Finding Resiliency in Healthcare

Fortunately, the topics of burnout, wellness, and resiliency have been popping up more and more frequently over the past 1-2 years across the media, social media, and even professional conferences. I welcome the increased transparency and willingness people have to open up about their experiences, concerns, and struggles, but most importantly, what we all are currently and will soon do about it.

Burnout is not a new problem. In the research journals the topic has been discussed and analyzed for decades. I searched Pubmed for “burnout healthcare” and the earliest indexed articles there were from the late 1970’s. In fact, the earliest article was from the Journal of Nursing, entitled “Burnout: the professional hazard you face in nursing,” by Seymour Shubin.

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I’ve read through at least 30 articles on the topic ranging from the 70s to earlier in 2017, and what’s encouraging is that we are finally starting to see a shift from describing the issues involved to how we can address them. As of the past 5-10 years, studies have emerged that actually analyze how effective or ineffective specific interventions have been on the issues of burnout, wellness, and resiliency. Even more hopeful, the large medical journals which historically are last to catch onto new waves and new ideas, are also publishing more on these issues.

I am glad for this change. Over the coming weeks and months I’m planning to discuss a couple of studies per week on related issues. Consider it my first #FOAMed contribution.

But in all honesty, personally I feel that the keys to addressing this issue are so broad, multifactorial, and involve both systems issues and individual professional level issues, that it will require much more than just discussing the issues and publishing about them to create real changes.

One of the things I want to focus on here is discussing and creating dialogue about the individual level options that can make a difference for us all.

Here are some thoughts from the above mentioned article which I thought were important to highlight.

I can’t stress this enough.


Let that sink in.

The more you take care of yourself, the more you have to give at work. The more caring a professional you can be. The more reliable and dependable a colleague you can be.

Contrary to what you may feel is expressed by supervisors, managers, administrators, colleagues, coworkers, etc, your longevity in the career you chose is important. Your longevity in your chosen work (physician, nurse, nurse practitioner, physician assistant, social worker, respiratory therapist, etc), is directly related to your “wellness factor.”

If you work with a negative wellness factor, meaning your experiences are multiplied by an overall negative sense of self image, self worth, and self care, means you are ultimately cutting career satisfaction and your own wellbeing down.

If you work with a positive wellness factor, meaning your experiences are multiplied by an overall positive sense of the above, your experience in general is going to be augmented. It helps set you on a trajectory for success, career satisfaction, and personal wellbeing.

As the Thanksgiving holiday has come and gone, I challenge you to think about how your current wellness factor is. What is your current state of affairs? What are the things that you struggle with? What’s causing you stress right now? Identifying issues is the first step toward improvement. Let’s get well.

Light Among Darkness, Part 1

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

This is, thankfully, changing.

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

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

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

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

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

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

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

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

What It’s Really Like Being a Doctor

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


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

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


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

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

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


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

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


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

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

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

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

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.

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.


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!

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.


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.