Patient Care Technician Quotes

Where there were once several competing approaches to medicine, there is now only one that matters to most hospitals, insurers, and the vast majority of the public. One that has been shaped to a great degree by the successful development of potent cures that followed the discovery of sulfa drugs. Aspiring caregivers today are chosen as much (or more) for their scientific abilities, their talent for mastering these manifold technological and pharmaceutical advances as for their interpersonal skills. A century ago most physicians were careful, conservative observers who provided comfort to patients and their families. Today they act: They prescribe, they treat, they cure. They routinely perform what were once considered miracles. The result, in the view of some, has been a shift in the profession from caregiver to technician. The powerful new drugs changed how care was given as well as who gave it.

It’s no one’s fault really,” he continued. “A big city cannot afford to have its attention distracted from the important job of being a big city by such a tiny, unimportant item as your happiness or mine.” This came out of him easily, assuredly, and I was suddenly interested. On closer inspection there was something aesthetic and scholarly about him, something faintly professorial. He knew I was with him, listening, and his grey eyes were kind with offered friendliness. He continued: “Those tall buildings there are more than monuments to the industry, thought and effort which have made this a great city; they also occasionally serve as springboards to eternity for misfits who cannot cope with the city and their own loneliness in it.” He paused and said something about one of the ducks which was quite unintelligible to me. “A great city is a battlefield,” he continued. “You need to be a fighter to live in it, not exist, mark you, live. Anybody can exist, dragging his soul around behind him like a worn-out coat; but living is different. It can be hard, but it can also be fun; there’s so much going on all the time that’s new and exciting.” I could not, nor wished to, ignore his pleasant voice, but I was in no mood for his philosophising. “If you were a negro you’d find that even existing would provide more excitement than you’d care for.” He looked at me and suddenly laughed; a laugh abandoned and gay, a laugh rich and young and indescribably infectious. I laughed with him, although I failed to see anything funny in my remark. “I wondered how long it would be before you broke down and talked to me,” he said, when his amusement had quietened down. “Talking helps, you know; if you can talk with someone you’re not lonely any more, don’t you think?” As simple as that. Soon we were chatting away unreservedly, like old friends, and I had told him everything. “Teaching,” he said presently. “That’s the thing. Why not get a job as a teacher?” “That’s rather unlikely,” I replied. “I have had no training as a teacher.” “Oh, that’s not absolutely necessary. Your degrees would be considered in lieu of training, and I feel sure that with your experience and obvious ability you could do well.” “Look here, Sir, if these people would not let me near ordinary inanimate equipment about which I understand quite a bit, is it reasonable to expect them to entrust the education of their children to me?” “Why not? They need teachers desperately.” “It is said that they also need technicians desperately.” “Ah, but that’s different. I don’t suppose educational authorities can be bothered about the colour of people’s skins, and I do believe that in that respect the London County Council is rather outstanding. Anyway, there would be no need to mention it; let it wait until they see you at the interview.” “I’ve tried that method before. It didn’t work.” “Try it again, you’ve nothing to lose. I know for a fact that there are many vacancies for teachers in the East End of London.” “Why especially the East End of London?” “From all accounts it is rather a tough area, and most teachers prefer to seek jobs elsewhere.” “And you think it would be just right for a negro, I suppose.” The vicious bitterness was creeping back; the suspicion was not so easily forgotten. “Now, just a moment, young man.” He was wonderfully patient with me, much more so than I deserved. “Don’t ever underrate the people of the East End; from those very slums and alleyways are emerging many of the new breed of professional and scientific men and quite a few of our politicians. Be careful lest you be a worse snob than the rest of us. Was this the kind of spirit in which you sought the other jobs?

In airplane crashes and chemical industry accidents, in the infrequent but serious nuclear plant accidents, in the NASA Challenger and Columbia disasters, and in the British Petroleum gulf spill, a common finding is that lower-ranking employees had information that would have prevented or lessened the consequences of the accident, but either it was not passed up to higher levels, or it was ignored, or it was overridden. When I talk to senior managers, they always assure me that they are open, that they want to hear from their subordinates, and that they take the information seriously. However, when I talk to the subordinates in those same organizations, they tell me either they do not feel safe bringing bad news to their bosses or they’ve tried but never got any response or even acknowledgment, so they concluded that their input wasn’t welcome and gave up. Shockingly often, they settled for risky alternatives rather than upset their bosses with potentially bad news. When I look at what goes on in hospitals, in operating rooms, and in the health care system generally, I find the same problems of communication exist and that patients frequently pay the price. Nurses and technicians do not feel safe bringing negative information to doctors or correcting a doctor who is about to make a mistake. Doctors will argue that if the others were “professionals” they would speak up, but in many a hospital the nurses will tell you that doctors feel free to yell at nurses in a punishing way, which creates a climate where nurses will certainly not speak up. Doctors engage patients in one-way conversations in which they ask only enough questions to make a diagnosis and sometimes make misdiagnoses because they don’t ask enough questions before they begin to tell patients what they should do.

When problems of transference are involved, as they usually are, psychotherapy is, among other things, a process of map-revising. Patients come to therapy because their maps are clearly not working. But how they may cling to them and fight the process every step of the way! Frequently their need to cling to their maps and fight against losing them is so great that therapy becomes impossible, as it did in the case of the computer technician. Initially he requested a Saturday appointment. After three sessions he stopped coming because he took a job doing lawn-maintenance work on Saturdays and Sundays. I offered him a Thursday-evening appointment. He came for two sessions and then stopped because he was doing overtime work at the plant. I then rearranged my schedule so I could see him on Monday evenings, when, he had said, overtime work was unlikely. After two more sessions, however, he stopped coming because Monday-night overtime work seemed to have picked up. I confronted him with the impossibility of doing therapy under these circumstances. He admitted that he was not required to accept overtime work. He stated, however, that he needed the money and that the work was more important to him than therapy. He stipulated that he could see me only on those Monday evenings when there was no overtime work to be done and that he would call me at four o’clock every Monday afternoon to tell me if he could keep his appointment that evening. I told him that these conditions were not acceptable to me, that I was unwilling to set aside my plans every Monday evening on the chance that he might be able to come to his sessions. He felt that I was being unreasonably rigid, that I had no concern for his needs, that I was interested only in my own time and clearly cared nothing for him, and that therefore I could not be trusted. It was on this basis that our attempt to work together was terminated, with me as another landmark on his old map. The problem of transference is not simply a

I know. I think they probably just want to see you performing the full load of a chief. It’s because they like you. Seriously.” I realized it was true: For the past few months, I had been acting merely as a surgical technician. I had been using cancer as an excuse not to take full responsibility for my patients. On the other hand, it was a good excuse, damn it. But now I started coming in earlier, staying later, fully caring for the patients again, adding another four hours to a twelve-hour day. It put the patients back in the center of my mind at all times. The first two days I thought I would have to quit, battling waves of nausea, pain, and fatigue, retreating to an unused bed in down moments to sleep. But by the third day, I had begun to enjoy it again, despite the wreck of my body. Reconnecting with patients brought back the meaning of this work. I took antiemetics and nonsteroidal anti-inflammatory drugs (NSAIDs) between cases and just before rounds. I was suffering, but I was fully back. Instead of finding an unused bed, I started resting on the junior residents’ couch, supervising them on the care of my patients, lecturing as I rode a wave of back spasms. The more tortured my body became, the more I relished having done the work. At the end of the first week, I slept for forty hours straight. But I was calling the shots:

The last refuge of the Self, perhaps, is “physical continuity.” Despite the body’s mercurial nature, it feels like a badge of identity we have carried since the time of our earliest childhood memories. A thought experiment dreamed up in the 1980s by British philosopher Derek Parfit illustrates how important—yet deceiving—this sense of physical continuity is to us.15 He invites us to imagine a future in which the limitations of conventional space travel—of transporting the frail human body to another planet at relatively slow speeds—have been solved by beaming radio waves encoding all the data needed to assemble the passenger to their chosen destination. You step into a machine resembling a photo booth, called a teletransporter, which logs every atom in your body then sends the information at the speed of light to a replicator on Mars, say. This rebuilds your body atom by atom using local stocks of carbon, oxygen, hydrogen, and so on. Unfortunately, the high energies needed to scan your body with the required precision vaporize it—but that’s okay because the replicator on Mars faithfully reproduces the structure of your brain nerve by nerve, synapse by synapse. You step into the teletransporter, press the green button, and an instant later materialize on Mars and can continue your existence where you left off. The person who steps out of the machine at the other end not only looks just like you, but etched into his or her brain are all your personality traits and memories, right down to the memory of eating breakfast that morning and your last thought before you pressed the green button. If you are a fan of Star Trek, you may be perfectly happy to use this new mode of space travel, since this is more or less what the USS Enterprise’s transporter does when it beams its crew down to alien planets and back up again. But now Parfit asks us to imagine that a few years after you first use the teletransporter comes the announcement that it has been upgraded in such a way that your original body can be scanned without destroying it. You decide to give it a go. You pay the fare, step into the booth, and press the button. Nothing seems to happen, apart from a slight tingling sensation, but you wait patiently and sure enough, forty-five minutes later, an image of your new self pops up on the video link and you spend the next few minutes having a surreal conversation with yourself on Mars. Then comes some bad news. A technician cheerfully informs you that there have been some teething problems with the upgraded teletransporter. The scanning process has irreparably damaged your internal organs, so whereas your replica on Mars is absolutely fine and will carry on your life where you left off, this body here on Earth will die within a few hours. Would you care to accompany her to the mortuary? Now how do you feel? There is no difference in outcome between this scenario and what happened in the old scanner—there will still be one surviving “you”—but now it somehow feels as though it’s the real you facing the horror of imminent annihilation. Parfit nevertheless uses this thought experiment to argue that the only criterion that can rationally be used to judge whether a person has survived is not the physical continuity of a body but “psychological continuity”—having the same memories and personality traits as the most recent version of yourself. Buddhists

I was amazed at how expensive economists thought doctors were. They instituted many economic maneuvers—de-skilling medicine onto nurses and physician assistants; computerizing medical decision-making; substituting algorithms for thinking—because they assumed that doctors were such expensive commodities. And yet doctors were not expensive, at least, not the doctors I knew. We cost no more than the nurses, the middle managers, and the information technicians, alas. Adding up all the time I spent with Mrs. Muller, the cost of her accurate diagnosis was about the same as one MRI scan, wholesale. Economists did the same thing with the other remedies of premodern medicine—good food, quiet surroundings, and the little things—treating them as expensive luxuries and cutting them out of their calculations. At Laguna Honda, for instance, while most patients were on fifteen or even twenty daily medications, many of which they didn’t need, the budget for a patient’s daily meals had been pared down to seven dollars, which could supply only the basics. I began to wonder: Had economists ever applied their standard of evidence-based medicine to their own economic assumptions? Under what conditions, with which patients and which diseases was it cost-effective to trade good food, clean surroundings, and doctor time for medications, tests, and procedures? Especially ones that patients didn’t need? Although Mrs. Muller was an impressive example of Laguna Honda’s Slow Medicine, she wasn’t the only one. Almost every patient I admitted had incorrect or outmoded diagnoses and was taking medications for them, too. Medications that required regular blood tests; caused side effects that necessitated still more medications; and put the patient at risk for adverse reactions. Typically my patients came in taking fifteen to twenty-five medications, of which they ended up needing, usually, only six or seven. And medications, even the cheapest, were expensive. Adding in the cost of side effects, lab tests, adverse reactions, and the time pharmacists, doctors, and nurses needed to prepare, order, and administer them, each medication cost something like six or seven dollars a day. So Laguna Honda’s Slow Medicine, to the extent that it led to discontinuing ten or twelve unnecessary medications, was more efficient than efficient health care by at least seventy dollars per day. I

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