Opinion
A PIECE OF MY MIND Timothy M. Dempsey, MD, MPH Department of Internal Medicine, University of California, Davis, Sacramento, California.
Corresponding Author: Timothy M. Dempsey, MD, MPH (tdempsey@ucdavis .edu). Section Editor: Roxanne K. Young, Associate Senior Editor.
The “Good Person” Sign When I started medical school, I received a lot of (mostly unsolicited)adviceonvarioustopics,rangingfromspecialty choice to the importance of keeping work-life balance to how to befriend nurses in order to get things done. I would listenpassivelywhilefriendsandfamilyblatheredonabout how comfortable their subspecialists’ lifestyles were. One recurring theme that I actively paid attention to was how oftenpeopleadvisedmetoavoidbecoming“oneofthose” doctors who distanced themselves from their patients. I didn’t quite understand why some people could ever view physicians to be uncaring, cold, and callous, and why physicians allowed themselves to be perceived as such. Medicineisstillthenoblestofprofessions,andonewouldexpect altruism as a baseline for all who go into the field. Personally, I was able to hold on tightly to my humanity and positive attitude throughout the preclinical years of medical school without issue. I even received high marks for compassion and empathy in our “doctoring” courses. At that point in my training I continued to feel as though I were above falling victim to the fate of the heartless physician. Sowhy,Iwonderedinmyshort,unwrinkled,andasyetunblemished white coat, were some physicians so detached fromtheirpatients?Oncetheclinicalyearsstarted,Iquickly discovered the answer. One busy rotation during the third year of medical school, I was assigned to take care of two ill patients whose rooms were next to each other. In one bed there was an alcoholic with recurrent pancreatitis who seemingly took pleasure in berating his nurses and causing a ruckus during his hospital stay. I, like others, generally avoided this room. In the other bed was a most pleasant elderly man who was to undergo a hemicolectomy to resect a mass in his colon. After his surgery, I actively sought out visiting his room. HourswouldpassasItendedtohimandhisfamilyeachday, listeningtostoriesaboutsummersattheNewJerseyshore towns where both my patient and I had grown up. These were good people, reminders to why going into medicine is so amazing. Four days later, he died of a complication of his surgery. In the next room over, my other patient was ready for discharge. Iwasdevastated.Thoughnotveryprofessional,Ifound myselfwonderingwhymyfavoritepatient—thegoodguy— had not made it when the jerk in the bed next to him had. Itriedtointernalizemyfeelings,untilfinallyonedayIopened uptooneofmymentors,whoassuredmewhatIhadexperienced was a common part of medical training. He then wentontoutterthephrasethatIhavesinceheardrepeated frequently in some iteration or another throughout my youngmedicalcareer.“Youknow,Tim,it’softensaidinmedicine[aboutpatients]thatbeingagoodpersonisapoorprognosticsign.”Andthereitwas,theanswer.Theanswertothe
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the
jama.com
questionaboutwhyphysiciansweresojadedandremoved, a phrase so ridiculous it was seemingly taken straight from thepagesofTheHouseofGod.ThemoreIasked,themore Ihearditechoed,and,unfortunately,themoreIcontinued to notice it in my own clinical practice. There was the man withsevereinterstitiallungdiseasewhochattedhopefully abouthisdaughter’supcomingweddingonlytosufferseptic shock from a severe pneumonia and die during his hospital stay. Or the war veteran with end-stage liver disease who would salute me each morning on rounds and was loved by the entire staff prior to suffering a massive myocardial infarction and dying under my team’s care. It was all too much for me to take. I felt like the closer I got to my patients, the closer I nudged them toward a terrible outcome. So I slowly started drawing back, in order to protect them and, in a way, to protect myself. Things only became worse when I started residency, as I found myself teaching (or perhaps warning) the medical students about the power of the “good person” sign as a poor prognostic indicator.Ihadbecomeexactlythetypeofphysicianeveryone had warned me about, and I had done it just two years into the start of my clinical career. After a particularly rough call one day early in my intern year, I talked to my parents about how hard it was and how removed I had become from my patients. They were quick to remind me about all the people who were counting on me not to become “one of those” doctors. After hanging up the phone, I looked through the log of memorable patients I kept on my desk. In it was the handful of previously mentioned good people in addition to others who had succumbed to their illnesses under my care. But there were also many more good people whom I had taken care of who had gotten better and who (when I let them) brought a lot of joy to my work and helped to remind me why I chose medicine as my career. Suddenly, I realized that the good person sign is just like any other sign or diagnostic test we use: it isn’t always accurate. Sometimes, being a good person has nothing to do with one’s prognosis. Sometimes being a good person confers other benefits such as having a strong support system or something to live for. Perhaps the good person sign as we see it is all about our biases as clinicians and what we think happens to such people, even though reality begs to differ. Since that realization, I’ve started working once again on not becoming “one of those” doctors. I’ve let patients back in to my life, and I’m a much happier resident for it. I’ve also learned a very important lesson: In the profession we have chosen people are going to die. Some will be good; others will be bad. But they will all be our patients.
Disclosure of Potential Conflicts of Interest and none were reported.
Editorial Note: In memory of Paul Frank (1960-2015), a very good person. R.K.Y.
(Reprinted) JAMA August 25, 2015 Volume 314, Number 8
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of New South Wales User on 08/26/2015
773
A PIECE OF MY MIND Timothy M. Dempsey, MD, MPH Department of Internal Medicine, University of California, Davis, Sacramento, California.
Corresponding Author: Timothy M. Dempsey, MD, MPH (tdempsey@ucdavis .edu). Section Editor: Roxanne K. Young, Associate Senior Editor.
The “Good Person” Sign When I started medical school, I received a lot of (mostly unsolicited)adviceonvarioustopics,rangingfromspecialty choice to the importance of keeping work-life balance to how to befriend nurses in order to get things done. I would listenpassivelywhilefriendsandfamilyblatheredonabout how comfortable their subspecialists’ lifestyles were. One recurring theme that I actively paid attention to was how oftenpeopleadvisedmetoavoidbecoming“oneofthose” doctors who distanced themselves from their patients. I didn’t quite understand why some people could ever view physicians to be uncaring, cold, and callous, and why physicians allowed themselves to be perceived as such. Medicineisstillthenoblestofprofessions,andonewouldexpect altruism as a baseline for all who go into the field. Personally, I was able to hold on tightly to my humanity and positive attitude throughout the preclinical years of medical school without issue. I even received high marks for compassion and empathy in our “doctoring” courses. At that point in my training I continued to feel as though I were above falling victim to the fate of the heartless physician. Sowhy,Iwonderedinmyshort,unwrinkled,andasyetunblemished white coat, were some physicians so detached fromtheirpatients?Oncetheclinicalyearsstarted,Iquickly discovered the answer. One busy rotation during the third year of medical school, I was assigned to take care of two ill patients whose rooms were next to each other. In one bed there was an alcoholic with recurrent pancreatitis who seemingly took pleasure in berating his nurses and causing a ruckus during his hospital stay. I, like others, generally avoided this room. In the other bed was a most pleasant elderly man who was to undergo a hemicolectomy to resect a mass in his colon. After his surgery, I actively sought out visiting his room. HourswouldpassasItendedtohimandhisfamilyeachday, listeningtostoriesaboutsummersattheNewJerseyshore towns where both my patient and I had grown up. These were good people, reminders to why going into medicine is so amazing. Four days later, he died of a complication of his surgery. In the next room over, my other patient was ready for discharge. Iwasdevastated.Thoughnotveryprofessional,Ifound myselfwonderingwhymyfavoritepatient—thegoodguy— had not made it when the jerk in the bed next to him had. Itriedtointernalizemyfeelings,untilfinallyonedayIopened uptooneofmymentors,whoassuredmewhatIhadexperienced was a common part of medical training. He then wentontoutterthephrasethatIhavesinceheardrepeated frequently in some iteration or another throughout my youngmedicalcareer.“Youknow,Tim,it’softensaidinmedicine[aboutpatients]thatbeingagoodpersonisapoorprognosticsign.”Andthereitwas,theanswer.Theanswertothe
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the
jama.com
questionaboutwhyphysiciansweresojadedandremoved, a phrase so ridiculous it was seemingly taken straight from thepagesofTheHouseofGod.ThemoreIasked,themore Ihearditechoed,and,unfortunately,themoreIcontinued to notice it in my own clinical practice. There was the man withsevereinterstitiallungdiseasewhochattedhopefully abouthisdaughter’supcomingweddingonlytosufferseptic shock from a severe pneumonia and die during his hospital stay. Or the war veteran with end-stage liver disease who would salute me each morning on rounds and was loved by the entire staff prior to suffering a massive myocardial infarction and dying under my team’s care. It was all too much for me to take. I felt like the closer I got to my patients, the closer I nudged them toward a terrible outcome. So I slowly started drawing back, in order to protect them and, in a way, to protect myself. Things only became worse when I started residency, as I found myself teaching (or perhaps warning) the medical students about the power of the “good person” sign as a poor prognostic indicator.Ihadbecomeexactlythetypeofphysicianeveryone had warned me about, and I had done it just two years into the start of my clinical career. After a particularly rough call one day early in my intern year, I talked to my parents about how hard it was and how removed I had become from my patients. They were quick to remind me about all the people who were counting on me not to become “one of those” doctors. After hanging up the phone, I looked through the log of memorable patients I kept on my desk. In it was the handful of previously mentioned good people in addition to others who had succumbed to their illnesses under my care. But there were also many more good people whom I had taken care of who had gotten better and who (when I let them) brought a lot of joy to my work and helped to remind me why I chose medicine as my career. Suddenly, I realized that the good person sign is just like any other sign or diagnostic test we use: it isn’t always accurate. Sometimes, being a good person has nothing to do with one’s prognosis. Sometimes being a good person confers other benefits such as having a strong support system or something to live for. Perhaps the good person sign as we see it is all about our biases as clinicians and what we think happens to such people, even though reality begs to differ. Since that realization, I’ve started working once again on not becoming “one of those” doctors. I’ve let patients back in to my life, and I’m a much happier resident for it. I’ve also learned a very important lesson: In the profession we have chosen people are going to die. Some will be good; others will be bad. But they will all be our patients.
Disclosure of Potential Conflicts of Interest and none were reported.
Editorial Note: In memory of Paul Frank (1960-2015), a very good person. R.K.Y.
(Reprinted) JAMA August 25, 2015 Volume 314, Number 8
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of New South Wales User on 08/26/2015
773
