Specialties & Topics
- Arthritis/Rheumatic Disease
- Breast Cancer
- GERD/Peptic Ulcers
July 15th, 2016
NEJM Journal Watch is happy to welcome a new panel of Chief Resident bloggers for the 2016-2017 academic year. Here’s a sample of what our new bloggers will be discussing, starting on August 1!
“Resilience” is defined as the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress.
On March 9, of this year, my colleagues (my friends) and I unclipped our pagers from our belts, scrub tops, and white coats to read, en masse, “Important announcement at noon conference today.”
At that noon conference, we found out that one of our fellow residents had committed suicide by jumping from the hospital housing building. This intelligent, dedicated, accomplished young physician was the third internal medicine resident in our 22 square mile city to perform this act with identical detail in just under 2 years. We were dismissed to return to our pagers.
We picked ourselves up, literally, from sobbing piles on the bathroom floor and answered our pages. The work did not stop.
Throughout the following days and weeks, we were offered grief counseling sessions and open forums during noon conferences, where we could discuss our feelings and reactions. One morning, we were given free breakfast. We received many emails detailing these logistics, often ironically referred to as “housekeeping” items by the administration. We were desperately trying to clean up our own mess. The work did not stop.
After more than 3 weeks of waiting for the institutional silence to be broken, we were again called to an important noon conference. We were addressed by a senior physician lecturer. He spoke about depression and suicide, and how these things can often be inevitable, unpreventable. We were reminded that we are in a high-risk profession. A stack of handouts made its way around the auditorium, offering a prescription for resilience. We were advised to train ourselves to develop a positive attitude, to face our fears and find a resilient role model. This was followed by an anecdote, highlighting the speaker’s ability to receive terribly tragic news involving one of his family members and to walk directly into a patient’s room to resume work after hanging up the phone. The lecturer proceeded to present his research on resilience, largely based on studies involving military personnel and prisoners of war suffering from post-traumatic stress disorder. Correlations were made between entering the practice of medicine and entering the battlefield.
As the lecture proceeded, I began to realize that the traumatic event to which we were referring was not only our colleague’s suicide, it was our residency training. Unfortunately, this is not a correlation with which I am unfamiliar.
The forum was then open. “Please share your thoughts, experiences… and let us know: What can we do?” What can we do?
After a long pause, one of our most highly respected senior residents spoke, expressing his frustration with the fact that we were expected to resume work minutes after being informed of this tragic and shocking event. He stated that the perception of needing anything more than to take a deep breath and simply get back to work as equivalent to weakness, in combination with the “fear of retaliation,” was likely why no one was saying anything in this forum. This was followed by a reminder from our program director that “some people were given time off, and some people are still taking time off.”
This was true. One or two people had taken time off. We were not yet aware of what the repercussions of this time off would be. One month prior to this event, our chief residents had sent email to some of the senior residents: “If you are getting this email, it is because you have sick days to pay back. Sick days need to be paid back before June 30 so the program can sign off on your 3 years of GME, so please pick up shifts when you can.” Any resident who had taken a sick day in the past year was instructed to find time to cover an extra shift in order to “pay back” the institution for allowing recovery time. I had a flashback to another mass email referencing recent lateness to an outpatient clinic shift: “These instances are deplorable… You will become that person whom people hate to work with because of your lack of professionalism. Don’t turn into that, there’s already plenty of them plaguing our health system and we certainly don’t need any more.” These words were sent from those chosen to be our advocates. A wise, seasoned (and resilient) mentor of mine once gave me this piece of advice: “The institution will never love you back.”
Despite these examples, I don’t consider my program malignant. Malignancy in residency training refers to those programs in which the residents are placed in a hostile working environment. Despite having rapid administrative turnover (four program directors and three medicine chairs in 3 years), we have administers who are generally open to addressing resident concerns and who attempt to make changes based on resident feedback. This larger issue is not institutional; it is systemic.
I pride myself on my resilience. I am a New Yorker. I watched the Twin Towers fall on September 11, 2001, knowing that my family members were inside, saving others’ lives and sacrificing their own. I shared the grievous guilt of every family member, not only acknowledging that it could have been me, but wishing it had been. When I was choosing my own career, my father sat me down at an old wooden table at Chumley’s Bar and asked me if I thought I was “too good for the fire department.” My fear of fire is one I chose not to face. During my first year as a physician, my intern year, I received a phone call from my mother’s husband, informing me that she was in the ICU, and it “didn’t look good.” My mother’s life was plagued by a series of self-inflicted illnesses, and its culmination was that of multiple organ failure and a series of failed and futile resuscitation efforts. When I got the phone call that “it was time,” I walked into one of my patient’s rooms and informed him and his family member that I would be gone from the hospital for the afternoon because I had something to take care of. The patient’s sister replied, “I’m sure you’re very busy and have plenty of things to do, but this is his life we’re talking about.” I’ve cried every time I’ve lost a patient, someone’s mother or beloved family member, ever since. I continue to reflect on my disappointment with the overwhelmingly accepted notion that our training — the apex of our years of education, the threshold of our careers as physicians — is a traumatic event unto itself. Although, I know, in some ways, this is inevitable.
We enter medicine as if we are walking into a sacred space: hallowed halls where hierarchical gods prevail and miracles happen… until they don’t. We spent thousands of hours staring at computers and making phone calls and answering seemingly incessant pages, attempting to address questions to which we may not know the answers. We struggle to balance quality of care with quantity of care. We carry the underlying responsibility for the most vulnerable, most intimate moments of many people’s lives. This can feel like both a blessing and a burden. We not only carry people’s lives in our hands, we feel responsible for their deaths. We are tested every single day. Our knowledge, our patience, our compassion, our skill, our determination, and our stamina need to be demonstrated, examined, and verified. We struggle to find ways to work within a system that often feels punitive for its own faults. It can be lonely. It can be exhausting. It can be traumatic.
The Intern Health Study, a longitudinal study of depression among interns nationwide, estimated that “suicide rates among physicians are something like 40 to 70 percent higher in males and 130 to 300 percent higher in women.” Statistical estimates state that as many as 400 physicians commit suicide every year. Three young men and women leapt to their deaths in one city, in 16 months. We are not experiencing a tragic event; we are experiencing a harrowing trend. What can we do?
“Our needs are our greatest assets. I’ve learned to give everything I need.” – Andrew Solomon
The quote above is from a TED talk that, for months, I watched almost daily during my commute. This quote and many others gave me a great sense of comfort when I was grieving, tired, lonely, insecure, and burnt out. Looking back on those words, I wonder if the sentiment itself, or my attachment to it, is a reflection of the pathological need of the physician to feel strong.
I stood up to speak, not yet aware that my emotional state was one in which anything less than an [administrative] offer to turn back time would be received as an insult.
The resilience lecture began to feel less therapeutic [albeit well-intentioned] and more like a venue for perpetuation and exacerbation of a culture that was in itself, the compressive stress. We were being trained like soldiers, in the wake of our fallen comrade, to go out and fight! Be strong! Our strength was being measured by our ability to silently struggle through whatever we were experiencing and get the job done. Admit. Discharge. Admit again. We were being given tools to obviate the natural human state of vulnerability. We were “tasking victims with the burden of prevention.” We were reminded to be proud of our ability to charge on. I ended my commentary by stating that we were using the language of an abusive relationship.
What can we do?
- Eliminate the word “burnout” from the lexicon: Not only does burnout minimize the severity of depression, detachment and (at extremis) suicidal ideation among healthcare professionals (HCPs), it implies that those suffering post-trauma have some inherent flaw or weakness that impairs their ability to remain functional. This mindset removes the onus from the system.
- End the stigma: Remove the question, “Have you ever sought treatment for any mental illness” from the job applications. We should encourage residents, physicians at all levels, and other HCPs to actively seek out cognitive therapy as we do vaccines or PPDs.
- Decide what graduate education is: If residents are primarily learners, we must protect their time and use it solely for educational (both clinical and didactic) purposes and not to provide underpaid labor to perform all tasks for which the hospital is at a loss, no matter how menial. If residents are employees, we must provide adequate pay for educational level, protect sick leave, and outline contractual responsibilities before enrolling in the agreement.
- Stop penalizing unwellness: Physicians and HCPs are as human as our patients. We are not immune to everything. There will be times when we will be ill, physically and emotionally. We will need time and space to heal.
- Structure the system in a way that minimizes fear of retaliation: If the person creating or enforcing destructive policies is the same person who needs to write the words “excellent candidate” on the letter of recommendation that carries the weight of your future career opportunities, your best and worst interests are one and the same.
- Embrace our own fallibility: Learn to be comfortable with imperfection. Let us have an equal respect for our accomplishments and failures. Employ mentors who set this example.
- Accept that medicine is not martyrdom: The work does not stop. Let it not deplete us. Let us take care of each other and ourselves and not give away everything that we need.
“Recover” is the key word in the definition of resilience. Physicians are intimately acquainted with the process of recovery; recovery is a process. I do believe we will recover from this event, although not quite restored to our original state. We can work together to implement changes to not only create, but demand an educational and professional environment of safety, wellbeing, and, ultimately, resilience.
June 24th, 2016
“Oh no, she’s calling again.”
I look at the caller ID in the Chiefs’ office where I sit with one of my co-Chiefs. It is the Documentation Lady. Her call is as regular as BMs with C. diff: Profuse, excessive, associated with a lot of hot air and a bunch of crap, but inevitable. We play a quick game of rock/paper/scissors… I lose. I pick up the call. My voice changes to a sweet phone voice with a sprinkle of passive aggression and self-loathing for the coming 3 to 10 minutes of ‘issues.’
Resident A did not conclude his note with a proper attending ‘supervision’ requirement. In plain English, that means that the resident concluded his note with: “will discuss the case with attending on rounds,” instead of “the attending of record is Dr. X.” Seems like a small difference… because it is. Seems like minutia and a waste of time… again, because it is. BUT, the reality is, she is inarguably correct.
Resident B did not use the proper document title in the note that described the reason for the patient’s conversion from observation status to full admission (needs to stay longer). The resident did explain why the longer stay was needed… but selected the wrong note title. Does it affect patient care? No. Does it affect the resident’s medical education? No. Does it warrant a phone call from the dreaded Documentation Lady? Yes. Again, she’s right. She knows it. I know it. Everybody knows it.
So we do our derisory dance on the phone, and I express false frustration at the false incompetence of residents who are caring for sick and dying patients and who are being assessed on clerical skills. To beat a dead horse: The documentation lady is right. Her justification for calling me demanding corrections is also right.
This is an example of the additional skills a doctor MUST learn in residency to one day work efficiently (make money) for his or her hospital. You cannot bill an insurance company without exact documentation, because the insurance company has their own documentation hawks looking for reasons not to pay the hospital. And so the game continues.
The problem is that I never knew I signed up for this game. Most doctors never knew that their lives would have as much to do with note-writing as patient care-giving. In the words of one of my attendings, “Medicine has become a scam.” There is so much administrative garbage to navigate in most nonacademic positions that doctors appear to be doing less and less doctoring — engaging in less eye contact with the people who need us and spending more intimate time with our computer screens. The harsh truth is that, here at the end of my training, my keyboard is more worn out than my stethoscope — and that scares me. I am a pragmatist, and I know that money makes the world spin and that patient notes are what makes the register ka-ching. But I didn’t know it would so significantly affect my ability to get to the bedside.
My phone call ends with a semi-sincere, “have a wonderful day, I am sure I will be hearing from you very soon!” I stare at my co-Chief across the table, and I can see the empathy in his eyes. We laugh at the absurdity, and then he speaks an absolute truth, “Man, I wish I was as good at being a doctor as she is at her job.”
June 17th, 2016
Reflections and observations from my last day in Greece as part of the SAMS (Syrian American Medical Society) medical mission for Syrian refugees:
1) It rained during clinic hours. It was a bit inconvenient for the team. For the refugees, it was catastrophic. Their tents, already damaged, allow the drops of precipitation to find their ways in and soak everything they own. They are drenched, their things are soaked, and there is no reprieve from the cold that follows. The rain puts out the fires they use to cook… to stay warm… to have some light when it gets dark. I have run out of negatively toned words in the English dictionary to describe the state of these human beings that could just as easily be me or you. I apologized a lot to them this week, on behalf of everyone. But to accept our forgiveness lies with them and God… and I cannot imagine how they could forgive us.
2) We met a man in his 30s, Greek, bearded, thin, a skipper by trade. He looked exhausted. He has no associations with Syria, Arabs, or Islam. He came to volunteer for 7 days — he extended to 10 days… then 14… then a month — that was 7 months ago. He lives here now, far from his home, among the refugees. He eats with them, sleeps close to them, and is engrossed in every aspect of helping them. As I was saying goodbye yesterday, I held his hands and told him he was a hero. He couldn’t look at me in the face when I said it, and I know he would never consider himself such. But that is exactly what he is.
3) As we left and said our goodbyes to the group we came with, I couldn’t help but feel like I was leaving family. One volunteer said, “I feel like I’ve fallen in love.” I agree — I have as well. I might never see most of them again, but I swear to you we are family forever.
4) In the video below you will see a Kurdish man, all alone, playing an instrument and singing a sad song, unaware of his audience. When he was asked why his song was so sad, he told us his story. He had sent his children ahead of him, and they now are in Germany seeking asylum. He was then separated from his wife who got stuck in one of the most war-torn areas of Syria, and he was only able to get as far as Greece. He now has run out of money and has been in the camp for months. Other refugees have given him some food and some supplies, but he has no money left. He cannot pay a smuggler to move him towards his children or pay for travel back to his wife in Syria. He feels as though he is the most alone man in the world. Indeed, he might be. May God help him find his way to his family.
5) Many refugees told us that they left, not for themselves, but because they didn’t want their children to see all of the dead bodies in the streets of Syria. The dead were purposefully left lying on the streets as a warning, and the killings occurred out in the open for the little children to see. One man had his wife and children with him and told us they almost made it past the Macedonian border when his wife had severely injured her knee while climbing through the mountains. She couldn’t go any further and had ordered her husband to take the children and leave her there by herself. She was going to die by herself, but at least she would know her children wouldn’t experience the horrors they had fled. The man couldn’t do it and instead had carried her to the Greek border and into one of the refugee camps. They were so close, but he loved her too much to leave her and had risked living in the camps forever so that they could stay together. Happy endings are few and far between for the Syrian people.
6) I did far less clinical work on this trip than my prior one because of the very fluid situation of the refugees. I feel like so much more needs to be done, but I am reminded of my most important role — to be a witness. To witness on behalf of Americans and on behalf of humankind. I will not ever be able to forget this problem exists. That there is an immeasurable amount of suffering among my fellow human beings and so many of us have ignored them. We have the blood of their misery on our hands (if not by direct action, then by apathy and purposeful ignorance), and the least we can do is acknowledge them, pray for them, and cry for them.
Video courtesy of Mayada Yousef
May 23rd, 2016
1) At one point today in the Idomini refugee camp, I was playing catch with a beautiful baby girl in between some of the tents. She could not have been much older than my own daughter and, like my daughter, would throw the ball backwards over her head instead of towards me and then would giggle for a bit before repeating it again… I could see her father and siblings smiling and watching me play with her; I walked over and began listening to their story. The father spoke to me warmly about how happy he was to meet us and how difficult it is to be refugees for him and his family in the camps. He talked about the near absence of medical care, edible food, and safety. He talked about how far they had come, how their home no longer existed in the city of Yarmulke because it was obliterated during Assad air strikes, and how uncertain every day was. He mentioned how one of his sons went nearly mute from fear of the bomb blasts and now only says a few words… He smiled and said kind words despite the misery he spoke of. At one point he joked: “I invited everyone over last night for a great party — it was so great that the wind made the walls of my tent dance until they fell over.”
2) Today we entered a new camp called BP/Hara (named after its location on a BP gas station and the parking lot of the Hara hotel). We treated about 50 patients out of the back of our van full of donated meds and supplies. Syrians, Kurds, Afghanis, and even some Pakistanis, all lined up hoping we could relieve some ailment or suffering. Often we could only provide some ibuprofen, bandage a wound, or treat a fever… It was not complex medicine, but it was something. Sometimes it feels as though all we are really delivering is a tiny bit of dignity and humanity in the few moments we are with them. Other times, it feels as though we did not do anything at all. It is a difficult set of realities to process.
3) Super heroes exist. I’ve seen them. Today a man pulled up in front of the camp in an RV he owned. His name is Ramees, and he is a physician from the U.K. Every so often, he flies from the U.K. to Romania, where he has his RV parked, drives down to Greece with his vehicle stocked with meds/supplies, and opens his doors and heart to the refugees. He is a one-man show who does this because it is who he is. He has already been here for a couple of weeks and plans on a few more days before he returns home.
I meet people like him and feel ashamed about how little I’ve done. This man (and there are many men and women like him), has sacrificed immense amounts family time, money, general comforts, and heart to come in and give something of himself to people he’s never met and probably will never see again. He gives me hope that, despite all of the terrible things in this world, there are still people like him who put it all on the line to make a difference.
4) I am more and more convinced that everyone needs to come and see the Syrian refugee crisis for themselves. These words and pictures mean nothing in comparison to staring into the eyes of a human being who has lost everything and wants nothing except to just have a chance at a normal life. I cannot convey the hurt and tears and fear and pain in a post. I cannot make you understand what I feel when I put my hand on the head of a child who has lost his parents or an arm around a man who has been stripped of his honor. I cannot convey the loneliness and hopelessness of knowing you will sleep in a tent on concrete tonight and the next night and so on… there are no words for these things.
May 22nd, 2016
1) The following are real conversations the team has had with patients/refugees in our short time here:
Young lady who came in with urinary symptoms:
“How old are you?”
“I am 27 years old… I hope this is the last year of my life.”
“I have to get out of here. I’ve spent 3 months of my life living in a tent in a gas station… I couldn’t even imagine living in a normal house anymore. I need to find a way out.”
Middle-aged woman who presented with complaints of headache and belly pain for a year:
When I asked her if she could tell me if there was a specific event that happened a year prior when the symptoms started, she forced a smile as tears ran down her face.
“A lot happened. I have not been home for 5 years now.”
After listening to her and doing a full exam, I told her that her symptoms were likely related to her stress and she nodded… More tears fell: “I haven’t slept in a very long time.”
2) We visited the Idomini refugee camp today. More than 10000 people live in a field, in tents with no running water except a few faucets located between a line of porta-potties. The ground is full of sharp rocks and gravel, and the refugees often have very little to lay down to cushion themselves when they sleep. Children, like the ones below, wander the camp doing what all children do. They play. They laugh. They fight with each other. They joke. They misbehave. They run. They have no idea that the reality they live is not the reality of the rest of the world. The entire world for a Syrian refugee child involves his/her experience of life isolated to having nothing and doing everything just to survive.
3) A teenager came to us with an injured foot related to a shrapnel injury he suffered 5 months prior while in Syria. It was clear he needed a surgical intervention — his foot was swollen and was extremely painful to walk on. I asked around — What do we do with people in this situation? Where do we send them? Who do we ask? Now what? The answer was painful: There is nothing we can do. There is no where he can go. We cannot help him… And nobody will be able to help him, because there are thousands like him… Thousands of people who have chronic medical issues with no avenue for acquiring treatment. They are, essentially, unworthy, in the collective eyes of the world, to be treated like human beings.
4) “Sharafna,” a boy called out to us as we left the camp. Roughly translated it means, “you have honored us by being here.” I wanted to reply in shame, “That’s impossible. The world is not deserving of any kind words from the Syrian refugees.”
May 21st, 2016
I am participating in the SAMS (Syrian American Medical Society) medical mission in Greece.
1) Loneliness is truly the darkest consequence of this crisis. The Syrian people haven’t just been kicked out of their homes. They were stripped away from their neighborhoods, friends, and family via death, destruction, sickness, and tough decisions that they had to make about splitting up loved ones to preserve their chances of survival. We saw many patients today who had no one. No parents, spouses, siblings, or children. They didn’t have to tell me. I could see it in their eyes. The material goods they have lost are immense, but pale in comparison to what else has been taken away from them. They walk alone in this world.
2) A bunch of conversations I had today with co-volunteers included the word ‘resilience.’ These people are awe-inspiring in their ability to be dealt a life of dirt and then to turn around and produce a garden. They make tents feel like home, plastic tables feel like a dining hall, and a gas station feel like a community. Let me explain that last portion: The EKO refugee camp is literally located on the property of an EKO gas station (picture included, so you can try to understand the absurdity of this). Simple camping tents laid out on concrete between and around gas pumps and the station’s convenience store. 3000 people live at this gas station…. 3000! HALF are children (around 500 are younger than 2!!).
3) A reflection inspired by my co-volunteer, Ammar Idelbi: It is summer in Greece, and the weather can get uncomfortably warm during clinic hours which are at midday. The clinic, which is an artificial outdoor space between two parked vans with a tarp overhead, occasionally gets a nice gust of wind which carries a taste of coolness that all the staff members appreciate. We pause and enjoy the air passing through our hair and take a moment to soak it in. The exact same ‘breeze’ we lavish in can be a nightmare for the refugees living in the EKO camp. Even a mild wind gust lifts their untethered temporary abodes off the ground and blows all of their remaining belongings this way and that. It makes a mess. It is a microcosm of their current life realities. They live moment to moment, not knowing if the next ‘thing’ is a blessing that relieves them or a hardship that afflicts them. All they can do is hold on tight and hope they don’t get blown away.
May 20th, 2016
Note from the NEJM Journal Watch staff — Ahmad Yousaf is currently on a trip to help care for refugees in Greece. He is sending daily updates to share his thoughts; we will be posting them here daily.
The discomforts of travel are real. Stress, related to the unknown: flight times, traffic to the airport, crying babies, ‘random’ security checks … Being alone, away from my wife and kid. It’s annoying. And uncomfortable. And a little sad.
Travel is frustrating … Even when you are the one who planned it. As I travel to Greece, I sit in the airplane thinking about the privilege of having those discomforts.
Greece is not the home of Syrian refugees either … but they didn’t plan the trip that got them there. Bombs and bullets booked their tickets. Flight times do not worry them; finding a safe place to live does. Traffic is not a concern; starvation and dirty water are. The sound of crying babies is not something they get annoyed by, it’s something they yearn for. The loneliness they feel is not as temporal as a planned itinerary, it has been made permanent. This is the reality of the Syrian refugees in Greece. Permanent travelers. Permanent strangers with seemingly permanently discomforts. Their homesickness is not like mine … Because I still have a home to return to.
I’m praying for the Syrian refugees. Praying for their homeland as it was and as it is now. It is the least I can do.
May 13th, 2016
“Be careful. He’s violent.” That was the way sign out began for Mr. T. The intern continued, “He has been in the hospital forever because he was kicked out of his nursing home. Good luck. And, oh yeah… he’s blind.” Puzzled, I looked at my list of patients and, not sure whether I should write “violent” by this patient’s name, I decided instead to write “blind.” I paused. The intern said, “Don’t worry, he hit someone with his cane. When you enter his room, just keep your eye on the cane.”
The next morning, as I approached the room, I was nervous and unsure of what to expect. When I knocked on the door I was greeted sharply with a bit of a grunt and a quick “Is that my breakfast tray?” I quickly responded ‘no’ and that I was the new doctor on the team. Knowing that a hungry patient can be tricky to warm up, I decided to sit down first. I found a very tall African American man sitting near the window, listening to the radio. Mr. T appeared much older than his stated age, and he wore a spirit of fatigue that was heavy and ominous. I could also sense his strong feelings of distrust, which I often see in African American patients, but his inability to see his surroundings presented an even higher barrier for me to climb.
During my first two days of taking care of Mr. T, I didn’t examine him. I just sat there with him. Shamefully telling my attending on both days that the patient was on his way to dialysis when asked why I was unable to examine him. I knew he felt violated and distrustful, so I wanted to wait for him to trust me. First, I started with asking about the music he enjoyed, since he was always listening to the radio. Through his love of music, I begin to learn about his life. I found out that he grew up in the foster care system, that he had been homeless for a year, and that, at the young age of 40, he lost his vision due to diabetes.
While getting to know Mr. T, I also began to learn the dynamics of the unit. Mr. T had been labeled as violent and there was no turning back. The nurses didn’t take to Mr. T, and he didn’t like the nurses. The doctors stayed away from his room and only entered with a quick hello in the early morning during rounds. The most striking thing I observed was how people would talk about Mr. T very loudly near his room and as he walked the halls, as if he were both deaf and blind. The nursing assistants would say loudly, “I had Mr. T yesterday, I want a different patient today.” The phlebotomists would ask the nurse next to his open door, “Is this the blind man? Do you think he will let me get his blood today?” I often would get a frantic call to Mr. T’s room to find him in a yelling match with a team member about his food tray and why his breakfast never came before dialysis. At first, I didn’t understand: This was not the gentle Mr. T that I knew from our afternoon chats. But then, I realized that it was.
I realized that Mr. T’s greatest problem was that he didn’t feel in control. He could not see, he was in unfamiliar surroundings, and his housing security had disappeared abruptly. One day, after I was able to calm him down from yet another shouting match with food services, I finally asked him, “Mr. T, why are you so angry today?” He said to me, “I hear how y’all talk about me around here. These people come in my room with an attitude and an opinion of me before they even meet me. And y’all wonder why I’m so angry. I just want to be able to get my breakfast before I go to dialysis. I come back 4 hours later, hungry and tired. Don’t you get your food when you want it?”
I had no response to make. Although I did not know all of the background about what had caused his displacement, I knew we were failing him. Failing him as a team, as a unit, and as a healthcare system. I also questioned how we formed our opinion of him in the unit. Were most of our opinions and feelings toward him formed before we even met him? Did we let our professionalism level slip as a medical unit because of our biased opinions? Isn’t true professionalism defined by our insignificant daily activities? We were anchored into our opinion of him as violent, similar to how to a doctor can be anchored in a diagnosis of pneumonia. When presented with new information on Mr. T, were we able to reassess our position towards him?
With time, Mr. T begin to mellow out and became less angry about his breakfast. Less because he trusted the staff and more as a sign of defeat because the prospect of him finding a long-term home became dimmer. His fear, which initially was displayed as anger, transitioned more into withdrawal and quiet spirit. Despite this change in spirit, the unit continued to label him as “angry” and, each shift, the nurses and doctors would sign out, “He’s violent. Watch his cane.” Without any mention of his distrust, loss of control, and the effects that his vision impairment had on his interactions with the staff.
Finally, a nurse came up to me and said, “I don’t know how you deal with Mr. T. He seems to only like you.” Frustrated with the stigma surrounding my patient, I wanted to ask everyone on the unit, “Why have we let our professionalism suffer when faced with the demands of a difficult patient?” But I was too exhausted and weathered from the dynamics of the situation. I simply answered, “I’m not sure either.”
May 6th, 2016
“Is he dead?”
I stepped up closer. He was yellow. Bright yellow. Steve had been admitted to the hospital for altered mental status when his last PET Scan revealed that the pancreatic cancer had spread from the tail of his pancreas into his liver where it now blocked the ducts that carried the bile out of his body and left him jaundiced. I had been paged a few minutes earlier by a frantic nurse who told me that the patient had stopped breathing. It was 1AM and although I could have been asleep, I was in my 2nd month of residency and too scared to rest my eyes. I rode the elevator up to the 9th floor with almost no idea of what I was going to do if, in fact, he was no longer breathing.
I had received sign-out from the day team that the patient was on inpatient hospice and ‘no heroic measures’ were to be taken if his heart stopped beating overnight. “Heroic measures?” I thought to myself. What did that mean? Thoughts of Superman performing super effective chest compressions and pushing epinephrine crossed my mind. The elevators opened, and I walked toward his room.
Earlier in the evening, I had introduced myself to his family who had been sitting by their dying father and husband. I had tried to smile warmly but was afraid I came off as an insensitive, grinning madman. I probably had stayed too long to overcompensate for my awkward smile; I had rambled about things that didn’t really matter. I almost made a joke… then thought better of it. I had ended the torturous encounter with a “so sorry” (I was not sure if I was apologizing or just searching for any words to fill the void) and a “if you need anything at all …” After fleeing the room I prayed to God that this patient would not die on my time. Unfortunately, my prayer was not answered that night.
Now, I stepped into Steve’s room and quickly realized that it was no longer his. It smelled of death, and I felt like I was walking into a room frozen in time. I had this eerie sense that I was walking in right after another had left with something more valuable. The silence was profound… except that there was something… I heard the sound of breathing. I approached his bed, and then I saw her. His wife had pulled up a chair next to him and was fast asleep, unaware of her husband’s passing. I stared at Steve and then back at his wife. How long should I leave them like this? She needs to know… but how terrible a thing to wake her up to the worst news of her life. I did not want to be the one to do that. I was supposed to be a preventer of death…
“Pssst!” The nurse was now at the door trying to get my attention. I looked over and shrugged my shoulders. I had no idea what to do. “You have to tell her,” she whispered sharply, “you have to pronounce him dead!”
My confusion must have been apparent because she rolled her eyes and said, “You need to listen to him and give him a time of death!” I nodded as if I knew that already. Much later, I heard about another intern in a similar predicament — she had been told that she was to pronounce a patient dead. She entered the room, which was full of the deceased’s family and stated loudly, “I now pronounce you dead!” She then exited hurriedly and told the nurse that the ‘pronouncement ceremony’ was over.
I exited the room and told the nurse to give me a second. I pulled out my Intern Manual and found the section about how to pronounce a patient dead. The manual told me to listen for heart sounds with my stethoscope placed on patient’s chest for an entire minute and, if heart sounds were absent, I should pronounce the patient dead and document the time of death in the chart. I re-entered the room with a bit more confidence and looked at the sad portrait in front of me — a loving wife lying with her beloved husband. It felt like a dream. I observed her chest rise and fall with every breath and his stay so motionless. He looked far more at rest than she did; her brow was furrowed, the area around her eyes dark with circles of worry and sleep deprivation. I moved close to her and placed my hand on her shoulder. “Ma’am… Ma’am.” She stirred a little… I glanced back at the nurse in the entrance of the room and realized she was growing more and more impatient. “Ma’am… we need to talk.” Her eyes began to open slowly as she rose to consciousness and then, suddenly, she sat up…
“Is he dead?”
The words hurt me. As if she had thrown bricks into my chest. I could not find the yes that was buried somewhere between my heart and my throat… I nodded. She let out a deep sigh and with it, tears fell from her eyes.
“I’m… I’m sorry.” Those words again. I really do not know why they always seem to fall out of my mouth in moments of perplexity. I stood there for a while watching the two of them. Watched her wrap her arms around him and speak to him as though he would answer. The nurse came in. She went over to Steve’s wife and asked her if there was anyone she wanted to contact. The nurse got a number and left the room. I still had not moved. This was the first patient I had ever pronounced dead. I looked at the clock: 1:54AM. That would go into a record somewhere, because I had stated it was the time he died. The moment was heavy… heavier than I had ever anticipated. I was no longer one who just tried his best to prevent death; I was now also an announcer of its arrival.
April 27th, 2016
The following is paraphrased documentation, authored by a physician I know, regarding an intoxicated patient in the ER:
1AM: Patient is telling nurse, “Before I leave, I need everyone’s name for my lawsuit. Tell the phlebotomist that if he’s good, he’ll get a cut.”
1:40AM: Patient is making inappropriate sexual comments and is verbally aggressive with medical staff. He is advised to stay in bed.
2:02AM: Patient (who had been sleeping comfortably) wakes up and begins screaming obscenities at everyone. When a nurse asks why he was angry, he says, “What do you think , mother f*****? I will wipe your a**.” Multiple attempts to calm patient fail.
I will stop here, because the insulting language, obscene physical gestures, and eventual threats of physical abuse only become more vulgar and inappropriate. The attending recorded in the chart, word for word, the things that spewed from the patient’s mouth and, eventually, when he became physically aggressive, called the Crisis Team who came and restrained the patient. The story was shared with me by one of the residents who had witnessed the entire discourse, and we laughed about the absurdity of some of the drunken babble. We also smiled in speaking about the state of mind of the doc who documented the conversation so meticulously in the chart. She must have just had it with the abuse and decided she was going to permanently record all the nonsense in the EMR.
As I sat by myself, thinking about the somewhat comical story, I realized that it really was not funny at all. This is the status quo. Healthcare professionals deal with patients like the one above every day. The verbal abuse and physical threats are so common that we have settled in to just trying to find some humor in them. This type of abuse is not unique to the healthcare field, but the difference is that you cannot just stop treating your abuser. You have to make sure he or she gets better… You cannot fire a patient in an ER who would die in the street if you kicked him out. Every doc or nurse has an anecdote in which they have been spit on, urinated on, cursed at, assaulted, or threatened.
In the medical world, we do not talk a lot about this aspect of our training and experience. Incoming residents have no idea that, along with their medical education, they will be getting a pedagogy in dealing with some seriously aggressive personalities. Whether it is a drunk patient in the ED, an angry family member, or the overtly psychotic patient on the psych ward, being on guard becomes second nature.
I remember one resident laughing hysterically as he described an enraged patient using the TV remote as weapon against his caretakers, swinging it in circles like a lasso. Or the time a family member broke into the medical lounge and attempted to physically intimidate a resident into changing a medical plan for a dying patient in the ICU. I have seen female trainees and attendings cat-called, harassed (both physically and verbally), and made to feel unsafe by the people they care for. It is tough to diagnose and treat someone when you cannot put your hands on them without fear of a violation of personal space.
This is medicine. There is so much beauty in the patient-doctor relationship and so much that I could say about the wonderful people whom I have learned from and loved while they were under my care. But, like anything else in life, medicine has a dark side that we rarely discuss with people outside of the field. With an increasing percentage of doctors feeling unappreciated, abused, and depressed, maybe it is time to share the whole story (N Engl J Med 2016 Apr 28; 374:1661).
Please share your experiences.
P.S. God bless nurses, who deal with this stuff even more often than docs do.