Shame, vulnerability and the Impostor Syndrome

Take a look at this TED talk. 

Brené did a mixed methods study on connection and shame and unexpectedly found that at the base of our connections was our comfort with vulnerability.

 “Connection is why we’re here. It gives purpose and meaning to our lives”. Connections are the basis for all social interactions. It is impossible as a physician to ignore connections in our daily lives. I think of the usual connections when I say this, the relationships we have with our patients and their families, our colleagues, our community, our own families and friends, and ourselves. Brené suggests that shame unravels connection. Shame makes us feel unworthy of connection. Underpinning the shame was excruciating (not comfortable) vulnerability. Impostor syndrome strikes again!! I’m not smart, thin, fit, happy, well enough to be a doctor. The sense so many of us feel that there was a mistake including us in the Hippocratic Oath. 

In this study Brené describes a subset of her population as having a sense of worthiness, a strong sense of love and belonging, and who also believe they are worthy of love and belonging. Brené calls these “whole hearted” people. She found they had a sense of courage, originally defined as telling the story of who you are with your whole heart. They had the courage to be imperfect. They had the compassion to treat themselves well first, then someone else, because we can’t be kind to others unless we are kind to ourselves. Lastly, they had connections in their lives because they were brave enough to let go of who they are. They fully embraced vulnerability, believing that what made them vulnerable made them beautiful, a necessary (if occasionally difficult) willingness to invest themselves in something that might not work out. To me, all docs must at some level be these whole hearted type folks. To apply for medical school, to write the MCAT, to apply for residency and finally join a practice requires an acceptance of our vulnerability, even if we, like everyone else we struggle with it.

“We numb vulnerability” with substances, poor behaviour, food, work, etc., but Brené suggests that this numbs all of our emotions as well. Essentially, if we are unable to allow ourselves to feel vulnerable, that we won’t feel joy, sadness, etc. There are lots of reasons for docs to feel vulnerable as we constantly flirt with the unknown, perform tasks others wouldn’t dare, etc. We also know lots of ways to feel numb.

 Certainty for us comes in the form of, well, forms and checklists and Evidence Based Medicine. If we can point to a study that allows us to stop/start/increase/decrease a statin, we can make a choice that we don’t have to worry about. I’m not advocating for a return to paternalistic medicine, but that we continue to treat the patient, not the numbers. Even writing that makes me feel uncomfortable. What if my patient has a stroke that is debilitating and decides to sue me because I didn’t push hard enough to keep her on a statin? Making choices with our patients in a patient centred way requires us to feel vulnerable in several ways. We are allowing our patients to know that we don’t know all the answers. This flies in the face of many of my preceptors who advocated that I pretend I know what I’m doing and talk about my proposed treatment plan as though it was unquestionable  to make the patient feel comfortable. As I’ve talked about before, there are thousands of new journal articles published every week making it impossible for us to keep up on everything, especially if we are generalists. I think it takes courage to prescribe ANYTHING given that there may be a time in a few weeks or a few years that this med is considered as useless as blood letting (or is that back in fashion again). Nutritional advice is a perfect example of how information flip flops. Again though, we are encouraged in our training to stand by our published guidelines of our various groups. These are helpful to be sure, but are still just guides to helping patients make decisions. 

Being taught explicitly and implicitly through paternalistic modelling, I rarely had a chance to feel comfortable in my uncertainty as a learner. Thinking about answers when I was being pimped, trying to consider more than one organ system in treatment plans, offering more than one treatment for an illness was discouraged. I was to be confident at all times, and if I didn’t feel it, I was to fake it. I was punished with poor grades if I acknowledged uncertainty in my assessments and plans. It makes allowing myself to feel vulnerable in my practice difficult. 

One step I’ve taken to correct this is to find my own therapist, and as Brené suggested, I found one who is a therapist for therapists - “it’s necessary because their bullshit meter is higher”. You know it’s true. Anyone who has ever done time in the ER with psych patients knows how to say what needs to be said to ‘pass’ your suicidal ideation screen. She is not a therapist of other doctors though which has provided me with a refreshing insight into what I’ve learned to take as gospel. She will frequently say, what? does everyone think that is reasonable?? and help me to find my place in this community. 

We need to believe that we are enough. This rewards our courage to feel vulnerable in front  of our patients and colleagues and sets the stage for an ability to feel grateful and well in the future. It sounds that uncertainty and vulnerability is something we can practice until we are comfortable with. We should promote vulnerability in our learners. We need to talk about the shaming that occurs in our profession (these young docs, thinking they should only take on 1000 patients at a time; oh, vacation AGAIN?, etc.) and show its ridiculous nature. Shame has no place in a doctor’s professional and personal life if at the end of our day we have completed our job to the best of our abilities. It doesn’t need to be perfect or neat, but given the resources of the day, it will be enough. The connections we have with other people in our lives will be stronger, and, hopefully, quiet the shaming and impostor syndrome voices. 

A True Love Story

First things first. Go get some tissue. Sincerely.

Next, watch this video. It's beautiful. Seriously. Watch it.

Did you love it? Of course you did. Daily love letters? Planning for a partner's life after you die?

Now you may continue.

This is a love story that I first learned about more than 10 years ago. They were one of my favourite couples who came to my restaurant when I was serving. They came from India during a time when you did not date outside your caste. Especially not the untouchables, but love goes beyond these invisible borders when you are good people.

They went to school and were educated in medical fields. One became a brilliant researcher and teacher, the other a fantastic clinician working to save lives. I have had the honour of hearing stories from the students and patients of these couples. They are well loved by those they serve.

The love they feel for each other was obvious in their dealings with each other - the tenderness they showed one another over their table through touch and words, the way they shared their meals, Mrs. would always bring home a treat for Mr. when he wasn't able to make it to dinner. They would tell me stories of their courting and their move from India to Canada. I would often end in happy tears with the two of them. (by the way, can you see why Family Medicine had to be where I'd end up?)

Fast forward over my medical training.

I am doing a hospital elective in the town I used to live in, where I first met the brilliant couple.

We are paged to see a patient who is not doing well. There is a long history of cancer and chemo complications. I'm shocked to recognise my Mr. Love Story on the hospital bed. He looks unwell. Very unwell. I can tell immediately that he's actively dying.

We catch up, I learn the course of his metastatic prostate cancer over the past year. About all the treatments he has been through for the past year. About how Mrs. LS has never left his side, sleeping many nights by his hospital beds. The entire time, they are holding hands, looking at each other with the doe eyes I didn't even know I had missed. Mrs. LS tells me that the love she feels for Mr. LS is only growing stronger through all of this. Mr. LS's biggest concern is that he is leaving Mrs. LS with unfinished business. And how will she continue without him around? Their children will be some comfort but, as with all families, they are busy.

Next comes the part I hate the most. The goals of care talk.

They think they are in the ED for a quick fix so they can go home together. I tell them I think that Mr. LS is dying. They aren't surprised but they are sad. Mr. and Mrs. LS want to have a few more months together. I'm hoping for a week. Mostly I'm annoyed that the colleagues of the LS's didn't let them know (or at least ensure they understood) during their treatments that Mr. LS was dying. I know it's hard to have perspective when the patient is someone you know. I learned that it is even harder when it's someone you love.

My colleague came to see the LSs and did the evaluation. My visit was to determine goals of care and ease the conversation for the next doc to evaluate and admit Mr. LS. The next doc came and told me that my week was overly optimistic and that Mr. LS would not have more than a day.

The funeral service was beautiful. Both communities came out to celebrate the life of Mr. LS and the love between him and Mrs. LS.

As with most of these painful encounters. I want to learn.

Lessons learned here:
1. Love stories are important. They are everywhere and give us something to hold onto when everything else is crappy. Ask patients and find out what their love story looks like.
2. Having perspective with patients who you are emotionally attached to is impossible. Ask for help. Know where the boundaries are.
3. Find out patient expectations early in the interaction to best help your patient.
4. Serving others provides your emotional self with great nourishment and can allow a love to grow exponentially through adversity. I served food as a waitress but now I serve my patients. I am constantly overwhelmed by the lives my patients live and their willingness to share these lives with me.

All of Life's Important Lessons

Everything you need to know comes from the movie Princess Bride.

Here, Buzzfeed shows us some of the funnier lessons.

A mom blogs about what Princess Bride taught her about autism. I love her take on it and think it's applicable to everyone, not just those who love someone with autism.

My favourite lesson is the first:

1.  Affection doesn’t have to mean saying I love you

Reading a story to someone who’s sick in bed, saying “as you wish” or playing rhyming games that annoy your boss... there are many more ways to show love than just those three little words.

I've found a new reason why this is important. Many patients that I have are stubborn. Shocking I'm sure. Today I told a woman that because she refuses her daughters' help, it's like she's not letting them show her how much they love her.

I may have just taken the guilt trip to a whole new level.

Med Students are Biased Against Obese Patients

I want to pull out the original study, but from this article it looks fairly well done.

Essentially, 3rd year medical students in North Carolina were shown drawings of a thin or obese person and the time to associate positive traits was measured. 1/3 were moderately to severely biased against the obese diagram.

This isn't shocking - we've seen it before with practicing docs.

When planning my education objectives in residency, I often hear warnings about recognizing that there are things I know I don't know, things I know I know, things I don't know I already know and things I don't know that I know

Something I like here is that they point out that we need to find a way for students to be aware of their bias. This is a tricky thing to teach since it often falls into the category "what we don't know we don't know".

Teaching students to recognize bias must be a lot like doing psycho therapy - challenging the thoughts that go on behind our actions. It may be that teachers acknowledging their own biases during case presentation may make it second nature for students to include acknowledging bias in their own work. Providing a positive role model to med students is important. We know that clerks are sponges for behaviours they see on the ward. It seems reasonable that positive behaviours can be picked up this way as well. Possibly, we need to devote class time to learning about distorted thinking. We discuss the biases which are inherent in most medical research but often miss the bias we bring to our everyday life.

"If doctors assume obese patients are lazy or lack willpower, they will be less likely to spend time counseling patients about lifestyle changes they could make," he said. "Doctors also may be less likely to recommend formal weight loss programs if they assume their patient is unlikely to follow through. "

Miller said bias might also make doctors less effective. "If a patient senses his or her doctor doesn't like them or doesn't respect them," he said, "that will damage the trust that is key to an effective patient-physician relationship."

This is an issue for more than just obesity. We see this in substance abuse and alcoholism as well. If we don't ask, don't offer help for change, we are cheating our patients.

More importantly, if we allow our biases to lead us, we are teaching the next generation of docs to do the same.
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The patients you think about

Have a look at this article. I've been following the blog on twitter and learning quite a bit. This case in particular raised my shackles a bit.

Similar aged woman presents late at night to my ED with a week of deep, dull chest pain. No risk factors. Her ECG was beautiful. D-dimer was negative. OE viral URTI. No improvement with ibuprofen. I was reassured and sent her home to follow up with her family doc ASAP.

Even now, seems reasonable.

I recognize though that I'm someone who suffers from "Nah, it can't be." I know in this case I did all the investigations I would have done for a 45 year old except calling radiology to get a CXR.

Having cases like the one described in the ECG teaching help me to keep perspective. I think we need to share. These odd cases so we remember that not everything we learned in med school was true.

The trick, as ever, is protecting patient privacy while expanding the knowledge base we have available.
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Doctors choose less care compared to their patients

I've talked before about how I feel about end of life care. I want my patients to be comfortable. I want to avoid any interventions that are not going to improve quality of life. Patients and their families don't always agree with what I want. That's their prerogative. End of life is a scary time for people and involves decisions we hope to never have to make.

Patients who are doctors tend to choose end of life care with the least interventions.

"In a 2003 article, Joseph J. Gallo and others looked at what physicians want when it comes to end-of-life decisions. In a survey of 765 doctors, they found that 64% had created an advanced directive—specifying what steps should and should not be taken to save their lives should they become incapacitated. That compares to only about 20% for the general public."

It may be worth including these stats when discussing end of life care with our patients and their families. We are always told to use evidence based medicine, and to not ever answer "what would you do if you were me" with a straight answer. This seems like an ethically sound way to answer this question.

Everything I need to know about being a doctor I'm learning from Terry Pratchett: Cackling

I love the Disc World series by Terry Pratchett. It is just silly enough to be a great distraction after work and just serious enough to make me feel like an adult while reading it.

There are many witches in the series who act as the health providers in this world - there are doctors too, but those are usually men who are in the city rather than in the mountains where illness is actually happening.

In the stories of Tiffany Aching, an up and coming witch from a sheep farm, we get introduced to the culture of witching and what is expected of witches. These books are rich with, what I consider to be but could very well be far too self centred, analogies to being a physician in a rural setting.

A good example of this is "cackling" which is mentioned in several books and warned against, lest you turn into a Black Aliss and get stuffed in your own oven.

In "Wintersmith", page 17, Pratchett explains cackling:

'When you got right down to it, it was all about cackling. No one ever talked about this, though. Witches said things like "You can never be too old, too skinny, or too warty," but they never mentioned the cackling. Not properly. They watched out for it, though, all the time.

....

"Cackling," to a witch, didn't just mean nasty laughter. It meant your mind drifting away from its anchor. It meant you losing your grip. It meant loneliness and hard work and responsibility on other people's problems driving you crazy a little bit at a time, each bit so small that you'd hardly notice it until you thought that it was normal to stop washing and wear a kettle on your head. It meant you thinking that the fact you knew more than anyone else in your village made you better than them. It meant thinking that right and wrong were negotiable. And, in the end, it meant you "going to the dark," as the witches said. That was a bad road. At the end of that road were poisoned spinning wheels and gingerbread cottages. '

The witches of the Disc World visit each other to keep an eye on each other. Physicians work in similar circles and hear stories about one another though they are frequently not as forceful as Pratchett's witches who will tell a sister witch that they are beginning to cackle. Physicians tend to hope that their fellow docs will figure it out.

We have the CPSO for patients and doctors to report inappropriate or self destructive behaviour. I don't know, because I can't imagine how one would go about doing this research, but it seems that we are likely missing quite a few docs who have begun to cackle.

Looking at the back pages of the Dialogue magazine you see many examples of physicians who have let their minds "drift away from it's anchor". A compassionate person can look at the examples of narcotics mis-prescribing as easy to fall into. It can start with someone who is having a bad time and needs help with pain and with escaping their reality. You've done it once, why not do it again? Bit by bit this can escalate to trafficking - thugs on the street are doing it, why can't I?

Self prescription and self doctoring is extremely easy to fall into. I know enough to take care of these 2000 patients, of course I know enough to take care of myself! I can prescribe just what I need. But, we need someone else to keep us honest. Having a doctor as a physician is essential and I think works very well to keep our thoughts on track - if this doctor will treat us as a patient who is a doctor, not as a doctor who is a patient, by which I mean will take the time to explain a thought process and why they suggest a treatment rather than simply asking what medication the patient wants and dutifully writing a script. If you haven't seen the movie "The Doctor", it's worth checking out for this. There's a scene where the hero has hoarseness and his physician isn't worried because his patient isn't worried.

Taking care of patients without reflecting on what a wonderful privilege this is or how much they give back may leave some docs feeling empty and spent and looking for a way to fill their lives again. It may make them feel entitled to certain allowances such as not keeping proper records, charging extra fees not acceptable by their college or possibly, unfortunately, taking advantage of patients. There are far too many stories in the back pages of the Dialogue about sexual abuse of patients by doctors. To be honest, one story would be too many.

While I never expect to see a doc wearing a kettle on her head, I have seen docs who are a little bit lax on rules, guidelines, and expectations. I have yet to let these docs know that they are beginning to cackle. I hope this is because of my position as a lowly resident without any authority rather than not having the back bone to keep my colleagues from "going to the dark".

It would be awful to lose a friend to being shoved in an oven by a couple of kids.

Obese Physicians

The January web volume of the journal Obesity contained an article "Impact of Physician BMI on Obesity Care and Beliefs".

It found that physicians with normal BMI were more likely to engage their overweight and obese patients in conversations about weight loss than their obese colleagues. These docs also had greater confidence in their ability to counsel obese patients about exercise and diet. These docs also felt that the patients of doctors who are themselves obese would not trust those obese docs to give advice about their patients' obesity.

They also found that 93% of the docs would only diagnose a patient with obesity if they were confident that the patient weighed more than they did.

There are a couple of implications to these findings that I find concerning.

The first is that obese docs don't trust themselves to help their patients with obesity. It makes sense. Obese docs may feel ashamed that they are unable to control their own weight. I see it more like an AA sponsorship though. A doc who has dealt with weight issues may be better able to share their experiences and help patients avoid pitfalls. There may be less judgement. Though in AA, a sponsor has achieved sobriety. With obesity, it may be the doc who reaches a normal BMI who is best able to provide this support. One study showed that the patients of obese docs are more likely to have a normal BMI than the patients of doctors with normal BMIs. The Cardiac Exercise Research Group compared this to smoking doctors who are less likely to counsel their patients to stop smoking.

The second is that docs with normal BMIs have so little faith in their obese counterparts. Given the squeals of "ew" when images of MRIs of obese patients were shown in class during med school, I shouldn't be so surprised. I wonder what it would take to change these beliefs?

A third is that docs are most comfortable diagnosing obesity in patients who weigh more than them. The implication here is that even docs who have a normal BMI are judging their weights against that of their patients. That's sad.

What I find most disturbing about this article though is how other media have been presenting its findings. E.g. "Fat Doctors Can't Help Fat Patients"

While I wasn't able to find articles on patients' perceptions of fat doctors, the comments on some of the articles I looked at speak volumes. Essentially that they wouldn't give a fat doctor's advice on weight loss much weight, if you pardon the pun. I wonder if this would be different though if they actually met the doctors and developed a relationship with the doc.

When you learn about the ways to help a patient lose weight, we learn about motivation and goals. It may be my goal to be a doctor with a normal BMI, but my motivation is to be a doctor who will earn the trust of her patients. Further motivation for me to follow my New Year's resolution of following the advice I give to my patients.

So a car accident walks into a bar....

It was like a weird joke.

Driving to work, I saw that a van had flipped and there were no flashing lights yet. I pulled over to help because it looked like a bad situation.

When I got to the van, there was someone perched on top working on pulling the driver out. He said "don't worry, I'm a paramedic", guy beside me said "and I'm trained in first aid" then, of course I had to say it, "and I'm a doc".

I've always known that the paramedics do so much for the patients at crashes but I didn't really get it until I saw this guy on his way to other gig standing on top of a van helping an injured stranger out through the passenger window. I felt useless aside from acting as cushioning in case either fell off the overturned vehicle.

When the driver was safely at the barrier, he looked at us incredulous "you ALL stopped to help me?". He hadn't seen the cars on either shoulder of the highway making sure we didn't need the extra help. We didn't. This driver had a small cut from broken glass and was otherwise perfect. Lucky guy!

The first aid responder said it best "that's just what you do - someone looks like they might need help, you help them."

Words to live by to make this a happier place don't you think?

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Doctors make the worst patients

I know I've said it before, but I'm a terrible patient. I hate being unwell and I hate admitting weakness in any way.

Right now I'm in the waiting room of my doc's office trying to look inconspicuous. Maybe if it's not obvious I'm here she'll miss me and I won't need to have an appointment.

My friend has been pushing me to go to my doc for a while. I thought I was doing well just finding a doc, but apparently she wants me to actually visit the doc too. Jerk.

I've been trying to diagnose myself. Every time something happens, I have a reason for it. I don't need someone else to tell me what's going on, I went to med school. What I don't have is perspective or the ability to differentiate between what needs to be included in a differential and what can be discarded. I have been throwing out almost all choices my friends suggest. I judge myself on a different ruler than I would my friends, family or patients. I feel ashamed for being sick. Goofy, but true.

Flipping into the mind set that I'm here as a patient and need to act that way is going to be difficult. I've always felt like I'm a bother at the docs office and since my own family doc retired, I've never really liked doctors. Like most in the health care field, my mom ensured that we were bleeding from the head or unconscious before taking us to the doctor. She sent me to school with a broken wrist, sure I was exaggerating. Even at 4 years old, I was ashamed of my broken wrist and the art work I made as a kindergartner with only one functional hand.

There's no reason for it and I don't know where this message of "thou shalt not be sick" came from but it really gets in the way of me taking care of my preventative health activities as well as getting to the doc when I am actually sick.

In general, I'm well. I get viruses like crazy because kids love sneezing in my face. While I'm this healthy and well, I should be fostering a relationship with my doc so that she will notice changes as I age that I don't notice because I'm too pig headed.

So, to my annoyingly bossy friend, I say, thanks for making me make this appointment.

Even if the doc is running over an hour behind schedule.

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New Year's Resolutions

Happy New Year!

I have a very ambitious new year's resolution this year. I want to follow the advice I give my patients.

Sure, there's the usual exercise, eat smaller meals, make sure to have at least a serving of fruits and/or veggies at every meal, etc. Those are obvious and frankly very similar to the resolutions I make (and break) every year.

Sometimes though, I give my patients pretty good advice that has nothing to do with calories in and out.

Give yourself a break. We all can be our own worst critics. It can be difficult to step back and have a bit of perspective. I often ask my patients if their best friend would let anyone talk about them like the way they are describing themselves (I'm too stupid/lazy/fat etc. to do this). We all need to act like our own best friends and support ourselves when we are thinking goofy, awful thoughts about ourselves.

Do what you love. "I hate my job", "I never have time for .... any more". Screw that. Make time. There are 7 days in a week, each with 24 hours, there has to be time to do the things we love to do.

Get the hell out of the house. It's so easy to get bogged down in the mundane triviality of our lives when we are stuck in the middle of it. Forcing ourselves to get out of the house and go to the theatre, lectures, painting classes, the lake front can make life worth living. And can add new categories of things to do that we love.

Dance. It's hard to take things too seriously while dancing. This can be done in the morning while getting dressed, at night at a bar, in the kitchen with the one you love while making a dinner full of veggies.

Let's see how this goes. I may need reminders that it's time to get out of my head and my house and that what I really need is a good dance, but this could make for a very happy new year.

The Impostor

I just got my internal medicine evaluation. It's times like these that I feel like I've pulled the wool over everyone's eyes. My preceptor gave me "exceeds expectations" in almost all categories. I know that at more than one point I knew some thing she didn't know, but I really think that was just luck since I've been to so many conferences recently.

Preceptors always say "it may be just because of your background but...." it's their way of turning my older than average status into a positive. This one however was more specific - my experience and that I'm accustomed to working at all. I apparently have a strong work ethic.

When my patients tell me that they think I'm a great doctor, I assume it's just because they like my smile (or, like my little woman from Honduras, because they like my eyes). It's hard to believe that my patients know enough about the intricacies of what is going on behind the scenes to make these statements. That is so incredibly pompous of me to not think that my patients are able to make these assessments.

It's difficult for me to take compliments but maybe it's just as well because I always feel so stupid that I need to study constantly.


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No, sorry, I wasn't talking to you

We have been trained in medical school to talk to our patients when taking their histories - not to their family members or friends - whenever possible.

I ask 3 year olds where it hurts, 99 year olds with dementia what is bothering them. Even if your family member is a doctor or x-ray technician, I'd rather hear your story from you. Other people don't mean to, but they end up flavoring your story with their own interpretation of the situation. This can change how I think about your illness which does you no favours. It took me a while to develop any sort of strategy for dealing with friends and families who insist on talking for the patient. I tell them I appreciate their concern but that I really need to hear the information directly from the patient.

Ideally we have translators that are not related to the patient interpret languages we don't understand to avoid this kind of pre-interpretation. When interviewing patients through translation it can be difficult to watch the patient not the translator when the translator is speaking, and to speak directly to the patient. The first few times it feels awkward but eventually it does begin to come more easily.

Twice now I've had patient family members come up to talk to me but I haven't recognized them because I was more focused on my patient than them. I'm very proud of this fact.

Now switch to my friend Wanda who had been living in France. One Sunday morning she woke up feeling funky but not terrible. During brunch she became quite pale and dizzy. Her heart was racing and her husband kindly described her as looking like sh...

They went looking for a doc who took patients on Sunday. The closest was a few blocks away and on the third floor of an apartment building. He was located in the third circle from downtown, definitely should be respectable. His office smelt of cigar smoke, his breath of whiskey. Not surprisingly, Wanda was concerned and wanted to leave, but her husband knew she was sick and made her stay.

When this doc found out that Wanda did not speak French well, he ignored her completely and spoke only with her husband. "does she feel this?" etc. Absolutely awful. Then he grabbed a rocks glass off his shelf, looked in it, and handed it to Nick to have Wanda go pee in it.

After being handed the glass, the doctor stirred the chem strip in the glass, giving Wanda and Nick the impression he was using a swizzle stick and may take a sip at any moment.

Even though this doc made the correct diagnosis and cleared up Wanda's pyelonephritis, he gave the couple the impression that he was not a good physician.

By the way, the reason those family members wanted to talk to me was to tell me that my patient had really enjoyed the care they got and appreciated my advice. I'm hoping that this is something I can internalize and continue to do when my life as a doc gets busier and the temptation to talk to the 65year old daughter of the 85 year old tangential patient gets stronger and stronger.

(sorry if the details aren't perfect Wanda, I'm not used to telling true stories on here!)


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Deep chart reviews

To save time and help guide our conversations when talking with patients, especially when doing consults, we will often look at old charts online and use previous consult notes.

The idea with doing this is that we will review our findings with our patients and/or their families to ensure that things are up to date. At 3 in the morning though, we sometimes get a bit lazy about making sure that everything we have written in the patient's past medical history is up to date and relevant.

We try to do the right thing by gathering information from multiple sources. We know what we need to be doing to be a good health care providers. I've been lazy and not checked info with patients, I know I'm not the only one. This makes me feel guilty and it should.

Mistakes get propagated when this happens. One patient I admitted had a mistake propagated through 3 years of consults. This patient had "bipolar disorder" in their past medical history, but did not have any psychiatric meds. I dug deeper in the chart and in the consult notes 4 years back I saw that the patient had been given a bipolar hip prosthetic. This is a fake hip with two sides to it, the cup and the ball. It is definitely not someone with an illness that should be treated with lithium or another mood stabilizer. Patients with psychiatric illnesses are treated differently than the general population. It's not something health care providers should be proud of. This was emphasized when my team realized the patient they had been explaining away cardiac symptoms as being caused by bipolar illness rather than following it up.

Another I've seen which has more dire consequences is pulmonary hypertension being changed to simple hypertension. The patient had low to normal blood pressure so the temptation to take him off his anti-hypertensives was strong. Doing this would have increased the pressure to the patient's lungs causing damage to the lung tissue.

Old notes can give us insight into a patient with chronic illness and how they first presented. Understanding our patients' health requires us to do more than skim past consult notes. We need to question those notes and make sure they are accurate. Since there are so many of us contributing to a patient's chart, we need to make sure that we use it as a communication tool. We are telling the next person who reviews the chart what the condition of our patient was at this point, and what we know their past medical history to be.

We also need to remember that these are legal documents and it's up to us to document only things we know to be true. If the history is impossible to obtain from the patient, which unfortunately often happens, we need to acknowledge that the history comes from old charts rather than from the patient.

At 3 in the morning when consults are pouring in it can be hard to remember to be diligent in out charting but our patients' health depends on it.


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My first site visit

Today I went to a community that I'm thinking about working in at the end of residency. It was very soul soothing to picture myself in a small community filling a role. And close to water. And trees. And fields. Swoon.

On the way there I went through Mennonite country.


That was a blast from the past too. Signs for maple syrup and quilts, buggies and smoke houses. This was exactly the kind of invigorating trip I needed.


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Food at work

What about eating in the hospital when you're working? This depends on whether you're a clerk, resident, nurse or consultant. It also depends on what service you're on.

When I was on the vascular surgery service, I lived on cheese and cookie sandwiches and diet gingerale pilfered from the ED fridge. My senior resident ate power bars between surgeries around lunch time. Eating an actual meal was scoffed at.

On general surgery, my team met for a working lunch to run the pt list and assign tasks. It was an incredibly busy day for all the other teams but our consultants were not in the hospital so our team had been pitching in as we could. One of the consultants from another team "caught us" sitting down to eat and made a snide comment about us being lazy. The comments and judging continued for the entire time I was on service: in rounds, on the floor, in the OR.

As someone who had been thoroughly convinced that general surgery was not for me, I wasn't as shy about speaking my mind. Given my absolute lack of sleep it wasn't my best retort though, something along the lines of being judged for multi tasking by running our list while eating so we didn't collapse in surgery later that afternoon.

The general surgeon residents got very good at finding spots in the hospital and cafeteria where they wouldn't be seen by consultants. That's ridiculous. It breeds a sense of us against them and a feeling that the bare necessities of life aren't important when you're a resident.

I was rather shocked when I went onto the eating disorder service next. Not only was I expected to eat lunch, I was also expected to eat morning and afternoon snacks as well. When I chose to work while eating my lunch I was harshly judged by the team. I got reminders when it was snack time. Wow.

The internal medicine service provided us with coffee every morning, lunch every day and cookies and milk on Friday afternoon. The pharmaceutical companies pay for these treats but we never really know who they are or how much they give. Lunches were done with rounds - line up to get yummy food (not just pizza!) then listen to lectures or take part in group discussions. These lunch hours were important for learning and for connecting with our teams and the residents and clerks on other services. Friday afternoons were EKG rounds with cookies and milk. It's hard to be terrified of not knowing how to read EKGs when you have cookies.

Something I keep being shocked about is that my internal medicine and some of my emergency medicine preceptors make sure that I get a lunch break. They often don't take breaks themselves but want to ensure that we don't continue that habit.

I think what shocks me about getting lunch is that I keep hearing so many docs (to be fair, mostly old school ones) saying that the problem with my generation of doctors is that we won't be working enough. Their fear is that we will not make medicine our whole life like they've done. Maybe that's part of the unexpected advice and push for us to take breaks - they don't want us to make the same mistakes they have.

When it comes right down to it, I don't really care if I get a nice break in the middle of the day. Having the choice to scarf some food down and access to coffee is all I really need. Every now and then I also need a breath of fresh air. Too much of a break makes me lose my momentum. Talking to my fellow residents though, I'm a bit of an anomaly. They want to have a full lunch break in their day.

Having the option to have a meal, snack, break or breath of fresh air is what makes the day go better. As with most folks in life, residents just want a bit of control over the basics of their life.


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What I learned at FMF this year

1. Skin to skin contact is important in the first two hours of life.
2. Pastry and coffee makes the world a better place.
3. The finer points of belly dancing and male exploitation.
4. My new iPad has a fantastic battery life.
5. That I still know nothing about obstetrics.
6. The best booths have free chocolate or IUDs to hand out.
7. I will never stay at a hotel without a liquor license again.

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Sometimes, I hate my patients

Like, really, really hate them. Want to punch them in the nose, squish their toes with the base of the gyne lamp, tell them they're stupid-dummy-heads, hate them.

I know that there are higher psychological reasons for why I hate them, that there is transference from someone else in my life, countertransferance of someone else in their life, personality disorders, weird smells, ..... It's just that sometimes I really don't care.

It takes quite a bit of effort for me to still treat them well. I find it hard to make my clinical decisions with these patients. Before I choose a test, a treatment or a referral to someone else, I need to check in with my conscious to make sure I'm not basing any choices solely on my hatred for the patient. Is that enema really necessary? Am I trying to ditch this patient into someone else's service so that I don't have to worry about it any more? Emotionally, it takes much more out of me. It also takes more of my time because I'm second guessing why I am making the decisions I am.

Even though I know I'm not the only one who feels this way about patients, it's nice to know that there is evidence to back that up.

I also know that I will spend more time with the patients that I like. This is something that I don't spend as much time thinking about but wonder if I should start. It would be just as wrong for me to not order invasive tests because I like the patient or spend time that should be spent on other activities.

These patients are going to more likely to lie to me to make me like them more. I have a patient who has been fibbing to me since day one because she didn't want to disappoint me. I finally called her out on it and we are going to start a different therapeutic alliance. I hate that it had to come to that. I liked being lied to and feeling like I was the best doctor ever because my patient was doing so well.

I swear, every time I think I have a handle on this whole doctor thing, something new pops up to let me know I've never had any form of competence.

Framing

Framing is something that happens quite a bit in health care settings.

It's when a patient's story is told by someone other than the patient and that story is somehow distorted.

Brian Goldman used an example of this in his talk I attended. From what I remember, the paramedics believed that the patient was on drugs, nurses thought he had borderline personality disorder. When the doc saw the patient, he believed the patient needed a head CT. This patient died of a head bleed in the CT machine. It could be that he had a personality disorder as well as the brain bleed.

When working in a rural ER, I noticed that a patient had been triaged number 5 - blue. I've never seen the lowest level of triage used before. This patient had been waiting for hours and I wanted to see why.

The nurses who had seen the patient said that it was a waste of ER space, that she just had a little cold and there was no reason to be here. I don't mind seeing kids with colds. When I asked why she and her aunt had come to the hospital, it was that they wanted to know if it was OK for the girl to see her father (dying of cancer) in the hospital or if she would make him ill.

While it's true that this wasn't an emergency, it was worth a visit for immediate help.

Last night, a patient came into the ED with "trauma". He tried to explain to the triage nurse what was happening, but she wasn't able to understand and chalked it up to "he doesn't speak English well". Same thing when he came to Fast Track, the nurse rolled her eyes and didn't understand why he was here.

I went to talk to him and asked him why he had come to hospital. He told me that he had a lot of pressure in one of his toes from trauma 1 and a half weeks ago.

In the past when he had a similar injury he had been told that he needed the pressure taken off to avoid the nail falling off. He had a whole story in his head for how it made sense. Pink finger was stage one, blue was stage 2 and a black finger was stage 3. He was stage one but didn't want to lose his nail.

His expectation for this visit was that his nail would be pierced and the pressure taken off the nail. He was afraid of losing his nail. This information made things make so much more sense and now I had something I could do.

By explaining to him how his body works and explaining how I knew that things were ok, he was happy and no longer worried. He will likely not access the health care system for something like this in the future but I armed him with red flags to show back up for.

This interaction could have easily been unsatisfactory for me and the patient if I had decided he was a drug seeker or a malingerer as he was framed to me. Instead, he left with more knowledge and I got to teach a patient about his body, something I love to do.

I'm hoping I always take the time to FIFE my patients. (Feelings Ideas Function Expectation) It's important to me and lets me sleep at night. Patients need to be heard. I need to listen to provide them the care they need.

OMG it's white coat black arts guy!!

So cool. Rubber chicken dinner number one as a doc.

He's much shorter than I expected.

Pearls of wisdom: plan your career from the top down. If your AAA is 3 cm, watch. At 5cm operate. When it's 9cm, panic. Emergency medicine is completely part time. Put your 10 000 hours in to what you love. For him, medicine and writing. Good things happen to those who wait. A Bic pen, swallowed by a kookie patient,removed under anaesthesia by a gastroscope will still write. Medical mistakes are a big problem; docs need to be able to speak freely about them, not made to feel shame. Docs need to make a connection w the elderly and remember that they have a vibrant history: their family members are important too.

Borderline personality disorder pts can be people w head trauma but erroneously framed by co workers.

He has had drug seekers tell him all their trade secrets.

He has slept in for presenting grand rounds. He changed his residency program half way through first year. He took courses on how to write during his residency. He hand wrote his first article and his mother typed it.

He started emergency medicine as a fluke because he could moonlight and write.

He's so my hero. I'm such a nerd.




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