Monday, July 20, 2015

Andrew Bomback - Hope is not a Plan: On Being Mortal, Doctors, and Death

My friend spent two weeks at a writer’s retreat in Vermont, where he met a former physician who was now working on a memoir about why she left medicine. The former physician told my friend that her memoir was not a doctor memoir, “because all doctor memoirs suck.” My friend, who’s not a physician, asked me, because I am, if I agreed with that assessment. Like many modern conversations, ours was over email. I wrote back: I sort of agree with your new friend that doctor memoirs suck, but I am a very biased reader. I always feel that the doctor is trying to make himself or herself sound like a much better person than he or she really is. It's quite possible that I am the outlier among doctors in being an on-again-off-again asshole, but I doubt it, because all my doctor friends have equally asshole-ish tendencies. And that stuff almost never comes out in those memoirs. And I think the narrative arcs in those memoirs tend to be artificial, too. Nothing in medicine is linear. Again, I'm really biased. 

Upon the recommendation of my wife, a fellow physician who specializes in hospital medicine, I read Atul Gawande’s latest book, Being Mortal. The book moved her to start a hospital-wide book club in the hope of spurring conversations about how healthcare workers deal with aging and dying. Nothing speaks to how poorly physicians, nurses, social workers, patients, and families handle mortality than the fact that my wife has been trying to plan this book club for four months, as of this writing, and still has not been able to get full buy-in from her hospital.

Throughout Being Mortal, Gawande uses Tolstoy’s The Death of Ivan Ilyich as a teaching tool on how doctors can manage or mismanage their patients’ death experiences. He himself first read the book as a medical student in a seminar series called “Patient-Doctor” that emphasized the humanistic parts of doctoring (many medical schools have such courses – mine offered “Clinical Practice” every Friday afternoon, and we read William Carlos Williams’s The Doctor Stories). The key part of the Tolstoy novella, for Gawande, is that Ivan Ilyich’s greatest suffering stems not from his fatal illness but rather from his doctors and his family refusing to acknowledge that he is dying. Instead of comforting him, they bring in new experts and try new treatments, well-intentioned efforts that do nothing to stop the impending advance of death. I wrote this last sentence about Ivan Ilyich but it could apply to any patient today in any intensive care unit in any American city.

Death, Gawande writes, is not what the very old fear. “It is what happens short of death – losing their hearing, their memory, their best friends, their way of life.” He quotes Philip Roth – “Old age is not a battle. Old age is a massacre.” – before lambasting doctors for having too narrow a focus. “Medical professionals concentrate on repair of health, not sustenance of soul.” These professionals, trained to “fix” more than “manage” problems, should not “be the ones who largely define how we live in our waning days.”

If I were teaching “Patient-Doctor” or “Clinical Practice,” I’d assign the medical students “Errand,” the Raymond Carver short story that relays the last moments of Anton Chekhov’s life. In the story, Chekhov is receiving hospice care in a luxury hotel in southern Germany, and his physician is summoned late in the night by Chekhov's wife, who reports that her husband is becoming short of breath and coughing up blood. When the physician arrives, he sees that Chekhov is nearing his end; oxygen might help, but that will take hours to retrieve, and by then Chekhov will be gone. The physician picks up the phone and dials the hotel's kitchen, ordering up a bottle of champagne with three glasses. Chekhov drains his glass, compliments the champagne, and then passes away. When discussing the physician's decision to order champagne instead of oxygen for the dying Chekhov, Carver writes, “It was one of those rare moments of inspiration that can easily enough be overlooked later on, because the action is so entirely appropriate it seems inevitable.” When I am confronted with a dying patient, I think of the doctor ordering champagne, and I hope that my own actions will someday be viewed by the patient’s survivors as “so entirely appropriate.”

My least favorite parts of Being Mortal are when Gawande recounts patient stories. I concede that non-physicians might find such tales interesting. To a doctor, though, these examples feel too precious, too convenient, too memoir-y. I don’t need to know what Gawande learned from each patient’s death. I want to know how he approaches a dying patient who won’t acknowledge death. Even more, I want to know how he approaches a fellow physician whose recommendations for a dying patient are not “so entirely appropriate.”

My favorite part of Being Mortal is how Gawande handles “The Median Isn’t the Message,” the essay by Stephen Jay Gould in which the paleontologist rejects the survival data he’s been given for his own cancer diagnosis in favor of the slim chances that his fight with cancer will be an outlier. Gawande says he thinks of Gould’s essay “every time I have a patient with a terminal illness…[W]e’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets – and have only the rudiments of a system to prepare patients for the near certainty that those tickets will not win. Hope is not a plan, but hope is our plan.” Here, Being Mortal sheds itself of memoir and announces itself as a book-length essay on why hope is the wrong plan for dying patients. Here, Atul Gawande gives his readers a flash of his own asshole-ish tendencies.


My daughter, Juno, was at a playdate with one of her friends, whose name happened to be June. Her parents also happened to be doctors – the mother a pediatrician, the father a cardiologist. The symmetry was amusing. While the children dressed up as Elsa and Anna from Frozen, we adults tried at first to talk about our town and our children. Soon enough, though, we were talking about medicine. My wife told the cardiologist that the new advances in heart failure management – ventricular assist devices, transcatheter aortic valve replacement surgeries, home infusions of milrinone – have made it harder for patients to accept that it’s natural to die of heart failure. The cardiologist said that one of his favorite headlines from The Onion was “World Death Rate Holding Steady at 100%.”

The truest line in Being Mortal, from a physician’s standpoint, is when a critical care doctor tells Gawande, “I'm running a warehouse for the dying.” Gawande writes that the critical care doctor said this line “bleakly.” This is a good example of why writing students are instructed to avoid adverbs, because Gawande compromises the line by saying it was delivered “bleakly.” The doctors I know would have said those exact same words but would have done so with a smile and a laugh. The line would have been delivered as a joke.

Malcolm Gladwell, discussing why people tell jokes about themselves (his specific reference was engineers making engineering jokes), calls such jokes “grievances.” Jokes are a way for a group of people to complain: This is the way we think! Why doesn’t everyone else think like us? If you want to learn about how doctors process the deaths of their patients, don’t read their published memoirs. Instead, listen to the jokes they tell each other.

A doctor tells his patient that she has terminal cancer. “Terminal?” she asks. “As in, there’s nothing you can do about it?” “Nothing,” the doctor says, “nothing at all.” “Well, with all due respect,” the patient counters, “I want a second opinion.” “Okay,” the doctor says, “you’re ugly, too.” Interpretation: Doctors are frustrated by patients’ inability to accept their own mortality. This denial can put us in the uncomfortable position of having to convince patients and their families that death is inevitable. Doctors – at least the ones I know and respect – laughed at the “death panel” fears stirred up by opponents of Obamacare. The laughter stems from our near total impotence regarding death in the hospital. The patients and, more commonly, the families (because the patients are too ill and only rarely have clearly defined advanced directives) decide which life-sustaining interventions they want, regardless of medical advice. We can use leading language, we can make heartfelt recommendations, we can outright say that an intervention is futile, but the patient and the patient’s family ultimately make the decision on what to do and what not to do.

An oncologist goes to the morgue to find his patient. “He’s scheduled for chemotherapy,” the oncologist tells the mortician. “Sorry,” the mortician says, “but you’re too late. The nephrologist just took him off for dialysis.” Interpretation: Doctors over-treat patients, but this over-treatment isn’t about making more money. The over-treatment – the “flogging,” as we say in the hospital – is rooted in our collective inability to admit defeat, which in turn is driven by fears of our own deaths. If I, as a doctor, give up on this patient, someday another doctor will give up on me. Older doctors flog more than younger doctors (I have no data to back up this claim, because no such data would ever be collected, but I assure you it’s true).

The doctor takes his patient into a room and says, “I have some good news and some bad news.” “Give me the good news,” the patient says. The doctor replies, “They're going to name a disease after you!” Interpretation: Doctors need to create emotional distance from their patients’ deaths. We teach our medical students how to deliver bad news to patients. They practice, first on each other, then on actors pretending to be patients, and then, eventually, on their own patients during clinical clerkships. In the title essay of The Empathy Exams, Leslie Jamison relays her experiences as a medical actor and describes the process by which she tried to evaluate a medical student’s empathy. She correctly points out that she was not grading the students on their empathy as much as their projections of such empathy. We don’t teach our trainees apathy, but this is a learned behavior, too. We must have some separation from the bad news we’re delivering, some ability to send home the patient who’s just cried in the office and move on to the next patient. We must have the capacity to leave the office and be with our own families and not think about our patients’ suffering.

On my first night on-call as an intern, I admitted a hemophiliac on a Friday night who died by Sunday of an intracerebral hemorrhage. He’d presented to the emergency room that Friday night complaining of a headache and severe constipation. He was given an enema and sent for a head CT. The next morning, presenting his case to my team, I explained my working theory that the intracerebral bleeding was caused, at least in part, by excessive straining to move his bowels. He’d burst a blood vessel trying to defecate. My first patient death may have been prevented by a stool softener, by laxatives, by prunes. Within a week, I was telling this story as a joke to my co-interns. None of us was more than a month removed from our medical school graduations, but we all laughed. We were doctors now.

Andrew Bomback is a physician and writer in New York. His essays have recently appeared in Human Parts, Hobart, The Harlequin, Full Grown People, and BULL.

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