Wednesday, August 31, 2016

Quality of Life I

Although quality of life feels incredibly fuzzy and subjective, I think it's important to contemplate. It is perhaps the truest and least-spoken goal of medicine. And along with passing on our genetic makeup, it may be our most fundamental want as people. We don't talk about it enough. In all the lectures of medical school, studies and articles in journals, and posts on this blog, it represents a tiny fraction of what we discuss in medicine. In the same way that death and the dying process is glossed over, the ephemeral phrase quality of life usually earns only hand-waving and idealism.

Although there are quality of life measures taken with psychometric tools and surveys, I like to think it is in the "I know it when I see it" category (originally attributed to Supreme Court Justice Potter Stewart). Yet I'm not sure it really is. Outsider (physician) impressions of the quality of a patient's life often differ greatly from the patient's assessment of his own life. We all have our own ideas of whether we would want to go to dialysis three times a week or be wheelchair-bound or not be able to eat or suffer constant pain. But if any of us were actually in any of those situations, we might change our mind.

Nevertheless, I will talk about quality of life as if we knew what it was. The reason we allow surgeons to cut into people, prescribe medications with side effects, and hospitalize patients is because we think it'll improve their quality of life or length of quality life. But we never think of it that way. It's almost a rote reaction; we diagnose a patient with hypertension and prescribe hydrochlorothiazide; we find appendicitis on CT scan and book the operating room; we witness a suicide attempt and place the patient on an involuntary hold. We do so hoping or imagining that as a result, the patient will live longer and/or have a "better" life.

Why is it that medicine's boundary stops there? Should we actively participate in enriching a patient's quality of life? Or is that out of our scope of practice, someone else's responsibility? Sometimes, I think our social workers who find shelters for our homeless patients, reunite families, and help patients cope with their illness have a more direct impact on quality of life. I think of our physical and occupational therapists who help patients get back to their sports or climb the stairs in their house or use a prosthetic limb. Why is it that doctors are concerned only with the disease and its treatment? Is medicine nearsighted this way? Or is it simply a division of labor; we cure disease and defer a patient's happiness to someone else? I'm really just rambling, but I figured this is an important topic of conversation, and I wanted to open the door.

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