Tuesday, March 12, 2013

Atherosclerosis of the Soul

As you may recall, my daughter, Dolly, is a medical student in at a Big (read: expensive) school in the Midwest. She's now in her third year, experiencing the joys of the clinical rotations.

Dolly has seen the usual suffering one observes in a hospital, particularly in the teaching institutions, and has had to learn to deal with her own internal reactions to the pain, sorrow, and even stupidity of the patients. Many times these past few months, she has called me in a state somewhere between tears and laughter, quite able to understand the science of what she saw that day, but wondering how to react and respond to the patient. I can see her distance herself from the victims, and on rare occasions, even from the rest of humanity, which is purely a survival technique in this business.

Oh, my. Did I really just say that? Yes, I did. One must distance ones' self from the pain of others to survive as a doctor. Ouch. Our dirty little secret revealed. But this shielding can go too far.

You have certainly heard of atherosclerosis, also known as hardening of the arteries. From the WikiPedia:
Atherosclerosis (also known as arteriosclerotic vascular disease or ASVD) is a condition in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol. It is a syndrome affecting arterial blood vessels, a chronic inflammatory response in the walls of arteries, caused largely by the accumulation of macrophage white blood cells and promoted by low-density lipoproteins (LDL, plasma proteins that carry cholesterol and triglycerides) without adequate removal of fats and cholesterol from the macrophages by functional high-density lipoproteins (HDL), (see apoA-1 Milano). It is commonly referred to as a hardening or furring of the arteries. It is caused by the formation of multiple plaques within the arteries.
I really though I had coined the term "Atherosclerosis of the Soul" all by myself, but a quick Googling shows a few previous appearances. one of which I might have seen years ago. From Philip Jose Farmer's The Dark Design, a part of the spectacular Riverworld series, comes this passage:
Groaning, Burton half-awoke.

For a moment, he didn't know where he was. Darkness surrounded him, darkness as thick as that which he felt filled him.


He lay for a while, rigid as a corpse, thinking, Here I am, a one-hundred-and-one-year-old man in the body of a twenty-five-year-old.

The Ethicals had softened the hardened arteries of the candidates. But they had not been able to do anything about atherosclerosis of the soul. That repair was apparently left up to the candidate.
The longer I live, the more I see this phenomenon affecting humanity at large, though perhaps physicians, including radiologists, are overly prone to contracting this debilitating disease. I confess to having it myself.

But just what do I mean by the phrase, atherosclerosis of the soul?  Like pornography, it's hard to define, but we know it when we see it. If we choose to see it, that is. It is a thickening, a coarsening of whatever it is that makes us, well, us.  It is a narrowing of our connection to others, an accumulation of the detritus of day-to-day living plastered across our being, choking off our humanity, limiting the communication to and understanding of the world itself.

We physicians acquire this disease early, though to varying degrees. The application process for medical school, I believe, selects for those who are more prone to catching it. One must be the best of the best, have good grades and dozens of extracurricular activities, the pursuit of which often limits any time to develop as a human being. The med school experience itself, while better than in my day, still promotes the shielding of feelings. Yes, there is lip service paid to caring, but situational grading is based more on how much one can regurgitate and how few feathers can be ruffled. Caring about the patient too much, and G-d forbid coming up with something the attending overlooked is rewarded by icy stares, and cold silence. The student learns quickly to simply "Keep calm and carry on". And to do what it takes to be noticed, climbing on top of the other skulls full of mush, but ONLY in the right context and setting.

And so it goes into residency and practice. The young physician is trained, subtly and not so subtly, to care more about themselves than anything else. The Doctor as G-d syndrome starts to kick in, and the youngsters come to believe that M.D. might just stand for Minor Deity as well as Mucho Dinero.  The outside of the soul is honed and polished, but this obscures the plaques within. Caring for patients, once an honor, an obligation, a privilege, has morphed into an entitlement, a position from which it's hard to retreat. Too bad the economy will no longer support an unlimited number of little tin gods.

I've been particularly saddened to see the feral, hungry tempers of more than a few posters on AuntMinnie.com. It's all about them, it seems. The old radiologists need to retire (or die) so as to make room for the young who are, of course, better radiologists than any 60 or 70-year-old has-been could ever hope to be. And some of those who do have jobs are quite upset that, again, it isn't all about them: their nasty, elderly superiors don't put out enough work, but parasitize their hard-working Bob Cratchit-esque junior radiologists. Here is a typical quote:
Too many old rads around skimming profits from hard-working young rads...(A)t least half of older rads in my group are gaming the system...It seems that most groups, at least in my experience, are squeezing the younger rads so the senior guys can maintain the income/lifestyle they had a decade ago.
And indeed there are at least a few old Scrooges out there who DO profit more than is justified from the efforts of those junior to them, who have declared that employees won't get a raise as long as their salaries are falling, and the like. A quote from a young radiologist on one of the AuntMinnie threads cuts both ways:
Why should we feel bad at all for people who were gifted a gravy train era and blew their money like pimps, or at least live beyond their means?

In the past, doctors were regarded with respect, and maybe even love, and some of today's entitled divas might have prospered way back when, even with the limited contact time they are now allowed with their clients. But patients' souls can corrode as well, and what was once a partnership has become in many cases an adversarial relationship. Bad outcomes, or even less than perfect results, prompt a phone-call to the medical board, and the lawyer who advertises in the back of the Yellow Pages.  Among the many foibles of Obamacare is the provision that requires patients have a direct portal to their medical records, and you can rest assured that many will peruse their data with great vigor, looking for anything and everything that sounds to their uneducated, cholesterol-coated souls like an attack their right to exemplary care at no cost or effort on their part.

Doctors (and patients) are reflective of society as a whole. We have to note the overall deterioration in the world around us. We recently reached what some call the tipping point, where the electorate now consists of a majority of takers rather than makers. The entitlement generation wins. Political power is purchased with the products of the efforts of others. What can you give ME? On a more personal level, you can see plaquing of souls in your daily life. I was on a plane recently, seated across the aisle from a couple in their mid-to-late thirties, and their 7 or 8 year-old son. Immediately upon buckling in, Dad stuck his headphones in his ears, and checked out, ignoring his son's screeching. Not that Mom did a lot to help calm the kid either, but at least she was fractionally engaged. Upon reaching 10,000 feet, however, Mom handed the kid his iPhone, and he was occupied for the rest of the flight. Like father, like son, eh? None of the three of them had an obligation to anyone but himself. Dad might just wake up about 30 years from now and beat himself for losing these precious moments with his kid, and he might wonder why his son is now an adult with intolerable behavior. But when your soul is corrupted, your spiritual nourishment compromised, you can't see beyond your own sphere.

I would love to provide the solution to this problem, Lipitor® for the Soul, if you will. While it's becoming less and less popular, I do think some sort of religious faith is critical to keeping the disease at bay. But even without that, we must start by looking around us, and trying to have some empathy, but we must also take responsibility where appropriate. Patients must realize doctors are human. Perfect results may not be forthcoming, especially for those who ignore advice and continue to smoke, drink, and do other bad things to themselves.

Young doctors need to have some respect for what their elders have built through sacrifice and risk. They have to realize that times have changed, and salaries will fall. That's just reality. Older doctors need to have some sympathy for the predicament of the young, with families to raise and student loans to repay. As one young fellow put it on AuntMinnie:
Those of us at the end of our training don't feel entitled, we are disillusioned and fearful. I have 300k in educational debt (in-state medical school) at a weighted average interest rate of about 5.5% and essentially zero assets. My ideal job was always to be in a small to medium sized democratic group where I could help build the business and become an integral part of the local medical community. Not in New York, Chicago, Boston, CA, etc, but within driving distance of my family in flyover country where most of you wouldn't dream of taking a job. Until 2-3 years ago, this was essentially a given. Now my concern is finding ANY job so I can pay off debt and actually start my adult life.
Sadly, he isn't speaking for all of his generation. That being said, however, expecting a seasoned doc to up and leave just so the young-in can march in is ludicrous at best. And no one, physician or otherwise, should expect anyone else to pay for their bad decisions. That you married the wrong person after building a McMansion is not my fault or my problem. That you chose a field with falling reimbursement is not my problem. That the economy is now in the toilet is not my fault (I voted for the fellow with business acumen).

For what it's worth, I will vacate my position as soon as is feasible, but don't expect to walk right in to my job. Chances are, I won't be replaced.

I've been trying to write this piece for a while. Now that it's done, I'm not sure if it serves as Lipitor® or a Bloomin' Onion with respect to atherosclerosis of the soul. Or maybe it's just a big dose of GoLYTELY®.

1 comment :

Celticpiping said...

"The Doctor as G-d syndrome starts to kick in, and the youngsters come to believe that M.D. might just stand for Minor Deity as well as Mucho Dinero."

I so wish that weren't true..