She couldn’t have been more than two weeks old, a newborn. Tussling in her mother’s arms just outside the patient’s room, she let out a gurgle of a cry. Her two brothers, twins by the look of it, clung to Mom’s pant leg for answers. Mom was speechless, tears burning lava tracks down her face. Her husband lay splayed as the centerpiece on display. Cords draped his chest, radioing green tachycardia to an overhead monitor. The man’s breathing was a tangle of labored dyspnea, harsh coughing and raw panic. A nurse suctioned his mouth while an intern vultured over his wrist, eagerly attempting his first arterial line.
I surveyed this scene through the unsullied eyes of a medical student, figuratively clinging to my resident’s pant leg for answers. I was young, confused, and scared by the drama. I didn’t know it yet, but by morning light, this “great case” would morph from “a 29-year-old with acute lymphoblastic leukemia complicated by severe community-acquired pneumonia” to one of the most powerful lessons of my career.
A lesson I wasn’t intended to learn.
For those of you unfamiliar with the term, the “hidden curriculum” is the things we are “taught” when no one thinks they are teaching. It’s not what teachers necessarily say; it’s how they say it, how they act, what they do. It’s nearly always unconscious, unintentional. We learn these things by watching people interact, the inflections and tone of their voices, their bedside manner, the way they treat staff and patients.
This is not just an issue for teaching hospitalists who are imparting these unwitting lessons daily. Rather, it is important to recognize that all of us have been exposed to, and our careers and practices shaped by, these hidden messages. Sometimes these lessons impart such helpful tools as noting how a skilled clinician puts a patient at ease before palpating their abdomen. Other times, the tutorial is less beneficial (e.g. subconsciously teaching bias or impatience). And sometimes the message conveyed is much more malignant.
I, unfortunately, was about to be taught the latter.
The man, stripped of his shirt, his pants, his dignity, winced with the pain of the third radial art-line attempt. He tried to hitch himself up in bed, drawing a scowl from the intern who had to readjust his sterile field—a rebuke from the nurse who got lubricant on her shirt. “Can’t you see that I’m trying to place a catheter in your penis?” she implored. Of course he could—as could I, his family, and much of the ICU. That was part of the lesson.
To be fair, I honestly doubt that anyone in room 118 intended to treat Mr. Davis in such a callous way. They didn’t intend to depersonalize the situation—make him an object, another cog in the wheel of their daily grind. They simply were trying to do their jobs—to save this new admission’s life. A noble intention, indeed.
However, in doing this, they employed a career’s worth of defense mechanisms aimed at fending off the stress of a life-threatening situation. And each of these actions moved them ever so slightly away from the compassion that defines our field and toward the seemingly uncaring automatons they had become.
The Lesson Continues
By now, Mr. Davis was breathing 40 times a minute. A neb of medications, a drip of antibiotics, and a facemask of oxygen did little to prevent his slide. Exposed, shivering, lights reflecting off the paunch of his naked stomach, he cried out for his wife. Coming to him, she was halted by the icy stare of the grizzled charge nurse called in to hold the combatant down. “You’re lucky we even allow you in the ICU with those kids,” she thundered.
The ABG was still pending, but the critical-care fellow was confident of its results. To nobody, he declared, “We have to tube this guy.” Terror was etched in the “guy’s” eyes as he searched the room for answers. What does “tubing” mean? he must have wondered. Am I going to die? Would my sons remember me? Would my daughter be OK? How will my wife do it without me?
Again, he called out for his wife.
It didn’t take long for the excitement to reverberate throughout the hospital. A surgical intern stopped by room 118 to see if he could put in any lines, while the respiratory therapist prepared a vent and a few more medical students rubbernecked in the hall. The oncology fellow took a moment to teach us about a recent article she read that showed that pneumonia was uniformly fatal in acute leukemic patients who got intubated. “Do you mean tubing him is essentially a death sentence?” I asked, death confronting me for the first time in my career. Meeting the patient’s eyes, she turned and lowered her voice to reply, leaving me to wonder if this was the kind of thing we should keep secret.
The wife, managing to momentarily penetrate the critical-care zone defense, was holding Mr. Davis’ hand while she filled his ear with whispers. With his daughter’s face mere inches from his, he appeared calmer. He tried to speak but was drowned out by the charge nurse who demanded he remove his wedding band. “But … I … don’t … want … ”
“I know you don’t want to take it off, sir, but you have to,” she demanded, shooing the wife from the bedside. “Your hands are going to get edematous in the next few days and you don’t want me to have to cut it off, do you?” she asked rhetorically. Crestfallen, he extended his ring finger to his wife, as he no doubt did years earlier, an understanding of his fate crossing his face. Missing the cue, the nurse deftly intercepted the ring off his finger, placing it in her pocket as she swooped out of the room to get the intubation kit, leaving Mr. Davis further agitated.
The critical-care fellow lowered the head of the bed, leaving Mr. Davis upright and calling for his wife. “My … ring … ” he panted, his breathing worsening by the breath. “I … need … to tell … my … wife … ” he gasped as the charge nurse thrust him a bit too harshly to the bed, adding that there wasn’t time to talk now—his message would have to wait. “But … ” the patient protested as the sedative coursed into this vein. “I need … her … to … know … ”
“Quiet now, sir, you have to calm down, you’re just making this harder.” The wife tore closer to him, no doubt wondering what could possibly make this harder. “I love you, John,” she said. “I … ” he replied.
The tube slipped in.
It’s been 15 years, but I think of this night often. In some ways, I am haunted by it; in many ways, my practice style was fashioned by it; in all ways, I was changed by it. I wonder if the same can be said for the other providers.
I also wonder about Mr. Davis. How did the world look through his eyes? Did he see us as his saviors or his tormentors? Did he worry for his well-being, or was he too absorbed in the welfare of his kids and wife to fret about himself? Did he worry about his kids seeing him sick, the impact that might have on them? Was he scared? How must he have felt to be left so powerless? To have no control over his situation. To have his wedding band taken by a complete stranger. To not be able to give his wife an urgent message.
Did it have to be this way? Could we have better balanced the urgency of the situation with the humanity it required? In doing our jobs, did we have to dismiss the one person who entrusted us to help him?
I also think about how that night influenced me. How it shaped my approach to the patients who privilege me to care for them during their most vulnerable times. I wonder what came of the Davis family. That newborn daughter is learning to drive, the boys preparing for college. And I also wonder what it was John so urgently wanted to tell his wife that night. As, no doubt, does she.
For Mr. Davis died that night, his words forever lost. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.