.

They’re fighting for a healthy death.

By the end of my clerkship, the patient had been in the hospital over 20 days. Dr. A and I paid him a visit in his hospital room. The operation had technically brought him back to a low level of consciousness: he stirred when his name was shouted, but he soon closed his eyes again without making a sound. His mouth hung open wide, and his face was sunken in. The sides of his forehead were indented, and there was a large U-shaped surgical scar on one side. You could see his ribs beneath his gown. It was clear this man did not have much time left, and it seemed cruel to leave his feeding tube in any longer to extend his life. There were no family members to serve as his advocate, and he had undergone a risky surgery that likely prolonged his suffering. The patient’s chart read that all medical interventions had now been exhausted, and there was no further action to be done. The ethics committee was scheduled to revisit his case to decide whether to prepare him for hospice.

Dr. A works on both ends of the spectrum of death. He prepares his healthy patients for the end by discussing their wishes over multiple office visits. At the hospital, he salvages patients from end-of-life catastrophes that might have been avoided by a healthy relationship with an involved primary care physician. I naturally avoid thoughts and discussions about death. I’m more interested in health and living an optimum life, and these values led me to pursue medicine as a career. Before beginning the family medicine clerkship, I was expecting to help outpatients lead healthier lives and recover from asthma, headaches, and the occasional sprained ankle. I was surprised how much of family medicine is about living well and about dying well. Shadowing Dr. A taught me how great an impact a family medicine doctor can have by relieving people’s suffering at any age. Physicians aren’t fighting death. They’re fighting for a healthy death.

Ruling Out Neurosurgery

I recently attended a dinner where I spoke with a neurosurgeon. Over the course of our meal I told him I am interested in ophthalmology, but as a second year medical student, I am not married to the first field that has piqued my interest in school. He challenged me to consider neurosurgery as a specialty, and proceeded to describe the variety of surgeries and technologies that make his career rewarding.

There seemed to be an all encompassing reverence for the brain throughout his appeal. He described the research and engineering potential of the brain to be on the verge of a scientific revolution. He cited big data analyses that are being championed by academic institutions, venture capitalist, and even Facebook. It seems to be at the forefront of people’s interests with backgrounds in medicine, technology, and business.

I have heard of many surgeons becoming disillusioned by their fields because they become specialized to the extent that they are performing the same few surgeries every day for decades. My conversation partner explained that he does around 12 different types of surgeries in his practice, while the average orthopedist performs around 4. He admitted that learning the procedures is not the hardest aspects of the job; as if once you surpass the learning curve, you are maintaining a skill that plateaus in difficulty. He said that the variety and interest even amongst those 12 routine procedures are more varied than any other surgical specialty. I’m willing to bet that as a neurosurgeon at an academic institution, there are plenty of complicated cases that provide sufficient challenge to avoid boredom.

I proposed several of my reasons for why I preferred ophthalmology to neurosurgery from my nascent stage of career development. He had counters for many of my points, which are paraphrased below.


Me: I like the idea of making blind people see. I was raised Catholic, and Jesus was a pretty decent influence.

Neurosurgeon: Most of the visual pathway is in the brain. The eye is certainly necessary for sight, but most of the phenomenon is in occurring within the brain.


Me: I want to affect more patients and have the largest impact as a surgeon.

Neurosurgeon: Sure as an ophthalmologist you may affect more patients, but probably not many more than a neurosurgeon. If you really want to have an expansive impact on society, go into public policy.


Me: I want to do research in biostatistics because I see all the big data that is being generated by novel technologies. There is infinitely more information than people who are able to make sense of it.

Neurosurgeon: Sure those are great skills, but you can get help from a biostatistician at the end of the day. Engineering and computer coding are the way to lean in research. These proficiencies are exceedingly rare in medicine. Figure out a way to apply engineering training as a physician researcher to truly set yourself apart from all the other applicants. They’ll all have equally as impressive or better test scores than you.


Neurosurgeon: As an ophthalmologist, your surgical domain is limited. The brain has so much more wonder to it, both in the lab and the operating room.

Me: You’re not wrong.


Neurosurgeon: No one can dismiss you as a neurosurgeon. At the end of the day the pulmonologist, the nephrologist, and the cardiologist’s care plans are all superseded by the neurosurgeon (in the case of a conflict). There’s rarely any point in keeping a brain-dead patient alive with pristine lung, kidney, and heart function. The neurosurgeon most commonly upends the care plans of ER docs. But it is best to be respectful and foster good relationships amongst colleagues as often as possible.


Neurosurgeon: No one can complain to you. You work 100-120 hours per week sometimes. Sometimes another specialist will tell you they can’t do something for your patient’s care because they need to sleep. As a neurosurgeon, you never have sympathy for those appeals, and everyone in the hospital knows it.


Neurosurgeon: In neurosurgery, there is a mentality that if there is a choice between what is easier and what is more difficult, the more difficult option is usually the correct choice. If you need MRIs before a surgery and radiology has not sent you the images, it is your responsibility to get the scans. You can’t let radiology stop you from caring for your patient. Along those lines, the 80 hour work limits are not feasible to successfully complete a neurosurgery residency program. You have to work over that regularly. And if any resident mentions anything about work hour limits, they are immediately perceived as weak. There are no formalities, but it is a cultural violation in neurosurgery to complain about hours logged.


Towards the end he went so far as to challenge the relevance of other surgical subspecialties in comparison to neurosurg. I find it amusing that physicians and surgeons from all fields need to question the validity of each other’s career choices, especially when high quality care takes an enormous team to deliver. It seems most doctors think their path is the most important. Egos are big in medicine. Go figure.

During the following days, I kept having the strange feeling that a small part of me may be possibly considering neurosurgery as a career. I wasn’t entirely convinced to shift gears towards becoming a brain surgeon, but I was inspired to spend a few hours researching the field instead of studying for boards.

At the end of my internet perusing, I was left with a reaffirmation of my initial sentiments: I do not want to live the unbalanced life of a neurosurgeon. It seems to me that if I were to become a neurosurgeon, I would be transformed into an incredibly high-tech piece of hospital equipment, which belongs in the hospital. And is to be rarely seen outside the hospital.

Neuroscience research does seem to be a possibility though. Time and time again I hear that the brain is the “final frontier” in medical research. And the technological integration of neurosurgery and neuroscientific research does have an undeniable sexiness to it, coming from an engineering background.


Interesting Links

Love, Life and Neurosurgery

Of the pieces I read, this was the most effective at conveying the existence of a neurosurgeon through the lens of a normal person. It seems if you ask a neurosurgeon what it’s like to be a neurosurgeon, they give you a very neurosurgeoney description that is full of technical information and innate fascination with the brain. Charlene Petitjean gives an insightful description of what it’s like to be married to a neurosurgeon.

AMA Neurosurgery Resident

Nothing like a firsthand account of neurosurgery from a fifth year resident.


Sources

Life, Love and Neurosurgery

IamA Neurosurgery Resident

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