This was my column in the March edition of Emergency Medicine News, as linked below.
My most important patient requires my constant diligence. For this reason, I am seldom far away from him. Only a few minutes inattention and there will be problems. I cannot forget my patient; I am trained to attend to him constantly. I am a professional, and my patient is, ultimately, my customer and the customer’s service is paramount, I am told. I am reminded by policies and procedures as well, and there are those who will contact me, day or night, regarding failure to do what my most important patient requires.
In these 29 years since I started medical school, I have seen many wounded and sick patients of varying degrees of complexity and interest. Legions of fevers and columns of colds, tribes of chest pains and nations of bruises, entire cities of coughs, herds (as it were) of nausea and vomiting and battalions of sprains. Flocks of fractures and entire civilizations of chest pain. But none of them, not one, occupied me like my most important patient.
I was guided by teachers in urgency and priority, I was taught to hurry here, take time there, but always be attentive. I was shepherded by wise physicians before me, but never did any of them put a patient on a pedestal the way my most important patient has been. Neither snakebite nor sepsis, aneurysm nor arterial blockage, pneumonia nor parasite has ever been thrust before me as the most important patient…until now.
What could he have, you ask? What affliction? Who could he be? Of what importance? Celebrity? King? Judge or politician? Child of my own? Parent or priest? Hardly. Not one, not even captains of industry who endow hospitals, have the power of this patient.
This patient, this most important patient of all, stares back at me all day long. I examine and treat him with my hands and sometimes my voice as I stare intently back into his face. I wander off to other ‘patients,’ but all pale in comparison to this one. He violates all privacy and priority and knows absolutely everything. I see a chest pain next-door, or a pelvic pain across the hall; a weeping suicidal woman a few rooms down. I come back and tell my most important patient each secret. The sordid or tragic details of every life I whisper to him, or write upon his screen.
Once my hands loved examining other ‘patients;’ the shape of normal and injured bone, the sound of clear and diseased lungs, the nuance of stroke, the tenderness of the abdomen that took so long to understand. Now I have no time. I must touch my patient, enter the password and let my well- trained fingers run across plastic, not skin or bone. Or speak into his ear with a microphone, far more expedient than time wasted with others. Far more important and billable.
Every time I wander away, my most important patient calls me back; ‘hurry, hurry, tell me about the others! Don’t take too long!’ And others humans, more important than I am, remind me. ‘Don’t neglect your most important patient! Finish everything he needs as soon as you can! He is the key to all of our money! And if you don’t, we will fine you, or punish you in some other way for failing to care for the most important one of all! But make sure the flesh ‘patients’ are happy; give them a little time or they might be upset and not come back, and then what will you tell your most important patient?’
My most important patient is now everyone’s most important patient. He (or perhaps sometime she) is in charge. Sometimes he is shy and recalcitrant and will not wake up, will not look at me with his glowing eye. When that happens, nothing can happen. No orders for labs, xrays or medicine. He is an angry god, and when he is angry no one else can be happy. Sometimes he is confused and plays pranks on me, so that what I thought I said to him is turned on its head or made unintelligible. He is capricious that way; but ultimately far better than ‘people,’ who say and do things that my most important patient isn’t programmed to understand or record. He doesn’t like that, and forces me to do things in a confusing manner because he is angry.
And he is a time miser; he wants all of my time and those who brought him to me (or rather brought me to him, a kind of sacrifice) know that he is greedy and yet expect everything to run as before, when other patients were important.
But I know, and you know, those days are gone like electrons on a wire. Because now, the most important patient of all takes the most time and the most effort and the most diligence because data and billing and tracking and policies are what he does and his handlers love those things the way we used to love humans. And spoiled as my most important patient is, I believe it is unlikely that anything will ever be the same again.
Pity. Humans are interesting. But sick or well, they simply cannot stand in the way of data entry.