Light Among Darkness, Part 1

Photo Credit: Nimit Patel (www.inimitable.io)
There is a culture of machismo still prominent in medicine. Locker rooms, physician lounges, clinics, and hospital hallways are full of doctors of all kinds, both men and women, who place unnecessary and unfair expectations on one another to “suck it up” and “just deal with it” without showing a single sign of emotion. In the absence of formal training on how to manage our emotions and what we feel, doctors historically just did not show emotion. You hear stories from decades ago, of people who never cried and never discussed emotional challenges, and yet they are baffled as to how so many people whose primary goals are to help those dealing with medical illness could help foster a culture of pent up emotion and practice such poor mental health hygiene. It also is no surprise that so many physicians struggle with depression, marital difficulties, substance abuse, and more.

This is, thankfully, changing.

I contributed to this by standing up in front of 60 people and telling them that I had struggled with burnout in residency. It was, though not a big deal, a big deal. I was squeezed between a lecture on the life-saving use of ultrasound in critical care patients and a discussion of the latest and greatest in the management of respiratory distress. It’s still considered “edgy” and maybe even “taboo” in 2017 to teach doctors to discuss their emotional experiences and struggles. It’s still considered unusual for a doctor or nurse to tell their colleagues about their struggles. That culture still exists – but the wall is coming down.

Day by day, one person at a time, one hug at a time, one moment of beautiful vulnerability at a time, we are working to change this. I realized when I was recovering from burnout that we spend much of our time in medicine finding ways to take care of others, but we constantly neglect our own health. Worst of all, the culture of medicine is that this is how it SHOULD be. When I started medical school in 2011, it was obvious the expectation was I would show up, do whatever it takes to get the job done, and simply never discuss what’s hard about the job or what keeps me up at night.

In a typical day at work, I take care of anywhere from 15-20 individuals and help them with a large range of medical problems. Most are minor issues, like an ache or a pain that is not serious. Some are dealing with severe infection, heart attacks, strokes, or other emergencies that will require admission to an ICU or even emergent surgery. If all goes well, I will help most of these people and they will have good outcomes. It often doesn’t go well.

One of the weaknesses in medical training is that I get ample preparation on how to handle good outcomes and facilitate them – but I get no training on how to handle bad outcomes. The patients, and their loved ones, who suffer the poor outcomes, are the ones I feel for the most. But not far behind them, I worry about those that devoted the hours, days, weeks, months, and even years to care for them. Second victim syndrome is real, and I have felt the pain it can cause.

If a physician or medical professional is involved in caring for a patient, and the patient has a poor outcome, it does not matter whether it was simply the course of the disease or illness, or if there was some error or problem with the care delivered. Truthfully, the medical professionals involved always feel some responsibility for what happens. Even when it may not have been their fault. No one wants to have a bad outcome on their watch. No one wants a patient to die. The problem is that they do, and often it has, unfortunately, little to do with the decisions we as medical professionals make. This is hard to understand unless you yourself are a medical professional. It contributes to the emotional and spiritual burden medical professionals carry with them.

You see a doctor intubating a patient to save their life, but I see a physician weighed down by the patients he has witnessed suffering incredible pain and hardship that she could do nothing about.

You see a nurse who is quickly drawing up a medication to help treat a sick patient, but I see a nurse who has seen so much death and hardship he doesn’t even know where to start to process it.

We all carry baggage. Medical professionals carry graveyards.
Stay tuned for part 2.
Advertisements

#WeWrite

Writing is an important way that I communicate with the world. I spent my childhood reading a lot of books, and I developed a desire to put my own thoughts into words and share them at a young age. It started in grade school and junior high with keeping personal journals. Photography was my primary creative outlet in high school and college but as I moved forward with my education, writing became such an integral part of my learning that I turned back to it. Today, as a training physician, writing is a large part of how I take the experiences I have and process them and share them with the world. 

I am starting a new project and I welcome any and all to join me. The rules are simple. 

1. If you’re a human being, you can participate. As a physician myself, much of my writing and inspiration come from my work in the hospital. As such this project may be more appreciated by others in the medical profession such as nurses, techs, prehospital providers, etc. There is no qualification here. We are all together in this. We are all here for each other regardless of title. 

2.  Once a week, each Tuesday morning, I’ll be posting a writing prompt on my site.

3. Participants can take the prompt and write a response however they prefer – their website, email to me at sspatel@em.umaryland.edu to post on my site, a link on Twitter, or even in your own personal journal. I’ll share any submissions that are sent to me with the world, with the permission of the authors.

4. The idea is to communicate through writing & create a community of people who are trying to support each other.   

With that, here is the first #WeWrite prompt:

“When is the last time you were extremely frustrated or overwhelmed at work? What were the circumstances? What would you do differently if you could go back in time? How would you change the situation to improve it?”

What It’s Really Like Being a Doctor

When I told my high school guidance counselor at the age of 14 that I wanted to become a doctor, I had this sense of what that meant. It had a lot to do with my dad, who has been a primary care physician trained in Internal Medicine practicing in NYC for the past 32 years. It also had something to do with my position in a local Emergency Department as a volunteer clerk after school and on weekends. I had witnessed my dad speak to patients and their families, fielding phone calls during family outings and dinners, or while we watched old sitcoms on “Nick at Nite” when I was young. Sometimes I would go to the office and do homework in one of the empty offices while my dad worked. I met his partner and the administrative staff that worked in his busy private practice in the center of Queens. I met some of his patients, too. They loved my dad. They never stopped gushing about how much they loved him. They sent cards thanking my father for his support and help. They sent gift baskets, chocolates, and even alcohol, which my father gave up early in my childhood. So, when I sat down with my guidance counselor and spoke the words for the first time, “I want to be a doctor,” I thought of my dad, and what I had seen until that point. I had no idea what I was actually signing up for. The photo attached to this piece is of my dad and me when I was exactly 374 days old. It was my first time putting on a stethoscope.

*****

I have seen and done some incredible things over the past 12 years. I have grown from a naive, inexperienced and socially awkward young child who suffered from tremendous self-confidence issues into a hard-working and eager young physician. Today, I can walk into a patient room in any of the 12 Emergency Departments I have worked in over the past two years, introduce myself, and get to work helping patients, without even blinking. I can obtain their medical history, figure out what’s ailing them, and come up with a plan to help them – most of the time. When I am not sure, or if I am going down the wrong path, which happens, my attending physicians and supervisors reel me in and get me back on track.

Practicing medicine is not a yes or no question. It is not a multiple choice question where you choose the best answer (like all of my unhelpful board exams to date have been.) Sometimes, the answer is black and white. Sometimes, when doctors are lucky, the issues they face are clear. It is then easy to move forward, and do what is best for your patients. However, I must emphasize that this is not usually the case. There is incredible variation in how doctors manage disease and treat their patients. They have such wide styles in how they communicate – or don’t communicate – with their patients and their families. Physicians of different fields and specialties all have different focuses and strengths, as well as weaknesses. Talk to a generalist like me, and you will likely get answers that address a bunch of information about a variety of organ systems and diseases. Talk to a specialist like one of my social media heroes, Dr. Eric Levi, a seasoned fellowship-trained head, neck, ear, nose, and throat surgeon, and you get a ton of expertise in a more focused area. Most people think that a doctor is a doctor. And that we are all the same. But that’s just plain wrong. Each physician, even within the same field, is a different human being. And every human being sees the world differently, sees disease and its treatment differently, communicates differently, has different values, and thus, will treat a patient differently. If there was one thing I wish I could share with those who are not familiar with a physician’s work, it’s the incredible uncertainty and lack of clear answers for what we do. More often than not, when I take care of you in my Emergency Department, I will rule out life threats and emergencies, and if I think you can survive to live until you can get follow-up with your primary care doctor or a specialist who knows more about your issue, I will discharge you home. But just know that for hours, days, weeks, months, and sometimes, years, I will wonder whether I did the right thing for you, and if you are okay.

*****

I know I do the best I can, but I don’t have all the answers, and any physician who tells you they know everything, or they know better than you and that’s why you should listen to them, you ought to walk the other way and find another one. There is nothing more dangerous than a physician with hubris. Eventually, all physicians are humbled. Sometimes it happens quickly in their career, like with me. Sometimes, they may carry on with their pride and “I am God’s gift to mankind” attitude for a longer period. But one way or another, we are all humbled. The part of medicine that we don’t discuss enough is the art of it. The gray areas. The nooks and crannies. These areas make our work challenging, but not impossible.

If not for these difficult and complex scenarios and situations, being a physician would be, well, boring. Computers and artificial intelligence systems can analyze an incredible amount of data and use protocols and reach decisions which can closely mimic or even surpass those of human beings. But the reason that AI systems or computers can never fully replace or replicate what I do at work is that a tremendous part of my job involves holding a patient’s hand, letting a family member cry on my shoulder when there’s a bad outcome, or getting someone a turkey sandwich and a blanket. There’s a human factor to what I do. The pro is that if I do it right, I can give someone support and guide them through complex situations to the best of my ability, and hopefully guide them toward better health and a better tomorrow. The cons are that I am imperfect and as a result, my decisions, recommendations, and professional work is, sadly, also imperfect.

That being said, physicians and other medical professionals are constantly researching and learning. The world of medicine is ever changing and ever growing. There is much to learn and better understand about what we do. The best physicians, in my humble opinion, are passionate about delivering quality care for their patients, and they understand that in order to do that, they have to be the best students for the rest of their lives. Our learning never ends. Do not be frightened when a physician says they don’t know the answer. Don’t be scared if they say, “I don’t know, but I will look it up, and find out for you.” It means they care to take the time to grow themselves, so they can provide you with the best recommendations, advice, and guidance humanly possible.

*****

Physicians and the medical professionals they work with are part of numerous systems. These systems and the people that work within them are healthcare. There are a tremendous number of moving parts and the entire ordeal is more complex than I can begin to understand. The best I can do at this point is be passionate about the areas I am a part of on a regular basis – namely, the Emergency Departments where I work and the community I live and work in. Often, medical professionals are burdened by the systems they are a part of. Resources are distributed poorly. Laws are passed which are not based on the latest research or knowledge. Politicians play games with people’s lives. Hospital administrators emphasize and prioritize a better bottom line than better patient outcomes. And no, no matter what anyone tells you, a better bottom line and a better patient outcome can never be the same priority. Because better patient outcomes by definition require the worst bottom lines, and administrators, insurance companies, and the big wigs in healthcare will never let that be the case.

Next time you see a doctor who is stressed out, or doesn’t know the exact answer right that second, or seems exhausted or troubled, it’s not because they are incompetent and can’t do their job right. It’s not because they’re inexperienced, “too young,” or a “bad doctor.” It’s because they’re not just thinking about prescribing you antibiotics for that cold you have. It’s because in the room next door, someone is dying of cancer and them and their family need help getting into a hospice program. It’s because before they walked into your room, they just lost a young patient who went into cardiac arrest because they had a genetic abnormality of their heart that was not previously diagnosed and it was too late for them. It’s because yesterday, they sent an elderly patient back to their nursing home, and when they got to their shift today, they got a call from the patient’s mother that she passed away on the floor, in her sleep, of uncertain causes. It’s because the week before, their supervisor called them into their office and told them they weren’t working fast enough and they needed to pick up the pace. It’s because when they decided to go into medicine, they thought it was about saving lives, when in reality, it’s about reading research and textbooks and translating it into terms their patients can understand, and then doing their best to guide them to the choices that are right for them.

Blogging

I’ve been meaning to get back into blogging for quite some time. I hope to share more of my thoughts and experiences here in the coming months and years. I would love if you could follow my journey and share your thoughts, too.

Having been a resident in Emergency Medicine for more than 2 years now, and having completed 4 years of medical school, preceded by 4 years of college, I feel I’ve had a bit of experience within the culture of medicine. I’ve seen it from many perspectives. I was a volunteer in high school and college. I participated in clinical research in college. I became a volunteer EMT and ultimately AEMT-CC in upstate NY in college and rode for my college agency for two years. I was a medical student in Philadelphia as well as the Lehigh Valley in Pennsylvania. For the past two years I’ve been a resident in the Department of Emergency Medicine at the University of Maryland Medical Center.

There are a lot of things I’ve seen and been a part of over the past 12 years that have impacted me, and changed me. I’ve gone through a lot of growth, and been through some challenging times. I do come from a background of privilege, and I am not aware of this. The challenges I have gone through are not the kind you may think of when you think of the word challenges. I have never needed to worry about survival, whether I would have a safe place to live, or food on my table each day. I have also been fortunate to come from a loving and supportive family that has been behind me every step of the way.

I will be discussing more about my experiences as a creative outlet.

I’m back!

Image result for I'm back gif

Many of those who interact with me on social media picked up on my brief hiatus from Twitter. I am now back and thought I would get back into the swing of blogging by discussing what happened and why I decided to take a break.

As a resident, my brain is constantly swimming with details about work, whether it be me wondering how a patient I admitted or discharged is doing today, or a dose of a medication, or whether I will pass my USMLE step 3 exam I’m taking tomorrow, or about my personal life, such as how I will spend time with my wife and pup on my next day off or how I will pay for my medical licenses, required training courses, and DEA number before I graduate residency. In between all of that, I ponder my own mortality and health, and try to maintain relationships with family, friends, and colleagues.

Social media has been a huge source of support for me ever since I started to participate and engage. I have met some truly remarkable people, most virtually and a few in person too, through my activity on Twitter. After the 2016 presidential election, and during it, social media was ablaze with political discourse. Some of it was productive and healthy debate but a lot of it was cruel, intolerant, and upsetting to witness.

I was finding that I was using my Twitter more to vent my anger and frustration at current affairs than for engaging with others to better myself, both from a medical standpoint and as a contributing member of society at large. It all came to a head when I realized that I was posting only political rants and I was not growing from my investment in social media. So, I realized it was time for a break. I shut down my Twitter for a while.

At first, I did feel the urge to check. I had gotten so used to checking my phone in between conversations, activities, and whenever I had some down time. Truthfully I was glued to my phone a little too much, but no one’s perfect, right? Then as I settled in, I found new and different ways to get news and information. I used to rely on the Twitter moments a lot when I was heavily active on Twitter. I started to look up articles on specific news sites. I used other news applications available such as Apple News and others. I discussed articles with my wife. I asked her for recommendations and sent her articles I read myself.

I had hoped to make more profound changes in how I interacted with people digitally and how I sought information and news. I made some changes, for sure. In the end, what I really gained from my break was a chance to reflect on what I wanted to gain from my social media presence. What did I want to say? What did I want to think about and converse about with others? What did I personally gain from my tweeting and blogging?

This and more I pondered for a couple of months, all the while intermittently logging into and deactivating my Twitter to keep it alive in the shadows. I’ll probably delve into all of this more in the coming months and years, as there’s much to share, but it’s good to be back.

Why do you use social media? What are your reasons for blogging, vlogging, tweeting, instagramming, or snapchatting?

We Need More Men Like Dr. Paul Kalinithi

The clouds are fluffy and the purest white. I have a window seat on the left, just a few rows in front of one of the pair of powerful jet engines, propelling us onwards and upwards. Beside me, my wife reads. An eighties hits playlist helps to fill the low drone of the turbines. I have just finished Paul Kalinithi’s When Breath Becomes Air.

As a physician myself, I have never read any one piece of literature that could get to the heart of my very existence better than Dr. Kalinithi’s masterpiece. Since the day I sat and met with my high school guidance counselor for the first time at the age of 14, and declared my decision to become a physician, I have never had this level of clarity. I never met Dr. Kalinithi, but his words echo throughout my soul, and I have internalized them as the wisdom of an older brother.

In the medical field, we joke amongst ourselves that the most important characteristics that go into a great physician cannot be taught – not in grade school, college, medical school, residency, or even fellowships. We must learn the lessons, develop the communication skills, and find the strength and love to provide compassionate medical care on our own, individual journeys. In his memoir, Dr. Kalinithi shares his own journey, from an inquisitive young man who showed the signs of future brilliance, to an exceptional neurosurgeon and neuroscientist, and finally, to a loving, fulfilled, and complete father to his daughter, Cady.

I myself have wondered about my purpose in this world a great deal. I spent many late nights, especially as a troubled teenager, trying to wrap my head around existence, and what it all meant to me. I have studied philosophy, literature, the scriptures, and the sciences in my quest to find meaning. Even as I near the end of my residency training in Emergency Medicine, thankful to have married my high school crush and celebrated our first anniversary this past September, with our future stretched out before us, I had felt this sense that I wasn’t anywhere closer to the understanding of my purpose and place in the world as I was in high school. 

However, in Dr. Kalinithi’s words, and in his and his family’s experiences, I have found that which has eluded me in my almost three decades of life. Never before have I encountered such a complete and honest treatment of what it means to be a physician, a patient, or the relationship between the two. Furthermore, as a young husband myself, I have yet to read words which have touched on the challenges that physicians and their partners face in relation to the training and work that we do. Reading When Breath Becomes Air has felt, in more ways than one, like coming home. 

I will explain it in this way. Last year, I read the wonderful Being Mortal by Dr. Atul Gawande. A gifted surgeon and writer, he addresses end of life care in this work, discussing the story of end of life care as it is, or is not, delivered in America today. He uses the stories of specific individuals, including the challenges his own father faced battling a terminal condition. However, Dr. Kalinithi’s When Breath Becomes Air has that total commitment to the mission that only he could achieve, by nature of his own challenges and how he rose to face them with his family.


The world needs more men like Paul Kalinithi.
The world needs thoughtful, hard working, and loving individuals who care about the people around them and dedicate themselves and their lives to the understanding of the human condition and the pursuit of meaning through meaningful work. Dr. Kalinithi inspires me to plan for the future while living with total attention to the present, to strive toward perfection knowing it may not be attainable, and to forever seek ways to better myself and the people around me.

Healthcare Professionals & Politics

I dedicate this post to all the men, women, and children who showed the world that Donald Trump is a man, and that he does not speak for us all. I dedicate this to all those who participated in the Women’s March, all over the world. I dedicate this to the leaders at FemInEM, PolicyRX, at my own University of Maryland Department of Emergency Medicine, and others, for inspiring me in my own career to engage.

Over the past few years, I’ve had a great experiencing exploring social media as a physician trainee and medical student. Before starting my Twitter, I had sworn off all forms of social media. I mostly wrote and journaled privately. However, using social media as a medical professional has been a vital source of inspiration & collaboration with people all over the world. Twitter as well as other online outlets have become go to places for me to engage in discussion & learn about current events. For those of us who work ridiculous schedules & hours, online communities work well for getting and sharing information. In a very basic sense, having a platform to let the world know how I feel has also been quite cathartic. 

However, in the past year, especially in the current state of affairs in the United States & around the world, I have become much more vocal about my views on politics and healthcare policy. I have been scorned by medical professionals who keep their online social media and other presences apolitical and purely clinical in nature. I don’t dispute that this is a good idea for many. After all, as with anything in life, we all have our reasons. 

What irks me, though, is judgment cast against those of us who DO share our opinions on current events & who DO take stances on various issues. If you don’t agree with me on this, there’s a simple solution – unfollow me, and move on. Don’t judge me though. Don’t think you’re somehow better. And most definitely don’t think you’re right and I’m wrong. 

Being a physician required me to take the Hippocratic Oath. Medical professionals dedicate themselves to caring for their fellow human beings. Yes, the majority of how I help the world occurs during my shifts in an Emergency Department, where I remain 100% apolitical and without judgment. I treat each and every single patient with the same compassion and work ethic as if they were my own family. 

I give medical advice and provide treatment and support to the very best of my ability, regardless of who you are, where you come from, or what your beliefs are. In fact, I have myself been judged by patients and other medical professionals. I have had racial slurs hurled in my direction when I made a clinical decision that patients did not agree with. I’ve been called a “sand nigg**” because I didn’t want to give my intoxicated patient opiates for his muscle ache. It wasn’t medically indicated and I told him so. Despite his slurs toward me, I gave him the benefit of the doubt and had to do breathing exercises the entire 10 minutes he stood by me, with nurses, doctors, staff, and other patients right there, as he insulted me, to remain under control.

I know I have a duty to care for my fellow men and women without casting any judgment on them or their choices. This is NOT the same as keeping your social media presence apolitical or purely clinical. I believe, in my heart, that it is my responsibility to use my education and my passion to create positive change for all, and to that goal, I use my social media presence to advocate on issues I think are important. 
I have posted about:

  1. Donald Trump & his presidential “campaign”
  2. Abortion
  3. Planned Parenthood
  4. The Affordable Care Act
  5. Women’s Equality
  6. Mental Health Issues for healthcare professionals 
  7. Health policy
  8. LGBTQ Rights & Disparities

In many instances I took a stance and tried to articulate my beliefs & reasoning.

What I hope is that we can create discourse and discussion that leads to positive change. You can’t achieve anything unless you’re at the table. And I believe, truly, that most medical professionals are not at the table. 

Many of us are simply too burnt out or exhausted to even participate. People have this notion that a doctor simply exists to try and diagnose conditions and write prescriptions. But that’s not even the half of it. There’s so much more to our work, and this applies to all types of medical professionals – RNs, NPs, PAs, techs, prehospital professionals, all types of therapists, and the list goes on and on. Yes we are expected to deliver clinical care but I didn’t sign up to simply be a cog in the medical industrial machine. 

I signed up to create change. 

Change requires dialogue, and for that to happen, you’ve got to share your voice.

I can’t force you to use your social media presence to engage in political discussion. I can’t force you to tell me what you think about the potential repeal of the Affordable Care Act or why anti-vaccination is dangerous for us all, but I want you to stop judging me and my colleagues who are willing to sit at the table.