I’m back!

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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. 

Star with MDCalc

For those of us who work clinically in an Emergency Department, Intensive Care Unit, prehospital, or other acute care setting, we know that our resources are limited and finite. Most of all, our time is limited. In our line of work, our demand is skyrocketing while we are expected to do a lot more with a lot less. This is where technology can be a tremendous help.

Over my 18 months in residency training so far, I have had the chance to try out many different tools and technologies to increase my productivity and aid in me in delivering quality, timely care. With the dramatic increase in volume of technology tools over the past years, it is hard to sort out what resources are valuable and which ones are white noise.

With the astronomical quantities of important data out there, it’s a huge challenge we face when we work clinically to not only remember which tools we need to use, but then the specifics – when the tools apply, what the evidence behind them are, what the caveats and quirks may be, and why they were devised and researched to begin with.


Enter MDCalc.

 

This site is a one-stop shop for all kinds of calculators and mathematical tools that are useful if not essential to my daily work. They are a physician founded and operated company with a simple mission – equip medical professionals of all types in all settings with the tools they need to deliver quality, evidence based despite the chaotic environments we work in today. All you need to use their services is an internet connection, and their application and website are 100% free. You can read more about their story here. Trust me, it is always great to see a company made for medical professionals that is extremely successful but remains humble and true to their mission.

There are a lot of great features packed into the MDCalc website and Apple Store application, which are both easily accessed once you set up a free account. Creating an account allows you to “favorite” any calculators or tools you use frequently or want to follow up on at a later time so they are quickly within reach. I have used the application and the website in the department and either way the website has a simple, user friendly interface which makes it easy to find what you are looking for and get to the point.

MDCalc has always been an integral tool since I discovered it in 2015, but recently, the makers released an updated product. The most significant update they’ve made is a new, improved, and patent pending search feature which actually allows you to search for calculators and tools based on a clinical scenario, chief complaint, and a variety of other qualifiers. The first of its kind, it enables you to combine elements to discover new tools. For example, if you are working a patient up for pulmonary embolism, you could combine “pulmonary embolism” and “diagnosis.” Later, if you are trying to understand how to counsel the patient and their family, you could combine “pulmonary embolism” and “prognosis.”

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This is a gamechanger in the area of free open access medical education and medical calculators. With this new feature, it is extremely easy to simply put in a clinical scenario or chief complaint, and the site will show you any of the tools in its database which may apply. Before, you had to know generally which tool you were looking for in order to make the best use of MDCalc. However, now the makers have allowed users to not only find tools they already know about and need a refresher on, but also find new and unused tools!

This is definitely a huge tool for me. It is so difficult to find time to study and learn about the latest and greatest in research and evidence based medicine. Though this does not replace reading the primary literature and other forms of continuing education, it is a really pragmatic way for us all, regardless of our field or practice setting, to quickly look up accurate evidenced based information to help deliver the best care possible.

Outside of this bombshell of a feature, the MDCalc product also has a wide range of attributes which I love:

  • Information about the researchers and creators who designed each tool in the first place, so you can read about the background of their work and get insight into their thought process and credentials
  • Tools organized in multiple ways, including by specialty and by system, making it super easy and convenient to find exactly what you’re looking for or discover something new
  • A continuously updated database of tools and calculators which ensures you are finding out about the newest and greatest, along with the tried and true, in terms of risk stratification tools and medical calculators

I attached screenshots of the beautiful mobile application showing how the calculators are listed, and using an example, we’re looking at the Modified Geneva Score for pulmonary embolism. As you can see, all tools are organized in the same consistent fashion, making it easy to learn and know where to look for information. You will see information about how the tool can be used, what the specific parts are, a calculator which interprets your score for you and then shows you the next steps, and background information on the minds behind the tool and references for further reading.

A Match Made in…

Looking at the calendar it hit me that around this time in 2015 I had completed my final residency interviews. Like all of the current fourth year medical students, I’d spent a lot of time, money, and energy traveling around from place to place, eagerly and anxiously trying to guess if and where I would end up for residency. Medical training is a strange experience. You’d think that a field that is based on the scientific process and data driven in many ways would equip students with the tools they’d need to not only choose the right specialties but also the right residency programs for them.

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Well, you’d think wrong.

Finding a residency program that suits you is like ordering a full wardrobe for 3-7 years based on online pictures, reviews, and referrals from others, but the catch? You can’t experience the clothes – you can’t try them on. You are expected to synthesize a bunch of circumstantial information mixed with some objective data such as salary, estimated cost of living, etc, and make a calculated, prioritized list of programs – the holy grail of lists – your rank list.

To that effect, as I’m sure many fourth years are currently pulling their hair out, finishing their fine whiskies and liquors, and ranking and re-ranking their programs over and over from now until the certification deadline, I want to share 5 pieces of advice I wish someone had shared with me when I was a big eyed MS4.

Disclaimer: There’s a LOT that goes into these decisions. I offer my humble thoughts here because I hope it will help at least one person out there struggling to make some hard choices right now. Obviously there may be some controversial suggestions below, but it’s meant to foster discussion and thought. I welcome your feedback too! Let me know if my thinking is flawed!

They’re in reverse order, because I’m weird that way.

5. Be a 5 year old again and use your imagination!

Seriously, one of the things I wish I’d done better in 2015 is spent time visualizing and picturing what my life would be like at my various potential programs. What would working in the ED feel like? What would the relationship I had with the nurses, technicians, administrative staff, respiratory therapists, consultants, etc, be like? Where would I live, if I moved there? What would I do if I had a family emergency? The more detailed your vision of the future, the more you will understand how your life might look like if you ended up at a particular program. This is a crucial exercise to perform with the top programs you are hoping to end up at. You may know they are going to prepare you in your chosen field well, but what will living through residency be like? The problems I have faced over the past 18 months have less to do with my residency program’s curriculum, and more to do with my finances, lifestyle, hobbies and how I am or am not able to keep up with them, what I can do with my wife when I have free time, etc.

4. When you talk to current residents,  pay attention to their walk, less so their talk.

Surprisingly, it’s easy for someone to look you in the eyes and lie. They may not even do it intentionally. After all, if you’re already at a particular residency program and stuck there for a while, you will find ways to acclimate and you may not want to badmouth your program. However, it is hard to fake satisfaction and contentment. A truly happy resident, a fulfilled resident, who feels supported and able to focus on learning and excel in their work, is a rare commodity in medical training. Looking back, there were some outstanding programs where I could literally feel the synergy between the residency program leadership and the residents themselves. When you are thinking of your rank list, don’t make light of your observations of how residents behave. It’s easy to say you’re happy but harder to show it. Lastly, if you found it easy to get to know residents, or if you were able to spend time with them outside of the interview dinner, lunch, and interviews, that’s a huge sign of a healthy residency program.

3. Run your rank list by your best friend, mentor, significant other…whoever knows you best.

You may have been told that you know yourself best, and you have worked hard to get to where you are today. Why should you share your thought process with others? Why should you let your significant other or parents or best friend mess with your rank list? The concept is simple here, really. We all have blind spots. All of us. And if you think you will figure out your rank list all by yourself, without discussing it with ANYONE else, you’re making a huge mistake. We are not perfect. We do not think of all scenarios. This is why you should discuss your reasoning and thought process with other people. The caveat? They have to be people you trust with your life. They have to be the kind of people you could call at 1 AM in the morning, and say, “I need you here, right now!” and they would buy a plane ticket and fly across the country or continent to be with you. If you discuss your reasoning with people like them, they will definitely pick up on things you may have missed. They will SAVE you from misery. Trust in them, and their judgment. Personally, I made my rank list, and discussed it with my wife a great deal. Ultimately, she helped me see that the rank list I generated was based on my comfort zone and what I assumed she’d want for us moving forward. By talking with her about the list, she helped me see that I actually needed to change my rank list to challenge myself, ensure I ended up at the best possible program where I knew I would be offered a chance to really grow and except, but also, to end up in a city that was a better fit for my wife and I to live and grow ourselves.

2. For programs you’re considering highly, go back for a second look.

The wisest mentors I had made sure to suggest this to me. It is quite doable for a residency program, the residency leadership, and residents to put on a show for you when you come into town for your interview. It’s also easy for you to play the interview game and ask the right questions and show the right amount of interest, etc. However, when it all comes down to it and the chips are on the table, the best thing you can do for yourself, whenever possible, is try to arrange a second look. First, whether or not you are even able to set one up is an indicator of the situation. If the program doesn’t have time for you, turn around and run…fast! If it’s relatively easy to set up, and if you ask to stay with or meet with current residents and this is also easy to do, those are all good things. When you have your second look, your goals are twofold. One, you need to spend time with residents outside of the hospital and away from the residency leadership, and try to get as candid an experience with them as possible. This can be a treasure trove of information for you. Second, you should try to shadow or spend some time in whatever unit you will be in primarily as a resident. This time, though it may be brief, will give you better insight into what actual work as a resident might be like, and can give you information to help you with your ultimate rank list.

1. Residency is less about the program, and all about YOU. Who are YOU really? The better you know YOU, the more likely you are to be satisfied with your decisions.

You have to really figure out yourself. This is the hardest part about this entire process. It is true that any residency will prepare you for a fruitful career doing whatever specialty you pursued. However, the time you will spend in residency is a life experience. Where you live, what you do with your free time, what support structure you will have…all of that will make a huge difference. But, unless you spend time really thinking about the things that are really important to you, it’s not really possible to make a good decision as far as your rank list. My dad always says, it’s hard to achieve a goal if you haven’t figured out what your goal is first. So I challenge you, work hard the next few weeks to figure out what you value. Write, talk to your loved ones, think…think a lot. You will need this soul searching to really make good choices so that when you look back on residency, as I am starting to do, you can feel good about your decisions and your experiences.

I wish you all a lot of luck, and want you to know that medical training is challenging, but you made it this far because you have something of value to contribute to this entire industry. Without you, and what makes you unique, we all become cogs in a machine. Let’s ensure we deliver the best care to our patients by first making sure we make the best decisions for our training.

Find me on twitter at @S_P_MD with questions, comments, or feedback!

Doing what we do

Diabetogenic

This morning, I sat in a restaurant in New Orleans with three of my favourite people and diabetes advocates. If anyone could bottle the tenacity, passion, determination, guts and cheekiness of these three women, they would make a fortune and be able to solve all the problems of the world.

I listened to Anna, Christel and Melissa – who I am lucky enough to call friends – talk about their work and we discussed the US health system which made me shake my head in disbelief and confusion. I don’t understand this it; I doubt I ever will. But these three not only navigate the system themselves, they are doing it for others as well as they trying to improve things.

All week I have been around people who are involved in important and life-changing work in diabetes care. From those who are developing smarter devices, using data better, improving access and doing reseach…

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Doctor, It’s Okay to Cry, Part 2

She lay there with her blanket pulled up close to her chin, with her arms buried in the three blankets covering her, as if she was in her own bed. My patient was an elderly woman from Bangladesh. Her daughters had brought her from home, where she lived with them, because she had been feeling generally weak and having more trouble moving around. She had fallen a few weeks ago at home and her daughters were worried her health was declining. The elderly woman, who was in her 80’s, appeared frail, but still had a round face. She was slow to speak, did not know English, and was very sweet and kind. The patient’s two daughters spoke with concern and anxiety for their mother’s wellbeing.

I pulled a stool stuck beneath the sink in the room and wheeled it closer to the patient’s stretcher. As her daughter’s translated for me, because the patient did not speak English, I took her history down. She was here because she had simply felt weak. She did not have fevers. She did not have pain. She sometimes felt a little dizzy. Her blood pressures may have been running high; sometimes her systolic blood pressure, which is the top number in the blood pressure reading, would read 160 or 170. The patient had not been vomiting, had no blood in her stool, and had not passed out or hit her head. But she had fallen. They described that her knees simply gave out beneath her and she had slumped down to the ground, unable to get up without assistance. The patient’s daughters were fortunate they were home at the time. They worried a great deal about what would happen to their mother if they were ever unable to be with her frequently, if she were to fall when they were not around. As we talked, my thoughts trailed off.

The patient was the spitting image of my grandmother. They were both roughly the same age. They had the same kind of wrinkles in the same places around their face. They had the same warm eyes, with different colors, but full of a sense of exhaustion at what their life had entailed. They had both raised large families, in countries and societies that did not have many resources or support for mothers, families, or young children. Now they were both in the twilight of their years, clutching onto what little strength they had, trying their best to adapt to the advancing world around them as their own bodies started to crumble from within.

I completed my discussion with the patient and her daughters, performed a physical examination by asking the patient to sit up, which she had difficulty doing. I helped her stand up, though she was quite unsteady on her feet, and begged to get back into bed. She said her dizziness was worse whenever she stood up. Her heart beat was strong and regular. Her pulses were equal in all her extremities. Her cranial nerves, which are important nerves which connect the brain with the rest of the body, were functioning well.

As I thanked the patient and her daughter for their patience with me, as this was only a few months into my intern year, I walked out of the room and fought back the tears welling in my eyes. I had just walked out of a room with a patient who was, essentially, my grandmother. Her daughters, with their concern and anxiety over their mother’s health, were analogous to my own mother and her sister. I began to think about all of the obstacles and difficulties this family faced in getting to the hospital today. They were in an inner city Baltimore hospital. The area around the hospital is known, sadly, for violence and crime. They chose not to call 911, but to bring their mother in by their own private vehicle. I could not help but think about what they would eat, as they are all strict vegetarians, and the time was now 1 AM in the morning. Any family they had in the country lived at least 5 hours away, including the patient’s grandchildren and son in laws. Some of them were actually back home in Bangladesh.

I tried to focus back on the task at hand – to identify what could be ailing my patient, what could be serious enough to place her in immediate danger – emergencies. I quickly listed out a variety of severe diseases and conditions which I needed to check her for, and made up my mind to admit her to the hospital because of her frailty. I was worried she may fall at home. I was worried that she needed physical therapy, and potentially a walker or a cane to get around. We completed her ED workup and admitted her to the hospital for physical therapy and occupational therapy, and to make sure we did not miss anything that could be contributing to her decline.

* * * * *

Five months later, while I was on my Medical Intensive Care Unit rotation, my heart stopped when I saw the patient’s name on my colleague’s admission paperwork. I became distraught and learned what was going on. She was being admitted to the ICU for monitoring because she had an infection, and was found to be very frail. Her vital signs were also concerning. My colleague offhandedly commented that the admission was unwarranted. I built up the courage to walk near the patient’s room, and sure enough, she and her daughters were there. Almost unchanged from when I cared for her in the ED. I could not bring myself to say hello, or visit her. I found a quiet place and let my thoughts race.

Will she be okay? What does it mean for her, to be admitted to the ICU? Based on my experiences here, patients did not frequently leave the ICU without difficult struggles with their health. Sometimes they even became afflicted with conditions as a result of our own efforts to help them – hospital acquired infections, injuries to their blood vessels from our attempts to insert catheters and tubes…I cried. I cried, feeling overwhelmed, feeling the weight of everything I had seen as a trainee, the pain and suffering I had witnessed not just that month in the ICU, but over the past 4 years in medical school, the prior 2 years in EMS, and the 4 years before then when I volunteered in an Emergency Department.

There is perhaps no greater struggle for us as nurses, doctors, and care givers, than to be tasked with caring for those who remind us of our own families and loved ones. But it is my belief that this particular situation – this emotional response and the associated feelings – is a necessary aspect of our work. I had been taught, both directly and indirectly, that these sorts of connections and emotions for my patients and their families, were not just inappropriate, but unsafe and dangerous. I disagree. Having done what I do for just this short a time, I can say that giving myself the freedom to feel the sadness, despair, frustration, and concern my patients feel, to truly empathize with them, is a source of strength. Many argue that it can cloud our judgment and bog us down, but my response is simply that the alternative, a world in which doctors, nurses, and others who care for patients simply ignore, or internalize what they feel, is far more dangerous for the nurses, doctors, and most of all – for their patients.

We must feel. It is our duty to feel. It is that very expression, that bond that develops between a physician, nurse, or health practitioner, and their patient, which allows us to deliver the best care.