Monday, February 15, 2010

Bedside Bad Manners | Health Care |

"Wordlessly, I said to him, 'You fucking bastard," John McPhee writes in this week's New Yorker. His vitriol was directed at a young doctor with a staggering lack of bedside manner who had just informed McPhee that his father was on the verge of death. What the doctor was thinking, we don't know. But based on recent articles written by doctors on the subject of bedside manner, the feeling may have been mutual.

McPhee's article is ostensibly about fishing for chain pickerel, but includes a description of the aftermath of his father's stroke. "I was startled by the candor of the doctor," McPhee writes. "He said the patient did not have many days to live, and he described cerebral events in language only the patient, among those present, was equipped to understand. But the patient did not understand: 'He can't comprehend anything, his eyes follow nothing, he is finished,' the doctor said, and we should prepare ourselves." The Health Policy and Communications blog points out that this doctor mistakenly neglected to include the family in his "continuum of care."

McPhee likely wouldn't get any comfort from Dr. Alex Smith, an assistant professor at UC San Francisco, or Dr. Mark Morocco, an associate professor at UCLA Medical Center and the former medical supervisor for ER. Each has picked up a pen (or pounded the keys, as it were) to offer insight into what doctors are thinking when they treat us. The result is more revealing, and certainly more controversial, than anything a physician would say on the ward. Also, I have a feeling that these doctors have excellent bedside manner, by virtue of their willingness to write transparently about the topic.

"Many people, including me, vary the language we use depending on our recommendation for treatment," Smith writes. He made me laugh when he described the intricate lingual game that patients and doctors play when discussing resuscitation. Below are some examples of questions he asks patients, followed in parenthesis by the answer he secretly desires:

"Would you like us to restart your heart if it stopped beating?" (Please say yes) (I'm just asking as a formality)

"Would you like to allow us to let you to die naturally?" (Saying no goes against nature) (We have an unnatural power over life and death)

"Would you like us, in what would naturally be your final moments, to press on your chest and break your ribs, shove a tube down your throat and poke you with needles in lots of places in a chaotic attempt that has a very small chance of giving you more time to be technically alive but unlikely to ever return to meaningful communication with others?" (Please say no) (CPR is horrific) (I don't want to have to do this to you)

Morocco wrote just as plainly: "From time to time, all doctors want to kill their patients." He described a perfectly awful patient he once treated just as he was finishing med school. "I wanted to kill Mr. Martinez. ... Not your bureaucratic, passionless, Sarah Palin-invented 'government death panel' killing, but a personal, pillow-wielding, Cuckoo's Nest-style snuffing out of Mr. Martinez's candle by the only person left in his life who was still willing to talk to him."

In the years since, I bet Morocco has met patients and family members, like McPhee, with Cuckoo's Nest tendencies of their own.