Island Med Student

I’m currently re-reading the famous book, The House of God, by Samuel Shem (Steve Bergman’s pen name). I read this book many years ago before ever starting med school, and I really enjoyed it. However, now that I’m doing my clinical rotations, I’m enjoying it with a new found appreciation, and I’m really starting to understand all of the subtleties and nuances of the story. I highly recommend this book to anyone thinking about going into medicine, med students currently doing clinical rotations, doctors, nurses, and just about anyone who enjoys a well written novel.

In the book, which focuses on the lives of interns in particular, the name “gomer” is given to the elderly, terminally ill patients that are always filling up the hospital, and who never seem to die. In fact, the first “Rule of the House of God” is that “Gomers don’t die.” The book gives an alarmingly accurate portrayal of how the main character, an intern, begins his internship with the medical student mentality that it’s possible, and in fact the doctor’s duty, to do everything possible to save a patient’s life. A much more seasoned resident tries to explain to him that for the gomers, this is not the best approach. Although the intern resists the advice of the resident at first, he soon learns the harsh reality that there is much truth to this approach.

Eventually the intern takes the resident’s advice and instead of “doing everything possible” to save the gomers, he does the exact opposite: he does nothing. Instead of running huge batteries of tests on the gomers, he doesn’t run a single one. Instead of administering all the medications and treatments that “medicine and science” would demand, he gives them little or none. And what’s the amazing result? The gomers end up doing way better on his watch. In fact, he becomes known as the hospital’s best intern, as he develops an amazing patient care track record.

I recently had an experience with a patient that was frighteningly similar to one described in the book (some details have been changed to protect patient confidentiality and to demonstrate my point). An elderly patient came in with the simple complaint of numbness and tingling in her arm. A chest x-ray was performed and showed a mass highly suspicious of lung cancer in the apex of her lung. A mediastinoscopy was performed in order to better visualize the mass and perform a biopsy. After the procedure, the patient developed a large hematoma and had to be rushed back into the OR to stop the bleeding. Because of blood loss, she ended up becoming very anemic, but couldn’t be transfused because she was a Jehovah’s Witness. The patient also developed pleural empyema and eventually a chest tube had to be inserted. The chest tube ended up causing a pneumothorax, which had to be corrected. After the pneumothorax, the patient developed subcutaneous emphysema. After all this, she eventually developed a nasty case of hospital-acquired pneumonia. The story goes on and on and ends with the patient having a very lengthy stay in the hospital. In addition to that, the mass turned out to be inoperable and the patient eventually left the hospital with the same complaint that she came in with, in addition to having to deal with all the complications that arose from all the procedures!

While this is an extreme example of complications arising from hospital care, I think it serves to bring home my point. Would this patient have received better care if her doctors had simply chosen instead to do nothing? This is just one case, but I could describe many others where a very sick patient’s life was extended by a few weeks, only to cause them to endure countless complications and pain. How do we know when doing nothing is doing more? How and when do we make the decision to institute hospice care? I know hospice care is not “doing nothing” (actually, in some ways, it is doing much more), but it is a different (and I think in many ways better) method of approaching and caring for the terminally ill.

I have so many thoughts on this, but I’ll save those for another post. I’d love to hear what all of you think. Do you think choosing to doing nothing (in terms of medical treatment, not necessarily patient care) can ever mean doing more for the patient?