When is too much really too much??

When I was a medical student, I felt that my "job" really consisted of 2 things. 1) I was responsible for talking to a patient. Getting to know them. Taking a great history, doing a full physical. Trying to gather EVERY single little piece of data possible to try to figure out how our team could possibly help this person suffering from whatever ailment they would have. 2) I would put the above information together, and come up with a differential diagnosis, diagnostic studies, labs that needed to be ordered, as well as come up with a treatment plan based on what I've learned in the countless hours I've spent reading books, notes, journal articles, etc. What I never really had to do as a medical student was actually IMPLEMENT most of what I would write down as my plan. We have the luxury of putting all types of treatment, no matter how invasive or possibly unnecessary it was. All it was for us was a learning experience, and it was to help us think of all the possible options.

Now as an intern, things are definitely different. First thing is, I don't have NEARLY the amount of time I used to have as a medical student to spend time chatting with my patients, gathering every piece of information I could possibly gather, and doing a COMPLETELY thorough physical exam. Of course, I will get as much history as I can, especially the information that would be pertinent to the case, and I do a complete physical, but focus it primarily to those organ systems involved with the disease process for each specific patient. ll of this while being paged by the nurses that someone's heart rate is in the 150s and someone else's potassium is too high. Then comes the diagnostic imaging, labs, and treatment plans. Cost is now something that I need to think about too. Before, it didn't matter what I wrote on the chart really, but now, when I order something (radiology, blood work, etc), someone's got to pay for it. This makes me think of the best approach to take, without wasting resources to come to a diagnosis. As for treatments, some patients should not have the most invasive procedure available just because it's an option, but rather based on each clinical situation.

Case in point. I will change some of this information around so that I don't violate any HIPPA rules here. Plus, I'll be vague. A patient that I'm following is nearly 100 years old. Although there are medicines that treat his/her condition, he/she seems to be failing these treatment options currently, and I'm starting to feel like I'm not getting anywhere. I've spent HOURS researching his/her disease, coming up with treatment options, deciding what path is next, discussing the options with my resident and attending, and even the patient's family. Of course, there is some definitive treatment, BUT it's highly invasive and for this patient, it just may not be appropriate at 100 years old. Plus, there is the whole issue of DNR/DNI. As a medical student, we learn about these ethical issues, but we don't need to actually DEAL with them. Now, I'm being faced with making some decisions of whether taking more invasive routes with this patient is really worth the risk. Of course, as an intern, I'm NEVER left alone to make these kind of decisions (THANK GOODNESS!!) and I have an extremely supportive resident and attending to help in this process.

The question becomes, when do you just cut your losses and decide that enough is enough?? Is the right thing to just try and manage this patient with medicine, despite the fact that it hasn't worked as well as we had hoped so far, and just see what happens? Also, there's the issue that the LONGER a patient like this stays in the hospital, the more likely they are to get sick with some kind of infection, pneumonia, etc.

Needless to say, this patient is very cute at around 100 years old. I've had this patient since my first day on service as a real doctor. Losing him/her would probably be a big blow for me, considering how much time I've invested in the treatment, planning, discussions, and research for the best option available to him/her. Our team is doing our best to help this patient get back to him/her previous status, but it seems like a rough road so far. We'll just see what happens....

And in response to the comments left by Paul, I am VERY careful when I cross the street at Brookline and Longwood :) I find that despite the "walk" signal across the street from me, I still dodge traffic every time I cross the street! Also, yes, the CIO must be great!