A doctor's tools

I like to think of myself as a minimalist when it comes to running tests and ordering medications in the urgent care. The nurses love it. My mother hates it. “You mean all you do is give them Motrin and a popsicle? That’s it?????” Yes, mom, that’s it. That’s all they need. Most pediatric disease is self-limited, either caused by a virus, or idiopathic (that wonderful term for “we don’t know what causes it”). Most pediatric injuries heal without major intervention. And so running a bunch of expensive, sometimes invasive tests that will most likely be normal seems like a waste in every sense of the word.

Plus, there’s a reason I went to 4 years of extra school and 3 years of indentured servitude residency. It’s called making a clinical diagnosis. You know, what doctors used to have to do for every patient, based on a good history and a thorough exam. They had to know how different heart murmurs sounded, because there was no same-day echocardiogram. They had to learn the signs of heart failure, because measuring brain natriuretic peptide hadn’t been discovered yet. And yes, they had to do a rectal exam on patients instead of getting xrays to diagnose constipation (which is still a more effective diagnostic tool, by the way). Call me crazy, but I like being a clinician instead of merely an interpreter of lab results and imaging. I pride myself on it most of the time. I spend a lot of time convincing parents that it’s a better way to go.

But if you want to make me doubt my clinical skills, if you want me to long for the ability to check a quick BMP or grab a chest x-ray, frankly, if you want to make me feel helpless, then take it all away. Put me in a teepee on the side of a mountain trying to tease out post-surgical abdominal pain in a teenage girl. Or on the phone with a worried friend who doesn’t want to make an unnecessary ER visit for her child. Or on the flag football field when someone goes down with a “pop” in one of his joints. My calm reassuring voice becomes laden with doubt, and I forget all of my training. Or at least that’s how it feels. At least for a moment. Then reason kicks in and I start to work through the problem, ruling badness in or out, looking for red flags, gathering as much information as I can.

The few physicians in my Wilderness First Responder course were sick of being outside the hospital, without any of our normal comforting resources (labs, radiology, even monitors) and not knowing what to do. We all needed a reminder that we are, in fact, clinicians first. We can use our eyes, our hands, and our brains instead of machines. I try to remind students of this when they rotate through the urgent care. It’s what I try to practice on a daily basis, even when I don’t have to, because it makes me a better doctor when I do have to.

And in reality, a popsicle is sometimes all the tool we need.

I hate fasting (I'm just gonna say it)

For someone who thinks about food as much as I do, fasting for Ash Wednesday and Good Friday are pretty much the highest form of emotional, mental, and physical torture that anyone could inflict. Which I think reiterates why I need it so much. Hear me out.

On a typical day, I wake up after having gone to bed the night before planning my breakfast. The important thing is a balance of sweet and savory, not too heavy on the dairy, and easy to make. I also need an adequate (but not too large) "second breakfast" if I'm working (needs to be portable and preferably quick to heat/eat because I can't use my "lunch break" on second breakfast). Don't forget the coffee, and if I went too light on the sweet side of things, breakfast dessert. As soon as I'm done with second breakfast, I'm thinking about lunch. Whether I'm in the mood for it, whether I can wait long enough, whether I'm going to have enough time to eat it, whether I remembered dessert. I try to have all the food groups (meat/protein, chocolate, fruit/vegetables, simple carbs with extra sugar, grains, dairy) and adequate portions. I usually roughly count the calories when I'm packing my lunch the night before. Then the question is whether I indulge in an afternoon beverage. If I'm at work, maybe a diet soda, green tea, or Crystal Light. If I'm off, something more in the alcoholic category. Dinner is mostly making sure I have enough protein to silence the tummy rumbles and an adequate dessert. And then I'm thinking about tomorrow's food.

Whew! I'm exhausted just writing about it. Imagine being in my head all day. There's no time to think about anything else. So when Ash Wednesday rolls around, I usually start the panic thoughts a few days in advance. What can I eat for my third meal that's bigger than the two small meals but not gluttonous? Do I have enough tuna packets for Ash Wednesday and that Friday? What's the best timing of the meals? Do I give up coffee and risk the caffeine headache or just drink it black as mild penance? How can I make sure I still have enough protein/fat so my blood sugar doesn't drop (this last one is a very real concern; remember, I'm a fainter)?

Add to that the complicating factor of working a 13-hour shift on Ash Wednesday. What if my blood sugar drops while I'm in a patient's room? What if I need to eat but can only get in half my meal before a sick patient comes in, then can I finish it later or does that count as an extra meal? Can I even stay up that many hours while fasting? (I usually try to sleep for most of these days if I can. Less awake time=less cranky time.)

And then there's the actual fasting. My tummy grumbles...everything makes me think of food...someone ordered pizza...I deserve a donut...wonder what my blood sugar is now...how many hours until lunch...does a graham cracker count as dessert...I'm weak and cold and have no energy. By the end of the day, I am not a happy person.

And all the while, my strangled soul is screaming GET A GRIP!!! I STILL got three meals. I STILL had access to clean water. I STILL had a warm bed to crawl into. I STILL get to wake up the next day and gorge on donuts. God will provide. Again and again and again. I do not need to be thinking this much about food. I need to be thinking this much about God, and what He wants me to do with all the gifts I've been given. I need to be made a little uncomfortable, because clearly my body is used to getting its own way. So, as much as I loathe fasting, this is perhaps a good reminder to me to do it more often, so that it becomes easier. Because I can't get much worse at it.

The end of suffering?

Last night I attended the 8^th Annual Great Debate in Boulder—sponsored by the Aquinas Institute for Catholic Thought—discussing physician-assisted suicide and whether it should be legalized in the United States. It proved an incredibly relevant topic given House Bill 1135 which will be brought before the Colorado legislature tomorrow. It’s also fresh in everyone’s minds given the recent celebrity of Brittany Maynard.

One thing that stood out from the debate last night was that in order to truly debate this topic, we must share a frame of reference, a vocabulary of morality and ethics, and in a sense, we have to agree on a certain worldview. For example, if you think that a person should be able to do whatever they want with their body regardless of the consequences, and that the law exists to protect that premise, then we have nothing to debate. For the rest of you, I offer the following considerations. (Sorry, they are not brief).

The basic premise of those in favor of physician-assisted suicide (PAS), reinforced by Dr. Michael Tooley’s arguments last night, seems to be that there are certain cases in which death is preferable to life, in which someone is “better off dead” (Dr. Tooley’s words), in which bringing about one’s death is a “benefit rather than a harm” (again, his words). Dr. Tooley asserted that it is up to the dying person to decide what that cutoff is. He specifically supported PAS in cases of extreme physical pain and suffering (and notably rejected it in cases of depression, temporary or sudden disability, or emotional suffering…hmmm).

This viewpoint has arisen, argued Wesley Smith (the other participant), from a shift in philosophy. Historically, from Plato to Descartes, virtue was regarded as the primary human good, primarily the virtues of knowledge and wisdom. But as advances in science gave humanity control over the natural world, Descartes directed his efforts towards “the conservation of health, which is without doubt the primary good and the foundation of all other goods of this life.” That’s a huge paradigm shift, and if you take it to its logical conclusion, humanity has a right, even an obligation to advance science in order to conserve “health”, at the expense of virtue or any other good.

Given today’s aversion to physical and emotional suffering, and our narrowed definition of health as “the absence of disease” rather than “complete physical, mental and social well-being”, it might make sense that we can and should use science to help us avoid suffering at all costs. To the extreme conclusion, as Smith put it last night, that “killing is an acceptable response to human suffering.”

I would argue that Descartes was wrong, or at least that we have warped his philosophy to an unsatisfactory conclusion. If health is the be-all-end-all, then is life really worth living? Are healthy people really the happiest, the most successful, the most virtuous? Have they truly achieved the greatest good? And if so, then what worth do unhealthy people have? It’s not a far leap to discount the disabled, the sick, the suffering as worthless. And yet, we know that’s not true. Consider Stephen Hawking, Helen Keller, FDR, who knew that they were more than their health, or lack thereof.

Yes, an appropriate response to suffering is to try to alleviate the suffering, but I think we have to realize that the absence of (especially physical) suffering is not the greatest good, to be achieved at all costs. Human life has dignity and purpose in the midst of suffering, and to let someone believe that a certain amount of suffering makes them “better off dead” is, as Smith said, abandonment.

Studies have shown that people requesting PAS primarily are afraid. Afraid of becoming a burden, afraid of losing control, of losing their dignity, afraid of not being able to do things for themselves. I think ultimately, they are afraid of losing their identity, their voice. By telling them they are better off gone, aren’t we agreeing with them? Shouldn’t we be reinforcing their worth, helping them achieve a measure of autonomy, allowing them to have a purpose, a place in a community?

This doesn’t even get into the slippery slope of deciding that there are certain populations who are “killable”, or the dangers of not treating mental illness appropriately, or the financial pressures of euthanizing over continuing medical treatment. It doesn’t get in to the dilemma of a physician who has taken an oath to “do no harm” being asked to kill. And it certainly doesn’t broach the argument that life is a gift from God and isn’t ours to take. I hope instead that by questioning the very foundation that suffering is an evil to be avoided and that killing is an acceptable answer to that suffering, that I can reach a broader audience, and help people think a little more critically about where our society is headed.

Also, please visit http://www.cocatholicconference.org/voter-voice/?vvsrc=%2fAddress to find your state representative and tell them we should not legalize physician-assisted suicide.