Medicine, it is said, it an endeavor like no other. Nowhere is this more evident than in the most intimate of doctor-patient interactions, that the history and physical exam. I was reminded the other day of what happens when my vision of my day does not match the visions of the other people necessarily involved in my day. I think it was the character Jeff Spicoli played by a young Sean Penn in the movie Fast Times at Ridgemont High who said “If you’re here, and I’m here, doesn’t that make it our time?”. Such wisdom, brings a tear to my eye. My day, not really. Sometimes, in medicine we forget that in order for us to actually be safer, or do better, our patients also have to want to be involved in those plans. I had a very stark reminder that despite all of our plans, and all of the goals, sometimes patients are just not on our same page and have an agenda all of their own. Sometimes, despite all of our efforts to do better, be safer, work smarter; our patients just see things differently than us. I offer, in advance, a disclaimer. Erasmus penned his “In Praise of Human Folly” with an eye towards reminding people that for all of our effort and smarts, we really are quite funny sometimes. I appreciate that in a profession such as medicine we are not supposed to find humor in other people’s misfortune, but, we really do have a special perch from which to view human behavior. Our actions, our patients actions, are well, pretty funny sometimes. So, without any further ado, I offer you “Kentucky”, a play that reminds us all that sometimes, no matter how much we try and work and labor, patients just may not allow us to be anything other than ‘human’.

Dramatis personæ: Me (JC), Nurse (RN), Patient (Kentucky). JC is a hell-bent anesthesiologist on a mission. He is going to take care of this patient and do it fast and well. He is the embodiment of everything safe and of quality in medicine. Not only will he monitor the vital signs, but he will make sure that they meet every federal and state mandate ever conceived. He will be super-anesthesiologist. He will do good. He will be popular and famous and his patient and her family will love him. Kentucky will offer him her family home and daughters and dowry in reward. She will supply him with a life-time supply of Basil Heydons bourbon. Life will be good. Kentucky, on the other hand, is a 76 year old spitfire of a woman who shares none of JC’s vision of the world. In fact, all we know of Kentucky is her age, and her illness. Not looking good so far.

Scene: Late night, operating room hallway. Kentucky is on gurney. When JC meets Kentucky she is lying on a stretcher, verbally accosting RN, while her hand is over her mouth.

The scene is set– JC approaches Kentucky with the enthusiasm of a zealot on a mission.

JC: Hi there Kentucky, I’m JC, your (dashing and zealous super-) anesthesiologist. How are you doing tonight?
KY: Aren’t you a little young for this job? (hand still over mouth…)
JC: Well that depends, what are we doing for you tonight and I will let you know if I am up to the challenge. (JC is of course trying to diffuse the anxiety here).
KY: They tell me I need surgery.
JC: Who told you? What did they tell you?
KY: Boy, not only young, but you don’t know anything either. (Her accent is much less cute by now and that hand is starting to gnaw at me).
JC: I may look young ma’am, but my time in prison aged me considerably.
(Nothing. Not even a gasp. Hand stays put though. I dig in for battle.)
JC: Ma’am, your hand, over your mouth, is there something bothering you, are you okay?
KY: My teeth.
JC: What about them?
KY: They took them.
JC: Wow. Did you call the police?
KY: What?
JC: I did when they took my hair. They never found it though. You still may have time if you act fast. (Not one iota of evidence she even heard me)
KY: Do I have to keep them out? I want them back now.
JC: I’m afraid so ma’am, its important they stay out for surgery.
KY: You can’t look at me then.
JC: A little challenging given what we are here for, don’t you think?
KY: You are not operating on my face. Are you? Didn’t they teach you anything in that fancy school you went to?

Touche. Clearly this is going to be a challenge: selectively deaf, impervious to my humor, AND concrete to the point of having me worry about giving her an Axis I diagnosis. I continue, unswayed.

(sometime later in the interview)

KY: Am I going to be asleep the whole time? I hear that people are awake during these things and can feel everything. I hear you guys read and watch movies in there.
JC: Wow. On DVD we watch movies? Really? How did they do that, with portable players? I’ve been surfing the net and getting surf control blocking all day long. Wow.
KY: Blank look. Nothing.
JC: Do you want to be asleep during he entire procedure? We charge more for that you know. We usually just put you out for the beginning and the middle. The entire time is a bit more money.
KY: I want to go to sleep.
JC: Okay, I can swap out my drugs. The ones in the room now are for people who want to be awake. I gotta go hunt for the ones that put you to sleep. I didn’t know your preference, I’m sorry.
KY: Hand still over mouth, now sneezes into her hand and wipes it on the gurney.
JC: Truth be told Kentucky, I have no problem with keeping you asleep, its the waking you up part that I have trouble with sometimes.
KY: Do you have a hanky or something? And, can I have my teeth back now?
JC: Do you have any more questions for me?
KY: Besides your age? Where did you get that necklace thing around your neck?
JC: Oh that was a bracelet that was like XXXXX large. I wear it as a necklace. My husband’s girlfriend gave it to me.

Nothing. Nada, zip. No response. All I see is hand. Wow.

JC: Anything else?
KY: Yes, when I wake up will anyone see me without my teeth?
JC: Depends.
KY: On what?
JC: Whether the TV crews show up or not. I’m on parole and really shouldn’t be here.

Finally, something begins to happen. The hand slowly falls down, and for a moment, I think I have broken through. Then, it happens.

KY: You’re pretty funny, for a kid.

Now of course some of this is exaggerated for dramatic effect (her name wasn’t Kentucky), and some of my comments were imaginary (Bret Easton Ellis’s classic American Psycho was playing in my mind). Yet, this woman did remind me, seriously, that Medicine can do all it wants to try to get its “house in order” so to speak, but sometimes, the best laid plans of mice and men (you know what they say). We can get all the evidence, write our guidelines, have our Root Cause and Peer Review meetings, and go full-bore, nose to the grindstone with our efforts to do better, and it is entirely possible and even likely that are patients have no interest in allowing us to do that job. It is during these times when I worry very, very much about what Medicine is becoming. I worry very much that if we are put in some situation where we cannot apply protocols and guidelines and pathways, that we may be left standing there, with nothing to offer our patients. I worry that we will have forgotten that before we were doctors, we were just people. And through all the haze and the slurry that is modern medicine, our greatest talent and skill should not be lost in the haze of improvement. Sometimes, the best medicine is to just sit down, forget the core measures and the antibiotic timing and just listen to our patients. What they tell us may not help us to do better, but it will absolutely remind us of why we love our jobs, why we chose this career, and how much fun there can be in human folly.