One of the best discussions my book group has ever had was triggered by Atul Gawande’s Being Mortal. Several members had recently lost parents after grueling journeys through our country’s often overwhelming, fix-it-at-any-cost healthcare system, and Gawande’s book offered welcome ideas for better end-of-life care.
Being Mortal sits atop a heap of intelligent, informative, and often moving books that help demystify illness and mortality — including Siddhartha Mukherjee’s The Emperor of All Maladies: A Biography of Cancer, Abraham Verghese’s Soundings: A Doctor’s Life in the Age of AIDS, Jerome Groopman’s How Doctors Think, and Gawande’s Complications: A Surgeon’s Notes on an Imperfect Science. These are not prescriptive self-help books per se (unlike private health manager Leslie D. Michelson’s recently published The Patient’s Playbook: How to Save Your Life and the Lives of Those You Love); instead, these authors address experiences and decisions we will all confront, one way or another, from the knowledgeable point of view of medical practitioners. They also offer fresh perspectives and insights that are far more dependable than the alarmist hodgepodge you’re likely to uncover in late-night Internet searches on previously unfamiliar conditions.
The Shift, by Theresa Brown, a nurse on the medical oncology floor at a teaching hospital in Pennsylvania, offers another angle on our healthcare system and another provocative choice for book groups. This riveting account of a day in the life of a highly competent and compassionate but overtaxed bedside nurse provides an up-close, insider’s view from the perspective of one of the worker bees of the medical world. It raises important questions about staffing, shift lengths, various protocols, and the role of touch, empathy, and record keeping in healthcare. If nothing else, The Shift will leave you with a better understanding of why your hospital call button doesn’t always bring a nurse running as quickly as you’d wish.
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Brown taught English (in which she holds a Ph.D.) at Tufts University before deciding to become a nurse — a change that was prompted by the birth of her twin daughters, which gave her “a taste for the life-and-death struggles that are our daily bread in the hospital.” But she’s kept a hand in literature, contributing pithy columns to The New York Times’ “Well” blog and now producing this well-written book, which is paced like a novel. The Shift recreates one of her thrice-weekly, twelve-hour stints on a unit where fragile leukemia patients often reside for weeks at a time after receiving stem cell transplants.
The book offers plenty of hard facts, including the number of nurses in America (3 million), the percentage who quit their first nursing job within a year (one in five), and the elaborate multi-step procedure for dispensing narcotics, which are given out “like candy on Halloween” on Brown’s unit, because “our patients need them.” There are explanations of the biology of sepsis and the mechanics of shift changes. There are also literary references to Hemingway, Shakespeare, Blake, and Milton, and discussions of the sometimes frustrating hierarchy of power in hospitals, which ranks nurses below doctors, residents, and interns, despite their mutual dependency.
But the living, breathing heart of Brown’s book lies in her vivid, composite profiles of the handful of patients (disguised for privacy) who come under her watch on the day in question, and her enormous concern for them. These portraits remind us of Oliver Sacks’ assertion — recently quoted by Gawande in his New Yorker memorial of the neurologist — about the importance of focusing not just on patients’ clinical details but on the people experiencing those symptoms: “To restore the human subject at the center — the suffering, afflicted, fighting, human subject — we must deepen a case history to a narrative or tale,” Sacks wrote in his preface to The Man Who Mistook His Wife for a Hat.
Brown doesn’t have time to get to know her patients as well as Sacks knew his, but she makes a concerted effort to see the person behind the illness. This includes an ailing seventy-five-year-old scheduled to begin chemotherapy for his lymphoma with a tough drug that Brown fears he will not survive. As she monitors this weak, somnolent man throughout the day, she worries about “clinical myopia . . . focusing on the need to treat without also considering the possibility of harm.” It’s an issue faced by many patients and their family members, weighing risks and suffering when deciding how far they should go in the hope of buying time. When the man perks up in his son’s company during his first infusion, Brown is jubilant that her worst fears have turned out to be unfounded; oddly, she doesn’t consider what might have happened had the doctors heeded her qualms.
Brown’s easiest patient is a woman triumphantly ready for discharge after six weeks on the unit, impatient for the ever-distracted Brown to finish the necessary reams of paperwork. But Brown is repeatedly called away by more urgent concerns, including a desperately ill young woman with a blood clotting disorder and severe stomach pain. A CT scan reveals an intestinal perforation. Brown is dismayed by the swift coolness with which the surgeon informs the patient that she has a twenty percent chance of not surviving the necessary surgery, and she tries to provide solace. Despite the dangers of sepsis, the woman’s anti-clotting medication must be sufficiently cleared from her system before they can operate, so it’s a race against time that requires constant monitoring throughout Brown’s shift.
Another drain on Brown’s attention is a readmit whose reputation as a “PITA: Pain in the Ass” precedes her. Back for an autologous transplant of her own cancer-free cells, this “youthful-looking, athletic and strong” woman in her early forties keeps Brown hopping. The woman’s pushiness raises questions about the respective merits of self-advocacy versus compliance, which reminded me of a bad stormy night I’d once spent in the hospital after surgery, when my nurse went AWOL for hours and failed to deliver promised meals and meds. When I mentioned to the charge nurse the next morning that I assumed they were short-staffed because of the storm, she blanched. They weren’t. That wasn’t the end of the incident. Once home, I received multiple follow-up calls and apologies. As Brown advises her quietly suffering “perf” patient, “Sometimes it’s good to be the squeaky wheel” — especially when it comes to keeping ahead of the pain cycle.
What resounds most in all this is the frazzling, almost unbearable intensity of Brown’s workload. Nursing requires constant prioritizing. It is not a job for people who can’t multitask or tolerate interruptions. Brown does such a good job capturing the constant, overwhelming demands on her attention that I found myself wishing she would just ignore the PITA, for example, and finish the checkout process on her homeward-bound patient. We certainly come to understand her arguments for higher nurse-to-patient ratios, with caseloads of two or three patients instead of four. “Three allows me to treat my patients as people,” she writes.
We also come to understand Brown’s criticism of a health care system that emphasizes charting and checklists and “the bottom line” but “sometimes forgets it exists to serve human beings rather than bureaucrats or businessmen.” Ever wonder what the nurses are up to staring into computers at the nursing station? Chances are, they’re “charting,” endlessly updating patients’ records, in accordance with regulatory requirements for hospitals. Brown comments, “My concern is that over time charting has become a simulacrum of good care, rather than a record of it.”
Although Brown concedes that checklists in hospitals do save lives, she writes, “I sometimes wonder if sadists designed our software. It should not be easier to order a sweater from Lands End than to chart on my patients, but it is.” She adds, “It needs to be quicker, though, because the irony right now is, the time I spend on the computer carefully documenting a patients’ fall risk is time I could physically spend in the patient’s room talking about how we can work together to keep him upright and on his feet.” She also notes, “We need a menu that includes the option: spent time comforting patient with life-threatening diagnosis. But nothing that empathy-intense gets included in our required paperwork.” Instead, she says, “A lot of what nurses document is strictly CYA, as in Cover Your Ass.”
In taking us through her paces, beginning with an early-dawn two-mile bike ride to the hospital in the chill November air that gives her “an unexpected patina of toughness, which matters in health care,” Brown conveys the enormous focus and energy required to do her job well — and the vital importance of that job to all of us.