At a luncheon, I listened to one of my primary care colleagues explain the realities of the 20-minute office visit. She happens to be very knowledgeable in treating developmentally challenged pediatric patients but her problems apply to any patient with developmental, physical or intellectual challenges. Like most physicians who are employed by health systems, she has productivity quotas and goals that are set by people who are outside the realities of medicine, usually administrators/business managers.
Medicine is not a Business, even a Home Business
The reality of being the primary care physician who treats patients with cognitive, physical or some combination of both types of challenges is that these patients have needs that will affect every aspect of their office visit. Many times, their transport to the health care location will involve public transportation or some other means adapted for them. Sometimes just getting to the transportation source requires hours of planning by the patient/caregiver only to find that their transportation left early or did not show up at all.
Imagine if it takes 20 minutes for you to dress your special needs daughter, it’s going to take 20-minutes to get that same child undressed for vital sign measurement and evaluation in the physician’s office. Keep in mind, that many special needs patients have behavioral and cognitive issues that prevent them from understanding the vital nature of complete and comprehensive health care assessment. For them, they are out of their secure and familiar environment; in a place where there may be excess and unfamiliar stimulation that will affect their behavior for the rest of the day.
The other reality for the intellectually or physically disabled is that they may have very complex health problems that they may not be able to address or their caregivers may not be able to relate to the physician. Couple this with unfamiliarity of the physician in terms of the diverse needs of this population, just because that physician may not have more than one or two challenged patient sin their practice and the business of medicine has created a situation where problems may not be properly addressed. My solution in terms of wound care for these often fragile patients has been to go to their facility/home but my primary care colleagues do not have the luxury of leaving their clinic to do home visits with any regularity.
Why we entered medicine in the first place
Most of us were trained to solve patient problems by identification of those problems and application of extensive medical knowledge. With the emphasis on getting patients in and out of clinic as rapidly as possible, many problems are never addressed or solved. Imagine if you are not cognitively or physically challenged but are the appointment following or concurrent with the patient who has these issues. Not only will your visit be abbreviated or affected, much of the office staff will be spending time and resources on the patient who needs more help. As a result or dealing with possible frustrations on the part of the needy patient, the physician may not be able to focus on your needs or the needs of other patients in the office because they have been frustrated as they are attempting to give the best care possible to their impaired patients.
At this time, we are better in terms of identifying those with physical and intellectual challenges as opposed to addressing their medical needs. We know that great rewards come with treating these populations especially when we are able to prevent or slow any discovered disease processes. Providing the highest level of care is always paramount in the mind of the primary care physician. To this end, my primary care colleague said the the primary care visit should be longer, because it’s often more comprehensive and the specialist visit should be shorter, because it’s more focused. Regardless of specialist or primary care, the office visit should reflect the needs of the patient and should not be limited by a “one size fits all” approach to office visit length. Rather than decrease the costs of health care by shunting more bodies through the door, the “numbers” approach likely ends of utilizing more health care dollars because of missed opportunities to address the comprehensive needs of patients.
On another occasion, I listened to a colleague speak about not wanting to treat any patient who would not fit in the chairs of her waiting room. This was her way of stating that she would not treat obese patients. “They bring down my productivity,” she said emphatically. I can’t afford to lose money on treating these types of patients so I made sure that they don’t fit in the chairs in the waiting room if they weigh more than 200 lbs. Imagine if you are a patient who is morbidly obese, more than 100 lbs overweight, who enters a physicians office and can’t find a chair that will accommodate you so that you can attend your office visit.
Imagine the embarrassment if you have to ask for a properly sized chair so that you can sit and even fill out the paperwork to prepare for that visit. Imagine how welcome you would feel if you receive less than respectful and comprehensive care. The morbidly obese, the developmentally challenged and the mentally challenged individuals in society all have medical issues that need to be addressed. By its nature, morbid obesity is a chronic metabolic problem yet my colleague who makes sure the chairs in her waiting room discriminate against morbidly obese individuals, would treat them differently from the Type I diabetic or the patient with chronic obstructive lung disease. Is is ethically sound to discriminate against a population of patients who are simply seeking, and paying for your services by not accommodating them in your office?
Taking Back Medicine
Imaging a situation where patients get the care that they need without exception. In this situation, the physician determines the patient’s needs and has the time to address those needs. Rather than being pushed by time constraints, the physician (and office staff) would have plenty of time and resources to treat patients with special needs. In truth, patients do not come to physician offices to socialize but come because they need care. It is up to the physician to take back the delivery of that care and set the parameters in which that care is rendered. When a patient receives less than optimal care because of the time constraints placed on the physician, the physician bears the brunt of the criticism. “Those money-grubbing doctors didn’t take time to talk to me”.
As physicians, we need to set the standards of patient care, much the same as we set the standards of practice of medicine. One of those standards needs to be ensuring that the limited resources of primary care physicians are addressed. A good primary care physician can be the resource that decreases health care costs if giving the tools to address all problems in a comprehensive manner that reflects the individual needs of the patients. As specialists, we are often given an advantage at the expense of our primary care colleagues and their vital work. This leads to burn-out and frustration on their part but also leads to increases in health care costs because patient needs are not addressed.
These problems are not solved by increasing the number of mid-level practitioners who often lack the medical knowledge/training to lead the comprehensive care team. While mid-levels can assist with comprehensive patient care, they are not the solution to effective or efficient delivery of comprehensive care. It is the primary care physician who should and does leads the best comprehensive care team and who can provide the most cost-effective care if given the tools and resources for their work. The greatest and most needed resource right now is time to deliver care. The public enjoys greater satisfaction and those of us who are in specialties, are able to obtain the best information to perform our services when the primary care physician can expedite a sound referral. In short, we as physicians need to take back the management of health care and deliver the best health care on our terms as the patient needs not according to a general plan that is even frustrating for relatively healthy people let alone those who have multiple chronic problems.
Occasionally, I have an opportunity to do a case with my senior partner, a surgeon who spent the first 15 years of his career in the United States Army, having graduated from West Point before attending medical school. He retains many of the armed forces characteristics; not the least of which would be his closely cropped grey crew cut/buzz, no facial hair, excellent physical condition and minimal chatter with a clipped mid-western accent. When he walks into any room, we all tend to “stand at attention”.
On this occasion, he asked me to place a vascular access port for chemotherapy, for this patient who had cancer. He had another portion of the case to perform with a resident but thought it would be more efficient for me to place the port while they completed their portion of the case. Of course, this was a chance for me to enjoy the pleasure of doing a case with another physician; always a pleasure for me.
As I entered the operating room, I heard the wonderful sounds of one of my holiday albums (I realized that he had purloined my “Come to the Celebration” CD by the Birmingham Southern College Alumni Choir) thus, the atmosphere in the room was joyous and wonderful. A twinkle in the eyes of all participants in this case (light anesthesia); positive sounds for the patient.
I set about the work of placing the chemo port, finished and then took a seat at the circulator’s table. The lights were then lowered; the laparoscopic portion of the case began. The resident was in the middle of his first year; still becoming comfortable with the mechanics of the operation of the foot controls for the electrocautery. My partner, ever patient and calm, spoke encouraging words as the resident struggled with nerves and the foot pedal a bit.
Here I sat, an opportunity to listen to soft and melodious holiday music along with observing a master teaching surgeon. “How about if you hold the cautery this way, you can have more control,” he spoke softly as he corrected the hand position of the resident. I could see the nervousness of the intern start to dissipate with the touch and words of the professor. The dimmed lights, the soft holiday music and voice of the professor.
“Try to keep the instruments in the center of the field”, he said to the physician assistant who was driving camera for the first time on this case. “Move slowly but follow the case,” he said. I was reminded of my first camera drive when I was a medical student. Certainly, my professor back at that point wasn’t as nice or as instructive. He took the time to correct the PA too.
As the case moved on, the professor and student took turns making the repairs that were needed; hundreds of moves in almost perfect choreography. It became time to close the small incisions from the procedure. “Have you closed these before?”, he asked. The intern said that he had watched but hadn’t actually closed. “Let me show you the technique,”, my partner said. He took the suture from the scrub nurse and explained every hand position, needle angle and move that he made.
“Now you close the other one,” he said to the resident. He softly talked the resident through the simple stitch to close the small incision. He adjusted the hand position and kept encouraging the young surgeon. “I will show you a couple of ways to practice this at home so you won’t forget what you have learned today. You are coming along fine.” he said.
I was lost in absorbing the encouragement, the teaching and the affirmation that the professor imparted to his trainee. I was reminded that surgery is taught from master to apprentice. The better we teach, the better our residents become. It was wonderful to watch this master at work and savor every moment!
I was listening to a couple of the senior residents talk about the confidence factor that every physician has to develop. “Sometimes you have just be a jerk in order to get respect,” one of them observed. As I watched my partner teach his intern, I realized that being a jerk is the last way to earn the respect of others.
Here was a surgeon who had spent time in Army hospitals in Europe and the Middle East. He had attained the rank of Lieutenant Colonel before leaving the Army for the life of a civilian surgeon. He stood arrow straight most of the time with his 6’3-inch slender frame but readily adjusted the height of the operating table to accommodate the 5’7″ height of the resident.
As I watched my partner teach a relatively simple case to an inexperienced intern, I had nothing but infinite admiration for this father, husband and physician. I realized that with his day-to-day performance of his teaching and patient care, he is the “hero” that those of us in an academic practice should seek to become. With my years of experience, I had picked up a couple of new bits of knowledge by just observing this case. I hadn’t said a word because the conversation from master to apprentice was a great instructive experience for me. “You still here?” he questioned when he finally looked up from the case.
There was never a time, even when the intern didn’t know the answer to a question, that this professor uttered a negative word. Perhaps it was the affirming holiday music, perhaps it was my presence in the operating room but I suspect that it was the result of just being an “everyday” hero.
We have changed into a new calendar year and some of you will be taking on new challenges in academics or medicine. The important thing to remember is that challenges are to be looked upon as a chance to change anything that needs to be changed but keeping a good course if your course has been fine. Change is inevitable in life and medicine thus embrace the change/challenge and keep your perspective.
Your perspective must include facing each challenge/change as it comes and doing your best. If you need help, don’t be afraid or so caught up in your ego, that you don’t reach out if you need to reach out. At the first sign of a problem, analyze situation and take care of it, seeking help when you need help. I am always amazed when residents or students tell me that they were afraid of what I might “think” if they sought help.
What I actually “think” is that if you need my assistance, ask and it will be provided. No one was born knowing everything in medicine. I certainly seek the assistance of my colleagues when I need them and never give a passing thought because the welfare of my patient is my only concern.
This tactic applies in academics too as you need to seek the help of your faculty even if you believe you are on the right track. Check your understanding to make sure that you are on course. If nothing else, you make get a better perspective and do even better. Faculty office hours are there for you to get help, get an understanding check and to keep you on course for your best performance. I can’t emphasize this fact with any more emphasis.
Your faculty are experts in their subject matter without exception. Take full advantage of that expertise and strive to get the best instruction possible. You are paying good money for that expertise so get everything that you can. It is far easier to be proactive concerning your studies than to do “damage control” because your ego was in the way of your judgment.
If you are starting clinical rotations, remember that your evaluations will be subjective. A good first impression can often make more of a difference in your clinical grade than anything else. You don’t have to “fake” an interest in everything clinical but you do have to learn to perform your best in a clinical situation. Be enthusiastic about the learning even if you don’t plan on entering a particular specialty. There is a baseline clinical knowledge that every clinician needs thus you need to be sure that you are well above that baseline.
I entered medical school with the idea that I would be a pediatrician, as I had an interest in adolescent medicine. I savored all of my tasks on my pediatric rotation (my first). Midway through clinical year, I found that I loved surgery more than anything I would ever do but that pediatric, family medicine and psychiatric knowledge (the rotations that I did before surgery) have been very useful in my career as a surgeon. In short, while you may change your mind as you are getting clinical experience, everything clinical is useful. Listen, learn, read, learn and ask questions as you go.
My last clinical rotation was Neurology/Neurosurgery. I learned to perform an accurate and thorough neurological exam. These skills have proven to be invaluable in the treatment of trauma and burned patients. In short, all clinical knowledge is useful for a physician or a physician assistant. In the middle of the night, that sound clinical base may make the difference in a patient’s outcome.
Again, mastery of the knowledge of a discipline is useful at the pre-med or pre-PA level too. Don’t approach a course as just something that you have to get an “A” in but look upon those courses as learning practice and useful for your future patients. I remember when I remembered that exogenous insulin did not contain Peptide C (cleaved out when endogenous insulin is synthesized by the body) thus checking a Peptide C level is a good idea in a patient who appears to have high insulin levels. If the Peptide C levels are low and the insulin levels are high, that insulin is coming from outside the body and not from something like an insulinoma (insulin-secreting tumor). I learned about Peptide C as an undergraduate student at university; reinforced in medical school.
Also remember that your faculty, undergraduate, graduate or medical school is there to see you successful. No faculty member gets “points” by having a high number of students fail to navigate their coursework. As a faculty member, my job is to help my students and residents to become the best professionals that they can become, without exception. I can’t “dumb down” the curriculum but I can give you every strategy that I know, to help you get the material mastered. My only hope is that you seek out help and get any assistance that you need.
My next point is for you to try to put yourself in the place of your patient. They are putting their health and trust in you to give them the best care that you can achieve for them. For me, this is the honor of being able to practice. The trust of a patient is something that I cannot violate under any circumstances. I might not have all of the answers but I have the stamina and the resources to get those answers. As I said above, I do not hesitate to consult a colleague when I need their expertise for my patient.
Finally, take time on a regular basis, to relieve the stress of being in an educational system. As a faculty member, I place a premium on my stress relief. For me, physical activity in the form of running, has been great for stress relief. I use that time for meditation/prayer, problem-solving and for the sheer enjoyment of pushing myself to the limit of my stamina. When I feel as if I am too tired to exercise, I go to the gym (or for a run) and I always feel better. If you can’t do 30 minutes, do 10 minutes but do something physical.
Trust the process because the process will get you where you want to go. Trust yourself and your feelings along with the process. If you find that your anxiety level is too high, do something to alleviate the stress. School or residency is not torture but a chance to see something new or learn something new. I can promise you that even a jaded old surgeon as myself, learns something new everyday!
I settled into an evening of reviewing my lecture for the next day. It is a lecture on the early recognition of the signs of shock, a topic that is “near” and “dear” to most surgeons. This lecture is one of my favorite topics because I deliver this information in a “user-friendly” manner that I wish I had received in medical school. It took years of training in graduate school, medical school and residency/fellowship for me to “make peace”, read comfortable, with early recognition of signs and treatment of shock. Once the peace had been exchanged, I worked out what experience has taught me and my colleagues and pass that on to my students.
As I tweaked a slide here and there, the emergency tone on my phone sounded. Odd, I thought, for me to get this call on this day because I was not even on back-up duty. I called the number and heard the voice of one of my colleagues who is a trauma surgeon. “I have a young woman; shot multiple times in the upper torso and neck”. “Can you come in because we have a mess here and I need another pair of hands?” Of course, I would come in if called, without hesitation as one of the sheer joys of what I do is the old surgical mantra “A chance to cut is a chance to cure”. Besides, if I had made the same call to any of my colleagues, they would be at my side as soon as they could.
I drove my 1997 rusty gold Toyota Corolla through the sheets of rain that were falling as I made the 20-mile trip to the hospital. If I had been on call, I would have stayed at the hospital but since I wasn’t, I had to drive in. The rain pounded my wind screen in the early evening darkness. Why do these types of situations happen on cold, rainy and foggy nights? Even my chihuahua would not venture out on a night like this. (I left my heated throw on low for her to snuggle into as I left my townhouse). ” A night that is not fit for man nor beast.”
I arrived at the hospital, parked the car and headed in through the emergency department. This was the quickest way to get to the operating room and would allow me to check out the radiographic studies before I headed upstairs. I scanned all of her films with the radiologist on duty and headed up the four floors to the main operating room. “They are in Room 6”, the desk clerk said as I removed my wet coat and entered the women’s locker room.
I changed into scrubs and grabbed my headlamp from the top shelf of my locker. I piled my wet hair on top of my head, pulled on a scrub cap, shoe covers and then placed my headlamp; tucking the cord into my back pocket. I peeked into the room where my partner,covered with blood, winked at me as a sign of relief. I grabbed my surgical loupes from their wooden box, already placed on the circulator’s table, and said I would be right in as soon as I finished scrubbing.
The surgical scrub is where I take the time to center myself and get into the ritual, the mood of beginning a case. I always say a prayer for God to guide my brain and hands and to guide the hands of those who will operate with me. This has been my brief meditation as I scrub since medical school. I take the time to relax my arms, shoulders and breathe slowly, deliberately before I move into the operating room. With all of the tension of the drive, the rain and the run up four floors gone; I am ready to get to work.
I never want any surgical case to be mindless. I want to be mindful of every step and every event that will unfold. For the patient on the operating table, nothing about what I do is ever routine and will in all likelihood, be a sentinel event in their lives. Once something is cut, it’s never the same as before the cut. No, there is no mindless routine for me or for the patient but for me, there is a sense of compulsive perfection to get it right and to get it done.
The patient had been shot multiple times with wounds in the neck, upper torso, abdomen and shoulder. She had been standing outside her house with a group of friends when a car pulled up and multiple shots were fired. A policeman, was present in the operating room to take all bullet fragments that we would remove. As I donned my surgical gown and gloves, my partner motioned for me to take over the shoulder vascular repairs that he had been working on so that he could move to the abdomen. From training and experience, get control and make the necessary repairs and move onto the next task.
My partner had completed only a tiny portion of what needed to be completed in this complex wound. The bullet had shattered two bones in its trajectory but the vascular damage was immense. I completed a couple of repairs to larger vessels and proceeded to take care of some of the smaller vessels. It was going well and she would have a good blood supply around this mobile joint.
I moved to the upper arm as my orthopedic surgery colleague moved in to do his part with this case. The bone repairs needed plates and screws. Not great to put hardware into places where filthy bullets had been but there are techniques to avoid infection. Most of the tissue that had been in direct contact with the projectile had been removed because it was not salvageable.
The upper arm wound was a clean pass-through which I explored and closed. This would need broad spectrum antibiotics but not a major vascular repair. My trauma surgery colleague had started to explore the abdominal wounds assisted by a resident as I completed the upper arm repairs. The anesthesiologist said that she was holding well and wouldn’t need any further transfusions. We were getting ahead of the damage one “mess” at a time.
“I am going to run the bowel and get out of here”, my trauma surgeon colleague said. “How’s things going up there?” , he asked. “We are almost done,” my orthopedic surgery colleague said. I looked at the neck wound which had amounted to a superficial graze with no penetration of the platysma, a sign the residents had not missed on their initial exploration in the emergency department. The torso wounds had been superficial largely, because of the angle she stood from the shooters.
I helped the orthopedic surgeon close above his work and then turned my attention to helping my colleague close the abdomen. In all, there were seven people around this patient, a diminutive young woman of 19 years. She would not remember those of us who worked on her that night in that operating room but she would bear the scars of being in the wrong place at the wrong time. She would live with some loss of range of motion in her left shoulder but she would be able to live a relatively normal life.
What would she change about her life after this event? Even more important, who is she and why was she in front of 8 bullets on a cold, rainy and foggy night? Who was so cruel that they inflicted this on this woman who was approximately 25 feet from the car when she was shot? This woman is 19-years-old and just starting adulthood but could have been dead from this event. I would receive answers to some of these questions in the coming week after this case but some of the answers will never be known.
There is no “ego” to making these repairs and doing this work. There is a compulsion, on my part, to try to get the best outcome possible for every patient. I see damaged vessels and try to affect the best repair possible for restoration of their function. The wounds have to be explored, evaluated and repaired. There is no value judgment on these types of wounds; only repairs and restoration of blood flow. Get control and get the repair done as safely and as completely as possible.
This young woman is an honor student today with a passion for the study of literature. She has almost completed her undergraduate degree and is poised to enter graduate school. She is mindful, contemplative and readily shares her story with those who have a life of violence either by choice or not. She was visiting her grandmother the evening of the shooting and had just arrived in our city. She didn’t know any of the young people in the car, that shot her.
I always readily volunteer for duty at the hospital during the Christmas season. My church celebrates one of our biggest services on Christmas Eve (I can usually get coverage for this) but I always spend Christmas Day covering for my partners who have families and children on this wonderful day. I am happy and grateful to have these duties.
On past Christmas Days, I have sometimes seen tragedy, loneliness and despair but I always see a joy in those who are working with me. We generally try to discharge as many people as possible for the holiday but we often have a smaller staff even with less patients to care for. This means that there is a wonderful “pitching in” by all of us, no matter what our jobs might be.
I have gladly transported patients to radiography humming along the way. I have gladly greeted all who are working on this day that is usually a welcome rest and get-together with family and friends. My Jewish colleagues always find great Chinese food to share, my Christian colleagues have brought in more food and goodies that I should be allowed to see in one place. (I am happily snacking on grape tomatoes and carrots).
The weather has been unusually warm for December for most of the country. This is welcome for us because we have not been dealing with the cases of hypothermia that sometimes fill our unit when winter sets in. We have seen an uptick in gunshot violence which is disheartening but in any urban area, this is something that we have come to expect regardless of warm weather.
For many young people, shooting another human being with a gun is an answer for presumed slights and many other problems. I have asked many of these young gang members, “Why?” because I just want to understand why they choose to kill, hurt and carry these acts with them for the rest of their lives. Too often, they can’t answer because they don’t survive; another grieving family who has lost a child.
On Christmas, I have tried to remind each of my friends and colleagues that I appreciate their role in my life. Some have been a lifeline for me this past difficult year and some have just been a joy because they are simply in my day to day life and breathe air. My partners have been a wonder and an education at times but always I am thankful for their knowledge and professionalism.
As the year ends and a new year comes in, I am looking forward to more challenges. Each year, I want to “push the envelope” of experience and knowledge. As medicine gets increasingly more scientific, I challenge myself and my students/residents to make medicine more human. I challenge them to take the time to listen and appreciate the wonder of another human being who has put their health and trust in your hands.
The wonder of medicine is that we are privileged to enter the lives of our patients and their families, many times, under raw and painful situations. It is up to us, as physicians, to bring as much comfort, skill and humanity to these difficult situations. I find that as I have aged in this profession, I cry more and feel more; not less. I never want to become immune to the humanity and suffering of my patients.
I also, as the leader of the health care team, want to continue to be mindful of the feelings of the first responders and the others on my team. We all have the same sense of despair when we find that despite our best efforts, a 14-year-old dies. We all feel that same sense of grief when a Mum cries out in pain after being told that her 14-year-0ld son did not survive. I encourage all members of our team to share these feelings and feel them fully.
As I sit here in my office on this misty, foggy and rainy Christmas Day of 2015, I am thankful for this profession that I love. I am thankful for my life, colleagues and friends but most of all, I am thankful that it’s Christmas Day and the joy, lights, sounds and smells are everywhere.
I have been fannying about the hospital, home and church doing all of my duties for the Advent holidays and so forth. I have a wonderful internet friend (New Zealand) who writes some of the most beautiful words that I have the pleasure to read. Here is a Christmas treat that applies to physicians, physician assistants and all who need to just stop and take a close look at all of the wonder around us. Medicine is magical especially at this time of year but everything is magic; so enjoy! How I See The World
At the end of each calendar year, I try to reflect on what I have learned and what surprises me. After some years of teaching and medical/surgical practice, one would believe that there is nothing surprising out there for an old surgeon but I have moments of amazement and wonder every day. This is the nature of my practice of medicine even today.
This past year, I have become more comfortable with my extreme connections with my patients and students. I see the greatness of their humanity and in the case of my students, I have had some moments of disappointment in their lack of humanity. In the case of my patients, I see more humanity because I spend more and more time with those who have cognitive, intellectual and physical impairments.
My patients with cognitive impairments often communicate without words. For me, this is the greatest gift that I have received from them and I am fortunate to be able to stop and make those connections. From a wonderful colleague (Daniel C. Potts MD; his blog is linked to this blog), I have learned to be more mindful which has enabled me to stop in the moment and appreciate all that this group of patients has to say and wants to say. These relationships are pure gold for me.
My patients with intellectual impairments show me the wonder of human achievement daily. Most of this group of patients thrive on having a physician that connects with them and not their caregiver or the person hired to accompany them on visits to the physician’s clinic. It takes a bit more time to make that connection but the relationship here is as rich for me as for the patient. I am thankful that I make and take the time to give these patients what they crave no matter how much it falls outside of the time constraints.
My students have been the greatest surprise this year; not always in a rewarding manner. Many have shown an unwillingness to meet goals in the professionalism that the practice of medicine demands. I know that it is my job, as professor, to make sure that they have the tools for practice but this year has been a challenge for me in many ways.
Many of my students have a fixation on comparing themselves to others. My mantra for countering these comparisons is to say that the only person with whom one can compare, is yourself. Every day, or every second for that matter, is a chance to change your thinking. What another person does or does not do, has no bearing on what you can do for yourself. I constantly remind my students to use social media for information but evaluate that information and surely do not use what is posted on Instagram, Snapchat or Facebook as a means of comparison with others. You have to be the best person that you can be and not compare yourself to what you believe others are.
The lack of appreciation for the humanity of those who would be the future patients for my students is also a challenge for me as their professor. I was fortunate to have mentors and professors in medicine and surgery who reminded me of the privilege of practice. My professors spoke often of the extreme trust that patients place in physicians. We earn that trust by mastery of our craft and by humility because we are not the healers; we are the instruments of healing. To practice medicine/surgery for ego is a straight line for burnout and exhaustion because of all professions, medicine will destroy an ego very quickly.
I am grateful for being able to climb onto the roof of my hospital (14 floors up) and just meditate in the early mornings. In the predawn darkness, I can hear the traffic below, smell the fuel of the helicopter as it lands and I can take a few moments in the stillness of that place to center myself. I can see for miles on some mornings but on others, I am surrounded by rain and fog which is equally comforting. My days of sailing have taught me to love the moments before the sun rises and appreciate the ever changing colors of each new day.
As the Christmas holidays approach and the first semester has come to an end, I try to take some moments to appreciate my wonderful friends. They are a source of wonder and discovery. This year, one very new friend has been a “touchstone” for me in terms of validating what I always knew in terms of the spiritual nature of medicine. His friendship has been truly inspiring and affirming. Though we are totally opposite in just about every aspect of our lives, we are in total agreement in terms of how we approach medicine. I am very grateful for all that I learn from him on a daily basis.
This year has been one of change for me as I have achieved many of my goals in terms of physical and mental conditioning. I have made running and weightlifting a significant part of my lifestyle. I was a varsity athlete in college but moved away from regular conditioning as I navigated graduate and medical school. I have reached many of my physical goals, being able to play rugby again but I am working on getting stronger and stronger.
This year, I learned to kayak (my new means of exploring nature) which has added a different range of being able to appreciate being outdoors. Being solitary in nature for me, has always meant hiking, again so that I can be alone with my thoughts and meditations. With learning to kayak, I have been able to explore rivers and two of the Great Lakes (Erie and Superior). Being on the water alone in a kayak is to perceive much in terms of spirit renewal. I strongly recommend finding some means to get away with your thoughts and enjoy what is around even if you are only able to take a walk in a nearby park.
This year, one of my extreme experiences was to spend a week hiking Joshua Tree National Park in the California desert. There is no location on earth like this magical place. The desert was magical, spiritual and allowed me to appreciate each grain of sand that surrounded me along with the huge stone formations of Joshua Tree. The Joshua trees were amazing in that no two are alike but all are like friends with arms outstretched in fellowship. I loved each spine on each cactus plant too. The desert, the surrounding mountains and the Joshua trees gave me a great sense of place in humanity.
As this semester ends for those who are in medical school, those trying to gain admission to medical school and for those who are in some stage of medical practice, I would hope that you strive to see your place in humanity by any means that you can. I would also hope that you enjoy the spiritual and connective nature of the profession that you have dedicated yourself to. There is pure magic in what we do on a daily basis and I am very grateful for the privilege to see that magic.
A very wise and gifted colleague of mine, Daniel C. Potts MD FAAN published this piece a few days ago on his blog. It is about communication. It’s one of the best-written pieces I have encountered on this subject. Please enjoy this writing as it is worth several reads. Mindful Listening: Learn to Communicate Without Words With Your Loved Ones
Alzheimer Disease (AD) is the leading cause of dementia in older adults at this point. With no cure, no specific cause identified and little available to slow the progress of this disease of progressive cognitive degeneration/impairment, it is very likely that no matter what specialty in medicine one chooses, AD patients will be in your patient cohort. Since AD patients can present at any course in the development of their impairment, it is imperative that all physicians (and health care workers) be aware of AD presenting signs (memory impairment, behavioral symptoms and psychological symptoms) and most importantly, not to marginalize these patients. Loss of memory, judgement and other cognitive functions do not mean that the AD patient is lost by any stretch of the imagination.
My Mum suffers from AD, residing now in a memory-care unit; casting myself and my sisters into the role of distant caregivers. While the course of her disease has slowed somewhat in the past couple of years, at first, it was disheartening for her children to watch an independent, vibrant, high-functioning woman who managed a 90-acre horse farm, become dependent on others for her care. When she became unable to walk to her mailbox and wander along the back roads of our farm, we knew that keeping her at home was no longer an option even with 24-hour caregivers.
Along the way, we have discovered that my Mum has much of her wittiness; can always tell my sisters and me apart over the telephone and has produced many sculptures (always was artistic) that line her room at her residence. Her spirited nature has resulted in a couple of “run-ins” with other residents but she is well-cared for albeit not in her home as she had wished.As a physician, I no longer look at what my Mum has “lost” in terms of cognition but what she gives to us.
What I have learned from Mum is priceless in terms of keeping our relationship. She still critiques my style of dress, surprising since I have been dressing myself independently since age 4 or 5 years. “Are you going to go out in that,” she will admonish and it’s precious to me now. She will hold my small white chihuahua for hours stroking and chatting softly, something she didn’t do very often before AD. She pushes my sisters to be more patient with their respective spouses. In short, while my Mum has lost her short-term memory and some of her profound cognitive abilities, she has gained a patience that she didn’t display very often.
Along the way in my role as caregiver to my Mum, I have learned to appreciate what other caregivers undergo. As a surgeon who treats a population of patients who have been severely injured (burns, trauma and chronic wounds), I have placed more focus on caregivers as well as their loved one. There is increased emphasis, on my part, in making sure that caregivers see the relationships that still remain rather than focus on what may be lost. In most cases, a richness of interaction can remain and develop if one is able to adjust and adapt to a new reality for interaction with their loved one; something that health care practitioners can appreciate in not “writing these patients off” as lost.
Cathie Borrie, a gifted author (“The Long Hello: Memory, My Mother and Me”- Simon and Schuster.ca) in a Question and Answer presentation with the British Columbia Alzheimer Society illustrates the richness of relationship here: British Columbia Alzheimer Society . Ms Borrie who is a nurse, attorney and holder of a Master of Public Health has written a delightful book of caring for her mother with AD and the wonder of wisdom from her Mum who was deeply into the progression of AD. Even more profound is that as one reads this Q & A session, one comes to see how much caregivers can receive from their loved ones and no how much is lost. I have given this book to many of my patients’ caregivers even while they waited in the waiting room of our burn unit. Ms. Borrie’s book will be available in the USA on April 5, 2016. This is a great book for anyone anticipating practicing medicine as it gives much insight into the rich relationships that anyone with dementia is capable of maintaining. The Long Hello: Memories, My Mother and Me
Additionally, Daniel Potts MD, has written extensively on his relationship with his father who suffered from AD. Dr. Potts is a neurologist, gifted poet/writer, speaker and educator/scientist who has been an award-winning advocate for caregivers of patients with AD. His blog Maria Shriver-Igniting Architects of Change contains many stories and much wisdom learned from watching his father, Lester Potts, produce countless amazing watercolor paintings while suffering profoundly from Alzheimer Disease. Dr. Potts has been a shining example of what all physicians, especially this one, should aspire to in terms of seeing the dignity in the most vulnerable of patients.
As you go through this month and this day, seeing purple around your neighborhoods and communities, be sure to give a donation, lend a hand and most of all, if you are a practitioner, look at your patients with AD in terms of where they are and not what they have lost. We have seen the success of the “Ice Bucket Challenge” in terms of increased awareness and funding for Amyotrophic Lateral Sclerosis (ALS) but as health care professionals, we are far more likely to encounter patients with Alzheimer Disease than ALS. A 2011 article “Nature Review Neurology -Reitz C” estimated the global burden of Alzheimer Disease to upwards of 24 million and double every 20 years to 2040. This is a tremendous number of patients who will have a significant number of caregivers. Let’s support caregivers, research and most importantly the patients who suffer from Alzheimer Disease with our passion to be good physicians and our dollars.
One of the duties of a physician is to attend to those, who are near death, who are dying and who will die in your care. From the time of the first patient that I pronounced as a newly minted MD to the present, I consider my presence at the end of my patients’ life one of my sacred duties as a modern practitioner of medicine.
My first experience with death as a physician
The second-year resident had paged me to let me know that a patient was coming out the TCV (Thoracic, Cardiac and Vascular Surgery Intensive Care Unit) into my care as the resident covering the Thoracic floor. She said that she would write transfer and floor orders but as this patient was dying, all I would have do is to pronounce and fill out the “Death Pack”. She said that she didn’t think he would last very long and would be no “trouble” for me.
As soon as the floor notified me that the patient had arrived, I ran down the stairs to see what I could do for this patient. He was a 38-year-old man who had a massive dissecting thoracic aortic aneurysm that was inoperable. He was not conscious but I could see that his breathing was shallow and slowing.
“Does he have any family that need to be notified?” I asked the nurses. They said that they were sure that he had no relatives. I looked at his chart and found no family contacts. I headed back up to my call room to fetch my surgery journals. Since my father’s death (before I started medical school), I will not allow anyone to die alone. I would be present in this moment with this patient.
I settled into a blue chair next to his bedside and moved close. I looked at his peaceful yet young face with curly blonde hair and a very neatly trimmed mustache. “I am not going to leave you,” I said. “It’s OK to leave because you must but I am here if you need anything,” I said to him as the nurse looked at me quizzically. I said a prayer of thanks for being able to be with this very young man in the final hours of his life. I didn’t know him, other than what was on his chart but I knew him as a human being.
I decided in the moments that I sat with this patient that sitting with my patients in death, being present with my patients in death, is something that I would do for those under my care. I would be thankful for the privilege of being present as a soul that might connect with another soul beginning a journey.
Death and being a physician
We can read many articles and texts on how to handle the death process from the standpoint of being a physician. In some manner, every physician finds a strategy to deal with the death of a patient that is under their care. Some attempt to look at death as an opponent that must be conquered while others look at death as a part of life.
As a physician who is a life-long Christian and a person of faith, death is neither an enemy nor part of life. Death is a transition into eternal life for my patient, my belief since childhood. The physical body is left behind but the soul soars and continues eternally. As a physician, my vocation challenges me to make sure that the physical body, in terms of health, is optimized but death of the physical body happens no matter what we, as physicians do.
In the Christian doctrine
“Jesus said to her, “Your brother will rise again.” Martha said to him, “I know that he will rise again in the resurrection on the last day.” Jesus said to her, “I am the resurrection and the life. Whoever believes in me, though he die, yet shall he live, and everyone who lives and believes in me shall never die. Do you believe this?” – John 11:23-26
Many of your patients (and their families) will be Christians and will have heard the above Biblical passage many times. Still, in most cases, the death of a loved one will be very difficult evoking anger, sadness and a host of other emotions. Additionally, other faiths have explanations of death and its place in the life experience.
No matter the faith (or non-faith) of my patient, I try to assure them that I will make my patient as comfortable as possible. If family are present, I encourage them to speak with their loved one even if there is no answer. I encourage family members to touch, embrace and hold their loved one. If no family, I can do this easily.
Many of my fellow surgeons
Many of my fellow surgeons are very uncomfortable with spiritual aspects of patient care and the spiritually of their patients. From my Introduction to the Practice of Medicine in medical school to my present practice, I was never uncomfortable with sharing the spirituality of my patients or their families. For me, this sharing has been an honor. My practice partners tend to dismiss spiritual matters in favor of surgical matters but for me, spirituality and surgery are intimately connected.
I have often shared my belief that patients who are spiritually connected and comfortable have better outcomes in all aspects of their care. As I have aged in my practice, I have become more, rather than less spiritual. As a medical student, I was encouraged to ask patients about spiritual beliefs and discuss them if necessary. One of my fellow surgeons said that he would rather have “brain surgery” than discuss “religion” with a patient. I simply asked, “Why not?”
“Why are you infinitely comfortable with your hands in a patient’s abdomen but you are uncomfortable with discussing spirituality?” As I have gained more life experiences, I tend to see that when I may not be able to treat illness with a scalpel, I can give care spiritually and that’s all right with me surgeon or not which is why I can be found sitting at the bedside of a patient who is dying.