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02/19/2016

When the Patient is One of Our Own

by Craig Klugman, Ph.D.

A physician walks into the break room, looking forward to a few minutes of downtime with a cup of stale coffee and some space to breathe. The minute he opens the door he knows something is wrong as the floor is covered in blood. A nurse has fallen over, smacked her head on a table and lays unconscious, bleeding on the ground.

“If it was a patient, I would know exactly what to do,” said one of her colleagues. “But she’s one of ours, I just stopped because the simple decisions of what to do next did not come so easily.”

Much has been written about physicians who become patients. These range from Oliver Sack’s A Leg to Stand On, to OpEds in the New York Times, to books written by bioethicists, to books about bioethicists as patients. Two papers from the early 1980s talked how the physician become patient is challenging because the physician has a specific role identity, may be inflexible in accepting the patient condition, and has trouble putting him or herself under the control of colleagues.

Other studies have found that physicians recommend different treatments for themselves than for non-health care professional patients. Even as a graduate student who underwent several months of diagnostics for a condition (that was found to be benign), I noticed that I was treated differently, spoken to differently, and offered a different range of options once medical personnel learned that I was “a student in a medical school.”

But what happens for the care provider who is now performing surgery on a colleague or taking care of that person at the bedside. This may be someone you know well, or have seen in the hallway most days for a decade. In some ways, this is not different than caring for a family member—you can lose objectivity and may make decisions based on emotion rather than logic. Neuroscience studies have demonstrated why: That emotional connection of familiarity means decisions are processed in a different part of the brain than when we make non-emotional choices. Thus, if our protocols and reactions are encoded in the logic centers, suddenly filtering through emotional processing can make well honed reactions seem sluggish or more difficult. Often, there is a sense that illness and injury occur “out there” and the hospital is where people are cured, treated, or comforted. The idea that someone “in here” is injured, especially “one of us” brings about feelings of mortality that most of us hide from.

Plus, with the familiarity of someone you know, there is grief to process. Unless a family member of the patient, we do not have the luxury of having a health care professional explains things in neutral tones, and several times. The hospital staff are the ones who have to act to treat and save the colleague turned patient. And because the patient is “one of us,” confidentiality is a big issue. Everyone wants to know what is going on and the patient’s progress—it may be viewed as gossip, not an invasion of privacy. [It is technically a violation of privacy.]

On the other side, we may be more likely to be sure our colleague gets the best care possible—the best surgeon, the best room, around the clock visits: More so than we might give to a non-colleague patient. This can be fatiguing for the patient’s family. It can also bring up questions of resource allocation—do we give more to one of our own that we would to an outsider? Do we prioritize care of our own than others? This recently came to light for me in working on a government crisis standards of care plan where we debated whether first responders should have a claim on health care above “the public” since they have (a) put themselves in the line of danger to help others and (b) that knowing our own is being cared for increases morale in a difficult situation.

So how to handle such a situation? Dr. Anne Clarke wrote in BCMJ that when caring for a colleague “that person is a patient first and foremost.” In other words, treat the colleague the same as every other patient. Do not assume that he or she knows what a health professional knows. Try not to give them more care or services than another patient. And give the family time to be alone.

As of this writing, the patient-colleague in the scenario is in the ICU and is starting to respond to commands. The long-term prognosis is uncertain. What is certain is that few people are taking their lunch in the break room. “It just doesn’t feel right.”

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