Sunday, September 19, 2010

How to Learn "Fake It Till You Make It" Compassion

The Wall Street Journal has a new piece in their Taste column, "Physician, Humanize Thyself", about the proliferation of White Coat ceremonies at medical students, and whether they instill a greater level of compassion for students as they advance in medicine. The ritual was started a few decades ago, when students were noted to have less idealism and more cynicism than their predecessors, who had since traversed through the medical malpractice and billing changes. The idea was to make them more aware of the figure at the center of the medical world, the patient, and to retain that essential sense of compassion. Another figure in the article questions how effective this ritual can be, since the white coat is intended to visually set the doctor apart from other figures in the hospital setting, not to make the patient feel as if the doctor is on his or her side. Other techniques used by medical students often involve rituals for the cadavers, such as an appreciation ceremony where letters and poems are read aloud to the brave donors. The article misses the point, however, about what real compassion is and how it is manifested. When I applied for medical school, the two themes which pervade the interview are those of compassion and thirst for medical knowledge. But the reality is that almost no medical student truly understands compassion in a specific medical sense (unless they were previously a medical worker in some other capacity).

Compassion, when you are well rested and well fed, relaxed and without pressure, is fairly easy for most people. It is easy to walk into a patient's room at 9 am, and say that you are sorry for their problematic situation, and here is what we are planning to do, and do you have questions? Great! Thanks. Anybody who is a decent human being can do that. But real compassion is an acquired skill. It is the ability to care when you are so tired that you just do not care about anything else except sleep. It is the ability to care that someone is in pain, even if they have a long history of causing the same self-trauma over years. It is the ability to thoroughly describe a medical problem in layman's terms when you have no time to spare, and not lose patience when the patient still did not understand. It is the ability to understand that taking care of someone might require you to cause them some pain or discomfort in the short-term sense, and still be able to do it anyways without hesitating. These are all things that you just cannot pass on in a white coat ceremony, or any other ceremony. Like so many of the real skills in medicine, you have to work them, one 24-hour shift at a time. And until you have those skills mastered, you have to pretend you have them already, lest you cause major damage to the patient and family. In other words, to become a truly compassionate doctor, sometimes you have to fake it until you make it.

It sure would be nice to be able to help medical students with the faking part, at least. My medical school did one thing that I appreciated, which was practicing patient encounters with actors. Many times our experiences were laughable, and taking them seriously was next to impossible. Specifically, I remember an encounter where I had to tell a "wife" that her husband had died from a heart attack. Her response was to repeat "I can't deal with this right now, I need to get the groceries and pick up the kids" ad nausem, and then eventually stop talking. I had to bite my lip to keep from laughing, because it all felt so fake to me. (I had been expecting to see her cry, or yell at me, or have some kind of response which actually related to the news.) But having now spoken to several families after patients pass away, or are about to, I see that that experience was actually helpful in preparing me for the variety of ways that humans can respond to news. More important than the formality of a ceremony for medical schools would be the investment in standardized patient encounters, and education in situation-appropriate language. This is an area where most students (and many doctors) are still painfully lacking. At least if we have to fake compassion, we can do it with sensitive language and formalized demonstration of respect.

Tuesday, September 14, 2010

Treat For America

My first month on in-house surgery is coming to a close this weekend, and I can honestly say that I will miss it. It has been tough, of course, being Q3 and so on (and Q2 this week, to make up for getting Labor Day weekend to spend with my sister), but overall I really did enjoy things. It's nice to write focused notes, and speak quickly and succinctly, and justify not hitting the gym because I run around so much. My residents this past month have really looked out for me, and I've been able to throw in a few central lines without too much difficulty. Hopefully when I re-start surgery again in December at an outside rotation, I'll be able to hold my own.

I'm not sure my residents all feel the same way in terms of nostalgia for surgery at my hospital. Without saying too much to identify my medical center, it is an old, small community hospital in the NYC area. I have rotated at a lot of not-so-well funded hospitals in NY, and this is probably the least funded of all. At our hospital, it is often difficult to find very basic supplies, especially in the middle of the night. Shortages of medications or fluids are common, and interns often stash blood-drawing supplies in their pockets at night because the nurses' stations are never re-stocked for the evening. In summer, we have our fair share of mosquitoes and other buggies, and humidity shoots through the roof. The call room I was using had a massive hole in the wall leading to outside, with no insect screen or boarding up, for several weeks.

Small discomforts aside, there seems to be an undercurrent of deeper unhappiness amongst residents that our hospital at times seems ill-equipped to handle some patient complications. This feeling is more pronounced in the surgery residents, because we do more invasive interventions and cannot always optimize the outcomes to the standard we would like. Some residents have taken the position that if we cannot manage care at the same standard as bigger academic name-brand facilities, then we should not attempt such procedures in-house. Added to that, of course, is the general feeling of uneasiness that all residents feel when they realize just how little the patients truly know about the goings-on of inter-department politics, inexperience of residents, complications of procedures, and alternative options for care.

Somehow, I have managed not to share too much in this same experience, although I find that chipping away slowly. Last night, I had to spend 40 minutes hunting for 2 blood culture bottles so that I could find out of my acutely feverish patient had a bacterial infection post-operatively. It was time I could have spent writing better notes on my patients or spending more time checking on them (or sleeping...), and it didn't feel too good knowing that I got the last set in the hospital when we presumably have many other patients who may also be running fevers. The resident I was on with is one of the main people who quietly voices his opinion regarding our inability to provide gold-standard care at all times, and by the end of the night, I found myself getting more annoyed with my hospital's precarious financial state.

I called my sister, who is flying out tonight back to London, to basically complain for a few minutes about how I got slammed last night and how there was so much to be done, and how my hospital is disappointingly unable to provide all care for our patients. I was surprised when she (not a doctor) laughed at me, and reminded me that medicine is not equal-opportunity, no matter how much we try to make it so. "The fact is, richer hospitals exist in richer areas because you have richer taxpayers, and vice versa. Poorer people receive lesser care because the people in their areas don't have insurance and can't fund their hospitals as much. It's really that simple." She went on to remind me that American schools are often in a similar situation, but young college graduates apply in droves for the prestigious Teach For America program. "Of course it's not the best education for kids, that's the point. You're investing your time to make a bad situation better. You don't complain once you get there that there isn't enough paper or textbooks or parental support. It's a poor school. Duh."

The final note she left me on was the reminder that other family members we had who are also doctors perhaps would not be able to work under the same conditions and thrive. "Are you kidding me? They would just get frustrated that labs aren't done on time, and that not everything is on the computer, and miss the whole point of working somewhere needy. You, unlike them, can do this, you're built for it." And she's right. One day, many eons from now, I will be stronger for having worked at a rough-around-the-edges hospital, and when everyone flails because the expensive wound-vacuum system is malfunctioning and the patient is dripping bile from his fistula, I'll know how to jerry-rig the damn system, old-school.

So, I've decided to look at my program as like a 5-year volunteer course instead of a regular old job. Treat For America, it is.

Saturday, September 11, 2010

10 Things I Hate About My Life

This isn't really much of a philosophical post as much as it is...bitching.

Here are some things that I find overwhelming and just cannot stand anymore:

1) Having to beg people to do their very basic jobs
2) Having to act like they have done me a favor afterwards, and I am beholden to give them my first-born child
3) Criticism that is neither constructive nor appropriate, and unceasing even when I state a desire for cessation.
4) External pressure from people for things that are not yet in my control
5) Not drinking enough water because I am too busy running around, and then feeling like I have a UTI afterwards
6) Call rooms filled with mosquitoes that keep me from sleeping
7) Multiple parties all vying for my time and attention, followed by the same multiple parties acting offended when I cannot meet them 100% unless I forgo sleep and study time
8) Being told that I am not doing enough, and then being told that I am too obsessed with doing the same activity
9) Any level of running commentary on my appearance, ever.
10) Having finally gotten my own job, apartment and paycheck, and still not being able to exist with room to breathe.

Ok, rant over.