Frequent fliers are a common fixture for any Emergency Department. These are the people that seem to visit more often than what can be accounted for as actual emergencies. My department is not unique in this regard. Over the years I have gotten to know many of these patients - some by name and diagnosis, some more personally.
There are many reasons why someone may visit the ED frequently. For many there is some underlying psychiatric comorbidity. But for others, they come to the ED as a consequence of intoxication and substance abuse.
The latter group of patients can be the most challenging. The clinical presentation is limited. They are prone to medical complications of their intoxication. And between the nature of the presentation and the agitation or belligerence that follows they generate profound negative emotions among the medical providers. Frankly, it is hard to keep a positive attitude while picking up the pieces from patient's self destruction.
I noticed this acutely myself at the beginning of my training in Emergency Medicine. I found, as an intern, I would become inwardly angry at the drunk patient at 2AM. Namely because they had made a wreck of themselves, and I had to be awake at night, away from my family making a wreck out of my circadian rhythm to pick up the pieces for their indiscretion. Since then, I have been less bothered by the 2AM drunk. But I have seen this same attitude in many coworkers manifest in cynical behavior and conversation about patients.
I would venture to say, that cynicism is rather pervasive throughout medicine. All of us, at one point, have answered the medical school interview question about why we want to be physicians with some altruistic response or claim that we want to help people. But, we quickly lose sight of the idealism that pushed us into medicine as we chat with our colleagues about the drunk in bed 1, the chronic pain patient in bed 5 and the IV drug abuser with endocarditis in bed 30.
Fundamentally, cynicism doesn't represent the values of our profession. But practically, cynicism leads to many problems in the delivery of medical care. Patient cares suffers. And provider wellbeing suffers. So how do we manage and mitigate cynicism?
I recently heard a line in a commencement address given by Jordan Peterson that "Every person has something of value to bring into this world." I was struck by this statement and it got to the idea of value and dignity that I have used to help fight cynicism.
In the context of this particular talk, Jordan was making the argument that people should recognize that in light of their existence they owe it to the world to bring something of value into the world and failing to do so leaves the world a less rich and vibrant place. Why? Because value recognizes the inherent worth and dignity of every human individual. In order to say that someone has something of value to bring into the world you have to say 2 things.
That individual "Has" something.
Value, dignity, worth (whatever we word we want to use) is granted to them the by nature of their existence. It is inherent to their being. They do nothing to gain the thing to give to the world. This doesn't mean that individuals do not need to work to bring that gift to full maturity, but fundamentally it has been (to borrow the language of our founding documents), "Endowed by their creator."
The thing that individuals have is of "Value."
This principle flows from the concept of the imago dei. That is, as created individuals, we have been created to reflect the nature and character of our creator. This is articulated in the creation narrative when God said, "Let us make man in our own image" (Genesis 1:26). Being made by and being made in the likeness the creator grants dignity and worth to the creation. So the necessary conclusion then is that every human (every patient) no matter what their present circumstances, by virtue of their existence, has been endowed with inherent dignity and worth.
Additionally, that thing of value is unique to that individual. If we all are identical then it would be easy to justify replacing one individual with another. And this certainly has been done around the world in certain societies. Communist countries view the value of their people on their ability to work. Inherent human dignity is reduced to this single and commonly shared characteristic. But the reality is that we are all unique. We have vastly different backgrounds, experiences, interests, desires, and goals. This diversity makes all of us unique and irreplaceable.
So what does this have to do with cynicism? Think about this next time you are at the bedside with an undesirable patient. This idea of value and dignity ultimately leads to the antidote for cynicism. That is, the way that we frame our thinking when it comes to seeing that drunk who fell yet again because they are only ever drunk. In the words of C.S. Lewis, "There are no mere morals." Even though patients don't aways behave in a way that manifests their value, strip away the present clinical circumstances. Under the intoxicated or self-destructive surface of our patients is a human who by their very existence has inherent worth and dignity.
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