Mama's rules

Too good not to post!

from: [Ann Emerg Med. 2009;53:688-689.]

The author is a Professor of Emergency Medicine and Associate Dean for Health Policy at Emory University. These remarks were given at the Emory School of Medicine’s 2008 commencement ceremony.

Class of 2008, you are one of the last to graduate under the Emory School of Medicine’s traditional (some might say “old”) curriculum. It followed the same general structure as mine, except you had 28 years of additional scientific and clinical discoveries to learn. It challenged you, like NPR radio detective Guy Noir, “to find answers to life’s persistent questions.” But you didn’t have to answer them all at once.

During your first 2 years of medical school, you spent most of your time pondering what and where. What molecule, hormone, physiologic function, pathological process, bone or nerve causes what effect? And where is the dad-gum thing located in the body?

After mastering what and where, you spent the last 2 years of med school seeking answers to how and when. How to perform an efficient history and physical, how to do all sorts of clinical procedures, how to present patients on rounds. And when to order a test or treatment, when not to; when to dazzle your attending with your brilliance, and when to avert your gaze and hope she or he would call on someone else. …

But before we turn you loose, I want you to spend a few moments pondering the most important question of all: why.

Let me explain why this is necessary. When you start your residency a few weeks from now, life’s persistent questions will no longer march up, 2 by 2. They’ll come in a howling mob, often at the most unexpected times. And if you aren’t careful, you’ll become so focused on what, where, how, and when that you’ll lose sight of why.

The following story illustrates my point.

Before I begin, I need to explain one thing: the specifics of this story require me to identify the resident’s specialty. But make no mistake: all of us, regardless of specialty, are prone to the mindset this resident displayed.

The incident was sparked by disagreement over who would admit a patient. The individual in question, a homeless man, literally dragged himself into the Grady ED. Recently discharged from the hospital after surgery for bilateral tibia fractures, he had external fixators on both legs. Unable to care for himself on the streets, he’d come back. The skin around his hardware showed early signs of infection.

The ortho resident was called. After completing his assessment, he refused to admit the patient. “This guy’s no longer our problem.” He declared, “His fractures are fixed. All he needs are antibiotics and a care home. Admit him to Medicine if you want. We only admit patients who need surgery. ”

Needless to say, this decision didn’t sit well with the emergency medicine resident (or a nearby internal medicine resident). Tempers flared, and voices were quickly raised. On-looking patients, including the man with 2 broken legs, heard it all as 3 young, gifted, and highly educated doctors argued bitterly over who “had” to take care of the patient.

That’s when a faculty colleague, Dr. Ric Martinez, stepped in. Like many attending physicians at Grady, Ric has a distinguished pedigree. A member of the Institute of Medicine, Ric directed a major federal agency during the Clinton Administration. Today, he’s back at Emory doing what he loves most: teaching, and caring for patients.

“What seems to be the problem?” Ric asked.

The ortho resident, red-faced, described “the problem.”

Ric answered, “It’s clear that this guy can’t make it on the street. Since he was so recently discharged from your service, don’t you think you should take him back, and make better arrangements for his care?”

“I am not admitting this patient!” The resident boomed. “We only admit patients who need surgery!”

“Look,” Ric said, “I’m not going to argue with you. Pick up the phone.”

“You want to talk to my attending?” The resident glared as he reached for the phone.

“No,” Ric replied. “I want to talk to your mother. It’s 9 pm. I know she’s awake. If you can convince her that you’re doing the right thing, I’ll accept her decision and make other arrangements for the patient. Do you think she’ll agree with you?”

The resident stared at Ric, his jaw clenched. Then, the lines on his face relaxed. He smiled, hung up the phone, and began writing admission orders for the patient.

Mama’s rules.

Class of 2008, nothing you’ve learned in the last 4 years, and nothing you’ll learn in the next 4, is as important as what your family and friends taught you before you came medical school. They, and others who could not be here, gave you the answers to why. Why you chose to become a physician. Why you spent all those hours studying in college. Why you worked like a dog for the last 4 years. And why, in a few minutes, you will recite the Hippocratic Oath.

A few weeks from now, you’ll walk into a hospital or clinic. Before you know it, you will be challenged to balance the pressures of modern health care, the expectations of your peers, and your own pride against the best interests of your patients. When you are unsure what to do, place an imaginary phone call to Mama, or whoever serves as your inner guide. She’ll know what to do.

To demonstrate the power of this technique, I want to walk you through a hypothetical scenario: This is your last exam. It’s pass/fail. During work rounds, a utilization review nurse pokes her head in the door and informs you that one of your patients has used up his days of insurance coverage and must be discharged. You know that this particular patient isn’t stable enough to be released, but the look on your attending’s face offers no support.

Do you tell the nurse and your attending that your patient isn’t ready to go home and forcefully explain why or accept the decision as “the way things are” and discharge the patient?

Show of hands: How many for option A? Option B? Good! See how easy this is?

Class of 2008, I bid you farewell. Go forth with my best wishes and my respect. And don’t forget: when the going gets tough, and you aren’t sure what to do, remember “Mama’s rules.” For if you do, the answer will come, clear as a sounding bell.