Last year I had the opportunity to enroll in a course co-taught by Professor Irving Grousbeck at the business school and Dean Charles Prober at the medical school entitled “Managing Difficult Conversations”. It was a breath of fresh air from the typical medical school curriculum, teaching skills which are hard to define yet essential to the practice of medicine.
One part of the course discussed dealing with death. In the next few posts, I’ll share some of the stories, anecdotes, and lessons we learned. To begin, I’d like to share a story from my own clerkship experience as a medical student.
One day while I was rotating through the medicine service at the VA hospital, we had a light day of seeing patients on a Saturday, and we were presenting our patients’ progress to a senior attending physician. As we presented the complex management of a patient with a very large list of medical and social problems (obesity, diabetes, foot ulcers, poor compliance, drugs, heart failure…), he paused us in our presentation to make a point. Paraphrasing, he said, “You won’t remember the exact management of hyponatremia that I just taught you, but you will remember what I say about this patient. When I was growing up, people were allowed to die comfortably at home. How many patients today are allowed to die on the couch at home?”
Dr. Meyer’s point was that we as a medical team were getting overly caught up in the complex medical management of this patient, and our team was missing the forest from the trees. This patient was dying, and the priority needed to be ensuring he could die comfortably and in a way that was consistent with his values. The priority was not to perfectly titrate his insulin.
This story frames the issue, because the fundamental problem is that we are scared of talking about dying. So instead we focus on distractions, like a glucose level. It belies a fundamental problem that applies even more broadly to all of medicine. How often do we focus on the problem we want to deal with rather than the problem most important to the patient?