Thursday, December 4, 2008

White Coat, Black Art Follow-up

Well, I had sent a note to Dr. Goldman regarding his comments several weeks ago. He responded immediately with a very thoughtful email. I wanted to put a couple of excerpts into the blog as his response to my rant...It's only fair to allow a rebuttal in a debate!

'Generalizations are cruel to those for whom they don't apply! Sorry if you were offended. I've had 25 years of experience in the ED seeing residents from GIM and ICU have these conversations with patients and their families. I've seen what I've seen and I'm not backing away from that. I didn't just say what I said on the show. I tested out my experience with a noted bioethicist who agreed with me. I didn't ask him to.

I haven't worked in ICU, so you've got a huge advantage over me in that
area. I did a show last season on medical futility, in which I was able
to visit with and speak to staff at the medical ICU at the Halifax
Infirmary. I can certainly confirm that what you have seen and
experienced tracks with what others have. My sense is that the ICU
provides a place not just for patients to either get better or not, but
a parallel space in which families are able to understand and
(hopefully) accept what is taking place.

Jesse, context is everything. My experience is in emergency, the front
door to the hospital. I have witnessed a hospital-wide mind set that
patients are only the hospital's responsibility if and when they are
admitted. Thus, there is subtle yet powerful pressure to "think twice"
about admitting patients -- whether to GIM or the ICU. In that context,
my sense is that residents have assimilated the subtle message not to
admit patients to ICU or medical step down unless absolutely necessary
and to obtain advanced directives to obviate such transfers if and when
they become necessary. I believe the "brutal" honesty that I've
witnessed comes from the inherent role conflict that residents feel when
thrust into the gatekeeper role.'

Thanks Dr. Goldman for taking the time to reply to me. I do enjoy the show as I find that it really explores the 'religion' or 'sisterhood/brotherhood' part of medicine and opens it up to the light of day. I think that's a good thing. It will lead to the openness in medicine that I've talked about before in this blog. Maybe we're on the same mission in the end?

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