Night Float

When I was an intern I used to love night float, the month-long rotation where we worked the night-shift. The hospital was quiet, lights dimmed, monitors softly beeping, only a scattering of people sitting at the nursing station or walking in the halls.

My resident and I were a team, admitting patients from the ER until dawn, or until we reached our cap, whichever came first. Sometimes we would even have time to sleep, but I rarely tried - getting shocked awake by my beeper was worse than being tired. 

One night my beeper went off at 4:50 AM, ten minutes before the end of our shift. I gave my resident a look of dismay at the possibility of a late admission that could take hours of work. I returned the page, and the resident in the ER answered the call by making a whistling sound like an incoming missile, followed by a boom - a direct hit. 

My patient was a sixty five year old male, with thinning white hair, pale, blotchy skin, and a slightly startled look. He was alone in the room, sitting on his bed in a hospital gown and hospital socks. His wife had gone home to pack a bag when they were told that he was going to be admitted. 

He said that they had been watching TV at home when suddenly he had a seizure. At least, that’s what his wife told him; he had no memory of the event at all. 

A new-onset seizure at that age is never a good thing, and the diagnosis in this case would end up being just what my resident and I had feared when we first heard the case. My patient would turn out to have a brain tumor - worse, a glioblastoma, which carries an average prognosis of twelve to eighteen months.

But before all that was known for sure, I was sitting on a chair by the bedside, taking his history and writing my note. Maybe it was the quiet, or maybe he had a sense that it was not all going to turn out ok, but at one point he put his hand on mine to stop my scribbling, and answered a question with what seemed like a non sequitur: 

You know, he said, I've lived in the same town and worked the same job since high school, and I always pretty much hated it.  But it was worth it, right? I finally just retired, and now my wife and I are going to travel.

I remember being momentarily struck speechless. But I quickly recovered, continued with the interview, wrote up the orders, and finished the admission.

One of the first classes you take in medical school is Anatomy. You are introduced to your cadaver on day one, and for the rest of the year you learn the human body - every muscle, bone, and organ - by dissection. 

The other thing you learn is how to remain composed, rational and clinical while you are cutting apart a dead human being.

It’s called clinical detachment, and while it sometimes gets a bad rap, it’s an essential skill for a good doctor, up there even with empathy and compassion.

It’s a tension that is built into the heart of medicine: Who would want a doctor who was not distracted by the fact that their cadaver was once someone’s child, or wife, or mother? And yet, who would want a doctor who failed Anatomy because they were?

A young doctor can find it hard to modulate between the two - detachment and empathy - and easy to end up in one mode when the other would be better. Finding the right balance gets easier with experience and age. 

Another useful concept is the clinical divide, with doctors on one side and patients on the other. Early on, medical students think they have every disease they are learning about - it’s called medical student syndrome. 

But as time goes by the opposite phenomenon occurs, where doctors think that they are somehow immune to the diseases that their patients get. To a doctor in a white coat treating a patient in a hospital gown, the clinical divide can seem a lot less porous than it actually is. In fact, research suggests that many of us are drawn to medicine for that very reason: as a defense against the fear of illness and mortality.

Partly because of all this, while the weight of my patient’s words may have struck me, any deeper insight failed to sink in. I’m sure it was for the best. Who knows what lesson I would have learned at that stage? What if I had quit on the spot and - determined to seize the day and defer gratification no longer - bought a surfboard and a ticket to Bali and… (wait, is it too late??).

Much better that I was able to just focus on doing my job. There would be plenty of time to ruminate later. After all, while I may not have learned all I could from my patient that night, I never forgot him either.