Wednesday, December 20, 2006

Staying the course

One of the best attendings that I’ve ever had was an ICU attending whom I worked with as a fourth year medical student. Born, raised, and educated in India, he had completed his residency and fellowship in the U.S. and stayed on to become a bright and shining young medicine professor. Although his bedside manner was somewhat hampered by an inability to mince words, his patients were always keenly aware that they were receiving outstanding medical care. Each morning on rounds as he listened to patient presentations, he would focus carefully on every word, furrowing his brow at any irregularities or surprises. He would jot down notes, pouring over the data on his flip cards, and when the presentation had finished and the plan had been fully presented, he would reach into his magical hat of medical tricks and pull out an additional suggestion or two. No matter how long the patient had been in the ICU, with the same illness and the same basic treatment plan, he always had something new to offer, be it an antibiotic change, a new bowel regimen for constipation, a new physical therapy activity, or any other small change that might improve patient care or comfort. Staying the course was not part of his vocabulary. Although he didn’t explicitly state it, my attending seemed to feel that if there was not some new thing he could do for each patient each day, he would be better off just staying home.

Of course, now the specific language has been ruined for us by the war in Iraq, but the concept of staying the course was never a very good one to begin with. Whether in medicine, warfare, or just everyday life, staying the course implies a lack of imagination. It means that you can’t think of anything else to do that might improve your situation; that you are plain out of ideas, run completely dry. There are certainly times when a therapeutic plan or maneuver takes more than one day to implement and/or see through, but staying the course suggests satisfaction with the current progress and hesitancy to attempt anything else. As I learned in my ICU rotation, however, there’s almost always something more you can do.

Self-help isn’t really my thing, but I wonder what would happen if we applied our hospital techniques of patient evaluation to ourselves. What if we woke up each morning and asked ourselves if we had any concerns since the day before; if we examined ourselves, reviewed our own charts, considered in detail each of our own active and chronic issues and the best daily plan for each. It would certainly be overkill, and should we find ourselves behaving in such a way, ordering psychiatric evaluation of ourselves would definitely be warranted. Yet, if we were able to look past the eccentricity of holding self conversations and thinking about ourselves in the third person, imagine the power of addressing our problems in such a systematic and thoughtful way. Nearly anything could be conquered, any goal achieved. And if we believed that a new day was worthy of a new approach, idea, or endeavor, that in general it would be ok to maintain the overall plan but that the details would demand something fresh to be discovered or pursued, then the power to achieve and to build success would only be greater. A higher quality of life could perhaps be achieved. And the previous day would have to be truly amazing before one would ever say on the following one that the plan was simply to stay the course.