DEATH, UNCERTAINTY, AND THE VALUE OF OUR TIME
I once thought that being the smartest person in the room made you the best doctor. After I graduated from residency and experienced what it was like to practice medicine in a non-performative way, I realized that this wasn’t true at all. Knowledge matters, for sure, but experience, resourcefulness, and the wisdom to know how best to apply that knowledge matters far more. The scariest thing about treating a COVID patient for the first time wasn’t the fact that I didn’t know everything there was to know about COVID, it was the fact that there was no well-worn path for me to follow. There was no familiarity or level of predictability that I could rely on to put me or the patient at ease. The patients were understandably terrified and I was unsure of how best to comfort them. We threw the kitchen sink at people trying to save their lives and their organs. The treatment protocol we followed the week before was never the protocol followed the subsequent week. We did stuff because we otherwise felt helpless but it mostly didn’t work or didn’t work all that well. And so, I had to get comfortable with the notion of just being a human taking care of another human to the best of my limited ability. I learned to tell my patients the truth, which often involved the words, ‘I don’t know but here’s what I do know.’
More than two years later, it has become second nature. COVID is no more intimidating than treating pneumonia or heart failure. I understand it’s rhythm now; the way it looks like the sniffles for a few days in one patient and looks like multi-system organ failure in another. I have learned how to reliably predict which patients will do well and which will not. We now have some helpful interventions to support people through the worst of it, but a lot of it is just waiting out the storm to see which way things will play out. If you get hypoxic (meaning low oxygen levels) patients on oxygen and steroids early enough, then they usually get better. It’s a waiting game that people hate. They don’t understand that we really aren’t in control. At some unknown point, the inflammation will peak and after weeks, sometimes months, patients come way down on their oxygen requirements. At times they come off completely within hours. It’s stunning to watch.
I think back to the early days of COVID when I would sit with dozens of patients as they drew their last earthly breath. I have comforted their family members at the bedside. I have been the one to make the call to a family member as they were frantically making their way to the hospital to let them know that they didn’t make it in time. At the height of the pandemic, the dynamics of death were turned upside down. With the best of intentions, (i.e. containing spread) we inflicted psychological torture on our patients and their families. We isolated them for weeks with only a ventilator, a BiPAP machine, or an IV pump for company. Nurses and techs found inventive ways to avoid going into their rooms. They extended IV tubing so that they could operate the pump from outside of the room. Many consultants would simply visualize the patient from the windowed door, documenting a minimal physical exam. The intent was noble: to reduce exposure to self and cross-contamination to other patients. We didn’t know the emotional harm we were inflicting.
Patients would tell me that they hadn’t had any human interaction in days. I rarely needed to stay in the room longer than a few minutes to complete my assessment, but they would beg me to stay a while longer. The loneliness in their facial expressions and gestures was weighty; they needed another human to share that burden. I showed them pictures of my kids and talked about the weather (since most of them didn’t have windows in their rooms). They were just grateful to have anything to distract them from the fact that they were trapped and couldn’t manage to eat or go to the bathroom without their oxygen levels plummeting to dangerously low levels. Some of their chest x-rays looked like a snow squall and they had been told by the pulmonologist that if they proceeded with mechanical ventilation, they were all but guaranteed not to come off of it alive. I would look into the eyes of these patients, many of them elderly but some of them not much older than I was and see how badly they wanted to live. And so, I would hold their hands or feed them a cup of yogurt. I would let them cry or tell me how afraid they were. I didn’t get to stop being their doctor just because I didn’t have anything more to offer them medically. I still needed to show up and they still needed to know that they were important. The way that we treat dying people matters. Profound isolation isn’t humane. Denying loved ones access until the dying moments isn’t compassionate. A lot of people are carrying around these scars, not just because of the loss but because of the way that loss took place.
Sickness and death is hardly ever convenient. It doesn’t fit neatly into a shiftwork schedule or translate into productivity bonuses. It’s no coincidence that we bill based not only on medical complexity but time. Yet time is the one thing that the business side of medicine regards the least. Executives and administrators are always pushing us to do more in less time. How can the quality of what you offer to your patients not begin to suffer? Patients can sense what is lacking. You begin to miss details and make more errors. Your documentation becomes scant. Helping your patients and their families navigate a tough diagnosis takes time. COVID reminded us all of how meaningful our time is. The lesson was apparently short-lived for many of us. It hasn’t left us and now the downstream effects of it keep piling on. I see the lingering of COVID, in part, as a much-needed reminder to all of us of how we continue to misuse our time and each other. For me, being more present and engaged with the way I spend my time both at work and in my personal life has become my priority. I can’t control the minutes and the hours but I can control how I spend them. Don’t be careless with it. That’s what I learned from my patients who ran out of time before they were ready. I implore you to heed that same warning. Don’t be careless with your time.