I was glad she never asked if I had done this before.
My first nasogastric tube was placed on an elderly woman with chronic liver disease. As her illness worsened, it gradually turned her skin yellow, her abdomen swollen, and her mind foggy. One day, we realized that she was at too high a choking risk to swallow her medications herself. She would need a plastic tube to do it for her.
I gathered two pairs of gloves, water-based lubricant, adhesive tape, a syringe, paper towels, a cup of water, and the nasogastric tubing and placed them on the tray table next to my patient’s bedside. Then I went to tell my senior resident that I was all set. Success is 90% about preparation, she had told me earlier, pointing out how much easier it was to get an arterial stick with the rolled up towel propping the patient’s wrist, the bed at the right height, and extra gloves, alcohol swabs, and gauze within arm’s reach.
Before we re-entered the room together, my resident recapped what I was expected to feel. “Remember, don’t force it,” she instructed. “You shouldn’t feel resistance. If you’re in the right place, it will go down easy.” It’s actually a common lesson when dealing with human anatomy, I thought, remembering back to my surgery rotation where a theme was to dissect along anatomical planes. “Notice how easily it peels away?” my attending surgeon had asked as the resident’s tools glided across the screen, effortlessly pulling strips of fascia from layers of muscle beneath.
I had previously practiced nasogastric tube insertion on a mannequin who had the distinct advantage of see-through anatomy. I had watched as the tubing traveled through my plastic patient’s nostril, through the pharynx, into the esophagus, and finally, into the stomach. The most important part, my instructors had emphasized, was to get the feel for the procedure. The amount of smoothness I felt with the mannequin was carefully designed to match what I would feel in a real patient.
I handed my patient the cup of water and prepared her for what was to come. It would be quick, I said. You may feel your gag reflex kicking in, but take small sips of water and swallow – that will help the tube go down – and the whole thing will pass in a matter of seconds.
She gagged; mucus dripped out of her nose; but it was over in a matter of seconds. Meanwhile, I felt that path, that smoothness, the lack of resistance as the tube made its way into its destination. Even before the X-ray confirmed that the tube had not accidentally made a detour down the trachea and into a lung, I was feeling gratified with my success.
I asked the patient how she was, and I was even more gratified to hear her response: “It wasn’t as bad as I expected.”
Doctors learn to be doctors by practicing on patients. This is no secret. The process – and all ethical and interpersonal challenges embedded in that – is not a new subject. I’ve written about it before, and I’m in good company (see here, here, and here). For every procedure you would rather have done by a seasoned physician, there was once a point when that physician was a novice. Someone was that doctor’s first, and her second, and her third. And that goes for every doctor, and every procedure.
But there’s something that doesn’t make it to the surface of our conversations as much. It’s the question of whom we practice on.
She was my first. But I didn’t tell her that.
An hour before, I had gone in with a consent form. Her niece repeated what I said for extra emphasis, and when I asked if she understood the risks and benefits, the patient said she did. I informed her that I would be doing the procedure, and she nodded.
When it comes to practice, there’s a careful balancing act at play: prioritizing both patient safety (first) and doctors’ learning (second). It’s a struggle inherent to the medical field, and one that has been grappled with for a long time. Despite this, there is no consensus on how to go about it, and no good solutions that satisfy everyone.
Atul Gawande, Theresa Brown, and Sandeep Jauhar have suggested that often, we just go. We don’t explicitly lie; but we don’t explicitly ask, either. Many have suggested there is no way around it. As Gawande has pointed it, if we did ask, many patients would simply say no.
And yet, a read-through of the most popular comments on both New York Times articles suggests that patients are less than thrilled with any truth distortions – of commission or omission.
So there we are.
Whether it’s the hidden curriculum of the medical culture taking its toll, or the practical realization that nothing will ever get done if we are 100% upfront about our expertise, I think many in the medical profession – me included – have gradually edged toward the just go mentality. We justify it with confidence that we are being supervised properly, and that we are fulfilling our oath of doing no harm.
I don’t lie. But I do frequently act more confident than I feel. I find myself saying things like “I will be doing the procedure,” rather than, “may I do this procedure?”
Most patients don’t question it. Still, others are more on guard. How many of these have you done? Do you really know what you’re doing?
My nasogastric tube patient, an elderly individual with chronic liver disease and mild mental fogginess, asked none of these questions. She knew enough to consent, but not enough to question my credentials.
At the time, it seemed like the best possible balance.
Ms. D was 31 years old, Latina, and in labor. This was her first child, and I was impressed by how tranquil she seemed. Through our interpreter, she responded politely to everything we said, even as she squeezed her eyes shut and clenched her teeth through her contractions.
During rounds that morning, the resident noticed that our new ob-gyn intern needed to start doing cervical exams and deliveries independently. So after rounds, we drifted towards Ms. D’s room. The resident introduced the intern and then took the announcement approach: “Dr. K will be doing your delivery and everything leading up to it.”
Ms. D smiled as the intern shook her hand and said it was nice to meet her.
Within the hour, our patient was no longer smiling. She began to dilate more rapidly, and I went with the intern and the resident to observe the cervical exam.
As the intern felt around to the rhythm of the resident’s instructions, Ms. D was cringing in pain. Was this normal cringing? Was there such a thing? I didn’t know.
I also don’t speak Spanish. But I needed no interpreter when all of a sudden she shot forward and cried out “Por favor!”
The intern quickly withdrew and apologized. She looked stricken, and I wondered if she was thinking what I was: that in the process of learning to become people who can help, we sometimes cause hurt.
There was another fear lingering in my subconscious, one I wish I had expressed at the time. We have to practice. But why had we so readily drifted towards her? Her pregnancy was expected to be uncomplicated, but was that all there was to it? After all, she was not the only uncomplicated patient on the floor.
Even after the ordeal, Ms. D smiled and uttered the few English words she knew: Thank you, doctors.
The world of modern medicine unquestionably has more safeguards for vulnerable patients than it did in the past. We have an entire field – medical ethics – with principles like informed consent, respect for persons, and autonomy, and we have formal training and codes of conduct to help us honor those principles. Thankfully, we have an ethical and legal system in place to prevent abuses, and we have the utmost respect for the autonomy of patients to make decisions about their own bodies.
But I wonder about subtler injustices – stemming not from any overt inability to empathize with fellow human beings, but rather from subconscious biases. I wonder about the gray areas that permeate the decisions, small and large, we make on a regular basis. Because most of what we do is shaped not by formal decree, but cultivated through a culture: we see others acting, develop a sense for what can be done, and mimic it. This is the “hidden curriculum” of medical training.
When I really look at my training and that of my friends – whose lives have we entered with the most assurance? Whom have we gravitated towards to practice peripheral IV’s and insert tubes and drains? When do we announce instead of ask? Where are the extra steps more likely to be skipped? With whom are we likelier to explain less, and act more?
Maybe with every patient, at some point. But who gets it more?
I realized the answer involved another question:
Who makes it the easiest?
It’s a terribly unsettling way of thinking about patient care. But when time is short, efficiency needed, and practice necessary, I wonder if we perhaps follow the same line of thinking we use during procedures: We go down the paths of least resistance. We gravitate towards those who make it easiest.
And, as you’d have it, those tend to be the individuals who do not speak English well. Who are older. Who have difficulty with memory. Who do not have families at their bedside. Who are minorities. Who are of lower socioeconomic statuses. Who – for many possible reasons – don’t know to ask.
Those mental shortcuts affect more than just consent. It’s easier not to answer questions. It’s easier to walk out of a room sooner. It’s easier to just do it because it will be over so quickly anyway. It’s easier to talk at someone, instead of truly listen.
Recently I found myself on the other side, standing at a juncture between a medical team and my own family member. After my family member introduced me, there was a noticeable shift in the nature of the interaction. By virtue of my being in the medical field, there was a respect – mixed with a hesitance – on the part of the medical team to be perhaps as assertive as they might have been otherwise.
I couldn’t really imagine a medical student practicing on my family member. I also couldn’t imagine anyone ignoring our concerns. Because to do that, they’d have to get through me. Suddenly, intentional or not, I was a path of very high resistance.
I imagine most, if not all, of these differences in care are subconscious. And I don’t want to frame it as some doctors versus patients dynamic, which would be antithetical to the goals of medicine.
But we’ve reached a point where many injustices in the world are due to subconscious biases, and that does not make them any less real.
Hidden from the images we like to hold up of ourselves, it just makes them harder to combat.
As I guided the nasogastric tube into my patient’s stomach, the words of my resident ran through my mind. You shouldn’t feel resistance. If you’re in the right place, it will be easy.
It may be the right mentality while doing procedures. But the best advice for doing procedures is not necessarily the best advice for the steps leading up to them.
Sometimes, the path of least resistance is not the best path. Sometimes, a little discomfort can be a good thing. It can help us think more critically – to make choices that are actually good, rather than ones that maintain images of ourselves as good.
We can all think a little bit harder. We can all do a little bit better.