Blog | Monday, May 16, 2016

The dog in the fight


I came on as the attending on a Monday. An unexpected scheduling need had shifted my assignment from the outpatient clinic to the inpatient hospital service. By the time I joined the team, the month was nearly over and plans were mostly gelled. Consultants were following and things were rolling along as they often do. And during this week, the census was full and the patients were sick. Very sick.

Okay, so I come onto the scene as the Monday morning quarterback, literally. A new set of eyes who is looking at every case from the 30,000-foot view, first seeing the big picture and then trying to serially zoom in on the little picture parts. And this, this approach when I come into something where the ball is already in motion, is generally my approach. I observe and ask some questions. I make up my mind to be a skeptic and to not just go with what's already happening. Even though, most of the time, I am completely in agreement with the current plan.

Yup.

But sometimes when stepping in something happens. You realize that everyone involved has been so zoomed in that they've lost sight of that big picture. So you come strolling up and start firing off all your queries. They seem like obvious questions, actually. I know this because I've been there. The one who has been slugging it out for weeks on a sick patient only to have someone ask 1 or 2 things that make me wonder what the hell I've been doing all this time. That, or they point some very clear observation out that makes you inwardly cringe because it's the kind of thing you should have asked yourself a full week before.

Anyways. On Monday, that's where I was. And there was this one patient in particular that didn't seem to make perfect sense to me. I mean, it wasn't because the last attending wasn't awesome. It was more one of those things where the Monday morning quarterback had the advantage, you know?

So yeah. I look and I ask and I probe. And finally I resolve that we needed to shake up the game plan some. And by shake it up, I mostly meant that we needed to go harder as advocates.

Yes, that. Advocates.

So what does that mean? Well. To me, it's simple. What I do is close my eyes and picture myself as the very concerned mama-sister-wife-daughter-granddaughter-partner at the bedside. I push myself to let the patient matter to me as it would to that person. I pop in my mouth piece and shadow box in the corner. And then I go as hard as I can, as if that person's loved one is strapped on my back pleading with me to help.

Does that sound crazy? I know it probably does.

Okay, so let me explain what was going on without giving too much detail. Essentially, a lot of doctors were seeing this patient and weren't in full agreement. One said to do 1 thing which would require another one to do a procedure. But the procedure-doing doctor didn't feel so much like that was needed. Then, another consultant was somewhere in the middle. Maybe a procedure, maybe just more antibiotics. But see, for me? The main thing I saw was a patient who, despite all that, was still sick as stink. Which meant somebody somewhere was going to have to do something different than what we'd been doing.

Yeah.

And so. I strapped them to my back. The patient and the ones who love my patient the most. I fought with the zeal of a mama bear protecting her cubs. Called and spoke to attendings directly and asked some uncomfortable questions. Pushed my colleagues to be decisive and to also feel the sweet burden of caring like it is their loved one, too. And what I've found is that I work with some good, good people. These good, good people are very busy and often spread thin. But since they are good, good they are usually willing to slow down long enough to stick a foot in the way of the clinical inertia ball.

We all talked. And thought. Together. Someone pulled papers from the literature and others modified recommendations. The senior radiologists did more than just read the images; they re-read them with their experience in mind and the clinical context considered. And all of it felt right and good.

So what happened? Well. Slowly but surely, the patient started improving. But mostly, it felt more like we were on the same team, you know? Instead of just a bunch of stakeholders with our own prideful opinions, we were one big, bad team. Fighting the hell out of that disease and telling it that we weren't the ones to be effed with. Knowing that not only do we have a dog in the fight, we ARE the dog in the fight.

Yes. That.

And you know? It's not guaranteed that any of this will work. The patient could remain ill regardless of our earnest attempts and reroutes. But I like to remember 1 of Harry's quotes about losing a fight:

“I might not have won, but he knew I was there and I'm pretty sure he'd never want to fight me again.”

Ha.

Let me be clear: I am just as guilty as anyone else when it comes to all of this. I fall in love with a diagnosis or plan of care that I developed and can't see the forest for the trees. I also forget that my fifteen years at Grady has afforded me a voice that someone might listen to and entertain if I ask questions. I'm guilty of sometimes letting my exhaustion dampen my enthusiasm. Totally.

But then, like clockwork, in comes a Monday morning quarterback. A good, good colleague nudges me to do the right thing. To reexamine things with fresh eyes and to fight like my loved one depends upon it.

Does any of this even make sense? Probably not.

My point is this: There is a lot of stuff that just can't be learned in books. And this? This little shift in how we see ourselves as patient advocates is just one of them. I'm still learning. But 1 thing I can say for sure is this: I'm still trying, too.

Yeah.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.