Bedside Manners

In a quest for efficiency, some doctors lose touch with the most fundamental human emotion: compassion.

We doctors call them index cases, patients who forever change the way we approach our work. For surgeons, most index cases appear in the operating room—such as the man with the 20-pound tumor or the woman with the uncontrollable bleeding. Other instances have to do with difficult diagnoses or strange presentations of a particular disease. But the best of them, the index cases you remember even after you've practiced for years, are the ones that for a moment shed light on your competency, your values, even your sense of humanity—and then turn all three of them upside down.

I had a case like this 15 years ago. At the time, I was a newly minted M.D., an intern. The middle-aged woman I'll call Verna Ray Earl was in the hospital waiting for a diabetic foot infection to clear. She was also on the transplant list for a new kidney. She watched patiently as a daily parade of young interns and residents unwrapped her dressing, cleaned the wound and, with military precision, rewrapped her foot. Even on days when we got into the bleeding tissue, Verna Ray hardly said a word. I did get a smile out of her once, when I commented on a picture of a child on her night table. The little girl—who had braids, a broad smile and a missing front tooth—turned out to be her granddaughter.

That smile from Verna Ray was a triumph. Growing up, I'd imagined transforming diseased patients into grateful, backslapping friends. Once I started working in the hospital, though, I was quickly overwhelmed. Even 14-hour days did not contain adequate time to care for 30 surgical inpatients, 12 clinic patients and endless streams of emergency room and consult patients. Being on call—as in, working 40 hours straight—provided my only chance to catch up with paperwork and patient care. I could actually finish everything I needed to do by 2 or 3 A.M., if I didn't become unbearably tired first.

I knew this inhuman schedule was changing me into the hardened doctor I thought I'd never be. For some reason, that change seemed inevitable. After all, patients counted on me. They didn't want to hear that I hadn't gotten around to checking on their lab results. So I grew proud of my ability to accomplish dozens of clinical chores efficiently. I stopped thinking about what kind of doctor I wanted to be and began to focus on the doctor I was becoming.

Then, one afternoon, a nurse called to report that she could not draw Verna Ray's blood. Because of her renal failure, Verna Ray had been on hemodialysis for several years, and one of the complications of this type of dialysis is the clotting of veins. I knew that drawing blood from Verna Ray would be tricky, but not getting that blood had consequences far more challenging to me at the time. The other interns and I were responsible for taking blood from "difficult sticks," patients whose veins proved elusive to the phlebotomists and the nurses. As interns, we used to boast that we could draw blood from stones.

On the transplant floor, where Verna Ray was located, the attending surgeons demanded that every patient have blood drawn once a day. These blood tests were early indicators of changes in a patient's electrolytes that could lead to arrhythmias, seizures and death. Getting them done was also the sole responsibility of the interns. If, by late in the day, a single patient was missing lab results, the attending surgeon would launch into a harangue about an intern's lack of skill, intelligence and, most pointedly, professional promise.

I was not eager to be on the receiving end of such a rant, so I quickly went over to Verna Ray's room. The first thing I noticed was a pile of needles and alcohol swabs left over from the nurses' previous attempts; they obscured the picture of Verna Ray's granddaughter on the night table. Instead of sitting in a chair at her bedside as she usually did, Verna Ray was lying down, the crook of one arm covering her eyes.

"Hello, ma'am," I said, doing my best to exude confidence. "I'm here to get some blood."

She looked at me, then covered her face again with her arm and spoke quietly.

"Go ahead, doctor."