Medicine From The Trenches

Experiences from undergradute, graduate school, 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.

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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