Revisiting The House of God

Dr. Stephen Bergman, a psychiatrist, published his now-famous satirical novel The House of God under the pseudonym Samuel Shem in August 1978. The book’s protagonist, a young intern, describes the emotional and physical difficulties during the first year of residency. With more than two million copies sold, the work is something of a classic within the
medical profession.

Even in medical school, before we started our clinical rotations during our third year, some of my
friends and professors recommended I read the novel, so I borrowed it from a fellow student. I enjoyed it but couldn’t fully identify with the
characters in the story, which dealt with the hardships of residency: terrible hours, unsympathetic attending physicians, obstreperous and ornery patients, horrible deaths, and flailing personal relationships outside of the hospital because of the amount of time spent inside it. As a student, I hadn’t yet seen
these things and from the outside this all seemed unrealistic: How, I asked myself, could this even be close to the reality of a modern academic hospital?

Now that I am through my third and fourth years of medical school as well as my first year of residency I have re-read the book, and I thought it would be
interesting to reconsider my initial impression. Indeed, the novel is so much more relevant to me now. In order to illustrate this, it is worth looking at
just a few passages.

I got more and more tired, more and more caught up in the multitudinous bowel runs and lab tests. The jackhammers of the Wing of Zock had been wiggling my
ossicles for twelve hours. I hadn’t had time for breakfast, lunch, or dinner, and there was still more work to do. I hadn’t even had time for the toilet,
for each time I’d gone in, the grim beeper had routed me out. I felt discouraged, worn. (p. 41)

Though slightly hyperbolic, all this is scarily familiar to me. On some days there is so much work to do that one doesn’t really have time to sit down and
eat. Or, when one does finally have a spare moment (after 6 or 7 hours of running around), animal instincts take over and without being cognizant of
it one ravenously attacks any food available. Some of us stick granola bars in our white coat pockets to prevent this sudden and unfettered hunger attack
but even this is just enough to make us want more. Occasionally, the issue is that one forgets to eat and when we smell the trays of food being
delivered to hospital rooms during lunchtime, our intestines do somersaults, squeeze, shiver, and groan as we are reminded of our baser needs. We experience
pangs of hunger that occur throughout the day because meals, and even glasses of water if one has time for them, are far apart. I have, in multiple instances, come home at night or in the morning and stood for a moment in the kitchen while having an internal debate with myself: Am I more tired or
hungry?

And Shem’s line about the “grim beeper” made me laugh out loud. I remember twice walking into the bathroom to answer the call of nature, when suddenly the shrill sound from my pager or phone prompts me to abort the mission, walk out, and
answer the other call.

The talk was, on the part of the doctors, all medicine….

The accuracy of this is stunning. When residents get together or when we have a spare moment to chat at work, we don’t usually talk about politics or
friendships or relationships so much as we talk about medical stories. We trade tales of difficult procedures or illnesses or we tell hilarious medical jokes. Friends who spend time with us
outside of the hospital are shocked at how much we speak about work with each other. But a resident’s life revolves around the hospital. We (almost)
literally reside at the hospital and the eventful aspects of our lives usually occur in the healthcare setting. As one can see from even a quick glance at
some posts on this blog, medicine is filled with human drama, humor, sickness, death, and life. How do we avoid talking about all that in our spare time?

The House of God found it difficult to let some young terminal guy die without pain, in peace. Even though Putzel and the Runt had agreed to let the Man
With Agonal Respirations die that night, his kidney consult, a House red-hot Slurper named Mickey who’d been a football star in college, came along, went
to see the Agonal Man, roared back to us and paged the Runt STAT. Mickey was foaming at the mouth, mad as hell that his “case” was dying…. Mickey called a
cardiac arrest. From all over the House, terns and residents stormed into the room to save the Man With Agonal Respirations from a painless peaceful
death. (p. 245)

These can be traumatic moments, indeed (I have written about coding patients herehere, and here). Shem’s point is that we in the hospital sometimes do
chest compressions on patients we surely will not be able to resuscitate or, if they are resuscitated, will be dependent on a ventilator and unconscious
for the remainder of their days. Do we try to revive a 90-year-old with metastatic cancer to the spine and brain? Or do we try instead to make the patient as comfortable as possible?
From the patient’s side (and the patient’s family’s side) the difficulty, which seems insurmountable, is in accepting the end. For most physicians, like the
narrator of The House of God, the difficulty lies in cracking ribs and sending electrical shocks through someone’s body with no clear purpose. In fact, we
frequently ask families to let us make their loved ones comfortable, at least, before they pass away. But that is not always the decision that is made.
And in the passage above Shem satirically chides those who believe the best course is always to be as aggressive as possible.

Eat My Dust Eddie, being run ragged in the death-house, the MICU [Medical Intensive Care Unit], looked awful, and was talking about his previous night on
call: “I was admitting my sixth cardiac arrest and I got this call from the E.W. — Hooper, it was you — saying that there was a guy down there who’d
arrested and you were thinking of sending him to me if he survived. I hung up the phone, got down on my knees, and prayed: Please, God, kill that guy! I
was on my knees, I mean ON MY KNEES!” (p. 126) 

My colleagues and I have never wished that anyone would die. But, undoubtedly, we all identify with the feeling of being overwhelmed. When you’re exhausted
and still admitting patient after patient and trying to work them up for a new diagnosis while also taking care of other patients on the service, writing notes,
fielding pages or phone calls from nurses, drawing blood, and doing CPR, there are moments when it feels as if there is no more time or effort left to give.
You are working with rope with no slack or trying desperately to tread water. This is especially true in a place like the Intensive Care Unit, where patients are sicker
and require closer monitoring. During those moments, we beseech the hospital gods: “please, no more admissions, please no more.” Or, “please don’t let
anyone get sicker than they are.” It’s not every day one feels this way, but it is often enough that the sentiment is familiar.

*   *   *

When The House of God was first published it was not received well by Dr. Bergman’s colleagues and peers. As he tells it,

… my book The House of God enraged many among the older
generation of doctors. I was maligned and disliked. The book was censored by medical school deans, who often kept me from speaking at their schools. None
of it really bothered me, though. I was secure in the understanding that all I had done was tell the truth about medical training.

Thus, the book is not only a brilliant and witty piece of satirical literature, it is also a “fiction of resistance,” as Bergman describes it. Its most sinister and clueless
characters are the ones in charge. And in many cases their worship at the altar of medicine and science damages their relationships with patients,
residents, or each other.

Much has been written about this aspect of the book in recent years: Dr. Howard Brody of the University of Texas Medical Branch

wrote about its relevance in the American Medical Association’s Journal of Ethics in 2011
. Dr. Suzanne Koven, a primary care physician,

interviewed Dr. Bergman about the book for the Boston Globe in 2013
. Dr. Howard Markel, a professor of pediatrics, psychiatry, and the history of medicine at the University of Michigan, discussed the book in a piece for the New York Times in 2009.

The reason for this interest may have something to do with a story Bergman tells in his own 2012 piece for The Atlantic:

And then one day I got a letter forwarded from my publisher, which included the line:
“I’m on call in a V.A. Hospital in Tulsa, and if it weren’t for your book I’d kill myself.”
I realized that I could be helpful to doctors who were going through the brutality of training. And so I began what has turned out to be a 35-year odyssey
of speaking out, around the world, about resisting the inhumanity of medical training.

But the culture in medicine has changed dramatically since this book was written. Institutions are far more humane than they once were. Nevertheless, what we see and how much we need to see cannot change. Doctors ought to be exposed to a wide range of pathology; they
must be exposed to death. This is how one learns to be a great doctor, to diagnose obscure diseases, to treat common diseases successfully, and to save
lives during a hectic code in the hospital.

No matter how authority figures treat residents, Bergman’s book will always be precious to future generations of doctors. Like any great novel it identifies common yet significant human experiences. The author tells us, as it were, that “yes, I know
exactly what this is like and I laughed at the same things you did. I made the same mistakes. I had the same
difficulties.” Such commiseration ameliorates that unsettling feeling residents experience: the feeling that the hospital is a rabbit hole
that spirals into a detached and harrowing yet hilarious world. And, because of The House of God, there will always be a shared understanding
among residents and readers of the triumphs and tragedies accompanied by this feeling.

Becoming Cynical, Part 4

I have written quite a bit about why physicians become cynical (see herehere, and here). What follows are some more thoughts on this topic
that relate to my previous post on Parkinson’s Disease (PD).

Recently, a sixty-three-year-old patient came to the neurology clinic for a left-handed tremor that had become worse. He and his wife gave a classic history of the
onset of PD. His tremor occurred only at rest. He felt his left arm was weaker than his right arm — this was evident in some sessions with his personal trainer. He noticed his handwriting had become slightly smaller. And his wife said she couldn’t hear him well anymore.
She initially thought it was due to her own hearing loss, but her friends also found that his voice had become harder to hear. The attending physician and I asked other questions
regarding sleep (sometimes PD patients act out their dreams), drooling, and cognitive status. After a physical exam, a cognitive test, and some more
questioning, the attending physician concluded that the patient had PD.

At this point in my short career I had seen multiple patients with PD, some in its early stages, some advanced, and some in-between.
I was at least superficially familiar with the course of the disease. So when we broke the news to the patient and his wife, it felt slightly banal:
another PD patient, another diagnosis, and another prescription for PD drugs.

Shutterstock

But this patient’s reaction took me by surprise. Most people are upset, ask for some information about the disease, take
their prescriptions and leave. But in this case, the patient’s questions were far more detailed than I was used to (the attending, given the extent of
his experience and knowledge knew exactly what to say). The conversation eventually led to a discussion about the advanced stage of the disease. We explained
that medications and deep brain stimulation would become less and less effective. Ultimately, he would get dyskinesias and end up in a wheelchair.

We all know we’re going to die — that is one of the few things in medicine that one can say is 100 percent certain. But there is something eerie about hearing
exactly how you’re guaranteed to deteriorate. The attending was telling the patient in a very diplomatic way that his life would look just so in about twenty
years. It was said gently, but the patient understood the meaning well. His wife began to cry and he teared up, too. His movements, his hobbies, and control
would slowly peter out and vanish.

After I told this story to someone with experience in the medical field, the person responded with, “I don’t know what they’re so upset about — it’s just
Parkinson’s Disease.” This probably seems callous and insensitive. Just PD? Think of the horrible symptoms, the side effects of the medications, the
creeping debilitation. Imagine, eventually, being locked-in, frozen and unable to move, relying on a pill that becomes less and less effective for allowing such simple functions as turning
around or walking. It is indeed a terrible disease.

But for a physician who has seen far worse — such as ALSCreutzfelt-Jakob diseasetrauma, Sudden Infant Death Syndrome (SIDS), all of which involve rapid debilitation and death — PD can seem preferable, with its long course and all the available treatments, however limited they may be.

This tendency to compare the severity of varying illnesses is perhaps one of the greatest traps in practicing medicine. Physicians see so much that
diseases that are serious to most patients seem mild relative to the more horrifying ones. I have found myself falling into this pit more than once. I remember
doing CPR on a patient who had burst a pulmonary artery (a major artery in her lungs) as a complication of her lung cancer. As I did chest compressions, blood poured out of her mouth and onto my pants, soaking my shoes and scrubs. While this was going on, I got
a call from a nurse about a patient with a history of drug abuse who wanted more pain medication. He may very well have been in serious pain. But compare
his needs to this woman’s death. Clearly, one was much more affecting, disconcerting, and significant than the other, and it was a while before I
could address the drug patient’s pain appropriately. It can be all too easy to dismiss as a “mild” disease or complaint the sorts of conditions against which our exposure has hardened us.

Thus, with experience, our expectations change; it takes more to move us. We shrug off the majority of hospital cases as “not that bad” or “benign.” I think
all this is inevitable in a career in medicine. One must pinch oneself every day, at the very least, to recognize it.

Becoming Cynical, Part 3

The problem of physician burnout, which in a previous post I defined as a
“loss of enthusiasm for work, feelings of cynicism, and a low sense of accomplishment,” increasingly plagues the American medical profession. In an article in the Archives of Internal Medicine in 2012, researchers
found that U.S. physicians suffer more burnout than other American workers. This year, a Medscape Physician Lifestyle Report found that 46 percent of all
physicians who responded had burnout, “a substantial increase since the Medscape 2013 Lifestyle Report, in which burnout was reported in slightly under 40 percent of respondents.”

The consequences are deleterious: burnout negatively affects
patient care and is associated with higher rates of suicidal ideation. In two earlier posts (here and here) I offered a couple of reasons why physicians become
cynical. In this post, I expand on my previous entry
suggesting this phenomenon is partially due to the “patient population one deals with.”

Let me start with a story.

One night, the general medical team admitted a patient with severe hyperglycemia, or high blood sugar, who had a
history of IV drug abuse, alcoholism, diabetes, and hepatitis C, a viral disease that can destroy the
liver. The patient drank so much hard liquor that he got dehydrated, neglected to take his insulin and
went into a hyperosmolar hyperglycemic state. Patients with diabetes develop this
condition when they have an infection, preceding illness, or dehydration. In diabetics, physiological stresses like these reduce insulin, a hormone which
normally regulates blood sugar levels, causing unmitigated hyperglycemia. The blood becomes hyperosmolar due to the excess sugar and draws more fluid into the intravascular space
leading to dehydration of cells within the body and increased excretion of water in the urine — which in turn worsens the pre-existing dehydration. As urine is
excreted there is also a loss of electrolytes like sodium and potassium. Severe hypotension (low blood pressure) ensues and
patients can die. Treatment involves IV fluids, insulin to correct the hyperglycemia and continuous monitoring.

After recovering overnight, our patient declared that he would start a new life and give up drinking — he was ready to make a change. As his symptoms
improved and his labs normalized the medical team worked toward this goal. We arranged for follow-up appointments with a primary care physician, an
infectious disease physician, and a psychiatrist. The pharmacist managed to get him insulin through a hospital-assistance program. And the social worker
arranged for him to go directly to an intensive alcoholic recovery program gratis. In order to get there, he was offered transportation from the hospital. The
hospital ate the cost for treating him because he was uninsured. It is both wonderful and incredible that all these resources, given freely, go towards
helping a patient get back on his feet.

However, on the day of his discharge, the patient left the hospital but did not take the ride or his insulin. He drank two bottles of vodka and came back
that evening in a drunken stupor and a hyperosmolar hyperglycemic state. He cursed at his nurses and the female resident who admitted him. Because he also
threatened them, the hospital staff put him in restraints in his bed so he wouldn’t violently swing at those giving him medications. The medical team
repeated the previous day’s actions — but two days later, the patient did the exact same thing. And for the third time, the medical team readmitted him.

Shutterstock

This sequence of events elicits all kinds of thoughts and visceral reactions pulling us in two different directions. Surely, this patient has an illness
(alcoholism) and so we need to be understanding even if we hold him responsible for his actions. And yet, the hospital gave him multiple golden
opportunities to attempt to turn his life around and he declined to do so. At what point does the hospital turn him away and refuse to pay for his medical
care? Would it be ethical to do so? The money can be better spent on destitute patients who will take their medications but can’t pay for them. Given the
limited resources of any system, shouldn’t we at least entertain the idea?

Unfortunately, doctors face this conundrum on a weekly basis. Some diabetics refuse to take insulin; other patients refuse to give up an unhealthy diet;
some don’t take their blood pressure medications. Statistics back this up: in one particular review article in the Journal of the American Pharmacists Association in 2000, 43 percent of
the general population and 55 percent of the elderly population were found to be nonadherent to their medications. Approximately 125,000 deaths per year have been
attributed to nonadherence to treatment for cardiovascular disease. Finally, the direct and indirect costs of nonadherence to medications are estimated to
be $100 billion per year in the United States.

Physicians want patients to get better, and this is more than just a matter of prescribing medicine. They spend time talking to patients about their illnesses and treatments. They call consults from specialists who then take time to figure out a plan for a particular aspect of the patient’s ailment.
Social workers arrange for affordable medical services, transportation, and institutional and governmental help. Physical therapists and occupational
therapists see patients who need to regain strength. All this requires logistical tasks that aren’t always intellectually stimulating or exciting and may
not even be compensated for at all.

Of course it is true that the doctor can fail the patient, but it is also true that the patient can fail the doctor. In the Medscape survey I referenced above, physicians cited “too many difficult patients” as one of the reasons for their burnout. This reaction is completely understandable. After seeing patients make poor choices again and again, a general malaise can set in. At some point, physicians ask themselves, “why should we care?” Doctors may start to go through the motions of writing notes, coming up with a plan, and making
arrangements for these patients but with an emptiness of spirit. We may become embittered, both toward the patient and toward some of the annoying tasks involved in the work. A sense of futility and even detachment can follow.

Let’s not forget that the practice of medicine is a very human enterprise. Indeed, as healthcare professionals, we ought to
recognize the problem of nonadherence even after putting aside the issue of limited resources. However, it is useless to just complain about uselessness — to throw our hands in the air and ask “Why even bother?” In every field there is work that does not bear fruit; entrepreneurs, for example, fail 80 percent of the time when starting a new
business. Why expect a profession that relies on the Sisyphean task of changing a human being’s behavior and habits will be exempt from this fact?
Patient failure, just like physician failure, is an integral part of our fallible medical system.

Running a Trauma Code in the ED

Hospital image via Shutterstock

The paramedics flying the patient in by helicopter called the Emergency Department charge nurse and described the patient: a 40-year-old male in a construction accident with
deep lacerations (wounds) to the left leg. The moment between the paramedics’ call and arrival was only a few minutes.

During this time, the ED notified the
trauma surgery team that a patient may need surgical care and classified the trauma as level 1 (a level 2 trauma is less urgent). As the ED
notified the trauma surgery team, the ED nurses and an ED resident prepared the trauma bay, which is just a larger patient room in the ED. They kept IV
fluids at the ready; the blood bank prepared to get the patient blood; the resident placed an intubation kit at the stretcher side (if the patient is
unconscious and cannot breathe on his or her own, the resident places a tube down the patient’s throat in order to get oxygen into the lungs); an oxygen
mask was set to deliver oxygen; we medical students placed blankets at the bedside; and everyone put on gowns, masks, and gloves. The whole scene was
chaotic, not least because of the sheer number of people involved: multiple nurses, an ED resident, a general surgery resident and/or an acute care surgery
fellow, a trauma surgery intern, a pharmacist, medical students, and an x-ray technician to take immediate imaging if needed.

As the paramedics rushed the patient in on a stretcher (yes, just like in the movies), they recapped the patient presentation for the healthcare team and
provided slightly more detail about the mechanism of injury. A construction worker accidentally dropped a chainsaw onto his leg. The metal edges
of the saw cut through the patient’s left shin and thigh.

I don’t usually find blood upsetting. During surgery, I had no problem in the operating room watching the surgeons explore bowel or try to stop bleeding
from a severed artery. Objectively, I comprehend that it is gruesome, but it doesn’t induce an intense visceral reaction. However, this particular event was
absolutely disturbing. The metal blades cut the left shin so deeply that only half of the bottom leg was attached to the knee. The tibia and fibula bones
jutted out of the skin over large, severed arteries and veins. Muscle and tissue clung to the leg by a few strands of skin as blood seeped from the wound.
On the upper thigh, the damage was less intense — the saw tore through the quadriceps and the lateral leg muscles. Some of the superficial muscle hung off
the wound, which bled much less severely. This sounds horrible, but the sight of this, akin to some kind of horror movie, was not so affecting until one
pairs it with the fact that this patient was conscious.

His screams were charged with fear and intense pain, while he lay in a completely strange place with no family and no shortage of doctors and nurses and
paramedics aggressively intruding on his personal space. I thought of this passage from Tolstoy’s The Death of Ivan Ilyich: the screaming “was so
terrible that one could not hear it through two closed doors without horror…. ‘Oh! Oh! Oh!’ he cried in various intonations. He had begun by screaming ‘I
won’t!’ and continued screaming on the letter ‘O.’” For this person to experience all this commotion and pain while also realizing the possibility of losing
his leg must have been overwhelming.

But the struggle to provide medical care went on and the trauma assessment began. The upper-level surgery resident stood at the foot of the patient’s bed
directing the healthcare team and the ED resident stood at the head of the stretcher making sure the patient could breathe. The nurses, meanwhile,
confirmed that two IVs (one in each arm vein) were in place and working so that they could deliver blood, fluids, and pain medication as needed. The upper-level trauma surgery resident began with the primary survey, which identifies life-threatening injuries to the patient. For instance, an injury to the patient’s throat
or mouth that prevents the patient from breathing is an immediate concern. The resident scrutinized the vital signs and quickly assessed
for other urgent issues: airway (is the patient’s mouth clear from obstruction?), breathing, circulation (major blood loss), disability/neurological
issues, exposures to toxins/environmental control. We frequently use the mnemonic ABCDE to remember this. The nurses completely stripped the patient of
his clothing during this examination, for the sake of thoroughness.

If the patient is not on the verge of dying, the trauma surgery resident begins a secondary survey and fastidiously examines the patient head to toe for
other, perhaps less urgent, signs of bruising, bleeding, or anatomical abnormalities caused by trauma to bones or tissue. The hospital staff roll the patient
onto his or her side in order to get a clear view of the back and buttocks. The surgical intern usually performs this part of the exam, hollering out any
abnormal findings to a nurse who stands outside the room, documenting the patient’s injuries to a computer. The resident also performs a FAST exam (Focused Assessment with Sonography for Trauma), where he or she uses
ultrasound imaging to search for blood within certain parts of the abdomen, chest, and pelvis. It is a quick and effective way to assess whether a patient
is bleeding internally and needs immediate surgery.

The healthcare team did a secondary survey as the patient continued to groan and scream. Because of the severity of the injuries to different systems, the
trauma surgeons, orthopedic surgeons, and vascular surgeons all came to assess what kind of surgery this patient needed. After a quick huddle with the
attending physicians, the nurses wheeled the patient straight to the OR, never to be seen or heard from by me again. The one aspect of this patient’s
prognosis that I do know is that the surgeons thought they could save this patient’s leg and its function, which is demonstrative of the
miraculousness of modern medicine.

In the early seventeenth century the great English poet, cleric, and lawyer John Donne
reflected upon sickness and health in a book called Devotions upon Emergent Occasions, after battling illness
himself. In it, he wrote that “we study health, and we deliberate upon our meats, and drink, and air, and exercises, and we hew and we polish every stone
that goes to that building; and so our health is a long and a regular work: but in a minute a cannon batters all, overthrows all, demolishes all….” There
is nothing quite like a trauma to reinforce Donne’s observation about how fragile our condition remains; being struck by a car or being in a construction
accident shoves us off the tenuous tightrope of health on which we walk. Here, a healthy patient in the prime of his life was nearly destroyed by poor
fortune.

This is also an example of losing track of a patient’s outcome, which is so common in medical school and residency. I’ll never know his whole story — as
I’ve written, this is something that contributes to cynicism in medicine.

And another thought on this trauma: a Chinese proverb states that “no man is a good doctor who has never been sick himself.” This certainly sounds
right. How can one understand a patient until experiencing his pain? I disagree, though. We know that many who see other people in pain experience pain themselves. But
further, the power of human empathy can be surprisingly vast. True that nurses, students, and doctors may not directly feel the pain of a sharp metal edge
slicing through flesh, but can we not comprehend the horror of this? Can we not, in an admission of never wanting something like this to happen to us,
experience in a small way the terror of such an event? An empathetic emotional response is enough to prime healthcare workers to take great care of a
patient. The potential problem in medicine, then, is not what the Chinese Proverb suggests. The possible outcome is that when we see people like this every
day, the once-astonishing horror becomes treated as a daily experience.

Becoming Cynical, Part 2

At this point, I have spent one month on pediatric surgery, one month on trauma surgery (a service that deals mainly with adults who need emergency general surgical procedures), and one month on general pediatrics. It’s clear already that physicians treat pediatric and adult patients very differently. Children need high levels of protein and calories in their diets, and pediatricians need to have a higher index of suspicion for congenital abnormalities,
or genetic diseases. Children also swallow small objects, and stick objects up their noses, which can cause infections, shortness of breath, or scarring of
tissue; this happens much less with adults. But beyond this, there is also a clear difference in the way one reacts to treating these two different
patient populations.

With children, the world, from a healthcare perspective, is almost always black and white. One cannot blame a newborn child for soiling a diaper or for
crying when being examined. A baby is always innocent — poor parenting or an unlucky genetic lottery pick is usually to blame for sickness. One too many
children on the pediatric service fall into these categories. Some parents beat their children so badly that a portion of the intestine ruptures. One
infant had multiple broken bones, some of which were considered “old” fractures. I imagine just reading that sentence induces the kinds of horrific shivers
I felt upon seeing this child on the service. Who do we blame when multiple tubes need to drain out different colored liquids from the intestines because
of child abuse or premature birth? Anyone but the patient. The innocence of children is inviolable and, as such, one cannot help but feel an unrelenting
sympathy for them.

With adults, however, gray areas abound. Many older patients have chronic illnesses like diabetes, high blood pressure, obesity, high cholesterol, and
cancers. Undoubtedly genetics play a role, but we also hold adults responsible for their own well-being. Smoking, poor diet, refused medications: these are
just some of the life choices that invite those chronic illnesses.

Smoking leads to lung cancer. A poor diet leads to diabetes or heart disease. Taking medications regularly for Crohn’s Disease or Ulcerative Colitis can prevent the need for
massive abdominal surgeries in which portions of the intestine need to be resected. And if the piece of colon resected was necessary for the patient to be
able to defecate voluntarily, he or she needs an ostomy, a procedure in which part of the intestine is
connected to a bag on the outside of the abdomen, where stool collects; the patient then empties the bag manually. How easy it is to dump sympathy by the
wayside! When we know who the guilty party is, how can we behave impartially? The enervation of seeing patient after patient in a similarly preventable
situation on the adult floors eases one into cynicism despite the sympathy and empathy that brought us into medicine.

And this is where the question of physician burnout also comes up. Burnout is defined as loss of enthusiasm for work, feelings of cynicism, and a low sense of accomplishment. In one Medscape survey, physicians
of all different specialties were asked whether they experienced at least one symptom of burnout. Pediatricians experienced one of the lowest levels of
burnout. Another study, published in JAMA Internal Medicine, found general pediatricians ranked lower on burnout than every other specialty except dermatology and preventive, occupational, and environmental medicine.

Many, many factors account for physician burnout and cynicism in different specialties, including lifestyle, geographic area of practice,
private versus hospital practice, and so forth, and I will continue to write about this because it can affect patient care. But among the many factors involved, I do think that the
patient population one deals with affects the feelings a physician has toward the patient. After all, it is much harder to sympathize with those who have
made mistakes and poor decisions than with those who are only a victim of circumstance.

The job of the physician, and the art of medicine, involves trying to put aside the idea of the culpable adult or the blameless child and to treat the
person as he or she stands before the doctor. This is incredibly difficult, but I suspect this push and pull is integral to the imperfect system that we
have — a system that deals with human beings and human relationships as well as with science.