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Float On: Medicine is an Art, Not a Checklist

Coates

I just finished my first week of night float.

Working nights at the community hospital in Portland, Oregon, where I’m completing my preliminary year in internal medicine, means admitting up to five patients each night and cross-covering the entire teaching service of 40+ patients with one other resident.

As a morning person, staying up late and flipping my schedule by 180 degrees didn’t exactly come naturally. As a new doctor, making challenging medical decisions didn’t come naturally either. As a recent fourth year medical student, sustaining my attention and behaving responsibly for twelve hours straight came least naturally of all.

Confession: I have a hard time sitting still, and I’m not very patient.

I’m especially impatient when it comes to what I call “nonversation.”

Nonversation, according to the reputable source Urban Dictionary, is, “A completely worthless conversation, wherein nothing is illuminated, explained or otherwise elaborated upon. Typically, it occurs at parties, bars or other events where meaningful conversation is nearly impossible.”

I guess what I’m trying to say is that another thing that doesn’t come naturally to me is meaningless small talk. Well—perhaps a more accurate thing to say is that it comes quite naturally, but it also exhausts the hell out of me. Generally, I get to know people by figuring out quickly where they’re from, what drives them, what their hopes and dreams are, how they spend their free time and all the things and people they love. I become impatient when I can’t get to know people as quickly as I would like in the way that I would like to. If that sounds noble, it isn’t.

This week, I’ve been reminded that a lot of people who go into medicine put up high walls—sharp professional boundaries that keep life sectioned into neat little boxes labeled “work” and “home” and “feelings” and “insecurities” in order to cope with the rigors of daily workflow and prevent the chaos that might otherwise come from trying to blend all the aspects of who we are into a single, functional human being.

I understand that people need privacy. I understand introversion. I understand that my style pushes the limits of those who would prefer not to think and feel as deeply as I do during every minute of every day. In fact, an area on which I’m actively working right now is the ability to follow John and Paul’s wishful words of wisdom and just Let It Be when it comes to those who don’t seem to want to connect in ways that I deem meaningful. After all, who am I to say what’s meaningful? I’m just me.

But sometimes I think that the tendency I’ve observed to close ourselves off to all the feelings that the work we do inevitably conjures within us is responsible for the disconnect that many patients feel when they’re talking to us in the clinic or at the bedside. I can’t tell you how many times I’ve heard a patient complain that a doctor they saw, “Just didn’t listen to me.” It’s heartbreaking to hear that and think to yourself that the patient was probably right in their assessment.

We construct walls around ourselves based upon all of the things we think it means to be a “professional”:

• Doctors aren’t supposed to talk about their lives.
• They’re not supposed to curse.
• They’re not supposed to cry.
• They’re not supposed to admit imperfections or let on that they feel bored or tired or miserable or disinterested or burnt out.

For many of us, our entire lives have felt like a checklist—one series of goals followed by another, with no real end in sight. There are always more things to achieve, more papers to publish, and more reasons to worry that we’re on uneven ground.

When we get to the status of a resident, and we’re finally not competing for grades anymore, we have so many things to do in order to meet the requirements levied upon us that the day itself, each and every hour of it, becomes a checklist rather than an exercise in logical thought. I went into medicine because I like solving fresh problems, but many days I feel like I’m too busy to think. I walk around the hospital on autopilot, often more concerned with the list of things I have to do than for the people for whom I’m supposedly doing them. And then, I spend the little free time I have during each shift feeling guilty, worried that I’m the only one plagued by fatigue-induced disinterest.

Of course people feel like we aren’t really listening to them. So many of us don’t feel that we have time to listen, much less actually make a difference in their lives. I feel that this is especially true in internal medicine, where patients come to us with a laundry list of chronic diseases and we’re lucky if we have a chance to fully address one of their problems.

We (and I fully include myself in this “we”) come into a conversation with a hurting human being carrying a checklist of things to ask, and feel annoyed when their narrative doesn’t jive with the algorithm we have in our brains.

But medicine is not a checklist. What I’ve learned this week is that medicine actually is an art.

There is no one-size-fits-all approach to chest pain. You actually have to think about the story you’re being told, and that means asking the right questions rather than a string of unrelated borderline-nonsensical questions (umm… let’s see… have you been having fevers? changes in your bowel movements? pain with urination?) that mainly serve to meet billing requirements rather than extract valuable information; questions that create further distance in between us and the people for whom we’re allegedly trying to care.

I spend a lot of brain energy these days wondering what it means to be a professional. Perhaps, in medicine, a professional is someone who truly listens. Perhaps we have trouble listening because we don’t feel heard ourselves; the neat diagnostic box into which we’re encouraged to cram each patient’s story defies the art of medicine, turning our craft into something that feels more busy work. Perhaps medical encounters feel so phony because there are no other human interactions where one person does all the talking and the other person doesn’t contribute with anecdotes from their experience of being alive.

It’s exhausting, having a checklist approach to a day that’s filled with more nonversation than real talk. It’s exhausting, trying to be perfect all the time. I’ve decided that I’d rather try to be human. (And I’m still figuring out exactly what that means).

To be honest, I think we learned a whole bunch of bullshit in medical school.” ~ my inspiring co-intern, who shall remain nameless