Medicine From The Trenches

Experiences from medical school, residency and beyond.

Satisfaction?

Introduction

I am in the beginnings of reading applications from those who are seeking admission to the two medical schools on which I serve on admissions committees. If there are common themes in the personal statements, they center around a strong desire to make a difference in the lives of future patients; to interact and reach those who need care. In short, most people who desire to enter medicine are interested in being of service to other humans.

In stark contrast, as I interact with members of my medical societies, I hear countless stories of increased disappointment in medical practice. From despair at being a “cog in the wheel of profit-making” to “I just can’t keep up with the paperwork”, my colleagues are far less satisfied with their daily work and are increasingly looking for ways to exit medicine especially those who work in primary care (read on the front-lines).

Changes

Most physicians in today’s practice are employees of health systems\groups. The days of a practice such as that which my father and uncle enjoyed (two-physician Internal Medicine Practice and affiliation with one hospital), are gone. A couple of my “radical” colleagues have renounced the world of third-party payers and moved into their clinics where autonomy is of greatest importance. These autonomous colleagues have joined the ranks of concierge medicine where their patient cohorts pay a flat fee for unlimited access (not bad unless you have too many patients) or direct payment, often scaled. It is no accident that my colleagues who have the most autonomy over their practices are the most satisfied even if their income is less.

Additionally, when one begins practice, one has to have an income (loans have to be repaid and debt is certainly a burden) and one has to have some means of gaining experience with the skills learned in residency/fellowship. While the learning curve is steep; my younger colleagues understand and appreciate this but the constant erosion of personal time, income and increasing administrative tasks (scrutiny from those outside of medicine) have left many with a sense of hopelessness from lack of control.

A wonderful colleague in Family Medicine related that her administrative supervisor admonished her for not seeing enough patients even though she brought in the most revenue of her group and is probably the most efficient member of the group. She said that she spent hours developing patient aids and methods of getting patients seen, problems addressed and appropriate follow-up only to be told that she has to increase the number of people seen by 25% or face a cut in salary; certainly demoralizing.

Dissatisfaction?

I always remember my favorite residency professor telling me that “surgeons are not made, they are forged”. My forging was a relentless pursuit of honing my surgical technique along with the mental agility to assess my patients and take necessary action. I thrived in the environment of the constant challenge of a fast pace, physical demands and sheer grit to “get down there and nail the problem”. My residents today crave reassurance from me that they are progressing, something that I didn’t ever seek from my professors as I picked their brains for every ounce of knowledge that I could acquire.

When I completed my training, I too became part of a large practice group though I enjoyed a bit more autonomy because I enjoyed procedures and patients that my partners hated, perhaps my radical nature. Since I am willing to treat chronic wounds, hemodialysis patients, burned patients (most long-term), my colleagues have granted me a measure of being a free spirit which feeds my soul in medicine.

My primary care colleagues who crave connection with their patients are constantly being forced to limit patient contact. Couple limited patient contact with more time spent battling electronic patient record systems that do not meet needs, more regulations and less autonomy, it is no wonder that many have begun to look for other means of making a living outside of medicine. One of my friends just said that she is “tired” and “depressed” most of time. “I just have no joy in getting up and heading off to the office.”

Getting our souls back

How is it that we begin medical school with so much compassion and empathy only to end up dissatisfied and unhappy? Certainly the process of learning and acquiring the knowledge, application of that knowledge base and training can’t have removed that drive, compassion and empathy that got us through the undergraduate process (at high level) only to crash, so to speak, in the actual practice of our craft.

As I have moved though practice, I have become more dedicated to reaching and communicating with my patients. It is that patient interaction that enriches my sense of satisfaction with my work. My partners love that I will take on the more chronic patients that require more time and a more concerted effort. What I have found is that as I interact, especially with my patients that communicate less verbally, I am the one that is enriched.

Many times, it may be a sparkle in the eye or a touch on the hand that sparks a communication soul to soul. These small gestures may take more time but the results can be nothing short of amazing. When I speak of “caring” for patients, I strive to deliver that care. Rather than pushing patients to a periphery, I seek to draw them in closer. For me, this is the essence of why I entered medicine.

Many have questioned why a surgeon would be the one who wishes to connect on a deeper level with patients. After all, my practice is heavily skewed towards procedures but I maintain that my interaction on a deeper level with my patients is where I derive my satisfaction and my spirit in medicine. When the pressures of obtaining a corporate profit from patient care outweigh my ability to give the care to each of my patients, my days with that corporation are over.

A few months back, I was rounding with my team on the surgical floor. The chief resident and I were listening to an intern present the patient whose room we were about to enter. “The is a 75-year-old non-verbal male with dementia..”, he explained. He went on to state that the patients behavior had made evaluation of his severely infected diabetic foot ulcers very difficult. As we entered the patient’s room, I immediately grabbed a chair, pulled up close to the gentleman who was seated at bedside in the early morning.

I gently spoke a greeting softly to him; his eyes changed for a brief second; as I touched his hand gently (thankfully my hands were not their usual chill). I kept my right hand on his left hand as I explained why all of these people were in the room. As I took his right hand in my left hand, the chief resident picked up my “cue” and knelt down to look at the patients feet. I gently stroked both of the patients hands while chief removed the dressings and examined the wounds (in dire need of debridment). My eyes did not leave the eyes of this gentle soul as I spoke to him about his foot in soft tones, a great connection.

When we had completed the exam-yes it took a bit more time, I gently touched his face and said that we would speak to his daughter about the needed procedure. When I met the patient the next day in the holding area of the operating room, he reached out and gently touched the strand of pearls that are my signature. Yes, those small connections are why I do what I do and are immensely satisfying for me.

Final Thoughts

In yesterday’s Boston Globe, Bella English wrote about Massachusetts General Hospital’s Empathy and Relational Science Program. This program emphasizes training for physicians in empathy which “enhances relationships, increases job satisfaction and improves patient outcomes”. The importance of striving to develop relationships with our patients is of vital importance for our well-being as clinicians as well as for our patients. There is data now available that documents decreases in stress and decreases in malpractice claims. According to Dr. Helen Reiss, a psychiatrist who runs the MGH program, “Patients don’t sue doctors they like, with whom they have a meaningful relationship and whose intentions were good,” Good will and the building of meaningful relationships with patients by seeing the dignity and elegance in all of our patients regardless of our patients’ ability to communicate with us is a vital part of enhancing our enjoyment of medicine and why we are here in the first place.

15 August, 2015 Posted by | medical school | | 4 Comments

The Importance of Saying Goodbye

Introduction

I was consulted to place a chemotherapy port in a young man (age 14) who was going to need extensive chemotherapy in the coming weeks. These requests are not unusual but the lessons that I learned from my experience with this young man are with me today, years later. This was one of my earliest experiences as a newly minted attending physician. My learning curve at that point was so steep that I constantly risked falling backwards as I climbed.

Roger

Roger was a patient in the Pediatric Intensive Care Unit (PICU). He had recently been diagnosed with a fairly aggressive tumor that grew from his liver and pushed on his diaphragm. His presenting complaint has been shoulder pain for which he was worked up extensively. Since Rog, as he asked me to address him, was a volleyball player, the first thoughts were a hidden musculoskeletal shoulder injury but it became obvious as the workup proceeded, that something else caused Rog’s pain. The tumor was identified, biopsied and deemed inoperable as the malignancy had quickly spread throughout his liver. Thus pediatric oncology consulted me to place a port for chemotherapy.

Rog’s parents were adamant that they did not want staff to discuss Rog’s diagnosis (or grim prognosis) with Rog. They wanted no mention of cancer, metastatic disease or death with the patient. Since Rog was 14 years old, his parents wishes were followed by PICU staff whether they agreed with the parents or not. I spoke with Rog and his parents at the same time when I approached them for consent to place the port. Rog knew that he would need extensive intravenous medications over an extended period of time thus having a semi-permanent port would mean the there would be no repeated searches for a vein or multiple punctures if a vein was missed. I explained that I would place the port in the operating room with him practically asleep but definitely fully relaxed. He was fine with the procedure and his parents agreed. The next afternoon, I placed the port without problems.

Off and on over the next couple of weeks, Rog received his daily chemo and medications to mitigate the effects of the chemo. I watched a very athletic young gentleman begin to become frail, thin and jaundiced (yellow tint to skin).  His very lively team mates who came to visit were a stark contrast to the patient who seemed to age before my eyes. I stopped in to say hello to Rog often because we had enjoyed some lacrosse stories together previously. I also always greeted his parents who began to look more desperate with each day of chemo. I was sure that Rog, who was a very astute and sensitive young man, could see the changes in his parents even if they didn’t discuss his disease with him.  Rog’s 8-year-old brother often sat in the waiting room after school for a few minutes with his adored older brother. Charlie was a quite young man with sparkling dark eyes behind round wire-framed glasses and endless dark curly hair.

I always made it a point to ask Charlie about his scene. Charlie loved discussing flying with me and looking at photos of my little twin-engine Cessna plane. “Do you really fly above the clouds?”, he would ask with wider eyes. “Yes, I do get up there at times and I fly through them too but most of the time, I am beneath them, ” I would answer. “What you think is happening to Rog?”, I asked him one day. He said that the knew his brother was very sick and he was glad that he could wait outside in the waiting room because he didn’t like seeing his brother look so sick. He said that he was luckier than Rog because he wasn’t sick. Charlie wasn’t sick but he missed his brother and his world was forever changed by his brother’s sudden illness. Charlie missed his brother very much.

One of the PICU nurses who had also become very close to Rog, stopped by his room when her shift began and ended. She had been a flight attendant in her previous life; sunny smile, soothing voice and the stuff of a 14-year-old man’s dreams. She told us that Rog was worried about his little brother. She said that he wanted to say good bye to his family and brother but his mother wouldn’t let him say anything. She changed the subject when he brought it up. Rog’s favorite nurse decided to get a video camera and allow Rog to speak to his parents and little brother. She said that she didn’t know if she would end up fired from her job but it was clear that this young man knew he was dying and longed to say good by to those he loved. Shortly after Rog filmed his messages to his parents and his brother, he died.

As far as I know, no staff member discussed death or dying with Rog but he knew that he was not going to survive this illness. He didn’t have to be told by his parents. A couple of weeks after Rog died, Rog’s favorite nurse gave Rog’s parents the video tape. They were very grateful to have his last messages. Those precious words were a gift to the people that Rog loved most. Later in PICU rounds, we took the time to allow anyone involved in Rog’s care to speak about their experience with his case. The underlying messages from the fellows, the residents, the nurses and other caregivers was that not discussing Rog’s impending death with him sort of negated the feelings that we all knew Rog experienced. Rog knew that he was dying and desperately wanted to say goodbye to the people who meant the most in his life.

We have to learn to say goodbye

I am not going to criticize Rog’s parents. Their grief began when they were informed of the grave nature of their son’s disease.  Even my own grief in the loss of my husband came suddenly. He was healthy and with me one day and he was gone on the next day. I didn’t have an opportunity to say goodbye to him. Even today, I am still dealing with my feelings surrounding his death but my experience with losing someone that I loved very much has given me even more compassion for those who are losing loved ones. Dealing with grief and loss is individual and very complicated. When dealing with a prolonged illness, a patient with extensive burns, a major trauma or even a chronically ill loved one, part of my duty to the patient is to take care of their caregivers and in some cases, help them say goodbye to their loved one which starts the healing process for all of us.

Parents who are losing children and children who are losing parents know about death and often want to discuss their feelings surrounding their loved ones illness. In many cases, just listening to what they have to say without judgment is a very powerful act that can benefit both the patient and their family. As physicians, we want to attempt to solve every problem and move on but in the case of critically burned patient or a patient with a limited prognosis, we can’t solve the problem of making everything the way it was before the illness. Even for many physicians, dealing with survivors in these types of cases can result in us bringing those feelings of helplessness home where they can cause problems with our personal relationships.

I make sure to allow staff and family to openly discuss their feelings surrounding a critical patient’s illness. By having a safe place to discuss feelings of helplessness, anger and frustration can allow those feelings to be acknowledged. The simple act of acknowledging one’s feelings about a sad or tragic situation rather than attempting to hide them behind a professional mask. Sometimes as a physician, I have to cry with my patients (families) and pray with my patients (families) which is the best of humanity that I can give them. I can now do that with the staff too because we are as human as our patients. To pretend that Rog’s situation above was not gut-wrenching would have been dishonest because 14-year-old volleyball players are supposed to be worrying about acne and the prom; not worrying about how to say goodby to their parents and little brother because they know they are dying. Rog understood his death in the simplest terms and simply wanted to leave something behind.

Medicine in Today’s World

In today’s world of having to rush through patient encounters and get to the bottom of a diagnosis quickly so that one can move onto the next patient, we cannot lose our humanity. Our patients have much to share with us and as physicians, we are fortunate enough to be in a position to hear what our patients have to say. It is my belief that the profit-driven/cost-cutting world of medicine today where physicians are “burning out” and “dropping out” of medicine because of low job satisfaction is directly due to our loss of connections with our patients. It takes time and a willingness to spend time reaching our patients and their families. In the end, our “gallows humor” doesn’t make for us dealing with tragedy in a healthy manner as physicians are notorious for turning to alcohol and other substances or just repressing those feelings only to have them come out later and pathological for us.  Reversing the trend to spend less time with our patients is probably the best thing that we can do for ourselves as physicians.

I am also convinced that getting back to our humanity and our spirituality in medicine is vital for us as physicians. If we do not care for ourselves spiritually and emotionally, we are likely not going to meet the needs of our patients clinically. Medicine cannot be done by a computer or with “check lists” or pre-written forms. Medicine is done best human being to human being with ourselves open and listening carefully to what our patients have to teach us so that we can help them.

2 August, 2015 Posted by | medicine, practice of medicine | , , | 2 Comments

Why I went to medical school at a later age.

drnjbmd:

Since I am far away from my home base and living the life of a sailor, my thoughts have turned to why I entered medicine. This post was one of my earliest posts on this blog and long after my decision to enter medicine. Note the reference to a “Walkman”. Do they even exist anymore?  It was my father’s dream (he was an Internal Medicine specialist) that I follow in his footsteps. My uncle was my mentor (he was a Cardiologist). I was a scientist and entered medical school a bit later because I took the time to complete a Ph.D. I have no regrets because medicine/surgery is one of the most amazing things that I do, when I am not sailing.

Originally posted on Medicine From The Trenches:

Back in 1993 when I was a busy graduate student, I was happily contemplating my future career as a college professor. Even as a child, I knew that I wanted to be a research scientist. I had excelled in math and science in the English school that my Mum had so carefully chosen for my education. My Mum was very pro-active when it came to the education and enrichment of her children. She was my first and best teacher. She had taught me the value of an education and the value of observation. While directing the growth of her children on a self-sustaining farm, she made our 90-acre horse farm, a living laboratory for our education. Armed with this background, we were expected to excell at all things academic. The “buzz” around our evening meal was not about sports but about Einstein’s Theory of Relativity and higher mathmatics in addition…

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29 July, 2015 Posted by | medical school | 7 Comments

Starting the New Academic Year

Introduction

As many of you head back to school (or begin medical school or university), the time is great for considering some small changes that may make a large difference in your health and academic success. I wanted to list a few things since I am on an extended vacation/adventure and now have a little time to tend to my neglected blog.

Head Check

This is a great time to “let go” of anything negative from past academic endeavors. This is a new start, a new year and a new time to reinvent yourself. Why not spend a few minutes each morning with some positive thoughts (for heaven’s sake, this can be as simple as smiling at yourself or a positive affirmation). When students begin to become overwhelmed, negativity creeps in first and threatens to magnify any problems into significant issues. I have found that my first actions when I start each day are to meditate and begin the day positive with my spiritual thoughts. This places me in the proper frame of mind to meet each challenge as they come.

Consider that in this era of expensive education and limited funds/opportunities, the fact that you are a student is a great advantage. You have a body of knowledge to master and build upon. Keep your mind open and positive so that you take the greatest advantage of your present academic challenges and events. Nothing can limit a determined individual who calmly prepares themselves for anything to come and adapts to changes when they occur. Resist the urge to see your academics as a battle with your professor or fellow students. Your only competition is with yourself to do your best honestly and constantly.

Do not neglect your spiritual needs. Find some form of spiritual outlet, be it something creative or religious (even better do both). If you are in a new location, find a church that speaks to you even if you wind up exploring another religion or belief. Allow yourself the freedom and openness to learn about other religions and beliefs. These explorations can serve to strengthen your own beliefs or widen your spirituality. The fellowship and connection with others, preferably outside of medicine or school is great for your heart and soul. Yoga is a wonderful activity to explore with its calming and peaceful effect on both mind and body.

Body Check

Plan your meals for the week and plan healthy. The pizza and beer may be a wonderful treat but one can’t eat high fat foods and consume alcohol on a regular basis. Good academic performance takes a strong body to nurture sound thinking. Packing snack-sized bags of apple slices, a few almonds, cucumber slices, baby carrots and grape tomatoes are healthier, easy and cheaper than grabbing a high sugar candy bar from a vending machine. High sugar may give one a quick energy boost but in the long run, that boost doesn’t last. Ease up on the caffeine (dehydrating) and go for water rather than fruit juice. If you must have fruit juice, make it within the context of eating the fruit whole such as a whole orange or grapefruit rather than drinking bottled or canned juice.

Perform some type of aerobic exercise where you get your heart pumping for at least 30 or more minutes daily. You don’t have to run for long periods of time as you can break your aerobic work into 10-minute sessions. My favorite trick from residency was to run the steps (up and down) in between my surgical cases or run jog the length of the subway platform several times as I waited for the train. I used climb to the top of the parking garage and just enjoy the air and the birds from the heights (I used to wave at the train engineers from the garage too). You can even park your car far away from the building and hike in for some much-needed aerobic work. Let your aerobic work be relaxation and not competition or stress.

Pumping iron in the gym is also great for stress relief. I will admit that I use my iron work to give myself positive reinforcement. With each rep, I am grateful and thankful that I can perform those reps. I generally don’t have loads of time for the gym but I take advantage of every moment when I am able to get into the gym and get a good weight-lifting work out completed. I also follow-up with a dip in the pool as a means of keeping myself flexible (vitally important in surgery).

Sleep Check

You have to figure out how much sleep you need for peak performance. Trying to “train yourself” to get by on less sleep rather than more sleep is not a sound idea for optimal learning. There are plenty of fitness devices on the market that will give you an idea of how much sleep you actually are getting and the quality of that sleep. Figure out what is optimal and get proper rest.

Anxiety can often cut into sleep and can cause your quality of sleep to deteriorate. This can cause chronic tiredness and can make your study time far less efficient. Find healthy ways to reduce anxiety (not drugs or alcohol) so that you can sleep well. Even herbal supplements can erode the quality of your sleep thus you need to make sure that you are getting proper rest without chemicals unless properly prescribed by a physician for a diagnoses where an anxiolytic is indicated.

Unplug from your electronics

I have been guilty of keeping the smart phone next to the bed on most days. Now that I am on vacation, I started to turn off the phone and rely on my natural clock to awaken me. I have discovered that I don’t over sleep and I am more peaceful. My phone is in my purse which is across the room so that I am not tempted to grab it first thing when I awaken. I plan to carry this practice into my work life when I return home.

I have many wonderful connections with my friends on social media and enjoy those connections very much. I have learned to treat my social media times as part of my recreation time. Social media is a means for me to connect with colleagues and friends and not to iron out political problems. More times than I would love to admit, I have “UN-friended” someone because they are bent on berating me for my beliefs. I just don’t have time for that much stress these days.

Consider that during this time of emphasis on academics and school, you have a limited amount of energy which should be spent on your studies rather than being outraged about things that you may not be able to affect. Yes, you need to be aware and informed but gossip, shaming and bullying take too much energy and produce negativity. Support causes that you believe in but not to the point that you are consumed by your causes.

Finally, these are a few things that I am “tweaking” as I go along. As an attending physician, I take myself far less seriously than I did as a resident physician. I have come to embrace my humanity and to embrace the wonder that is the humanity in others.  There is tremendous joy in medicine and patient interaction especially when your patients begin to see that you care about solving their problems and you connect with them. At this point in my life and career, my patients, my students and the residents me teach me so much. For that I am eternally grateful.

24 July, 2015 Posted by | academics | , | 8 Comments

Patients that you might not “like” for whatever reason.

drnjbmd:

I am away from most of my writing tools. I thought I would reblog this because it’s timely. Enjoy.

Originally posted on Medicine From The Trenches:

I received a call about a consult for placement of a temporary dialysis catheter in the Medical Intensive Care Unit. When I arrived I quickly scanned the chart (coagulation profile, patient’s medical information etc.) and entered the room of the patient who needed the temporary dialysis catheter. Just before I entered the room, one of the resident physicians pulled me aside and said, “This guy weighs 500 pounds and let himself get to this point. On top of that, he smells. I just want to warn you to have your gas mask ready”. He laughed and I “thanked” him for the information and entered the room.

Lying in the bed was a 500+ pound gentleman who was restrained and mechanically ventilated. In one hand was an intravenous line which was leaking intravenous fluid. He had a very large abdominal pannus (apron of adipose tissue), multiple scars on both arms and…

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11 July, 2015 Posted by | medical school | Leave a comment

Suicide

I have wanted to push this post out for many months. This is very difficult to write about because I am still so close to the raw emotions and feelings. I want my readers to understand how much many of us who take on the task of teaching others medicine care about our teaching and our students/trainees. This was very close to me and stays with me because the young person that I write about left behind two young sons and a young spouse who is somewhat adrift even today when I spoke with them.

I met this young resident physician when they entered the program where I teach. That first day when everyone met and introduced themselves as we all sat around a large oval table. The PGY-1s and the faculty members who would get to teach them and get to know them. The resident was full of hope and anticipation being so happy and grateful for a match into our program. Everyone was so hopeful even knowing that residency pushes one to limits physically and intellectually in the case of surgery. Many believe that the major test of medical school is the measure of a physician but residency is where practice begins and starts the foundation of what will be a life of practice and learning. While medical schools gets one ready for residency, the experience of managing patients and performing surgical cases first as surgeon junior and then as resident is the making of a surgeon.

This resident started out on a ward-intensive rotation under a chief resident who was a patient teacher and generally supportive of the junior residents and medical students who were on the service. All reports were good and the resident was progressing well-not superior but more than adequate. All PGY-1 residents need to sleep more, read more and get out of the hospital as much as they can. The faculty in our program work with the chiefs to make sure that the workload is challenging but not oppressive. I love to do patient care along with my residents because I love taking care of patients. On many weekend mornings, I round, write my own notes and inform the chief of what I have been doing so that the junior residents and medical students are not so burdened.

By the end of the first half of the first year, all of the new interns (PGY-1 residents) seemed to be getting into a groove. The major services: general surgery, colo-rectal surgery, minimally invasive surgery and surgical oncology, were humming along well. The specials: vascular, pediatric, thoracic, critical care, cardiac and plastics were well-covered with interesting cases and patients. It seemed like the year was going to roll along in that predictable manner so that we could all gather at the end and make fun of ourselves while sending the graduating chiefs off in appropriate fashion.  Mid-way through this year, one of the new interns started to unravel a bit. I was asked to do a bit of counseling and unloading. I am happy to play this part for the program.

It is a general fact that most interns will not ask for help when they are getting overwhelmed, especially in a surgical program. There is the code of the surgeon being tough and resilient, thriving under pressure and invincible. Some of my fellow attending physicians still subscribe to this code of conduct but I am having little of this. I love showing my vulnerable side, and often do,  because it enables me to show my strong side at the same time. Yes, I am a human being that is the same as my patients and those I train. I learned from a very wise surgeon colleague that I have to allow those who encounter tragedy and stress to decompress immediately and to keep decompressing. As a leader, I owe this to those who work with me in this profession.

The intern seemed to have a difficult time dealing with the night float where one has to shift rapidly to cover the incoming patients. On my call nights with this intern, I would generally cap their load so that some rest and learning could take place. I calculated the average for the past week and capped when that number was met. Anything over the cap, I admitted, worked up and handled with the chief resident. This generally didn’t amount to many patients but it created a sense of teamwork and accountability for all of us. I loved presenting new patients in morning rounds and having the chief question me (same as the interns) about management. This is a great experience for all of us and continues today.

Along with difficulties on the night float service, personal problems at home began to creep into the picture. The spouse was having an affair and the children were feeling the effects of the strained marriage. Being single, I am surely not equipped to counsel anyone on marital stresses but I did strongly encourage this resident to seek some outside counseling. I assured this young physician that I would be as supportive as possible in making sure that my colleagues understood the grave nature of the home front problems without betraying any confidences. I know of great love and feeling for another person and the loss of that person can be raw. I also know that every person deals with loss in different ways and that with the stresses of a surgical residency, seeking some marital counseling is probably a sound idea.

Three week later, this intern was still trying to balance work and family struggles. Things were unraveling and I suggested taking a leave of absence for the remainder of the year. When things can’t be worked out and work can’t be done, a leave of absence is often the best solution. This was arranged by the program director with an offer for this resident to attend teaching conferences and educational classes as much as possible. We offered a research position that had been left by another candidate so that this resident could have some income. We all offered support and fellowship but substance abuse came into the picture.

I don’t know how substance use began but I noticed the smell of alcohol during one of our educational conferences. I immediately asked the resident to leave because the smell of alcohol can’t be on any physician who is in a clinical area without exception. I was deeply disappointed but asked to chat the next day when possible. The resident never contacted me. Later an admission for overdose of opioids (deemed accidental) along with alcohol. I rushed to the emergency department to find the resident semiconscious and unable to communicate. Clearly, as I spoke with them later, I emphasized the need to spend some extended time in counseling but I could sense a drift away. The shame of losing a training license and a residency position was more stress and deeper into a despair that I was not equipped to handle. I begged this fellow human being to reach out for the sake of the family and children.

Medicine and medical school into residency and practice attracts a person who becomes comfortable with work toward long-term goals. One has to have a high degree of comfort with the long term process because the journey is long. Along the journey goes the family and friends but the resident is the common factor. I know that my colleagues who have families are happiest when they spend as much time as possible with those families. One of my colleagues always says that he can’t understand where my recharging takes place (my spirituality, my adventures and my sheer wonder of all things as I go through this life). This experience rattled my entire experience with medicine and still does.

When this resident committed suicide, I plunged into a depression that only my faith could keep me going. I prayed myself to put one foot in front of the other one so that I could get out of the door of my house in the morning.  I know intellectually that I couldn’t force another adult human being into making better choices but I still can’t fathom leaving behind precious children. It is my firm belief that children can weather the disintegration of a marriage if the spouses involved are dedicated to raising them. I also believe that children only want your time and unconditional love (my experience with my nephews). In honor to this resident who felt so much pain and was unable to get the help needed, I listen intently to my trainees. In honor of this resident, I search intently for any shred of hopelessness in my colleagues, residents and students. In honor of this resident who was kind to their patients and to others, I strive to be kind to others. In honor of this resident, I try to learn the lessons of life and to be thankful for life.

30 June, 2015 Posted by | general surgery residency, intern, residency | , | 17 Comments

The Gift of Study

Introduction

Many who read this blog will begin their studies of medicine in a few short weeks while others will move into new roles perhaps with more responsibility and duties. I wanted to take a few lines to write about moving into your new roles be they medical student, intern (PGY-1), resident or attending physician.

Preparation

A mentor from my first days of medical school, actually during orientation, said in his soft southern accent, “Now go out and grab a copy of The New England Journal of Medicine and read it from cover to cover.” “You won’t understand it at first but keep reading it and studying the words of medicine.” Little did he know that he had just added more fodder to my constant journal reading and now had stoked a fire so huge that I could have been consumed in the flames, so to speak. As I look back now, years from those words and others that have shaped my current practice. Listen to those little bits and pieces of wisdom from people who will enter your medical education early on.

For those of you who will begin the study of medicine, your preparation is to open your mind, your ears and to consider the privilege of what you are to undertake. Yes, you will be “sipping from that fire hose of facts and materials” to be mastered but you have been given the gift of being able to study those facts and materials. You may want to allow yourself from time to time to marvel in what you will learn from the application of science to the practice of medicine. In short, take a moment to breath and enjoy the process.

For those who move “up in rank”, take a moment to look back on the things that you have studied. Every time one encounters a familiar concept, there will be new insight. For example, my intern year was spent learning the craft of patient care preoperative, intraoperatively and postoperative. As the weeks went by, I became expert, perhaps efficient in being able handling patient admissions to the hospital post-surgery, from the emergency department or from the clinic. Additionally, I learned to anticipate and manage the needs of those inpatients from their first moments under my care to their discharge from my care. My insight at this point was how my studies of symptoms and signs coupled with science now allowed me to care for my patients and see how amazing the human body and human spirit can be.

On my first rotation, as my learning curve was steepest, I felt as overwhelmed as I felt in my first week of medical school when biochemistry, anatomy and microbiology came flooding at me in torrents. At this point, it seemed that the work of history and physical exam with admission orders, checking tests/studies, checking wounds and discharge summaries would consume me but one week in, I was thriving and looking for every chance to get into the operating room in addition to my ward duties. I could take that moment to appreciate interaction with patients, nursing staff and get to scrub surgical cases. I was “basking in the glow of bright lights while playing with cold steel, “as one of my professors would say.

When I look back, one of my gifts on those first rotations was being assigned as the intern to the chief resident that everyone had whispered being the most difficult in our ranks. I came to appreciate my chief, the only person that I know who is as compulsive and anal as myself when it comes to the practice of surgery, is that I actually found that I could “get down there and nail things” faster than he could after three weeks. He made me stronger, faster, more efficient and more comprehensive. This allowed more time for me to obtain operating time which is why I became a surgeon in the first place. What other surgery interns avoided, I happily sought out. I was also the recipient of more valuable study advice from my chief, “Force yourself to read at least 30 minutes every day, more if you can, and at least 2 hours on the weekends.” There again is that gift of study. I stuffed my pockets with articles, pages from my textbooks and the surgical atlas. Even if I was exhausted, I had something to read or study in the back pocket of my scrub pants.

Performance

Back to my professor of surgical critical care: “Surgeons are not made, they are forged” was one of his favorite quotes to me. I thrived in the forge of residency because I didn’t look at study and learning while performing medical/surgical care as being in some sort of purgatory or prison. I was getting the opportunity to build a solid foundation of knowledge and skill that I would use for the rest of my life. I learned through being forged that I could solve problems and touch a multitude of fellow human beings in ways that others would never appreciate.

My professor would later say at my graduation that I never complained or said that I was tired when he knew that I was the oldest resident in the ranks. (I had attended medical school after graduate school). He said that he found that somewhat remarkable because as he had aged, he felt entitled to complain more and accept less mediocrity. He said that I was a person who accepted everyone as I found them without agenda. (Still one of the most interesting comments that I have heard about myself).

Under the scrutiny of my mentor in residency who like my first chief, was known for having a very challenging personality, read malignant here, I learned the clarity and performance of surgical skill. My mentor (faculty adviser), taught me to waste no movement in honing surgical skills. He loved that I studied as I learned and assimilated what I was taught in craft and theory. Again, back to those study skills.

Little did he know, I cut the spines from my surgical texts, punched holes in the pages so the they would fit in a ring and were more portable than the entire text (Sabiston’s Textbook of Surgery). My best memories of my faculty adviser are of him folded in a lounge chair in the surgical lounge with his Danskos next to his feet grilling me on how to handle this complication and what would happen next as this was more valuable than gold for me.

Even today, the residents, medical students and physician assistant students appreciate my high expectations of them in terms of work and study. I do not subscribe to the practice of berating as a means of teaching but go back to my very tough first chief resident and my faculty mentor in residency who generously gave of themselves to guide me towards performance at the highest level. I don’t have the difficult personality traits that were characteristic of many of my fellow surgeons but I have high expectations of those who have been assigned to me for instruction.

Practice

The gift of the study, and later practice, of medicine (if you are fortunate) is still one of the most divinely mystical and satisfying acts of a lifetime. Even if you are beginning your studies and are not enjoying much patient interaction, try to cultivate a love and appreciation for the gift of study. Those studies will allow mental efficiency which can lead to some of the most intimate and spiritual gifts from one human to another. Appreciate those gifts without complaint because many others will never have the privilege of enjoying them as you have them now.

26 June, 2015 Posted by | academics, medicine, practice of medicine | | 4 Comments

For Father’s Day

I want to share this post by a gifted physician, husband and father who writes about his father. This post which can be found here: A Father’s Story is an honor to a father from a son who is a father. For me, this wonderful post reminded me of my father who was a physician and my first and best mentor. Please enjoy this post and honor your father on this upcoming Father’s Day.

19 June, 2015 Posted by | practice of medicine | | 2 Comments

And there she sits…

I was called for consult on a patient in the “memory care” section of the long-term care facility affiliated with our health system. My partners hate to consult on patients in this facility and tend to “leave” these consults for me to work up because they just don’t care to do them, read, they say that I work with them best. For me, leaving the “mother ship” is a welcome time at the beginning of my day to drive over and see the patient in their surroundings as the first part of my work-up. You might ask why the patient isn’t transported to my clinic to save time for me but if the problem isn’t particularly emergent, I go to visit the patient and I am happy to do so.

 
She sat there in a wheelchair in the dayroom surrounded by other residents who were in various stages of behavior from a chair-bound woman who had removed most of her clothing while shouting to anyone who walked near her to a gentleman who sat in a chair by the window looking out at the bright sunshine reflected off the rich green leaves of the plants outside. I would have loved 5 minutes in that window for my sanity. She was surrounded by about 25 people some ambulatory and some sitting to watch the large television in the corner. As I called her by name, she looked first at my bright red suit and then at my small white chihuahua that I often take with me to this facility. This little white fluffy dog with alert tan ears and a bright red collar often provides comfort and serenity to patients while I perform an exam.

 
She sat there looking at my little dog who climbed into her lap and began the obligatory dog greeting. “Do I see a smile?” I said in a cheery voice. “I came to see you because you might need to have minor surgery on your arm”. “I thought we might get to know each other here rather than you coming to my minor surgery clinic with all of the hustle and bustle”, I said. She looked at my dog who by now had curled up in her lap. She didn’t say a word but didn’t appear to be frightened or even nervous by the dog.

 
The nursing assistant came over to let me know that my patient doesn’t talk and that she doesn’t understand what I am saying to her. “You should talk to her son and the nurse if you want to know anything” she said. “I said that I am doing fine and that I will speak with everyone but thanked her for letting me know. My patient sat looking at my red skirt as I sat in a chair across from her; still holding the chihuahua. (Being little and cute has some advantages that I will never know). “I just want to meet you and speak with you because I try to get to know my patients before surgery, if that is OK”.

 
My patient moved her hand to stroke the dog who was now dozing with her chin on my patient’s other forearm (the area that had the lesion). I looked at the arm that she kept so still as not to disturb the sleeping dog. She gently stroked the dog with her other arm as I examined the area of concern quietly leaning in as close as possible. She reached out to touch the material of my bright red suit and my arm. Still, she looked at the dog and not at me but put her finger to her lips in a manner to tell me to be quiet because the dog was sleeping.
“Now, I lay me down to sleep, I pray to the Lord, my soul to keep”, she said in a very soft voice. “I repeated softly with her. “If I should die before I wake, I pray to the Lord, my soul to take”. She still stroked the sleeping dog and a tear ran down her cheek. I completed my exam and moved my chair next to her as we both stroked the chihuahua. I can slow down my day, enjoy the bright sunshine and green leaves while my patient enjoys the company of a small dog.

 
I sat there for about 20 minutes thinking of who this very quiet but very kind woman might be and how best to treat her and keep the stress of the potential procedure to a minimum. When I see patients in the office/clinic who have come for workup for minor surgery, I generally complete the exam and information setting in 20 minutes but when I do a house call in the long term care facility, I like to take as much time as I need to get as much information about my patient as I feel is necessary. If this one patient takes my full morning, then that’s how much time she and I need.
My practice partners prefer to have a root canal done rather than visit the long term care facility. One of them remarked that if he slowed down for these type of patients, he would probably stop practicing. Another said that visiting the nursing home was just uncomfortable for him and that he didn’t want to be reminded of getting old as if entering this type of facility would speed up his aging process. Another partner said that he didn’t want to think about losing his mind and that these types of patients do this to him. “You are a woman and you do better with that stuff”, he said as I picked up the consult package on my desk.

 
I find their reactions interesting and somewhat distressing at the same time. Yes, they are admitting that they have a bias for treating older patients and I applaud them for recognizing that they are biased. Recognition of bias is a great way to overcome a bias if that is your goal. I am distressed because they attribute my being female to my having some extra ability to see the dignity and spirit in all of my patients (No, I am not a saint, I just feel privileged to be able to do surgery and see the wonder in all humans). Things like vomit and eye surgery are problematic for me but not my patients regardless of age, location or ability to communicate with me.

 
When I went back for follow-up post-surgery, I took my flute and played one of my favorite Bach Inventions (I seem to be able to remember those). My patient gravitates toward my dog, my music, my prayers and my brightly colored dresses that I often wear (when I can get out of green scrubs and a white coat, I do so). She longs for colors, sounds and the touch and interaction with others. As her wound heals, she has said few words but radiates the spirit and dignity of being a human being.

 
My partners may be right in that I am better at that “stuff” because that “stuff” is the “stuff” of my humanness. I have to bring that humanness to my practice even though a majority of my practice is procedures and acute. For me, being able to slow down and take the time to interact with patients who have lost some of their ability to communicate in a conventional manner is something that I enjoy and treasure. This is a gift from medicine to me and I treasure it.

17 June, 2015 Posted by | practice of medicine, surgery | | 3 Comments

The most valuable skill to develop and hone

Introduction

As medical offices, clinics and hospitals move to electronic/digital medical records, skilled use of these devices is critical to modern medical practice. While nursing and other ancillary staff can get away with asking questions (usually from a form) and typing answers as a patient answers those questions, a physician can’t afford to perform in that manner. This means that there are some vital skills that must be mastered as quickly as possible.

Clerical skills

Yes, information is generally entered into digital record systems via keyboarding. As a physician, one needs to be skilled at keyboarding to become efficient in completing medical records as quickly as possible. If you did not have a mother who insisted that I “learn to type” so that I could make some college cash typing papers for my classmates, then you will need to learn to type accurately and efficiently. There are many convenient typing instruction programs on the market. Choose one (or borrow one) and learn to type. This skill takes practice, well, learning to obtain a medical history took practice too, and takes constant work in terms of learning the proper finger positions for the keys so that one can type without staring at the keyboard.

Communication skills

Almost daily, I hear from my patients that the medical student, physician assistant student or resident is “so busy staring at the computer that they don’t look me in the eye”. This practice is interpreted by the patient as non-communication. “He was so busy tying to fill out the form that he didn’t are about me”. When patients are making these types of observations, this generally means that the visit is not going to yield the best information for getting the best outcome for the patient. Patients expect their physicians to communicate verbally and non-verbally with them. If one is busy “staring at the computer” one has cut off one of the most valuable means of non-verbal communication which is eye-contact. While you may be very adept at typing and listening (I was a master of this in medical school), your patient starts to feel neglected because they feel that they don’t have your total attention. In short, eye-contact is a valuable means of communication for both you and the patient.

The patient history

The patient history is perhaps the most important aspect of the physician-patient encounter because generally if one is listening very carefully, one can get an idea of why the patient sought your care very quickly. Obtaining a good medical history does not mean that one simply fills out those check boxes on a form in the medical records system but does mean that one obtains the key information that will help identify the problem that brought the patient to your care during the history. This is why one has to become adept in allowing the patient to tell their story (in their own words) and why one has to be constantly listening and processing the information, not attempting to fill in check spaces.

One has to constantly review and upgrade their history-taking skills as long as they are in patient care. Find a good history taking flow and stick with it long enough to make sure that you are efficient. Once you become efficient with the flow of the history, fine-tune that flow so that you can add or subtract items as the patient care situation directs. As you learned from your physical diagnosis course in medical school, the patient directs the history which directs the physical exam which directs the assessment which directs the plan. If you neglect any aspects of obtaining the most accurate and complete patient history, it will follow that your examination, assessment and plan will be neglected too.

When a patient enters my care, especially for the first time, I ask them to spell their name (sometimes those sheets are wrong) and I ask them for their date of birth (you don’t want to end up with notes on the wrong patient). After that, I put my pen, notebook, computer or tablet down and sit across from the patient and listen. I have my check list (form) in my mind so I don’t have to keep referring to a form or computer. This skill during initial history-taking, frees me to concentrate on communicating with the patient fully. I learned to keep the initial patient history in my memory long enough to either dictate it into my medical record or enter it after the patient has left my care.

I also learned to perform a review of systems while I am examining the patient. As I examine the patient’s head, I ask questions about any symptoms related to the head and move to the eyes, ears and so forth. If my exam is to be focused, then I just go through the systems are are related to the initial chief complaint and make sure that I ask about things that are move peripheral towards the end of the encounter. Again, I made sure that I became adept at either dictation or writing in performing these tasks so that my patient feels that they have my complete and undivided attention.

The patient

Novice physicians always feel that they are going to miss asking about some important fact which will result in a poor outcome for the patient. If one sits and thinks about good communication skills and obtaining the most relevant information, then one is less likely to miss something important. Another way to think of this is to think of yourself as a news media reporter who is on a city hall beat. When you first begin on your beat, you don’t know all the players well but you start to make observations and note what and who is key to your getting the best information. This same skill applies to getting the best information from your patients. You have such a short window of time in which to gather information thus you must use the best observations and make mental notes of what is most important. The more one practices this skill, the more one becomes accustomed to their “beat” so to speak, and the better the information obtained.

If your patient feels as if you are so rushed or that you are not interested in working with them i.e., you are more focused on getting your note in the computer, they they have a propensity to stop trying to communicate well with you. In short, if you have a patient who feels more uncomfortable with you in addition to the discomfort that brought them into your care in the first place, you have a situation that can’t turn out well for either you are the patient. In these days of patient satisfaction surveys, one cannot afford to concede even the smallest item because of trying to keep up with a medical records system.

The medical records system

While these digital masterpieces are wonderful for making sure that everyone involved with a patient has up to date information and billing, they vary in ease of use and interface. The data obtained from these records is only as good as the data that is entered into these records. When one enters a health care system, becoming fully familiar with the electronic data system is a significant part of one’s orientation to the place. Most large health care systems will use one system which was chosen by a few of their members but every employee has to work with and in that system. It is vitally important that you as the trainee or new employee receive a solid orientation on the system that you use so that your patient’s records remain secure and accurate.

If you are or become the person who is in charge of selecting a new electronic medical records system, you need to be fully familiar with the system that you are evaluating, the ease of entering information and making sure that everyone who uses the system is able to navigate the interfaces that apply to their specific jobs. Don’t rely completely on the sales person for a particular electronic medical records system because that person’s loyalty is with their company first (they want you to buy their product) and any potential commission that they might make in selling their product to you. This means that if you are in the position to evaluate potential digital software and hardware, make sure that you obtain solid advice and consultation with your company’s technical staff and that you know something about information systems yourself. In short, in today’s world of medicine, physicians have to make both clinical and administrative choices that can profoundly affect patient care. You need to make those choices from a position of having the best information possible not just being pushed by price (most expensive or cheapest systems may not be any better or worse).

Patient perception or put yourself in the patient’s place

As the physician that directly interacts with the patient, one has to make sure that every interaction is the best possible. If you want to get an idea of how you communicate with your patients, sit in front of a mirror, in your white coat and practice a patient encounter. Look at how you make eye-contact, how you hold your sitting position (one should never tower over a patient and ideally be on the same level as the patient). Make sure to time yourself and see what happens when you speed up or slow down your speech. Tape a mock patient encounter and critique yourself. You can do this with a digital camera and a colleague but look at whether or not your are actually communicating with your patients. In your practice encounter look at how your communication style changes when you are typing on a computer/tablet, writing or just looking at the patient and listening.

Read those patient surveys on a regular basis to see if you are developing any habits that may be detrimental to making your patients feel happy that they are in your care. I promise you, as a specialist, that my time is short on a regular basis but none of my patients would ever know that fact. This means that I do the following:

  • I never type while speaking with the patient
  • I never allow my cell phone or pager to be on anything except vibration/silence when I am with a patient
  • I do not allow my staff to interrupt me when I am with a patient unless there is a life or death emergency in the next room

Finally, I have learned to keep patient historical information in my head until I can get that information into my record system. As a surgeon, because I have to produce operative and procedure dictations, I am more adept at dictating than writing out procedures but I learn to produce both digital and written records efficiently. I generally do not take work home from the office because I always worry about patient information security as my home. I also make sure that the people that I am training learn to impart compassion, empathy and interest to their patients and not impart that they are more interested in entering information into a computer.

14 May, 2015 Posted by | computers | , , | 2 Comments

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