Rule 199: Being a physician is a high privilege. Don't abuse it.

A short story on the privilege of physicianship.

“Oh, quit worrying about me… I’ll be fine.”

Carol said this.

She said this just a couple weeks after having a stent placed to open an occluded coronary artery. She said this just a few days after having yards of bowel removed from her gut. She said this after enduring showers of emboli which caused significant damage to her liver and kidneys. She said this while in the ICU, a unit which housed the hospital’s critically ill… of whom she was the most critical.

This was Carol: an octogenarian with kind eyes and a formidable spirit.

Though her outlook was fierce, her prognosis was bleak. From her stent, she was at high risk for clotting and therefore required anticoagulation. Due to her liver disease and bowel resection, she was at high risk for bleeding and therefore could not have anticoagulation. She was a puzzle without all its pieces; a ship with cracks in its hull. As a result, our goal was not to “cure” as there was no curing her many medical problems. We simply aimed to get her home to enjoy her remaining time surrounded by loved ones.

And there were many of them. Her children visited frequently. A son from out-of-town. Two daughters as well. These were the ones who were instructed to “quit worrying.” They doted obediently and with great care. Their behavior spoke to their mother’s character.

Her liver seemed to be recovering, albeit slowly. Her heart had yet to stop beating. There was air in her lungs and blood in her veins, but her kidneys continued to misbehave. This was her biggest barrier for leaving the hospital. She required a specific form of dialysis called Continuous Renal Replacement Therapy, or CRRT. It is a slower, time-consuming, more brutal version of the dialysis with which you are most familiar. After discussion with her family, she chose to move forward with treatment starting Monday... which is where our story begins.

An Eventful Week

Monday morning arrives. Carol appears anxious, but ready… cracking wise while wearing a confident mask. With a golden hue from jaundiced skin and a crown of thin silver hair, she is a picture of courage. She undergoes CRRT. It is a tiresome process.

When Monday leaves, she is exhausted. The next day she sleeps. All day. All night.

Wednesday comes and with it another round of CRRT. She is apprehensive, but with subdued resolve she steps into the ring yet again. As Wednesday leaves, I check in with her. She is battered and spent, but still here. Though, it’s not looking good.

With Thursday comes joy and quality time. Her children visit all at once! Happy noise emanates from her room. They recount old family stories and memories. In doing so, they create new ones. Her eyes flicker brightly and with her characteristic spunk, but they flicker nonetheless. Her medical team — myself, my attending, her nurses, nephrology — we are heartened by her status. There’s a glimmer of hope that we can actually get her back home…

Full steam ahead!

Friday morning my attending and I round on our patients. We bump into Carol’s nephrologist and, collectively, decide to see her together before her treatment. As we approach her room we are met by her son, blank-faced and glassy-eyed.

“She’s had enough,” he says, “the dialysis is too much. She wants to be done.”

We’re shocked. Just yesterday all of us were “full steam ahead.” My attending asks when this decision was made.

“Just now — excuse me.” He leaves abruptly. Tears stream down his face, as if the glass levees holding them back had finally burst open. We three are left in their wake: simultaneously moved and paralyzed.

It’s jarring.

Nonetheless, paperwork must be done. The decision for “comfort measures only” must be formally made. Some time later, I grab the bright pink legal form. It feels thick and heavy in my hands. I enter their room to find Carol and her son. Carol, mouth agape with sunken cheeks, looks at peace. Her son, understandably, does not.

She cannot grasp the pen. She cannot raise her arm. She cannot sign the form. Her son, her health-care proxy, his face pale and wet, takes the pen and signs on her behalf. This was likely one of the hardest things he’s done in his life, yet he did so without hesitation and with great courage.

Carol would have been proud.

The next afternoon, I enter her room. It’s dark, though sun rays peek through small cracks in lowered blinds, as if to safeguard her passage from this world to the next. Shrouded in an ornamental blanket with vibrant patterns of gold, purple, and burgundy, only Carol’s face is visible; closed eyes and gray skin, her silver crown still sits atop her head, disheveled, but intact. Just a day earlier, this room was filled with noise from chattering machines and people. Now it’s quiet. Still. The only movement comes from her blanket, rising and falling with each labored breath. She’s dying.

Being her doctor was a privilege unlike any I’d experienced. As I left the hospital that day, Carol did not leave my thoughts… and she persisted even after passing away later that night.

A blanket like the one wrapped around her.

The Privilege of Physicianship

A privilege is an exclusive right or grant available to a particular person or group of people. What’s interesting to me is that the same could be said of the word burden. Yet we all know the difference between privileges and burdens: direction and desire. Privileges are positive, burdens are not. Privileges are desired, burdens are not. They are opposites.

However, being a doctor blurs this line. Physicianship is both a privilege and a burden.

It is a burden to care for the sick and dying. It is emotionally, mentally, and spiritually taxing. Consequently, one must place a professional buffer between themselves and their patient’s troubles for two reasons: to protect themselves and to perform their duties to an appropriate standard. This is a difficult line to walk and, when walked poorly, one can begin to view their patients as a collection of symptoms and organs, rather than a whole “person.” The danger in this is, if left unchecked, the over-burdened doctor begins to view their patient as a thing made of things. From this perspective, any ability to create and maintain a relationship is impossible, as well as its therapeutic potential.

On the other hand, it is also a privilege to care for the sick and dying. It can be emotionally, mentally, and spiritually rewarding. Dying is hard work. A sick person is at their most vulnerable. To treat them with respect and without judgement is, perhaps, one of the greatest gifts a physician can give their patient. And it is a privilege to offer this gift.

But Dr. Meador uses the phrase “high privilege” to describe being a doctor. What makes physicianship a high privilege, rather than just a “privilege?”

The answer lies in location. General or specific. Distant or near.

In general, it is good to care for the sick and dying. It is a privilege to do so. But this exists only as a concept. It is distant. It’s not applied to anything, or anyone, specifically. To become specific is to elevate this privilege into a “high privilege.”

To be clear, it’s not that I’m caring for the sick and dying… it’s that I’m caring for this specific person who is sick and dying. This is what makes it a high privilege. However, to make this jump is to shoulder the burden of physicianship: to know both person and pathology. In doing so, we risk our own vulnerability. We fly a bit closer to the sun.

It is here, if our patient allows us, where we can see who they truly are. What they are made of to their core. To know someone going through the lowest moment in their life is to truly know them. One will see that, sometimes, when a person is at their lowest, they are also at their best. This was the case with Carol. She let me see who she truly was. It was painful… and she was remarkable. This privilege — this high privilege — can only be found in the burden.

There is no greater honor for a person to offer. There is no greater privilege for the physician who accepts.

Those We Carry, We Remember

After every trip to the doctor, from hospital admissions to quick clinic visits, a patient receives an After Visit Summary called an “AVS” for short. This small packet of papers contains information about the encounter, things like prescriptions, vital signs, and instructions. For every patient I see, I finish my AVS instructions with the phrase — “it was a privilege to care for you!”

I do this for three reasons:

1. As a statement of fact.

2. As a reminder to myself.

3. In remembrance of her.

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Names were changed in this article to protect patient information…

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