"How are you able to continue working after witnessing a death like that?"

I had a great question from a very insightful medical student after the first case of our day was to Code Blue that did not get any better. The code was on a young patient in my primary care. She was very unwell, and I'm sure nothing would that have changed the outcome. Tragic, true, circle of life type stuff. 

Initially, I felt really upset with myself. How could I just move on? I know this woman and her family quite well. Should not I be more upset with what just happened?

With every death, every code, I ask my team to do a quick debrief with me (longer if needed) to ensure that we did all that we could, and needed to do. I go over everything in my head as well. Where could I improve next time? Were we all wearing PPE? Did I speak with the family in a respectful, clear manner ?

This time around, the police were with us. We're a small town, so all tragedies involve them. It's great, because they call victim services if needed, get in contact with distant relatives, chase after teens who "can not take it" and run off. They are a really good bunch. They surrounded me and checked in on how I was doing. Asking if I would talk to someone if things went poorly. I am telling me I was a rock star in the trauma bay, That the family completely trusted me and was incredibly relieved to know that I would be the one working on their loved one. Basically making sure I do not get PTSD from the event - something I try to do for them all the time but was not used to having it in return. 

I was a bit upset, but felt like I was not upset enough. That I was a big faker pretending to care. 

It was not until yesterday that I was able to figure out why it is that I can just pick up and go on. This was the third patient that description fit that died in front of me this year that I was able to continue working after their pronouncement. 

I have a therapist. Everyone should. She helps me figure out things like this that niggle in the back of my head but that I do not take the time to work through. She helps me figure out when the culture of medicine is nutso and I'm right to ignore the culture and do what is right. 

Here is the answer, finally, med student of mine. I have an incredible resilience built around patient deaths. 

When I first got into med school, I knew that someone like me with a soft hear t might have a hard time with death so I sought out situations where I would be challenged. I thought about each deat h as an unavoidable event and looked for the way that I could make it the MOST comfortable for the patient and their family and (even when the patient is a baby). I learned that I could cry with family in a respectful manner. 

Each of those links is a blog post I've done during my training and practice to reflect on death and my part in it. I see myself as separate from the patient and their family. I love them in a way that is not family or friend, but caregiver. My role in their life is just a step in their journey through this world. They hold the same role in mine. While our lives intersect, my goal is to make our lives both better for the experience. I learn my lesson, then a go to intersect with another life. The lessons I've learned stay with me forever, but they are not necessarily emotional. 

Sometimes they are. A patient died of malnutrition at a young age, and you bet your ass I got angry and looked to make change. But, because I want the rest of my patients to be healthy, because i was not dwelling on his passing. 

So, my thought process goes like this; reflect on the death changeable and my role in it, reflect on the interaction with family and colleagues, move on to the next patient who needs to see me. This might happen many times during the day following that death. I still wonder if I could have done more for my patient before she died, but that use as a way to be a better doctor, not to dwell on the past. 

Death is part of life. My job is to keep moving forward. I see my getting back to work and helping other people as a way of respecting my patients' lessons to me. 

I speak fluent poverty

It doesn't make me terribly popular with administration folks. I've recently been accused of being unprofessional. This stems from the way I talk about and to patients.

I treat my patients as thinking, feeling beings who can make their own choices about their health and their life in general. I call them out on their bullshit and try to find out why they're making the choices they do. There's no point in preaching at a patient about not eating fruits and veg if the food bank has been out for a month.

I don't use flowery language because unfortunately, most of my patients are illiterate. When I started practice, I assumed many would be health illiterate, but I certainly wasn't expecting this. My staff has stepped up (I love them so) and help my patients to fill out the millions of forms that we process every month. I've stopped playing along with "I left my glasses at home" and ask them straight out how their reading is. They've been so used to lying about it, it takes them back and puts them on the defensive for a minute or two until they realize there's no judgement, just me looking to do best by them. I've gotten into the practice of reading out my referral letters to my patients so that 1. I have to finish it while I'm in the room with them, 2. they know what I'm saying about them and 3. they can correct me as I go along. My patients frequently laugh at my "doctor words" that go into those letters. That lets me know that the way I'm speaking with them is different than how I speak with other docs. I like that.

From the stories I hear from my patients, they haven't had someone who will actually listen in a long time. They get painted with the same brush as their drug dealing brother, as their morbidly obese mother, and as their father who has been in and out of jail since they were born. These folks are rarely treated as an important individual.

The same approach works for those patients I have with money and more stable upbringing. I fancy up my language, but otherwise, I continue to treat them as individuals. I don't care that you were mayor for 20 years, we are just starting a relationship, I want to know WHO you are, not what other people see you as.

Part of my approach has to do with my appearance. I've written about this before and I think I've made it clear that I am an untraditional appearing doctor. Most patients ask to see the doctor after I've been in, even when I clearly introduced myself at the beginning. Their response is not one of disbelief but of relief. "oh! you're like a real person!". I'm a bit quirky, I'm overweight, I smile all the time, especially when I don't feel like it. When my patients die, or I need to give someone bad news, or someone has divulged some horrific part of their life, I cry with my patients. It's the only way I can think of to let them know that they matter to me.

I also have a strong feeling for what is and is not fair. This is something that comes through whenever I talk to a child living well below the poverty line. Their anger and emotional outbursts are almost always associated with a feeling that something that has happened is unjust. I grew up well below the poverty line and I still get surges of rage when things are unfair. I've learned to breath deeply, reconsider my stance, and decide whether or not I need to proceed. If I need to proceed, look out. It will feel like molten lava is being rained on your head, because on top of my previous poverty speak, I am now also fluent in affluence, biz speak, economics, and ethics.

This all sounds very Polly-Anna-y, and it might be. Putting my personality in with a hospital that has administration that could, easily, use walkers, doesn't always work. I'm optimistic though that I can persuade admin to my side even through continuing to be patient centred. It's in the mission statement of every hospital of Ontario, including ours.