Writing the Hidden Curriculum
Mr. D was an 81-year-old gentleman with severe COPD, with symptoms so debilitating that they could only be controlled with high-dose oral prednisone. He was admitted with a GI bleed, and was managed conservatively – monitoring blood counts, transfusing as necessary, but avoiding invasive procedures. His hematocrit stabilized, and he was discharged, but he came back three days later, this time with a dangerously low hematocrit. Five days later, the bleeding had stopped – for now – and he was discharged again. Everyone knew he would be back, but by then, his primary team would have switched off service, and he would have a new group of caregivers. Like many of my peers, I keep lists of the names of the patients I have cared for. Periodically, I look back through my lists, just to see how some old favorites are doing. Mr. D’s wife was his caretaker, and their relationship’s resemblance to my own grandparents’ was endearing and familiar, and earned him a spot on that list. One day, I was not particularly surprised to see that Mr. D had been re-admitted soon after I rotated off service. I was a little bit surprised to see that he had died shortly thereafter. As I clicked through the daily progress notes from my old friend's electronic medical record of his final hospitalization, I felt the sting of a lack of continuity for the first time. Mr. D, in addition to his COPD and GI bleeding, also suffered from (justifiable) anxiety about his health. I spent a lot of time in his room trying to reassure him, and sometimes we talked about things other than his immediate prospects – his family, or his job, or his recent travels with his wife. Before he went home the second time, I spent 45 minutes talking with him and his wife, trying to convey both my hope that he would get stronger and my fear that he would not. And so when I saw that he had died, I was sad that someone I had cared for had passed, but was also upset that I hadn’t been able to be there for him and his family at the end. Perhaps it's impossible for a house officer to achieve true continuity. We parachute into a hospital for three or five years, work 80-hour weeks, take care of patients in every conceivable setting, and then move on. Every four to six weeks, we rotate on and off of different services – from cardiology to oncology to gen med to the ICU. Even in my personal clinic, inpatient responsibilities prevent me from always being there to see "my" patients. Thinking of Mr. D’s death, I felt frustrated, so I decided to try something new. I would write Mr. D's widow a letter. It was a simple letter. I had grown to know Mr. D over the course of two weeks, not 45 years, so there was not all that much to say. But I wanted Mr. D’s widow to know that I knew and that I cared, and I wanted to add my name to the list of those whose lives her husband had touched. And as I wrote and sent the letter, I felt like I was doing the right thing, but I was not totally sure. Was this appropriate? Would Mrs. D even remember who I was? What could I say about her husband that would be unique, or even meaningful? Very few physicians write condolence letters (1), and the topic of the physician’s responsibility to a patient’s family following the death of the patient (especially once the family has physically left the hospital) has been largely absent from my medical education. And it seems that I’m not alone: A 2000 review of 50 top-selling medical textbooks found that only half had a chapter discussing end-of-life care at all, and that instruction regarding the physician’s role following a patient’s death was limited in most cases to a paragraph or two (2). Harrison’s Principles of Internal Medicine has 3610 pages, but only 162 words relating to a physician’s responsibilities following the death of a patient. It is easy to think of reasons that medical education has not historically focused on the responsibilities of the physician following the death of a patient. For one thing, it falls outside the purview of the traditional physiology-pathology model through which we think of disease and our role in treating it. For another, there is just so much to learn, and so little time to learn it. Finally, death often seems our enemy during training; preparing for it almost seems like an admission of failure. In medical education, much is made of the hidden curriculum, the unofficial and often unpalatable behaviors that students and trainees learn in the process of becoming doctors by mimicking those directly superior to them. But the hidden curriculum does not need to be comprised entirely of bad behaviors, and the physician-scientist can take the lead in modifying it to include more positive behaviors. The senior physician-scientist often has a portfolio of clinic patients that he or she has taken care of for many years. Many have formed meaningful relationships with their clinic patients, and these benefit both the physician and the patient. Unfortunately, there is no chapter in Harrison’s that includes instructions, and as financial realities continue to quicken the pace of medicine, I fear that my generation of doctors may not learn how to form that type of doctor-patient relationship. The best senior attendings have the ability to model relationship-forming behavior at the bedside, to put a patient at ease with a handshake and a personal-but-not-too-personal question. I would ask these attendings to go a step further: Tell me what my role as a doctor is during those momentous and delicate moments in my patients’ lives; tell me what you did in similar circumstances, and how it worked out; tell me how to mourn my patients, both for their families’ sakes and my own. Alexander Fanaroff, MD Duke University Medical Center PGY-1, Medicine
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