The Times, They are a-Changing…

In our day-to-day grind, it becomes easy to see medicine as a static practice. Sure, when we think about it, we realize our leech jars are now empty, but it is harder to see the daily small shifts in care, based on one new study or another that showed us a better path.  What I do today in caring for someone with a sore throat, chest pain, or abdominal pain really differs little from what I did yesterday.  Over the course of my practice, it does become more obvious there is change.  Now, not everyone gets antibiotics for a sore throat, STEMI’s get to the cath lab sometimes in less than 15 minutes, and ultrasound is the go-to tool to evaluate for right upper quadrant pain.

Sometimes, a sweeping change overtakes the practice of medicine, something that brings us closer to being scientists than Shamans.  Antibiotics are an example.  The members of Paul Erlich’s lab discovered arsphenamine (used against syphilis) in 1907. Alexander Fleming discovered penicillin in 1928.  From there it was a slow inroad from bench to bedside practice, with common use of antibiotics starting in the Second World War.  But that slow start altered the topography of medicine like a flow of lava, erasing all evidence of the prior hills and valleys.

Alternately, at times it isn’t new technology that shifts medical practice, but illness itself.  While we are learning about tools to fight disease, disease is conspiring in its little RNA brain to defeat us.  When I started my internship in 1992, HIV was a new disease demanding new practices.  Many of my senior practioners and nurses were not accustomed to drawing blood using gloves.  The concept of universal precautions was brand new.  It was a shock to their system to figure out ways to continue caring for patients, something they were dedicated to doing, with new systems in place.  It was actually easier for us, the interns, to do what needed to be done, because we did not have to unlearn old practices, but instead could learn the new practices as our first time.  Along with these new practices came new risks and practical dangers.  Before HIV, needlesticks were generally ignored.  There were no “needlestick packets” to be filled out by employee health workers, nor the implications of the dangers and anxieties associated with needing to use such a packet.

We are, of course, in the midst of one of these seismic shifts.  COVID has altered the face, literally, of clinical practice by putting masks on us all.  It is requiring us to pivot quickly to figure out how to keep families involved in their loved ones’ care by videocalls, how to connect with patients facing terrifying circumstances despite our masks and gowns, and how to treat this new disease effectively with rapid adaptation of new practices.  Experienced practitioners have been learning on the fly, adapting and changing to meet this new challenge, and it has been very, very difficult.  I would argue, though, that as challenging as this time is, it speaks more to the overall challenges of medicine.  The underlying goal of medicine has always been translating what we don’t understand into something we can affect with our practice and skills.  

Interestingly, interns might be at an advantage.  They have little invested in “the way things were”.  Their adaptability and fresh eyes can bring new solutions to current issues we are facing each day. They are “growing up” within a new set of parameters, as we are all scrambling to find the right path and system to treat this disease. And they do it with the same drive that brings people to the pursuit of medicine- the drive to help people.  As always in medicine, there is risk to those who undertake this responsibility.  These risks are frightening and bring to the surface our thoughts of self-preservation.  Some will choose to leave the fight, as more senior physicians are retiring faced with this new concern.  But for those who stay, the opportunity to remain as the voice that speaks to the frightened, that medicates the ill, and that adapts to the new landscape of illness developing new tools to allow us to progress further from our role of shaman is more real as it is during any crisis.  We will win the fight, and live to fight another battle against illness as the ground beneath us shifts in the future.

As we grapple with this new illness and create new systems to teach the interns and other residents, our education of these young learners will empower them to build on our pre-existing knowledge, to see “old” things with their fresh eyes and carry us all forward. As educators, it is our role to support these fledgling learners, to teach them what we know but also to allow their voices to join ours, immediately, in creating new systems and processes to help us through this tumultuous time.  Hearing their contributions will be essential in navigating this new terrain.  Their joy and enthusiasm can help temper our anxieties as we shift and adapt so we can all continue our mission: to care for those in need.

–Marianne Haughey MD @mthaughey

Director of Faculty Development EMA

Associate EM Residency Program DirectorLIJ/Northshore campus

Professor, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell

edited by Shannon Moffett, MD in conjunction with CORD ASC-EM (advising students committee in emergency medicine)

Old-timey apothecary Image by garlandjasper from Pixabay, Modern apothecary Image by Siggy Nowak from Pixabay 

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