Much of modern medicine has degenerated into an assembly-line approach. A patient gets an operation, spends x days in the ICU, then goes to the floor. We get the patient up by day two and ambulating, and discharge him or her on the morning of the fourth day.
It's a "cook book approach" that takes all the humanity out of medical care. I remember one of my patients was a Navajo woman who lived in a hogan seven hour's drive away on the Reservation. Her domicile had no electricity and no running water. How was she going to keep her incision washed and cleaned under such living conditions? Should I have sent her home on the same day as the person who had an extended family to take care of them in a plush house, in a neighborhood nearby in the foothills of Tucson?
The particular woman proved to be quite interesting. She was one of only three women in the Navajo tribe who had been entrusted with keeping and passing on the many secrets related to their legendary blanket weaving. As a tribal matriarch, she was considered, in the words of her own son, as "a scared vessel for our People." Whenever she came to see me in clinic, four or five Tribe members would accompany her, almost guarding her. At the end of a routine office visit, I told her casually: "You should come back in about three months." I assumed she would go out to the front desk receptionist to make an appointment.
She didn't. She waited through three full cycles of the moon before she had herself driven back down to Tucson - more than seven hours' travel from her home near the Canyon de Chelly (pronounced de Shay) region. She arrived in clinic with her “posse” of attendants, walked up to the desk, and asked to see me in clinic.
"Well, Dr. Hamilton doesn't have clinics on Tuesdays" the front desk informed her.
"He told me to see him in three months so I did.”
"When exactly is your appointment, Ma'am?"
"He said three months."
"Exactly when in three months."
"No time. Just come back in three months."
This went on for a while until finally one of the nurses called me in the Operating Room to tell me that this Navajo woman had just driven down hundreds of miles to see me without an appointment. The nursing staff in the clinic was of the opinion that the woman should simply be turned away and told to call back for a proper appointment to be seen in clinic.
Call with what? I remembered she had no phone. Besides, I thought to myself, she did what I had asked her to do: Come back and see me in three months. I explained that I would come up and see the woman as soon as I was finished with surgery.
As I finally arrived upstairs, the clerk at the front desk pulled me aside to inform me there was no appointment for this woman. There was no paperwork from the Indian Health Service authorizing a clinic visit. And I wasn't going to get paid for seeing her today. Maybe she thought this elderly Navajo woman was trying to pull something over on us. She seemed filled with suspicion.
I thought to myself: Doesn't anyone want to cut this woman a little slack for driving seven hours to see me in clinic? I imagined the old woman sitting stoically in an over-loaded pick-up truck, lurching over hot, dusty dirt roads leading off the reservation. She had earned the right to be seen by me. Right now. Reimbursement or not.
She passed away about three years later. Shortly thereafter, her son and another family member drove down again to Tucson to see me. Again no appointment. No warning. This time they came to give me a wonderful, red wool Navajo horse blanket the old woman had woven just before she died.
I protested that it was too much, too big a gift. But the family pushed it back into my hands. Her son said: "She was glad that you could see her when you could see her." That summed it up.
I believe Medicine is in danger of being suffocated by cynicism. Pessimism and sarcasm are becoming toxic to medical care. I have not yet figured out exactly where these poisonous influences come from. What I do know is almost every medical student I've met and interacted with was a compassionate and caring individual upon entering into medical school. I'm certain about that. What I've also observed is that, by the time students have finished their residency training periods, very few of them have not succumbed to being cynical.
So who takes responsibility for that? Well, I suppose I have to. So do the other attending medical and surgical faculty at all the university hospitals around the country. I have to blame myself if the programs in my own department turn out disheartened senior residents. We're the ones responsible for the effects of the training systems we have put into place and supervise. I'm partly to blame if a resident in my own program commits suicide.
So how do we stamp out this dark, sarcastic force that's invading medicine. How do you repulse that kind of enemy? By defending yourself, by standing up, by showing enough courage in your medical care that it inspires rather than undermines the compassion and tenderness that medical students bring with them when they first pass through our doors. Without the courage to be compassionate, physicians become enslaved.
William Faulkner wrote:
"He [man] is immortal, not because he alone among creatures has an inexhaustible voice, but because he has a soul, a spirit capable of compassion and sacrifice and endurance."
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