Friday, April 3, 2015

Bedside Rounds

I think about you often, sometimes early mornings before I am fully awake. Although, I met you just once, you have been one of the strongest influence on my medical practice. It has been over two decades since I met you that one time in a surgical ward in Kolkata but I have thought of you as much and as often, as I have done of close friends and relatives. This is my attempt at exorcism, though I think you have been a guiding light for me. I have been having dreams of you recently; so I think writing of you may help me get a better night's sleep.

You were young and admitted with breast mass for surgical resection. Thin, body draped in a sari, you looked scared as more than twenty of us- newly minted third year medical students, descended on your bedside, along with our fearless, ill-tempered surgical attending. He had a posh British accent, though it was too loud to be pucca sahib, in my opinion.

The surgeon, talked clearly and loudly about the fungating mass in the right breast and exposed her breasts for us to see. You shrank before our eyes and tears rolled down. I felt ashamed for all of us- for my desire to be a doctor, for my fellow students who rushed to examine you-your breast mass and axillary lymph nodes and for the loud surgeon droning on about breast cancer. I wish I had stood up for you, helped wipe your tears, did something, anything to stop the parade of your cancer, stopped the students and our preceptor from this bedside examination.

I did none of these things. I was a witness to your examination and your tears. I did nothing. I did not examine you. I did not stop anyone else from examining you. I did not wipe your tears. I wish I had done something to help. I will not be a silent witness to your sorrow anymore.

Thursday, March 26, 2015

Coping Skills for the Clinician

A question asked of me on twitter by a medical student and the recent Germanwings plane crush lead me to write this. All clinicians, at the front line of medical care, at some time in their career, some more often than others, feel overwhelmed. This is accompanied by a thoughts of incompetence, helplessness  which if left unattended, can lead to misery, burnout and self harm. I have seen this in myself after residency and had to take a career detour to sit and ponder and attend to the rest of my life. I am grateful to have had an opportunity to be able to afford to take a break, and not see patients for nearly two years. Afterwords, as I eased into practice, first a volunteer position looking after the uninsured and then locum tenens hospital positions- I felt able to cope with all the troubles and the chaos that clinical practice, especially that of a primary care, brings along with it.

These are the methods I used to foster resilience in my life and I hope these will be generalizable to others, as well.

1. This too shall pass
Events happen and sometimes, we just need to bear witness and not respond too quickly in a knee jerk manner. The nature of life is transience, and events can be beyond your control. If a patient is upset on rounds or in clinic, often it is nothing personal- it could be something as trivial as a bad cup of coffee (or, lack thereof). I have trouble with practising this consistently - most of us see ourselves as problem solvers and if something does not go right than we can surely, make it better. I am practising this - it is not always about me, I can bear witness without actively responding to something and possibly escalating arguments needlessly.

2. There is a larger world
There are bigger things than you- the patient comes first. There is a story behind every illness and life experience- finding it often unearths empathy which helps both you and your patient to cope better with the illness. This is not a panacea but looking for a bigger picture helps me in gaining perspective and looking forward.

3. Focus on the moment
Now, I sound just like my yoga instructor this morning. And I am aware that some may think I am contradicting my earlier advice. It is important that we consciously try to focus on what is happening in the moment. Anxiety about the future mars our interactions now. Mindfulness raises awareness and helps us respond better to situations as we are less distracted. This, I find helps anxiety and makes our patients respond better to us- because if we are mindful, they realize that they have our full attention so their anxiety about not being listened to, also decreases.

How does all this relate to the recent plane crash? This morning when I heard on the news that it maybe that the co-pilot of the German plane had crashed the airplane knowingly, it made me very sad to realize that this was a preventable accident and so many young students' family and friends would not be mourning now. The comparisons of health care, patient safety and airline safety are commonplace and sometimes, I find them odious. I find it challenging to think of health care episodes, the way I think of a flight, although there are some similarities for example, checklists have been shown to help with safety in both airline and health care systems. It is possible that overwhelming depression, suicidality was responsible for the airline tragedy and I see some parallels of this sort of despair in health care, too. Recent studies have shown that half of US doctors show signs of burnout and in my humble opinion ( some data to back this up ) my fairly commonplace advice to re-focus, be mindful and sometimes, take the long view has helped me keep burnout at bay.

Tuesday, March 24, 2015

Should Physicians Write about their Patients?

To survive, you must tell stories.- Umberto Eco

There was a discussion happening on Twitter recently after an article in The Atlantic Monthly by Dr Anna Reisman. As is usual on Twitter, there were many varied opinions. In a Medical Humanities book club that I participate in, the general view amongst the Philosophers was that Physicians ought not to co-opt the patient experience of illness, they felt that in their reading of pieces written by doctors that the tone was sometimes condescending and detracted from an balanced view of the illness experience.

As a doctor, who wants to write, I thought that it is important that one is able to express one's viewpoint as a clinician. Writing is a way of thinking and often, putting things on paper, clarifies situations and cements understanding. Writing is a way of reflecting about our relationship to the larger world around us.

As a means to aiding in a more reflective, self aware practice, I participate in a local medical humanities research group. It is a book club of sorts, where a diverse group of doctors, educators, pscyhologists, philosophers, students meet monthly, during the academic year to read and discuss books, essays, short stories, scholarly articles after dinner. When we have discussed works by physicians, some of the non-medical folks have remarked that the physician- writers can be facetious in talking about their patients and have objected to their viewpoint as being paternalistic, at times. They have felt as if the doctor in his narrative writing has co-opted the patient's illness experience.

I have to admit that I have never felt that my writing has impinged upon the patient's experience of their illness. I have frequently asked my patients if I may write about them and they have always generously agreed. Occasionally, they will look at me quizically, as if to ask, what is so interesting about me? I tell them what I find interesting about them and they seem to accept my explanation. I am conscious of HIPAA and make sure that no one I talk about is identifiable publically. Also, my writing is private, except for erratic blog posts. There is little chance that my patients will read about themselves.

Even so, my writing has therapeutic value for myself and indirectly for my patients, too. When I write about my patients, I am able to deal with my reactions to my work as a hospitalist. My patients are sick, scared and often in the process of dying. By writing about them, I hope to honor their experience and process the thoughts that arise when I am interacting with them. This is my best bulwark against burnout.