When is a Doctor Not a Physician?

OK, so there are a lot of doctors: PhDs, JDs, DDS. For the sake of argument, I’m talking about MDs here. Let me start by explaining night float.

Night float is an interesting rotation during residency when most people who are working during the day leave their hospital and their patient’s care in your hands. It is alternately some of the quietest times during residency as patients drift off to sleep and some of the most hectic as in when a surge of patients finally arrive from their ambulance- or helicopter-assisted journey across the state. Night float, or “the night shift” arose out of a recognition that sleepy interns having worked 30-hours straight sometimes do not make the best decisions or confuse their lefts and their rights.

In the name of patient safety, to ease the transition to another provider, there is a nightly ritual as the day teams attempt to summarize or “sign out” the care of their patients to you who will be their provider overnight. I think patients would be fascinated to hear how they come to be distilled in these brief, but important interactions: “this one’s a ‘sicky,’ we’re moving him towards ‘comfort measures only,’ but he’s FULL CODE/admit to ICU for now if he crashes; this guy’s got bad heart failure, but don’t worry, he’s got an ICD and just awaiting rehab placement; she’s on cefepime right now, but culture her if she spikes [a fever] and add vanc cause she’s got a central line that’s a little suspect.”

There is a feeling of being a True Doctor when you hear instructions like these and can nod along forming a mental image of each patient and knowing you’ve been there, done that. Throughout medical training, I’ve heard more than a handful explain the word “doctor” comes from the Latin docere, “to teach.” A True Doctor, then, must be a teacher helping patients understand what they must do to live healthier lives, or a teacher who “sees one, does one, and teaches one” to the next generation of doctors, or perhaps even a teacher who teaches what the night float doctor needs to know about each patient in order to make it through the night. Just as many times I have thought about the other meaning of the Latin, “learned one.” On my good days, that means someone who has committed themselves to lifelong learning or, on my more cynical days, someone at least 7 years over-educated in the practice of medicine, from the practical to the arcane.

For the longest time I have considered “Doctor” and “Physician” synonyms, with the True Doctor being equivalent to the True Physician. The word “Physician” also comes from Latin physica meaning “nature.” This is not nature like Mother Nature, but rather nature in the sense that saying someone is “good-natured” describes her nature, a part of her essence. The True Physician is someone who studies nature, the nature of humans and the nature of her patients.

Doctor and physician are not necessarily roles at odds with one another, but in health care they are made to be. Health “care” is itself interesting etymologically. Curare is the Latin word from which both the English words “cure” and “care” derive. Ironically, health care has evolved with an emphasis on the cure part. Hospitals want to cure patients of their acute condition and get them discharged as soon after that as possible. Researchers want to find “the cure” for heart disease or HIV or cancer, and the rest of the health system wants to provide that. But, in fact, with few exceptions, “the cure” we believe we create turns out to be more of a transformation, granting longevity in exchange for what may be a host of new problems (but certainly better than the alternative!)

When all diseases have been “cured” like this, what remains is a need for care. That means care for those in their extended care facilities, nursing homes, their own homes, and, yes, even those in the hospital on night float. Care is no cure. It will not eliminate disease. It is spending time to understand a patient’s wants and values knowing that at best they will “manage” their disease or know when it’s time to stop managing. It is practicing the Oslerian virtue of “treating the patient and not the disease.” It is understanding the physica of the patient in front of you. And it is really hard to to do on night float or for that matter in so many places in health care that have been optimized for the cure.

There is an anecdote to share here about a patient, Mrs. M, whom I have seen multiple times on night float. But you have been reading this long enough, so I will share another time.

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