Guilt and the doctor

This is from Edwin Leap's blog....he asks a tough ask. Live without guilt.It takes a lot of insight and predetermined reactiveness to go through I think.There is a little justification in the 100% mortality argument and death epidemic terminology of his....comes of sounding as the typical American reaction to things..try to escape a bad feeling by justifying a good angle to it.Finally he does not take extreme sides...thankfully.If we were to live our entire lives without guilt we would all be uniformly intelligent Buddhas.Read on...

Physicians, collectively, feel a lot of guilt. We feel guilty that we don’t know more. We feel guilty that we don’t do more. We feel guilt about our need to be on committees and be educators. We often feel guilt about the money we make, even as we feel frustration when insurers deny payment. We feel guilt when we speak angrily to another doctor, a nurse or staff member, and extra guilty when we talk down to our patients. We feel guilty when we don’t stand up to someone who berates us. We feel guilty about our delinquent charts. We sometimes feel guilty about the economics of medicine, and a fair amount of physicians feel guilty enough to advocate a national health-care system
We feel guilty that we eat junk food, drink too much coffee, and exercise too little. We feel guilty that we haven’t spent enough time with our spouses and children, then feel guilty that the retirement and college tuition accounts aren’t bulging with money.
And worst of all, we feel guilty about suffering and death. Because, especially in emergency rooms around America, what we see is a lot of both. We learned, as medical students, that death was the thing we were supposed to stop. And our constant inability to stem the tide of the death epidemic (now in it’s gazillionth year) fills us with untold milligrams of pure, autoclaved, concentrated guilt.
I realized this recently. I had some remarkable deaths in my department, and they left me feeling sad. They left me feeling guilty. And as always, they left me going back over the entire situation in my head.
Even as I write this, I’m considering the patient I saw last night (who may have died by now) after her toxic carbon monoxide inhalation. What could I have done differently? How could I have saved the other woman last week who died? Or the man the week before that? If only they could just open their eyes and talk to me again, and say ‘Thanks! I feel better! I think I’ll go home to my loved ones now.’ I wonder, as I often do, if I failed. Guilt quite literally rises from the dead.
Our culture doesn’t help the guilt problem. Every tragedy, every inconvenience, must be blamed on someone. We have review boards and commissions, congressional inquiries and consulting bodies, plaintiff’s attorneys and medical boards, and it seems at times that all they do is sit around trying to assign guilt (never guilty themselves, of course, for the problems and even tragedies caused by layers of administrative refuse). And we, in culture at large and in medicine in particular, respond with new policies, new procedures, new classes and algorithms, and with newer, deeper levels of guilt than ever before.
But here I want us to stop and ask this question. What does our guilt do for us? And I’ll give the answer, because I don’t want you to feel guilty while trying to find the answer. Guilt serves a function as a moral guide. Without guilt, we become sociopaths, incapable of feeling remorse, and incapable of making proper judgments in our interpersonal interactions. Guilt helps to hone our relationships with God and man.
However, it does little else. And when we feel guilt over things that have nothing to do with choices over right and wrong, then we misuse guilt. Like performing an appendectomy with a baseball bat, it’s simply the wrong tool for helping us make day to day decisions. And it is a horrible implement to use for our own self-assessment, for we are always our own worst critics who can never see how brightly we shine.
Guilt is an especially terrible thing to use on ourselves when we work in a place where pain and death are regular visitors. It wears us down. And usually, it is false. Because even if we make a mistake, it isn’t a moral failure. It isn’t that we intended to give a wrong dose, or miss a diagnosis. If we harm intentionally, we should feel guilt. But if we only make a mistake (and that’s what they are, mistakes) we should try to make amends, to undo the damage and to learn so that we do not repeat our error. But we don’t need guilt.
The thing is, we practice an imperfect science on human beings, who are uniformly doomed from day one. The will all have illnesses and accidents. And 100% will die. It’s our job to stave that off as long as possible. It’s our place to make humans healthy and comfortable, so that they can lead productive, happy lives. But it isn’t our place to make them immortal. And it isn’t realistic to think that we won’t do the wrong thing from time to time.
I know there are consequences to errors, and there are emotional weights to bear when we see death and tragedy. But guilt is one weight we have to learn to set down. It keeps us from moving forward. It drowns us in emotion and memories of what might have been. And it doesn’t help anyone, whether laid upon us by patients, families, administrators or attorneys. But more to the point, when we lay it upon ourselves, we are trying to make a sacrifice to atone for our humanity. And we can never scar ourselves enough to change who we are; mortal, fallible, imperfect, wicked, self-hating, amazing, near-angelic, loving, wonderful, awe-filled and God created. We will be those things no matter how much guilt we think we need to heap upon the altar of our hearts.
So lay it down. And try for once to live a day without guilt. It’s an amazing experience when you can do it.

Aus der Deutschland

Some of the demerits of socialised medicine: There cannot be one fixed standard for all.This is from the lancet.


Physicians' groups in Berlin have slammed an aspect of the government's health reform which has left around 20% of doctors having to pay for their patients' medicine out of their own pocket, with some also facing fines for their prescribing practices.
The new Bonus-Penalty Ruling (Bonus-Malus-Regelung) placed even more pressure on doctors to spend less on medicine.

The Bonus-Penalty Ruling drew on the daily defined dosage (DDD) notion pioneered by WHO. Though WHO originally introduced DDD solely as a means to compare prescription demands in different countries, the Bonus-Penalty Ruling takes the notion of a DDD and attaches a fixed daily budget to it.
As a result doctors in Germany are now allowed to prescribe only a set daily dosage at a set daily rate.Under terms of the Bonus Penalty Ruling, set daily rates apply for drugs used to treat high blood pressure, depression, migraines, prostate illnesses, and osteoporosis. Drugs, for example, used to treat depression, migraines, and blood pressure are only allowed to cost 37 cents (around 25 pence) per day.
The potential benefit of the legislation for doctors is that if they spend less than their budget, their regional KV will award them with a form of “credit” allowing them to spend more on prescribing drugs thereafter. For this to happen all doctors within one regional KV must together spend less than a collective budget. If, however, this collective budget is exceeded, the individual doctors who spent less than their individual budget, go unrewarded.

Interestingly the WHO says that DDD system by itself is not suitable for guiding decisions about reimbursement, pricing and therapeutic substitution.

And I thought.........!

People who are others have had harder, more painful tales to narrate,
Been wretched with angst and pestilence;hunger and insatiation
Lost a parent or two, eyes, limb, insight, faith and hope ;
Honor, love, ambition and home for no fault of theirs, maybe.

They have taken hope in mere nothingness, and themselves
Cried to Lord, Eli Eli Llama ...... . there was no one else to cry to,
Perhaps not even the Lord, why would they have felt thus if He were?
And built themselves, as much as for themselves , still weeping.
What do I weep for: I haven't half the pain; eyes moisten, but heart's never wailed

The weary Chariots trundled into sunset; dust, blood, grime and disillusionment
Heavy on the forehead of the armored warriors whose flagging,creaky bodies followed
With no protest, among scythes that had sliced clanking on helmets that shielded.
They shall eat and sleep. to awake to go kill or get killed, chanting on their lips
'Dulce et decorum est, pro patria mori'...it is glory to die for your fatherland.
They never cried,how ever could they - someone wailed their hearts out for them.

BJMC Hostel E Block

Who says we don't have fall colors in India.

Dull Makhani to mull on

Am reading Haroun and the sea of stories. The early Rushdie. Lots of magic realism, lots of beautifully OTT spontaneity.Full of Iffs( the water genie with colored whiskers) and Butts ( the hoopee with an attitude and the bus driver chasing the sunset)and Gup and Chup- the two sides of Kahani the second moon of the earth , a place where stories flow as water currents to be piped to the emotionally barren regions of the earth whose people have forgotten to smile;Prince Bolo, Princess Batcheat and P2C2Es( processes too complicated to explain) and all that other chlorophyllosophy of the Pasha of Phantasmgoria.
Get the drift.....ok, good.

There is a story about Dull, the lake( not 'the Dull Lake', each inanimate thing seems to come alive here)- whose emotions mirror those of the people who stay in the valley of K( cant get Kashmir out of him!)So you know why it is mistakenly called Dull now.
But when someone gets angry the wind blows huffingly to rock the boat, and when someone is depressed the air reeks of a stench and the sullen mist envelops. Then Haroun tells them to think of the happier moments of their lives, even if they were like an interval siesta mode..and you know what happens- the mist and the stench clear, the silver peaks( snow) and the golden fields( saffron) reappear from the hue.

" Its just a story"...Haroun says.

Thats a two tailed statement...
"its a story, thats all"
OR
" its all just a story"
....whichever way you view it.


I hope you get the drift- I am not an iota of a gifted storyteller as Rushdie is. Deepa certainly did not get the idea I was hinting to when I extrapolated this to " attitude determines altitude"Remember the Champu, Gokul and Banshi story from Std VIII reader- pratikriya hi jeevan hai aur jeevan pratikriya.

From the Lotos Eaters

How we change....How perception and clear thought is clouded...by the overwhelming righteousness of emotion.....how eternally we want to be in this Rubaiyat like "ah my beloved fill me the cup "world, this myrrhic SakiNaka of sorts.

.......from the Lotos Eaters by ALT.

They sat them down upon the yellow sand,
Between the sun and moon upon the shore;
And sweet it was to dream of Fatherland,
Of child, and wife, and slave; but evermore
Most weary seem'd the sea, weary the oar,
Weary the wandering fields of barren foam.
Then some one said, "We will return no more";
And all at once they sang, "Our island home
Is far beyond the wave; we will no longer roam."

Messhealth

Polls are not the time for discussing legislation- motives are often appeasement, treading the safe line, keeping most of the people happy most of the time. Thats why Hillary Clinton went two steps back on a more aggressive socialist health plan to go slow. Who would want to pay out of their pockets really for someone else's health...and if this becomes negotiable in return for a vote.........are you nuts...!?!


http://content.nejm.org/cgi/content/full/357/12/1173?query=TOC