Monday, February 21, 2005

A pet peeve

"23 is asking to speak with a doctor."

I turned. The nurse was addressing me, waiting expectantly for an answer. "Who?" I asked.

"Room 23."

"Who?" I demanded more insistently. I knew exactly which patient she was talking about. In fact, I was being a bit of a jerk on purpose, to make a point. You'll see why in a minute.

"Mrs. Smith," she finally said. ["Mrs. Smith" is, of course, not the patient's real name.]

"Thank you. Tell Mrs. Smith I'll be there in a few minutes," I replied.

I was on call last weekend. Normally, most of my practice is outpatient visits and outpatient surgery, but about once every month or so, for a week at a time, I'm on call for new consults. Part of that duty is to come in and round on the group's patients over the weekend. During these call weeks, I'm suddenly immersed in the hospital lifestyle once again, sometimes after being a way for a few weeks or longer. Last week, I was on call again after an unusually long stretch of time not being on call. Consequently, I had forgotten one of my pet peeves about hospitals, something that's irritated me about every hospital I've ever worked in (and I've worked in hospitals in four different states now). Can you guess what it is?

Yes, indeed. It's the tendency of nurses and hospital personnel to address patients not by their names but by their room numbers. Nurses, ward clerks, orderlies, and just about all the other staff do it. People who have been patients have no doubt heard variations of these kinds of statements by nurses and others:

"15 needs the bedpan."

"Room 54 needs his pain medicine."

"27 is throwing up."

Now, such terminology can serve a legitimate purpose when it's used for an overhead announcement. It protects the privacy of patients. I'm not saying that ward clerks should make announcements that every can hear in which patients' names are used. Also, I realize that nurses are assigned rooms. Unfortunately, it permeates every other interaction in the hospital, even those that happen behind the ward desk or even in the nurse's lounge. I've heard people justify such a habit using HIPAA (regulations that govern patient privacy), but this is a long-standing custom in hospitals that has irked me ever since I was a medical student in the 1980's. HIPAA took effect less than two years ago.

Don't get me wrong. This is not nurse-bashing. We doctors are just as guilty of dehumanizing patients by not using their names, perhaps even more so. It's just that we tend favor a different style of dehumanization. We tend to refer to the patient by his or her disease or surgical procedure, rather than room number. We'll refer to "the choly [short for "cholecystectomy"] in room 10," "that pancreatitis patient," or "that lower GI bleed in the unit." These sorts of usages irk me just as much as the nurse's telling me that "23 wants to talk to me." No one is immune to using this sort of terminology in medicine, even me (although I do try to stop myself when I find myself starting to use it).

When I was a second year medical student, my preceptor for Physical Diagnosis (the course in which we learned the basic techniques of physical examination) warned me about this tendency. He reinforced strongly that each patient was a person, an individual. The patient is not just a disease and is certainly not just a number. That patient has hopes, dreams, and fears, just as we do, and that patient deserves always to be treated with respect. He was correct. However, once a young medical student (or nursing student, orderly, or technician) is immersed in the culture of the hospital, rare is the individual who doesn't find him or herself occasionally (or even frequently) slipping up and referring to patients as numbers or diseases. In fact, during residency, when I was frequently overwhelmed by work, dog tired from spending 36-40 hours straight in the hospital, and all too often cranky, I found it very difficult indeed not to just "go with the flow." It's also particularly difficult for surgical residents on the trauma service, where the patients are all too often alcoholics, violent, or otherwise very unlikeable. In such situations, the patient becomes the enemy. Samuel Shem's House of God is still relevant today, even though it was written decades ago. I could speculate on how such dehumanization could serve a psychological purpose, protecting health care professionals from emotional reaction to the disease and death they see around them or how exposure to such suffering can dull one's senses to the humanity of even the most obnoxious patient (who might be obnoxious precisely because he/she is suffering and being obnoxious is the only way to get attention). But that doesn't make it acceptable.

As those who've been reading this blog a while know, one of my major themes is a critical (or skeptical) examination of alternative medicine and the science (mostly, sadly, the lack thereof) behind its claims. Indeed, my first substantive post to my blog after my manifesto was a post about why otherwise intelligent people choose alternative medicine over conventional medicine. In that article, I pointed out that one reason was the people with diseases for which conventional medicine doesn't have particularly effective treatments are desperate for any hope and will grasp at straws. That's not the only reason though. Certainly one other reason is that alternative medicine practioners, for good or ill, often give the patient the human touch they crave. They listen to their patients and take the time to explain their treatments, probably more so than "conventional" physicians. That their explanations are scientifically implausible or even obviously erroneous does not matter, because most lay people don't have the background in science to recognize the scientific and logical fallacies in their treatment rationales. Indeed, such alternative medicine practitioners are only rarely sued when there is a bad outcome, because they have developed a bond with their clients.

I don't claim to know how we in the medical profession can go about reclaiming the human touch for our patients. Certainly there are individual doctors who do a fantastic job of doing just that, and I highly doubt that any doctor wants to be perceived as impersonal and uncaring. But individual efforts not enough. The problem is systemic in modern medicine, and has been so for a long time, at least as long as I've been in the field. I may not know how to change the system, but I do know how I can change my little part of the system.

Here's what I can do. I can refuse to address patients as diseases or room numbers and insist that the nurses, medical students, and residents who deal with me do likewise. I can do so even if it means being a bit of an asshole sometimes, as in the example with which I started this post. I can hope that this example teaches or inspires. Whatever my other personality faults may be (and, as those who know me best know, there are many), I can hope to follow this one precept. It's not much, but it's a start.

9 example(s) of insolence returned:


At 2/21/2005 1:00 PM, Blogger Dreaming again said...

From someone who has, too often, been referred to as "the myasthenic in room 13" (or whatever room I was in for that particular hospital stay)
I thank you!

 

At 2/21/2005 8:43 PM, Blogger poopie said...

Yep...check the armband if you're not sure. ^j^

 

At 2/26/2005 6:12 PM, Blogger gollux said...

thank you. The dehumanization of modern medical care is the worst thing for it. It's the best friend of alternative medicine, and probably actually detracts from care, as we are not just physical beings. Our emotional state and comfort will greatly affect the course of our physical maladies. Dehumanization by hospital policy is never good.

 

At 2/28/2005 12:40 AM, Blogger Socialist Swine said...

I'm actually a little more optimistic about the resurgence of bedside manner than some people here. Last year I got the opportunity to work as a preceptor for a "soft" theory course and from what my students said it seems like they're actively getting taught patient relations. I don't know if such training will be effective. However, that effort is being placed into training the next generation of physicians to interact with their patients as people is a good sign.

 

At 6/07/2005 9:30 AM, Blogger Doctor Disgruntled said...

You know, Orac, you're absolutely right about that - it is somewhat dehumanizing to refer to patients as "the ectopic" or "the pre-eclamptic in room 3" etc., but I've always thought that a small part of that is cognitive efficiency (laziness?) and also focusing on the most relevant part of the many things that are important about your patient(s). I mean, I'm not supposed to care if Mrs. Smith is married or an unwed mother, if she is rich or poor, if she is beautiful or ugly, if she is kind or cruel, but I'd better care a lot about whether she's anemic, hypertensive, exsanguinating, etc. So the shorthand may reflect a failure to consider the "whole person" but it also reflects the obligation doctors have not to let the social or even physical attributes of our patients (consciously) influence our treatment of the disease.

Thus, I don't care if you're a Democrat, a Vegan, a Right-to-Lifer, a bricklayer, or a CEO - on the table, it's me against the disease, so maybe I can be forgiven for targeting my skills at the one part of the person that is most important in the professional sense...

Respectfully,

Doctor Disgruntled

 

At 7/27/2005 11:13 AM, Anonymous Anonymous said...

Once I went to a new doctor and when she entered the room, without looking at me or saying hello, she asked, "you're the leg rash?"

I never went back.

S.

 

At 7/27/2005 11:18 AM, Anonymous Anonymous said...

Oh and by the way, the antifungal cream she prescribed didn't work, but I read on an "altie" web site that some rashes are caused by food allergies, so I stopped eating wheat and it went away (after having had it for 2 years).

I do agree with being skeptical of unproven claims, as you are, but I also think it's important to acknowledge that there isn't as much money in researching natural medicines that aren't patentable, which is one reason why that research doesn't get done.

S.

 

At 8/24/2005 6:12 PM, Anonymous marsglow said...

When I was a ward clerk, an old lady had died the night before. Her only relative, a nephew, came from out of state to see her. He asked the nurse where she was because her room was empty. The nurse said, "I'm sorry. She's gone." And he said ,"So when will she be back?" I hate euphemistic expressions for death.

 

At 8/25/2005 7:58 PM, Blogger Orac said...

I agree. I don't like euphemisms for death, and that dislike even flows over to science. For example, I hate it when people refer to "sacrificing" experimental animals? Are we performing a religious ritual or something? I much prefer the word "euthanize" or or even "kill," both of which far more accurately describe what we are doing at the end of an animal experiment.

 

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