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.

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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)

Why Physicians Benefit from Social Media

As a teenager I grew up using social media platforms such as FaceBook. It was mostly used to keep in touch with friends and family and waste time. Those days of aimlessly browsing news feeds and playing FB games are gone. I also had a Twitter account I hardly used and mostly because I never knew how to actually use it. By the time I reached my second year of medical school, I had lost any interest in social media and my FB has been deactivated almost all the time for the past few years. My old Twitter account was deleted. I enjoyed focusing more on my day to day life and went about my routine.

Eeventually I reconnected with my now wife, graduated from medical school, and began residency. As a fourth year medical student, I learned about the phenomenon know in the social media world as Free Open Access Medical Education, abbreviated #FOAMed. See this fantastic post by Dr. Chris Nickson (@precordialthump) on the concept and how all kinds of medical personnel (nurses, technicians, paramedics, researchers, including doctors). I loved the entire thing!

What could be better for all stakeholders in healthcare than getting together on a shared platform, discussing new ideas about medical care, medical education and training, research, and all sorts of highly relevant and important issues affecting people that deliver emergency healthcare worldwide?

It got better and better as time went on. I became an avid consumer of #FOAMed. I connected with not only globally known clinicians famous for their ability to educate and spread wisdom in medicine, but have gotten to know literally thousands of people I have never met or even spoken to who I now regularly keep in touch with using social media.

As I enjoyed exploring Twitter as a doctor, it occurred to me that most physicians think one of two things when it comes to social media:

  1. I can use social media to make money by publicizing myself and driving potential customers to my website and ultimately medical practice.
  2. Social Media is a black hole where doctors go to get sued and lose their licenses and there is never a time for a physician to be involved on social media.

I lesrned to to shy away from those physicians who believed in number 1, and I was utterly shocked and confused by those in number 2.

However, as time went by, I identified that physicians are perpetually claiming they have no time for personal lives, with families, to keep up with their medical work, that for the vast majority of them, learning how to get active on social media in a climate which makes physicians in America worry that they will get sued for simply looking at their patients the wrong way is not ideal.

Physicians are value based individuals. They are trained to look at pros and cons, and weigh options, because they advise their  patients to navigate those situations on a daily basis as their career. This is my attempt to share the value.

I posit that many physicians deal with burnout and poor job satisfaction because they lack a support group of peers who they can discuss their concerns, experiences, and hardships with.

I hypothesize that physicians struggle to identify what information is relevant for them to know.

I believe that healthcare social media, or networks and communities of people that are passionate about not just delivering healthcare but shaping its future, is the BEST place for an engaged physician to be.

  1. My involvement on Twitter has allowed me to connect with other individuals excited and passionate about delivering quality patient care.
  2. My involvement on Twitter has opened my world to entire fields related to healthcare that I never even knew existed such as healthcare design and patient experience design.
  3. My involvement on Twitter provides me with an added layer of support beyond my family and friends who work in the same settings, devote their lives for better or worse to guiding patients & their families through suffering and pain on a daily basis.
  4. My involvement on Twitter especially chat groups such as Healthcare Social Media, Healthcare Social Media Philippines, Healthcare Social Media Canada, Bioethics Chat, Medical Education chat, and Patient Advocacy Chat.
  5. My involvement on Twitter has taken me not only to the most fun, knowledgeable, and influential people in Emergency Medicine, which is my field of medicine, but it has taken me to the patients and their advocates who are working tirelessly day in, day out, to make sure that patients are at the center of health care today and tomorrow. For examples, you must get to know @NatriceR, @CancerGeek, @Colin_Hung, and @Colleen_Young.

Why should physicians be active and involved in social media? 

In 2016, we have finally reached a point where physicians can engage in social media in a professional way, without compromising patient confidentially or laws such as HIPAA. Furthermore, the entire medical field is encumbered by physicians and other healthcare providers who are exhausted, stressed out, and struggling to deliver quality care while maintaining their own personal lives.

Examples I have myself experienced:

  1. I have  met wise educators in Emergency Medicine and have had new opportunities come to me just because I am enthusiastic, involved, and willing to try new things.
  2. I have connected with countless patients, patient advocates, healthcare designers, and read their blogs and ideas, and have become a more innovative, creative, and open minded member of the healthcare world now.
  3. I have found much needed support from colleagues and other individuals who deliver medical care when I have been dealing with depression and emotional anguish related to work.

I never once thought that when I started @S_P_MD, that I would be so positively impacted by it. Now I cannot imagine a life in which I do not use #FOAMed or Healthcare Social Media (#hcsm). The time has never been better for physicians to get active on #hcsm! Share this with a colleague who is skeptical and connect them with resources to help them get online!

10 Commandments for Intern Year

I’ve been inspired by the #TipsForNewDoctors trend on social media. I’ve decided to start posting some thoughts and advice based on what I have gone through on my blog.

These are simply recommendations I can make for any first year residents based on my own experiences and observations over the past 8 months of intern year. I don’t have any evidence to support my words, though I hope they might help others.

1) Thou shalt be a team player.

You should make it your priority to be courteous and respectful to everyone you encounter. This isn’t limited to your immediate resident colleagues, medical students, or attendings, but includes custodial staff, administrative assistants, patient care techs, transport staff, literally anyone. Make it a goal to get to know as many names as possible. Many of my heroes like Dr. Amal Mattu and Dr. Michael Winters have emphasized that learning names positions you to be a leader.

2) Thou shalt take care of thyself.

If you are chronically sleep deprived, sick, or emotionally unstable, you not only put yourself at risk of burnout and further health problems, but you put the lives of your patients in danger. Imagine when you are on call in the ICU, in many hospitals making critical decisions for your patients without direct oversight at times. Seek help early if you start to find you are struggling. Every residency program must guarantee resources for physical and mental wellness.

3) Thou shalt read daily.

This is a tough one for me to do myself, but I guarantee you that if you can keep this one up, you will excel. Success as a resident, attending, and beyond does not require marathon study sessions in the library. Leave that in medical school where it belongs. Read about 1 patient you care for daily. It can be FOAMed, a review paper, or even discussion with a colleague. Something. Every day!

4) Thou shalt not incur debts.

While it may seem pointless to be fiscally responsible if you have hundreds of thousands of dollars in debt like me, do not be fooled. You will have limited month to month cashflow, and any extra debts you incur, especially for purchases you don’t need, will cause you unneeded stress when bills are due. Every penny you don’t spend is going to make a difference as a resident. Be wise with your money and you will be glad in the end.

5) Thou shalt put the patient first.

It may seem silly to emphasize this point, but entitlement and privilege are pervasive among medical students and physicians. Because of the hard work and sacrifices we all endure, the bumps along the way can be tough to deal with. Avoid giving into the urge to make everything about you. The day you became a medical student, and especially the day you start residency, you are truly making the rest of your life about your patient. You had many years to make up your mind about being here, but your patient, especially when they are sick, did not ask to be in the hospital. Maintain compassion for your patients and their families. We sometimes take health and healthcare for granted because we see it from the physician perspective. Try to see the situation through your patient’s eyes and you will understand it can be frightening and overwhelming to navigate the system.

6) Thou shalt not sign out loose ends.

Trust me, if you don’t know what I’m talking about, you will know soon enough. Do not be that resident in your program who develops a reputation for awful sign outs. Sometimes you have to stay late past your shift or call night to close the loop. Resist the tendency to think of it as doing procedures or examinations you don’t want to do; instead think of it as better for patient care. Nothing is worse for your patients than poor quality sign outs. If you need to call a consultant, perform a procedure, complete an examination, or finish a discharge or admission, be the resident that stays to take care of it. It’s not just a good habit to develop. It’s better for patient care, and that’s ultimately your first priority.

7) Thou shalt be professional with everyone.

This is a huge one. There are going to be times when you have a sick patient and you might feel like staff around you are not helping you with their care. There will be moments when you need help from a consultant or colleague in a different specialty or field and that physician may disagree with your plan or concerns. There are frequently situations when you will feel unsupported and like you are the only person who wants to care for your patient. You are not alone, and it is never, ever acceptable to be rude, discourteous, or nasty to others. It is never okay to raise your voice, swear, speak profanity, or speak rudely to another person. It doesn’t matter who that person is, whether a colleague, staff member, patient, or other human being. You are now held to a higher standard, and you must accept that, or you will flounder.

8) Thou shalt be early.

I must admit, this one is challenging for me even to this day, because I have trouble being organized. I am working on it though. That being said, it doesn’t matter what kind of residency you are starting, being early is the new “on time.” Showing up on time demonstrates work ethic and everyone remembers if you are late. If you develop a reputation for being late, it can be hard to overcome this moving forward. It sends the wrong signal, which is that you don’t care about your work. You most definitely do care about your work, and you have worked hard to get to this point. Don’t screw it up by being late.

9) Thou shalt surround thyself with positive influences.

Wise people rarely become wise by their own virtue. They simply understand that they are influences by those around them. If you seek out uplifting, motivated, and success oriented individuals to spend time with, get advice from, and learn with, you will 100% benefit from this. As you move forward, understand that not all health care providers are created equally. Some of them ended up where they are by mistake, are unhappy, and will try to get you to join their complaint corner. I say, find a senior resident or attending you admire early on, and reflect on what makes them so good at what they do. What qualities do you appreciate about them? What about their personality or professional life do you wish to emulate? Then, go one step further and identify where they may be able to improve. Write all of this down, and you have your road map for your own growth and development.

10) Thou shalt remember you are human.

At the end of each day, you need to take a deep breath. Being a physician, nurse, physician assistant, nurse practitioner, patient care technician, EMT, paramedic, or any other staff member that cares for patients, will be hard on your mind, body, and soul. You are not perfect. You have limitations. You should aspire to be your best but accept that you will have some bad days. Perhaps many bad days. Learn to laugh at yourself. Develop a tough skin to receive criticism and use it as an opportunity to improve. When you see patients and their families suffer, allow yourself to feel their pain and empathize with them. Humanism is sorely lacking in healthcare today. Patients, doctors, and everyone around can tell. Bring humanism back to medicine.

If you have any feedback, suggestions, comments, criticisms, or advice, or if you want to add your own commandments to this list, please comment or reach me at sspatel@umem.org or @S_P_MD!