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.
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).
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.
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.
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.
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 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.
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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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.
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.
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).
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.
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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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.
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.
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.
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.
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.
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.