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.

Changing the Culture of Mental Health Stigma in Healthcare

From the time undergraduate students start taking their pre-medical courses such as introductory biology, organic chemistry, biochemistry, and others, there is unfortunately a deep sense of competition that can often overpower even the kindest of souls. This is understandable as gaining admission to medical school continues to become more and more competitive. However, even from this stage, an inappropriate, dangerous, and maladaptive sense of machismo is infused in those hopeful to earn an MD or DO down the road. Bear in mind this is just my humble opinion as someone who has gone through the process to apply to and graduate from medical school in the United States. I certainly am not saying that all pre-medical students are the same, but if you were to ask most how they view themselves and their peers, you will hear similar tales and reflections.

Instead of focusing their efforts on mastering the content and collaborating on quality public health initiatives or research projects, many pre-medical students nervously eye one another during their group activities and lab sessions. I did not feel comfortable expressing my true self because there was this illogical fear that if I expressed my emotions, my anxiety about the process, that I was showing weakness. I quickly found that in my case, I could not sustain this inhuman sense of confidence, superiority, or complete lack of self doubt.

When I arrived in medical school I was shocked to find that things were even worse. Every other person around me was exhibiting signs of almost primal like competition. Along with this attitude of needing to prove oneself to be the best, to impress the supervising physicians and researchers who taught our preclinical courses, it become apparent there was a facade of 100% strength and fortitude that the majority of those around me displayed. An unspoken culture of repressing any emotional or spiritual issues we might have regarding what we were learning developed and was perpetuated. It was taboo to discuss our feelings regarding our patients except in the confines of late night conversations with our best friends. Even then, we were all nervous, somehow. Imagine – training to be a physician, tasked with being a healer and guide to others toward better health, yet we ourselves expected to maintain some kind of fortitude few if any could.

Here’s the reality, after 10 months of being a physician.

I do have doubts. I wake up every day wondering whether I have made the right decisions. Often I go to bed wondering whether the choices I have made that day, which today impact my patients and their health, were the right ones. I question my judgment on a minute to minute basis. I seek help when I am not sure of what is best. I have learned that without accepting that I am human, that I am allowed to experience uncertainty, I will not only be unhappy but I will endanger my patients.

I think that it’s important for physicians to break down the culture of stigma around mental health ailments and depression perpetuated across the generations. I have heard time and time again from seasoned physicians of all kinds with gray hairs purporting wisdom that “In my day, you would have been deemed unfit to treat patients!” Scary is an understatement.

You could identify many issues with health care today. Out of the grave financial and ethical burdens we face as a society all the time, quite a bit of the issue lies in the way we train our future physicians. How can we expect a young physician who is expected to never feel emotion, never express emotion, never exhibit signs of depression or even the slightest emotional response, to be emotionally supportive to his or her patients? How can we expect physicians, who are some of the worst at perpetuating stigma about displaying “emotional weakness” or seeking help for mental health, to continue to bear the weight of their calling day in, day out, without breaking?

Recently, a nurse, mother of two boys, and paramedic who I follow on Twitter, Jess Morton, delivered a talk at a Paramedicine conference entitled SPANZ16 on the issue of mental health stigma among care givers. I am eagerly awaiting the video of the talk and will link here when I have access. From what I followed on Twitter, the talk was well received and applauded. It was so wonderful to see an individual with experiences such as Jess deliver a talk on such crucial topics. I hope that as time goes on, we in the medical profession incorporate more and more discussion about mental health wellness and breaking down stigma for those who need and seek help.

We need more doctors, nurses, paramedics, EMTs, nurse practitioners, and physician assistants to speak out and break down stigma around mental health. It’s time that we dropped the facade. It’s time we stopped chastising care givers who themselves need care. We should welcome and celebrate honest and respectful discussion among those who deliver care in our health care system. In fact, it must be a priority to break down stigma surrounding mental health and wellness for everyone, regardless of who they are or what they do.

 

Doctor, It’s Okay to Cry, Part 1

Preface: I am planning on starting a series for young trainees of all kinds, including physicians, nurses, physician assistants, nurse practitioners, Emergency Medical Technicians, patient care technicians, and Paramedics. The purpose of this series is to share what I have learned along my journey so far, and what I continue to learn for the rest of my career in Medicine and Emergency Medicine. Please be patient with me as I work out the formatting, organization, and schedule for these posts. I felt this was an important topic and decided to start with a post addressing mental health among trainees, and those who deliver medical care. This is the start of my blog post contributions to #TipsForNewDocs. I welcome any and all comments, feedback, and hope that you may be inspired to share your experiences and join in allowing the medical community to feel empowered to share and process their experiences and emotions.

Note: Please be aware that the contents of this blog post contain descriptions of patients and their health conditions which may be graphic or upsetting to certain readers. In order to protect patient privacy I have kept things as general as possible, changed some of the situations around to protect those involved, and I hope you all understand the purpose for this post and do not dwell on the specifics. The specific patient situations are simply what I have observed, but all in health care will have their own stories.

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Many of you will recognize the photo above. It went viral last year after it was posted on social media by a friend of the physician posted in the photo, by permission. For those of you who are unfamiliar with the photograph and the story behind it, I encourage you to review this post which synthesizes the events that transpired and the background of this quite well.

This photo, and the story behind it, resonated with me so much when I learned about it. All my life, I had been known by family and friends to be emotional and attached to those around me. I knew going into medicine what was in store for me. That being said, it hasn’t and doesn’t make it any easier for me to deal with bearing witness to the suffering and loss that I do on a daily basis in my line of work.

I wanted to share some personal patient encounters that troubled me and caused me grief and emotional suffering afterward, because I think it is important we allow physicians, nurses, physician assistants, nurse practitioners, patient care technicians, and all those who participate in patient care, to experience, process, and truly be open about how they feel.

The first time I really cried after starting medical school was when I was a fourth year medical student. During one of my away rotations in an Emergency Department, I helped in the care of a police officer who was shot in the line of duty. I had assisted with and observed innumerable trauma resuscitations by this stage of my training, so the actual events transpiring in front of me were not unfamiliar to me. However, what was different about this situation, the first time I was directly involved in caring for an officer who was injured, was the sheer emotion of the situation. The officer’s colleagues flooded the Emergency Department. There was a complete different tone of urgency among the supervising attending physicians and trauma surgeons. I could see in the eyes of the nurses, technicians, physicians, and officers around me, that this was hurting them. The pain and suffering the policeman was enduring, the treatment that he was receiving, it was causing a tidal wave of many emotions throughout the facility.

There must have been 15 police cruisers that showed up outside of the department within moments of the officer’s arrival. Several of his lawmen had brought him to the department in their cruiser, since there was concern that by the time an ambulance arrived, the officer would be too sick to save. This was one of the first times I learned that in some situations police officers, because of the environment they served in, had to transport patients with trauma to Emergency Departments in their own cruisers. Not many people know this about police officers, and with the recent negative publicity that surrounds law enforcement all over America, I wish it to be known that police officers do so much that the news media never shares. They are, in many ways, endangering themselves day in and day out, for the general benefit of the citizens they serve. Bad apples always exist, and create negative publicity, but please do not forget what the men and women of America’s law enforcement agencies signed up to do for us – protect us.

The officer was rushed to the operating room, and there was silence in the Emergency Department. For anyone who has ever worked or been in any ED for any period of time, even as brief as 30 seconds, there is never silence. If an ED is quiet, you should worry. It took a good 30 minutes for the entire department to shake the effects of the trauma resuscitation. Staff, patients, officers who lingered behind for a time, appeared dazed. You could see some were emotional, but most looked stoic.

I went about the rest of my shift as usual and went home. It wasn’t until several days later that I realized how much this had affected me. I was watching The Wire with my wife (SPOILER ALERT) and watched an episode in which an officer was shot. In the make believe show, the officer was transported to Shock Trauma for resuscitation. I immediately and suddenly burst into some of the most awful crying I have ever done in my life. It rivaled how much I cried when I was kneeling besides my dying grandfather at home, who was on home hospice for his bad lung cancer, and whose hand I held as the last glimmers of life left his eyes. As I write this, I am fighting back the desire to again cry, because I happen to be writing this in a public space.

My wife held me close, and comforted me. She was patient, she did not judge, and she was everything I love her for. She waited for me to speak first, and then proceeded to very calmly and compassionately try and find out what was wrong. I explained to her, not mentioning specifics, what I had observed in the Emergency Department with the police officer. She immediately understood without much explanation why the events that transpired in The Wire affected me so much. I continued to cry and bawl my eyes out, until finally I regained my composure. I felt a lot better having shared my emotion with my wife, and for allowing myself to feel the raw emotion I was dealing with. This was an important moment for me because I realized that this needed to happen for me.

(To Be Continued)

Doctors Are Not Judges

I was browsing my Twitter feed this afternoon, looking over messages being posted from conferences occurring around the world I am interested in for the medical knowledge, advice for health care providers and trainees, and general uplifting ideas being shared. Suddenly, I saw a headline from The Atlantic on my feed I could not believe.

When Doctors Refuse to Treat LGBT Patients

Now, even without reading into the details of this news story, I can assure you that as a physician, there are very few situations when it is ethically or legally acceptable for a physician, nurse, nurse practitioner, physician assistant, or other health care provider to refuse to provide medical care to a patient.

As an Emergency Medicine resident myself, if a patient is threatening physical violence toward myself and my staff, if they are brandishing weapons, or endangering other patients, colleagues, or me, legal justification may support my decision to not treat them until the situation can be deescalated.

I have spent the past 13 years of my life training toward becoming a physician. At every step of the way, I learned that by becoming a physician, I make sacrifices. Many already are aware of the monetary and time sacrifices that many health care providers make in order to gain the expertise and training necessary to provide quality medical care.

Delivering medical care is a privilege, not a right.

Receiving medical care is a right, not a privilege.

According to The Atlantic article linked above, in Mississippi and Tennessee, laws have now been passed by legislature which makes it “legal for doctors, psychologists, and counselors to opt out of any procedure or choose not to take on any patient if doing so would compromise their conscience.”

There are numerous ethical dilemmas and consequences that arise from such laws.

First, physicians, who I can speak for as a physician myself, are trained and ethically taught to provide quality medical care regardless of our own beliefs, values, or ideals. For example, no one would allow physicians to decide not to provide care to a potential patient on grounds of race, gender, or age. Furthermore, as an Emergency Physician, I am bound by the Emergency Medical Treatment and Labor Act, a federal law which expressly prohibits a hospital, or the physicians providing care in them, to refuse medical treatment to anyone on the basis of financial ability to pay or not pay.

The laws in Mississippi and Tennessee are now permitting physicians, as well as psychologists and counselors, to refuse to provide medical care to individuals based on anything which goes against their conscience. That is in direct contradiction on moral and ethical grounds to what it means to be a physician.

Second, the problem with such laws is that they are extremely vaguely written. Picture the scenario below.

I am a physician in Mississippi. A patient presents to my facility who expresses to me views which I do not personally believe in. He tells me he thinks all Hindus should be sentenced to death. As a Hindu myself, this patient offends me, and goes against my own beliefs. Under the new law, I am now legally permitted to tell this patient I cannot provide them medical care. They will have to look elsewhere for treatment.

Imagine what you would feel like if your medical provider decided to refuse treatment to you based not on any scientific reason, but simply because they did not agree with your particular beliefs. Imagine how you would feel if you took your wife or your daughter to an OB/GYN because she was pregnant and needed prenatal care, only to find that your loved one cannot be treated because of their sexual orientation, their religious beliefs, or literally anything at all that might go against the physician’s “conscience.”

Furthermore, if Mississippi enforces these laws and allows physicians, psychologists, and counselors to decide when and why they may not want to deliver medical care, it will become increasingly difficult for citizens to receive medical care. It’s possible that if the patient holds a belief, religion, or other ideal that caregivers in the area do not agree with, they will certainly have decreased access to medical care.

This situation is in direct opposition to efforts such as the Affordable Care Act, which are attempting to make access to medical care easier. As a nation of Americans, we must take a step back from the situation and decide what kind of country we want to be. It has become popular, as Donald Trump has exemplified, to be bigoted, hateful, and discriminatory.

It has become acceptable, apparently, to pass laws to limit access to vital and crucial medical care like what happened with Planned Parenthood affecting millions of women this year. It has become acceptable, apparently, to pick and choose which Americans individuals, organizations, and now, medical providers can discriminate against. It has become acceptable, apparently, to base an entire political campaign on the grounds of discrimination, bigotry, and open hostility toward particular citizens of our nation.

America, we have to take a hard look at ourselves right now. This cannot wait. Who are we, as a society? The rest of the world is laughing at us. A nation founded on the noble concepts of the rights to life, liberty, and the pursuit of happiness is now segregating using conflicting value systems and discrimination. Our founding fathers established the United States of America not with the intention that one day, specific populations of people within our borders, who live alongside us, who deliver our medical care, who sell us our groceries, would be declared unworthy of the same rights and freedoms we all share. The men and women in our armed forces, and their families, do not sacrifice their lives for us to defend hatred, discrimination, or bigotry.

I implore you, if you believe in America, if you love your country and your countrymen and women, speak out against laws, organizations, and political parties which threaten the values that define who we are. I beg you, as a citizen of the United States born and raised within the confines of this nation, as a contributing member of society with love for all individuals around me regardless of what they believe in or look like, do not allow America to become a country defined by hatred or discrimination.

Save America. Save her, for your families, for your children, and for our future.

Language Choice in Health Care

Recently I read a fantastic blog post by @RenzaS, a writer with Diabetes who shares her perspectives on the patient experience and is a patient advocate. You should first read her post here on “Difficult Patients” to get background on this discussion.

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How we say things matters as much as what we say.

As a physician, an avid reader, and an unrefined, unexperienced writer, I understand the importance of our language and word choice. In my line of work, daily, I must pick my words carefully to help explain complex medical problems in a way my patients and their loved ones and caregivers can understand. I feel one of the services I provide my patients is actually translation – I translate the complex medical problems, treatments, and research I am tasked with understanding into terms my patients can understand.

That being said, I have to say that many health care professionals, in my experience, use language and terms that can be construed as offensive and derogatory. I bring up the issue because I want to encourage readers who are physicians, nurses, physician assistants, nurse practitioners, technicians, paramedics, etc, to consider changing the way they discuss patients and their care.

Below are some examples of terminology I have heard over the past 13 years which makes me uncomfortable. When I hear these terms, I cringe. I refuse to use them myself.

  • Patients in rooms or beds referred to by their room number, not their name, or even worse, by their disease or chief complaint.
    • Example 1: “Dr. Smith, the chest pain in 1…”
    • Example 2: “Dr. Lee, room 1 needs…”
  • Patients referred to by their disease process in a made up, often derogatory phrase.
  • Patients referred to as “difficult”

These are just some of the examples I have heard. Now keep in mind, I myself refuse to use these terms, or refer to patients in this way. The reasons why should be obvious. It is offensive and unprofessional! I know there may be those who disagree with me, and they might claim that how they discuss patients in private conversation is up to them. I have heard all to many times that in 2016, we worry too much about being “politically correct.” However, this is not about being politically correct.

This is about changing the current culture of health care which finds as many ways as possible to make the patient experience matter as little as possible, and which places the power in the physician-provider and patient relationship squarely in the hands of the physician-provider instead of in the hands of the patient, the most important person in health care!

So, the only term I have seen used that is quite frequently used is “difficult patient.” Healthcare providers often use the term “difficult” to refer to patients who are in distress of some kind which affects their decision making capacity. For example, a patient who is under the influence of mind altering substances like alcohol or PCP. Healthcare providers also use the phrase “difficult patient” to refer to patients who are angry, hostile, combative, or physically abusive. Especially in the Emergency Department, we often take care of patients who present via law enforcement or EMS because they are psychologically unstable, who may have diagnosed psychiatric illness, and are making it hard for us to care for them. Lastly, some healthcare providers use “difficult patient” to refer to patients who have many questions about their care or who question decisions made by the healthcare team.

All of these situations are different, but what I can honestly say in all of them, is that there is no need to use the term “difficult patient,” ever. It’s ambiguous and open to interpretation. I venture a guess that most patients actually take that phrase to refer to the last scenario above, referring to a patient who has many questions or concerns about their treatment. This term has a negative connotation and perpetuates a culture where the patient’s voice is less important or implied to be irrelevant, when in reality, the patient’s voice should be the loudest, and we healthcare providers should be working to augment their voices.

Renza recommended in her article here that we use the phrases “empowered” or “assertive.” I thoroughly agree with her, because these terms have positive connotations, and elevate the patient to the center of the healthcare provider-patient relationship. Renza also referred to @annareisman who wrote a wonderful article covering the inappropriate use of the term “difficult patient” and she emphasizes that patients who asks questions are excellent teachers. She stated, “Don’t dread patients bearing questions, I told my students. Welcome them. They’re some of the best teachers you’ll encounter.”

At the end of the day, patients are simply trying to receive care for their medical problems. As healthcare providers, it falls on our shoulders, based upon our years of training and commitments to our patients, to always do what is right for them. This doesn’t stop at our medical decision making. It absolutely includes our communication, because how you say things matters just as much as what you say!

 

An Ode to You, ED Nurse

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There are many people who work in health care. There are patient care technicians, physician assistants, custodial and housekeeping staff, dietary, patient transporters, nurse practitioners, and yes, doctors too. However there is truly, in my humble opinion, one individual in the hospital who does the majority of actual medical care. Yes, physicians, nurse practitioners, physician assistants, technicians, they all contribute important activities for patient care. Physicians, and their teams, intubate, place central lines, deal with complex medial situations and make decisions that change the course of their patients’ lives.

You may have guessed it by now. Yes, this is going to be about nurses.

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Nurses are the heroes of healthcare. No ifs, ands, or buts about it. Anyone who tells you otherwise is in denial. My purpose in sharing my opinions on nurses is simple: they are never, ever recognized enough for their tireless, selfless, genuinely caring efforts.

Don’t get me wrong! I am not saying that all those who work in healthcare don’t deserve accolades. They absolutely do! But truthfully, I have never been able to thank the nurses I work with for their hard work and efforts enough, and this is my attempt.

A wise nurse I worked with at the Baltimore VA ED taught me last July, when I was a brand new intern, that patients don’t go to hospitals to see doctors – they go to receive nursing care. It was profound, and true. Doctors get the glory for good outcomes, but though they are essential in the delivery of healthcare, most doctors are pretty useless without the nurses they work with to deliver actual medical care.

Look around the hospital. Who is giving patient’s their medication? Who cleans patients when they soil themselves? Who dresses a patient’s wounds? Who takes the patient’s vital signs? Who assesses patient’s more frequently than anyone else in the hospital – universally? Who deals with problems with patient care as they arise more often than anyone? If you answered anything else but nurses, you’re wrong.

All nurses, wherever they work, whatever their area of expertise, deserve recognition for their tremendous efforts. I thank the nurses I work with each and every day. I have learned from my mentors that whenever I leave a shift in the ED, before I leave for the day, to share gratitude with the nurses and other staff that helped deliver care that day (including housekeeping, administrative assistants, transporters, literally everyone!) It sounds silly, but don’t be mistaken, it’s so important to recognize those around you for their hard work.

That all being said, there is one kind of nurse that I have tremendous respect and admiration of. If I had to be stranded on an island and needed medical attention, I would want this type of nurse there to care for me – an ED nurse!

ED nurses work in a chaotic, stressful, and unpredictable environment, day in, and day out. They never know what they will deal with. They are often the first people in the hospital to see the sickest, most helpless patients – even before the ED physicians! ED nurses are tasked with the often challenging and sometimes impossible – take care of everyone, address all of their problems, with what resources you may have.

Do you have too many patients to take care of? Did your patient tech call out sick? Is the nursing staff short for the shift? Do you get to call for help, or ask administrators to reassign nurses from other departments? Nope. The answer is a resounding, “Deal with it, friend.”

The CDC states that in 2011, there were 136,000,000 ED visits in the United States. Each of these patients were cared for by at least one, often multiple ED nurses. That means more than 1/3 of the entire country’s population has essentially been cared for by an ED nurse. Not all ED visits result in admissions, so you must accept that ED nurses are the most seen nurses in the entire field. Let that sink in. (I may be wrong on that, and if I am, please let me know. I just don’t see it being any other way.)

I have witnessed, since I first set foot in a hospital as an Emergency Department volunteer clerk back in 2003, ED nurses exhibit such unwavering dedication and commitments to their work. They are cursed at, spit on, yelled at, and sometimes even physically attacked by their patients. They are responsible for taking care of multiple undifferentiated patients with often uncertain medical diagnoses all at once. Furthermore, if we as physicians have any issues with patients, their care, or anything related, we frequently rely on nurses to help guide us to the next resource we need.

The best physician advocates for a patient in the hospital are frequently ED physicians, because they see the patients earliest, and are tasked with deciding what the ultimate plan for a particular patient is. However, the ED nurses who work with those ED physicians are even stronger advocates for their patients, because they are the first to bring up issues with the physicians they work with. I’ve lost track of the instances when nurses were concerned about a patient’s condition, whether it was because they were complaining of worsening pain, their breathing was becoming too rapid, they had abnormal changes in their vital signs, or some other reason, and they brought up their concerns with the physicians they work with. Most of the time, in a good ED, the physicians will learn to respect the ED nurse’s assessment. Good ED physicians know they should trust and rely on the ED nurse colleagues for their clinical gestalt, or “gut feeling.”

Just to be clear, as well, ED nurses have an awe-inspiring ability for versatility and resilience. They often deal with the sickest patients before we know exactly what’s going on. They take care of patients that should be in an ICU, where the nurse to patient ratio is often 1 nurse for 3 patients or even 1 nurse for 2 patients, BUT, often carry 1 or 2 ICU level patients AND 2 or more patients. ED nurses are efficient, quick thinking, and a TON of fun to work with. They are smart, they are compassionate, and they are incredibly fun. I am so lucky that in the ED where I spend most of my time, not a shift goes by when I don’t laugh with the nurses I work with, and they have made me feel better about difficult patient encounters or helped me deal with suffering I have witnessed more than I can ever thank them for.

This is why, for the rest of my career, I will be sure to show my gratitude for and advocate for ED nurses everywhere.

I thank you, ED nurse, for the tremendous work you perform.

I thank you, ED nurse, for the role you play in public health and wellness through your role in the ED.

I thank you, ED nurse, for the sacrifices you make to take care of the entire country.

I thank you, ED nurse, for being the ultimate troubleshooter, the “MacGyver” of all nurses.

I thank you, ED nurse, for putting up with me, my colleagues, and aiding us in taking care of our patients.

I thank you, ED nurse, for somehow finding a way to get it all done, while maintaining a smile on your face, and keeping me laughing too.

I thank you, ED nurse, for coming back day, after day, after day, after day, to see so much hardship and suffering, often in a broken and dilapidated healthcare system that makes it harder and harder for you to do your work.

Never, ever change!

To everyone else, #thanknurses! I encourage you all to share gratitude with nurses you work with. Let’s use the hashtag #thanknurses to let them know we appreciate them. Spread the word, get your colleagues in on it, and share the love!

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