“I love ITU because it is just a numbers game. Our ward round is a ten-minute discussion outside of the patient’s room. I like it even more when the patient is intubated because then they can’t talk (so the consult is really short).”
I overheard this in the doctors’ office when some of the senior trainees were speaking about their preferred rotations in comparison to their less preferred rotations.
When I heard the statement above I was taken aback. There are always going to be points in a doctor’s career where it feels frustration overwhelms reward. We are not all saints, but we are all human. Of course, an intubated patient cannot talk, and the degree of intervention make much of medicine on ITU very number-centric. But the overall sentiment is what’s important. What does this sentence really reveal about the individual who said it? What does it say about the medicine that we have come to practice?
It suggests to me that the patient is not the focus of the doctor’s job. Playing a ‘numbers game’ has replaced the patient as the focus of the doctor’s attention. Yes, normal medicine relies on results of blood tests and imaging, but I have always been taught that these are only partial contributors to a clinical diagnosis – the rest depending on a patient’s history, examination in tandem with subjective and objective opinions of wellbeing.
This doctor set out to be human. Why do they now seek comfort in playing only a ‘numbers game’? Is it burnout? Are they tired of talking to patients? If solely an intolerance of humans, this implies that they are ‘losing’ their humanity.
Is it a product of the system? The sheer number of patients needed to be seen? Perhaps, if a doctor is exhausted by seeing 30 complicated patients, having an opportunity to solely focus on numbers is a relief. I can surely see this as a feeling I will experience in the future as a busy junior doctor. We all run the risk of exhaustion, loss of empathy and the development of apathy and burnout.
What do we lose if we treat numbers and lose humanity?
Numbers are only a snapshot of a metric or biomarker within that individual. In no way does that number reflect that individual as a whole in the present, nor does it show that individual’s path through life – their long term history, the events immediately running up to their presentation, their hopes and beliefs that they will carry forward.
If we don’t understand the patient’s long term history – we don’t understand the cause of the disease. The socioeconomic background, their relationships, their behaviours and beliefs. The food they eat, their job, their sleep, the things that give them purpose. Try treating a heart attack with a statin without addressing the root cause of the inflammation, metabolic syndrome or cardiovascular fitness- perhaps that patient will come knocking again sooner than hoped. Treating a number does not respect the entire human and does not provide sustainable care.
What if by playing a numbers game we provide unnecessary treatments? If the patient is intubated, how do we know what their wishes are? If they were in a car accident they would not have predicted to fill out a Do Not Resuscitate form. We treat a number, not the patient.
What about a patient with a terminal prognosis? If we treat a number rather than the individual in a patient who has a brutally finite amount of time to live, are we unknowingly causing protracted suffering with the good intention of maintaining life? I really recommend Being Mortal by Atul Gawande.
When I approached Dr Mark Cucuzzella about this occurrence and the phenomenon of “burnout”, he recommended a film called Escape Fire. I haven’t watched it (fighting my own fires), but Mark gave me his synopsis.
It went something like this:
When a firefighting crew is confronted by a raging forest fire, they work tirelessly to try to bring the fire under control. Despite their efforts, the battle can often seem futile. Sometimes, the battle is dangerous.
When the fire comes rushing down through the forest at incredible speeds towards the fire crew, there is only one option for survival. Running sideways doesn’t take you away from the fire, running backwards is impossible. The only way to escape is to create a smaller circular fire to burn the forest in a ring around the firecrew. When the large forest fire approaches and consumes the forest nearby, it will not consume the firecrew. Fighting fire with fire, the crew carved out their own space that gave them survival and the ability to continue on.
The concept of Escape Fires have a huge concept for career survival in medicine. Like the fire crews, those in healthcare are also pushing forwards for a common goal. Often, the job is tough and sometimes, it seems futile. We might switch from a human-centric approach to a ‘number’s game’. In the madness of our own personal fires, what can you do to create a refuge that gives you hope? Because, as the analogy goes, if you cannot create an escape fire, the insurmountable forest fire will keep rushing down the mountain, fire crews will die and doctors will burn out.