"My daughter killed herself by jumping off the 12th floor."
My heart sank, and it was then that I felt the weight of a father's heart.
It was a busy overbooked clinic day. I started 30 minutes early and hoped for uncomplicated consults and straightforward patients. Every patient had an assigned 10-15 minute time slot to check whether they were taking their medications, monitor for complications, analyze abnormal lab results, check and examine if there were any new symptoms to address, and discuss a plan forward. Any deviation from a targeted consultation might mean an additional 5-10 minutes and a lengthy wait for those sitting outside.
It was my second time meeting Mr Ong*. He had a chronic condition that required him to take medications on a regular basis. Prior to seeing me, he was being cared for by another physician for over 8 years, but had his care transferred to me as a result of some changes in the previous doctor's schedule. Mr Ong was what doctors would consider a "good patient" - he took his medications on time, was compliant to lifestyle advice and had good insight into his medical problems. He never took more than his allotted 10 minutes of consultation time. The first time I met him, he shared that he was having some back pain that he thought may have been a result of carrying some heavy good the week prior. I had not had time to speak with him at length about his family and social background during his first visit. I'm just meeting him for the first time, he might not be so comfortable. Maybe I will get the chance to next time, I thought before, as I trudged through my busy clinic afternoon.
That day, Mr Ong walked into my clinic alone.
Good afternoon, how have you been Mr Ong? How was your Chinese New year?
Me? I have been okay...my daughter though, has not.
It was then that he shared with me what had happened. His daughter had been diagnosed with a psychiatric illness, and was struggling with school related stress. It sounded like a long drawn battle with auditory hallucinations and self hate that culminated in a choice to end her life.
I told her, no need to think too much, she was going to complete her final year of tertiary education. But still...my words never got through to her...
He shared with me photos of her funeral, the wreaths that were gifted, the photos of her siblings and her burial grounds on his mobile phone. A beautiful girl, laying serenely in a coffin. Her youth, broke my heart.
I had no words to say. How was I to console a man who just lost his youngest child, a girl not far younger than I am? I listened in silence. Mr Ong did not shed a tear as he spoke, but only stopped to pause in between his sentences as he looked at the photographs, the longing in his eyes, all that he had left to remember his beautiful child.
It was then I had a glimpse of the banner placed behind the casket. It read "I am the resurrection and the life. The one who believes in me will live, even though they die. John 11:25"
Hope. Because Jesus lives, we also will live. In that moment of grief, we shared a moment of hope that is in Christ, that there is a hope of being reunited with his daughter on that glorious day when Christ comes again.
It was perhaps 15 minutes later when Mr Ong kept his phone and asked about his medical results. He had a clean bill of health. His lab results were pristine, his back pain was resolved. He need not come back till half a year later for routine review.
"God is good. We gain some, we lose some."
We talked about how we could help him and his family cope during this difficult period. Before he left, he shared that he clung tightly to the hope that is in God.
"希望, 我们有耶稣的希望"
I'm not certain why Mr Ong decided to share such a personal event with me, an almost-stranger, that day. Perhaps he needed someone to talk to, perhaps I reminded him of his daughter. Perhaps it was my own reminder from Him who is above - of Hope.
Easter is a celebration of victory over death. Christ is risen. Christ will come again.
*Names and details changed.
Showing posts with label On Being a Doctor. Show all posts
Showing posts with label On Being a Doctor. Show all posts
Sunday, April 1, 2018
Thursday, August 17, 2017
Dusting off this space
It's been a quiet two weeks at work, being rotated through a relatively light posting.
First week, my judgmental self had my eyes proptose at the people who came through the door, my hears twang at what information was being exchanged. Second week, I myself was rebuked when more information was revealed and what led to the circumstances as they were.
Everyone is fighting their own battles.
We recently celebrated Ye Ye's birthday, it was a quiet celebration and also an excuse to play sparklers. The photos we took were so precious, and remembered for time to come.
Tomorrow we fly off for Euro Trip 2017! With a small human in tow. Hope she enjoys it, and that jet lag won't kill us all.
First week, my judgmental self had my eyes proptose at the people who came through the door, my hears twang at what information was being exchanged. Second week, I myself was rebuked when more information was revealed and what led to the circumstances as they were.
Everyone is fighting their own battles.
* * *
We recently celebrated Ye Ye's birthday, it was a quiet celebration and also an excuse to play sparklers. The photos we took were so precious, and remembered for time to come.
Tomorrow we fly off for Euro Trip 2017! With a small human in tow. Hope she enjoys it, and that jet lag won't kill us all.
Wednesday, July 1, 2015
Carrot cake
Today I recognized the carrot cake uncle as the son of my patient whom I saw in ED a couple of days ago with ARU. It was a nice moment to ask him how his dad was doing and also a reminder to see my patients caregivers beyond the caregiver role and in the community. What a nice end to 3 years of doctoring.
In other news, here's to unemployment! D:
In other news, here's to unemployment! D:
Monday, May 11, 2015
IPMN
There are some kind of favours that no amount thanks or gifts can ever repay. One can only hope that an opportunity may arise that the favour may be repaid in kind.
D was recently diagnosed with pancreatic cancer. The hows and the whys remain a blur to me, but it started off with persistent epigastric pain. Given the timing and circumstances, I did whatever I could in my capacity to expedite treatment. I remember the day the report came out, I thought long a hard about how to find a surgeon. I had a terrible posting as a houseman in Surgery, and hardly made any long lasting friendships to be able to pull any strings. I had asked around, and many big names came up, top surgeons in particular from SGH who do complex oncological surgeries. I thought long and hard about how to get an appointment with these people whom I have absolutely no personal connection with, and found no other way other than to ring up the SGH hotline and ask for an appointment the conventional way.
Somehow Dr A's name came up later on. Once, twice and a third time. He was young no doubt, compared to the other old birds in the field, but up and coming nevertheless. It then occurred to me that he was my Facebook friend (!!). From the days of Surgical OSSEs, I wondered whether it would be really creepy and weird to drop the Professor a Facebook message to ask him for his opinion. He was always the deadpan funny tutor who sacrificed his afternoons and nights to teach us. His wife taught me during the BASIC course, and I remember poring over his family's facebook photos pre-MBBS in MD6. And so I did, I actually dropped him a Facebook message. Within 4 hours, we had a first slot clinic appointment on the Monday morning and before we knew it, D had gone for surgery within the week.
Perspectives are different being on the other side of healthcare. But understanding what happens behind the scenes made me rather zen to everything that happened. Movement in between clinics, blood tests, doctor speak and pre-operative assessments. I crossed paths with many angels along the way. M has been understandably anxious. The longer the wait outside the OT, the exponentially worried she got with thoughts of complications from surgery and anaesthesia etcetc. Grateful for friends like K who gave me live feed updates from inside PACU and M who even got the chance for MIL to go in for a bit. As the "doctor in the family", I had to give answers to many difficult questions that often have no good responses. Is D going to be okay? What did Dr A mean when he said suspicious stomach lesion? Does he need to go for chemo? I could give a good medical answer to all those questions, but unlike in the usual situation, I myself needed to deal with the uncertainty that comes with vague replies that doctors always give. Fifty-fifty, as we always say, which essentially means "I don't know".
Long clinic waits, many blood tests for which the patient never knows the reason for, days in the hospital unsure of what happens next, various choices that are given which never make any sense to the uninitiated, incessantly beeping equipment in the HD (stupid IA line waveform), worries about appetite and pain and post operative care - the patient experience is a torturous one, one that hopefully I in my capacity may help to ease for the patients who come my way.
SJ says we all should face death right in its face, and I fully agree, though not many may find easy to stomach. Death remains a certainty, in the same way we have assurance beyond death with hope in Christ.
D was recently diagnosed with pancreatic cancer. The hows and the whys remain a blur to me, but it started off with persistent epigastric pain. Given the timing and circumstances, I did whatever I could in my capacity to expedite treatment. I remember the day the report came out, I thought long a hard about how to find a surgeon. I had a terrible posting as a houseman in Surgery, and hardly made any long lasting friendships to be able to pull any strings. I had asked around, and many big names came up, top surgeons in particular from SGH who do complex oncological surgeries. I thought long and hard about how to get an appointment with these people whom I have absolutely no personal connection with, and found no other way other than to ring up the SGH hotline and ask for an appointment the conventional way.
Somehow Dr A's name came up later on. Once, twice and a third time. He was young no doubt, compared to the other old birds in the field, but up and coming nevertheless. It then occurred to me that he was my Facebook friend (!!). From the days of Surgical OSSEs, I wondered whether it would be really creepy and weird to drop the Professor a Facebook message to ask him for his opinion. He was always the deadpan funny tutor who sacrificed his afternoons and nights to teach us. His wife taught me during the BASIC course, and I remember poring over his family's facebook photos pre-MBBS in MD6. And so I did, I actually dropped him a Facebook message. Within 4 hours, we had a first slot clinic appointment on the Monday morning and before we knew it, D had gone for surgery within the week.
Perspectives are different being on the other side of healthcare. But understanding what happens behind the scenes made me rather zen to everything that happened. Movement in between clinics, blood tests, doctor speak and pre-operative assessments. I crossed paths with many angels along the way. M has been understandably anxious. The longer the wait outside the OT, the exponentially worried she got with thoughts of complications from surgery and anaesthesia etcetc. Grateful for friends like K who gave me live feed updates from inside PACU and M who even got the chance for MIL to go in for a bit. As the "doctor in the family", I had to give answers to many difficult questions that often have no good responses. Is D going to be okay? What did Dr A mean when he said suspicious stomach lesion? Does he need to go for chemo? I could give a good medical answer to all those questions, but unlike in the usual situation, I myself needed to deal with the uncertainty that comes with vague replies that doctors always give. Fifty-fifty, as we always say, which essentially means "I don't know".
Long clinic waits, many blood tests for which the patient never knows the reason for, days in the hospital unsure of what happens next, various choices that are given which never make any sense to the uninitiated, incessantly beeping equipment in the HD (stupid IA line waveform), worries about appetite and pain and post operative care - the patient experience is a torturous one, one that hopefully I in my capacity may help to ease for the patients who come my way.
SJ says we all should face death right in its face, and I fully agree, though not many may find easy to stomach. Death remains a certainty, in the same way we have assurance beyond death with hope in Christ.
Wednesday, May 6, 2015
4 May 2015
Saturday July 2012. I was still a houseman. I clearly remember seeing his gangrenous fingers from the three ionotropes he was being supported on. The stumps of the bilateral BKAs that he had undergone in a life-saving measure. My patient died not long after. I remember thinking to myself, it might as well have been a blessing, compared to having had to wake up to no more feet left.
My call two nights ago was a heart wrenching one. Into the OT as one whole, and out with an AKA stump. I was not sure if he knew, when he woke up from the anaesthesia. He was trying to say something, but I was not sure if I could bear to answer. Gram negative bacteremia announced its arrival later that morning. Then there were two little six and seven year olds sobbing by the bedside of their father, whose body was slowly growing cold from the call of death.
On days like this, I feel like medicine can be so great, but so helpless all at the same time.
My call two nights ago was a heart wrenching one. Into the OT as one whole, and out with an AKA stump. I was not sure if he knew, when he woke up from the anaesthesia. He was trying to say something, but I was not sure if I could bear to answer. Gram negative bacteremia announced its arrival later that morning. Then there were two little six and seven year olds sobbing by the bedside of their father, whose body was slowly growing cold from the call of death.
On days like this, I feel like medicine can be so great, but so helpless all at the same time.
Saturday, December 13, 2014
German Winter Reflections
Riding on the train along the German countryside triggers certain thoughts. How life could be living in a small country house, walking to work through the blistering cold winter air and ending the day with a cup of hot chocolate. Throw in some cute kiddies with the cutest fluffy beanies and life is perfect. I honestly don't think there is a catch. Throw away a little bit of that Singaporeanness and anyone could indulge in living in a place like this. The Germans are smart, clean, efficient and best of all, punctual. The people are real good looking too.
We often think of life in 5, 10 years. Maybe by then I could be consultant, sipping tea before the leisurely morning round. Maybe I would have the imagined children that people have been asking me about. But then, maybe I could have a brain cancer, and die even before 10 years is up. Life never turns out the way you think it should. Marriage, careers, health, wealth. Somewhere, something trips up. A well-loved church leader and friend recently passed away, his life celebrated by many at his funeral. I thought about the day the people I love died - my mum, my grandma, my brothers, SJ. Am not sure how that would feel. Death comes to all, and what if it did tomorrow? I selfishly hope it comes to me before everyone else so that I wouldn't have to feel the painful lost. So then, what is our life? The greatest hope and answer to Life lies in the message of Christmas, that there is hope and eternity beyond death, that death brings us only a temporal separation.
I had a nightmare about CVM manpower last night. Bizarre that even on leave I'm plagued by these rostering woes. W had warned me that being the roster monster AND in CVM really shows you the worst (as well as the better) side of everyone. Very odd call requests bordering on unreasonable, unanswered calls for help, many more reasons for being unable to lend a hand. Humans are selfish, myself included. After all, it is all luck of draw if you end up as ambulatory MO for a month or in HFS solo for the entire posting. First impressions lasts a lifetime, and honestly, there are some people I would hope never to have to refer my patients to.
I guess no one can save the world, we are just trying to save ourselves. Two years and 6 months of doctoring and here I am...admittedly a teeny weeny bit jaded.
We often think of life in 5, 10 years. Maybe by then I could be consultant, sipping tea before the leisurely morning round. Maybe I would have the imagined children that people have been asking me about. But then, maybe I could have a brain cancer, and die even before 10 years is up. Life never turns out the way you think it should. Marriage, careers, health, wealth. Somewhere, something trips up. A well-loved church leader and friend recently passed away, his life celebrated by many at his funeral. I thought about the day the people I love died - my mum, my grandma, my brothers, SJ. Am not sure how that would feel. Death comes to all, and what if it did tomorrow? I selfishly hope it comes to me before everyone else so that I wouldn't have to feel the painful lost. So then, what is our life? The greatest hope and answer to Life lies in the message of Christmas, that there is hope and eternity beyond death, that death brings us only a temporal separation.
I had a nightmare about CVM manpower last night. Bizarre that even on leave I'm plagued by these rostering woes. W had warned me that being the roster monster AND in CVM really shows you the worst (as well as the better) side of everyone. Very odd call requests bordering on unreasonable, unanswered calls for help, many more reasons for being unable to lend a hand. Humans are selfish, myself included. After all, it is all luck of draw if you end up as ambulatory MO for a month or in HFS solo for the entire posting. First impressions lasts a lifetime, and honestly, there are some people I would hope never to have to refer my patients to.
I guess no one can save the world, we are just trying to save ourselves. Two years and 6 months of doctoring and here I am...admittedly a teeny weeny bit jaded.
Wednesday, September 24, 2014
A balancing act
When I was young(er), I never thought about work-life balance. To me, work was life, and hence never the need to dichotomize both. I remember as a puny primary 4 girl watching my brother stay up late to study for his secondary 2 streaming exams, how admirable I thought that was. At primary 5 I stayed up to 12 midnight when everyone was sleeping just to make notes for the fun of it (nerd alert). It seemed novel, to devote an immense amount of energy into something that would eventually pay off. It usually does anyway. This seemed to hold true even up to years of higher education, beyond academia. I enjoyed staying back in school to work on projects, building machines (Odyssey of the Mind!), practising for school plays. Move along a few more years, I would still opt to stay back in school to finish tutorials, do Council scudwork, study with friends. Never saw a difference between the definition of work and life.
Fast forward many more years and here I am, sometimes counting down till 5pm, thinking of what I am going to do first when I get home (chop garlic? clear the laundry? or hang up with the hubs on a couch?) The distinction between work and non work perhaps is particular stark as a doctor, since not much work can be brought home anyway. As a junior doctor, the extra work usually comes in the form of reading, studying for exams and preparing presentations, all of which are difficult to do at 8pm after dinner and after a long tiring day. As such, I often find myself squeezing all forms of work-related work to between 7AM and 5PM, making the distinction between work and non-work fairly clear.
I complete my junior residency come June 2014. Looking back, no regrets starting residency on graduation. Certainly envious that my own peers who began later than me have the chance to explore the breadths of medicine beyond the constraints of a residency program, but also thankful for God's good timing in all things. I recently met up with some first year students from the LKC school of Medicine. It was rather random, and they asked me for advice. I thought about what I would have liked to know as a 2-week old medical student. So I told them to open their eyes to the breadth of medicine. Medicine isn't just being a specialist in a hospital. Neither is it just sitting around in a fancy clinic dealing with cough, cold, chronic diseases. It certainly is not just holding your patient's hand at their deathbed. Medicine is everywhere, in the laboratories, in the radiology room, in the ministry, in the community, in the environment, in education, and in your home. I told them never to be narrow minded, to explore the breath of Medicine, and to enjoy all the magnificence that it has to offer.
So coming back to work-life balance. Career or not, there is probably only so much our bodies can take. Decisions and questions, what now?
Fast forward many more years and here I am, sometimes counting down till 5pm, thinking of what I am going to do first when I get home (chop garlic? clear the laundry? or hang up with the hubs on a couch?) The distinction between work and non work perhaps is particular stark as a doctor, since not much work can be brought home anyway. As a junior doctor, the extra work usually comes in the form of reading, studying for exams and preparing presentations, all of which are difficult to do at 8pm after dinner and after a long tiring day. As such, I often find myself squeezing all forms of work-related work to between 7AM and 5PM, making the distinction between work and non-work fairly clear.
I complete my junior residency come June 2014. Looking back, no regrets starting residency on graduation. Certainly envious that my own peers who began later than me have the chance to explore the breadths of medicine beyond the constraints of a residency program, but also thankful for God's good timing in all things. I recently met up with some first year students from the LKC school of Medicine. It was rather random, and they asked me for advice. I thought about what I would have liked to know as a 2-week old medical student. So I told them to open their eyes to the breadth of medicine. Medicine isn't just being a specialist in a hospital. Neither is it just sitting around in a fancy clinic dealing with cough, cold, chronic diseases. It certainly is not just holding your patient's hand at their deathbed. Medicine is everywhere, in the laboratories, in the radiology room, in the ministry, in the community, in the environment, in education, and in your home. I told them never to be narrow minded, to explore the breath of Medicine, and to enjoy all the magnificence that it has to offer.
So coming back to work-life balance. Career or not, there is probably only so much our bodies can take. Decisions and questions, what now?
Sunday, July 20, 2014
Sunday, April 27, 2014
Till the break of day
This weekend has been one of reflecting. From Friday evening sitting in the car waiting for SJ to knock off, to this moment post ACLS, I have swung from feeling sorry, feeling guilty, feeling energized and feeling rested.
The second of May 2014 would mark 2 years of doctoring for me. As the newly minted doctors share their excitement in starting their careers, I can't help but remember fondly the days post MBBS, of looking forward to being called Doctor with great anticipation and also trepidation. These days, being called Doctor means being asked to "Please order Panadol. Patient having fever" and "Patient family requesting for update now. Please appear and talk to them."
Burnout. I look on to the generations that have gone before with great admiration. As I look back on the Saturday round just past that took up more time that I wish it did, I wonder if I qualify as being burnt out. My Friday evening was spent feeling sorry for the long 34-patient weekend round that awaited me come Saturday morning, followed up another Sunday burnt doing ACLS. I am but a baby-MO with less than 100 calls to my name, two years of weekend rounds, hardly any difficult decision making (since it is all deferred to the Registrar) and a handful of resuscitations, it seems quite unjustified for me to be feeling this way.
We attended the ARPC Saturday service this weekend since I couldn't attend Sunday service, and it turned out to be a Family Service (think children running around and action songs for worship). The second song struck a cord.
The second of May 2014 would mark 2 years of doctoring for me. As the newly minted doctors share their excitement in starting their careers, I can't help but remember fondly the days post MBBS, of looking forward to being called Doctor with great anticipation and also trepidation. These days, being called Doctor means being asked to "Please order Panadol. Patient having fever" and "Patient family requesting for update now. Please appear and talk to them."
Burnout. I look on to the generations that have gone before with great admiration. As I look back on the Saturday round just past that took up more time that I wish it did, I wonder if I qualify as being burnt out. My Friday evening was spent feeling sorry for the long 34-patient weekend round that awaited me come Saturday morning, followed up another Sunday burnt doing ACLS. I am but a baby-MO with less than 100 calls to my name, two years of weekend rounds, hardly any difficult decision making (since it is all deferred to the Registrar) and a handful of resuscitations, it seems quite unjustified for me to be feeling this way.
We attended the ARPC Saturday service this weekend since I couldn't attend Sunday service, and it turned out to be a Family Service (think children running around and action songs for worship). The second song struck a cord.
Give me oil in my lamp, keep me burning burning burning
Give me joy in my heart, keep me praising praising praising
...
Give me love in my heart, keep me serving serving serving
...
keep me serving till the break of day.
The words of the third stanza were difficult to voice. I think back on the times where I'm looking at the clock at 4:50 PM and see a new admission roll into the ward. I'm wishing that the patient is actualized at 5:01 PM which means I can knock off on time. We don't need any randomized controlled trial to tell us that patient outcomes from admissions during working hours certainly exceed those on call where the doctor-patient ratio drops exponentially. I question my heart. Keep me serving till the break of day. Not 5pm, but the break of day. What difficult words to live by, what a high calling.
Sunday rolled by with ACLS. Once again there is this sense of dread of having weekends burnt, wanting to finish and get over and done with it as soon as possible. Should the day turn out, I was assessed the last in my group, meaning that I had to observe/participate in the various cardiac arrest scenarios without being assessed. We all completed far ahead of time, and the rest of the weekend freed up was a nice surprise. Again I question my own intentions for wanting to just get over and done with it. Here we are, talking about literal life and death situations. Why has it become a flippant weekend-vs-work deal, do I not want to be thoroughly equipped?
Turning 2, I will no longer have the excuse of "but I'm just a baby MO". This walk forward may continue to incline upwards, and my prayer is for God to give me love in my heart to keep me loving till the break of day.
Sunday, February 23, 2014
Breather
Been rolling through 2014 like nobody's business, trying to keep afloat with studying, working, wife-ing, houseworking and travelling. Pastor's message yesterday on Jesus' inner circle was certainly an apt one, as I struggle to win membership into prestigious groups, I have neglected the precious privilege of being in the circle of the Most High.
Recent travels to Ho Chi Minh City, where we certainly did not do any justice to this travel destination by just lounging by the pool and making use of our Accorhotels privileges. Spent a grand total of about 2 hours "sightseeing" in the war museum and at the Independence Palace, after which we quickly proceeded to sit in a coffee and having some Vietnamese drip. Brought home some beans And a Vietnamese press
for enjoyment at home.
for enjoyment at home.
Life seems to be moving quickly. Friends getting married, becoming officers, getting pregnant, becoming Registrars. Wonder where I will be maybe 2 years down the road...maybe I will be...dead! Who knows?! Life is short. We often are asked to "foresee yourself in 10 years" - successful, presumably. Youth does not acknowledge its mortality, oh the folly of youth. Turning a quarter of a century old this year, the oldest I've ever been.
I miss my friends. Friends with whom I used to spend more waking hours with than with my family. Doing saigang, going on holidays, finding horcruxes and mugging in the library. Everyone's time has become such a precious commodity. In my mind I want to throw a big party inviting all the people I've been wanting to meet. Then I remember how I dislike big parties, and settle for trying to carve out coffee breaks in everyone's mini madness of a schedule.
Been wanting to write about strange patient encounters and the odd hospital experience. I recently stumbled upon some of my older blog entries, preMBBS, where I often stepped back to reflect on each unique patient encounter. Most of the time these days I am more flustered about the exploding team list rather than the patient's name, getting changes done rather than sitting by the bedside like the good old days. Its true. Hopefully preparing for the next exam will reignite the light in my eyes the first time I heard a ball and cage valve. The magic of Medicine, gone with the winds of time.
I miss my friends. Friends with whom I used to spend more waking hours with than with my family. Doing saigang, going on holidays, finding horcruxes and mugging in the library. Everyone's time has become such a precious commodity. In my mind I want to throw a big party inviting all the people I've been wanting to meet. Then I remember how I dislike big parties, and settle for trying to carve out coffee breaks in everyone's mini madness of a schedule.
Been wanting to write about strange patient encounters and the odd hospital experience. I recently stumbled upon some of my older blog entries, preMBBS, where I often stepped back to reflect on each unique patient encounter. Most of the time these days I am more flustered about the exploding team list rather than the patient's name, getting changes done rather than sitting by the bedside like the good old days. Its true. Hopefully preparing for the next exam will reignite the light in my eyes the first time I heard a ball and cage valve. The magic of Medicine, gone with the winds of time.
Sunday, November 24, 2013
Where to, Lord?
Identity crisis!
Some days I feel like I could be superwoman, be a top internist, heal the world, save the sick and dying. And on top of that be an educator, policy changer, researcher and leader. I would be totally okay with working 12-14 hours a day, 7 days a week and still come home to clean (not cook) wash up and be a good wife, daughter, daughter in law, friend. I feel the need to join lots of outside things, committees, service, life improvement projects, be busy in general, just because something drives me.
Then on some days all I feel like doing in be lazy, wake up at 9am and roll out of bed and a short drive to a good coffee joint. On days like this, the morning will comprise of an extended breakfast, a good read and a stroll through the supermarket for grape deals. There is nothing on the agenda, just spending time with SJ and me, planning the next holiday and the next awesome meal.
Where to, Lord? What and who and why? Does it matter?
Some days I feel like I could be superwoman, be a top internist, heal the world, save the sick and dying. And on top of that be an educator, policy changer, researcher and leader. I would be totally okay with working 12-14 hours a day, 7 days a week and still come home to clean (not cook) wash up and be a good wife, daughter, daughter in law, friend. I feel the need to join lots of outside things, committees, service, life improvement projects, be busy in general, just because something drives me.
Then on some days all I feel like doing in be lazy, wake up at 9am and roll out of bed and a short drive to a good coffee joint. On days like this, the morning will comprise of an extended breakfast, a good read and a stroll through the supermarket for grape deals. There is nothing on the agenda, just spending time with SJ and me, planning the next holiday and the next awesome meal.
Where to, Lord? What and who and why? Does it matter?
Saturday, September 21, 2013
Medicine’s Search for Meaning
By DAVID BORNSTEIN
Every day, we are reminded that the health care system is in crisis. We are going bankrupt. There are too many lawsuits. We practice defensive medicine. We restrict access. But surveys of doctors indicate a problem that penetrates much deeper than this. Today, almost 50 percent of doctors report symptoms of burnout — emotional exhaustion, low sense of accomplishment, detachment.
Countering doctor burnout with a refresher course on the capacity to heal.
Medicine is facing a crisis, but it’s not just about money; it’s about meaning.
We often think of medicine as a science, and many doctors do come to think of themselves as technicians. But healing involves far more than knowledge and skill. The process by which a doctor helps a patient accept, recover from, adapt to, or endure a serious illness is full of nuance and mystery. I was often moved by how much my father-in-law — an actor who died from a form of leukemia — drew comfort and even inspiration from the relationship he had with his hematologist (who requested a Shakespeare recitation at each visit).
Great doctors don’t just diagnose diseases, prescribe medications and treat patients; they bring the full spectrum of their human capabilities to the compassionate care of others. That is why doctors, upon entering the medical profession, speak noble words like the Declaration of Geneva (“I solemnly pledge to consecrate my life to the service of humanity…”) or the Oath of Maimonides (“May I see in all who suffer only the fellow human being.
Yet by then, considerable damage has already been done. Nearly half of medical students become burned out during their training. Medical education has been characterized as an abusive and neglectful family system. It places unrealistic expectations on students, keeps them sleep-deprived, overstressed, and in a state of fear of making mistakes, and sends the message that doubts or grief should be kept to oneself.
While the training formally espouses the ethics of empathy, compassion and altruism, doctors and researchers say that the socialization process — the “hidden curriculum” — teaches something very different: stay detached, objective, even a little cynical. Five out of six doctors say that medicine is in decline and close to 60 percent would not recommend it as a career for their children.
As administrative and documentation burdens have exploded in the past three decades, doctors find themselves under pressures to work as quickly as possible. Many have found that what is sacrificed is the very thing that gives meaning to the whole undertaking: the patient-doctor relationship.
“These high levels of distress, depression, loss of satisfaction, fatigue, and burnout have big repercussions for quality of care,” explains Dr. Tait Shanafelt, director of the Mayo Clinic Department of Medicine’s program on physician well-being. It leads to medical errors, substance abuse, and doctors quitting — something that a country with an aging population and a shortage of doctors can ill afford.
How could we help medicine overcome its own illness?
That’s a question that has occupied Dr. Rachel Naomi Remen for decades. Remen is a clinical professor of family and community medicine at the U.C.S.F. School of Medicine and the director of the Institute for the Study of Health and Wellness, at Commonweal. Over the past 22 years, she has been advancing a powerfully subversive addition to the medical curriculum, a course called The Healer’s Art.
For the first six years, Remen taught it with 10 friends, all community physicians drawn from outside the school. She was half afraid that her dean would discover it and throw her out. But gradually, the course began to spread by word of mouth, to two schools, then four, then 16, then 25. It is now taught annually at 71 schools in the United States (half of the nation’s medical schools) and schools in seven other countries.
More than 1,600 students take the course each year and about 13,000 have gone through it. And while it is described as a simple elective — a 15-hour course given in five three-hour sessions — many of the doctors who teach it, and the students who take it, see it as part of a movement. In evaluations, large majorities of students say the course fills a gap in their medical education. It helps them to feel more committed to medicine, more supportive of their classmates, more confident that they can be good doctors, and more clear about what they can personally offer patients. More than 95 percent of them say they will recommend it to other students.
“What our students say loud and clear is this course helps to keep their spirits alive as they go through the training,” explains Nancy Oriol, dean for students at Harvard Medical School.
Remen’s life has been shaped by her own experience living with illness. By her own admission, she has not been well for 60 years. When she was 15, she was diagnosed with Crohn’s disease. She underwent nine major surgeries and took large doses of steroids daily for 15 years. “My doctors told me I would be dead by the time I was 40,” she says with a laugh. She’s now 75 and has been a doctor herself for 50 years.
After medical school, on her first day in training as an intern, a 3-year-old was brought into the emergency room after a car accident. The doctors were unable to save the child’s life. Remen accompanied the chief resident as he met with the parents to inform them that their child had died. When they broke down, the sadness was too much. Remen found herself crying, too.
Afterward, the chief resident took Remen aside and said that her behavior had been highly unprofessional.
The message stuck. By the time Remen was senior resident, she hadn’t cried for years. That year, another child, a baby, was brought into the hospital after drowning unattended in his bathtub. The doctors were unable to resuscitate the baby. This time, Remen was the one responsible for informing the parents that their only child had died — and as they held each other and fell apart sobbing — she stood silently by in her white coat, maintaining her professional distance. After a while, the baby’s father, with tears running down his face, apologized. “‘I’m sorry, doctor,’ he said. ‘I’ll get a hold of myself in a minute.’"
How had she become the person a grieving father apologizes to? This is a common outcome of the hidden curriculum.
The Healer’s Art is predicated on the idea that medicine is an ancient lineage that draws its strength from its core values: compassion, service, reverence for life and harmlessness. When students and doctors connect to these values in a community, they derive meaning and strength, and can “immunize” themselves against the assaults of the medical curriculum and even the health care system itself.
To help people tap into these deep currents, the course is delivered in an unusual manner. Students and faculty members meet together in small groups in the evenings, participating side by side as equals. There are no experts, no hierarchies, no wrong answers; anyone may speak about his or her experiences or simply listen.
It begins by reminding people that it is not by chance that they are in the room. “We ask: ‘How old were you when you first realized that the needs of a living thing mattered to you?’” says Remen. “For most doctors and students, the impulse to respond to the needs of others, plants, animals, insects, and even people, goes back to early childhood, sometimes as far back as they can remember.”
Remen recalled a student who told the class that his mother used to bathe him in an old claw-footed bathtub. “At the end of his bath, she would pull out the stopper, reach behind him and get a towel, sit him on her lap and dry him. One day he stepped on the drain and it was sharp — there was pain and blood — and his mother said, ‘Never stand on the drain again.’ A few weeks or months later, as he was waiting for her to dry him, he noticed the water circling the drain as the tub emptied. He remembered how sharp the drain was and worried that the water was being hurt. After that, when his mother pulled the plug, he would drop his washcloth over the drain to protect the water.
“This is magical thinking. He was probably about 3,” said Remen. “Now he is a pediatrician and he brings the same intention to make a difference in pain and suffering to his little patients himself.”
Every culture approves and disapproves of different qualities. As the price of admission, medicine implicitly asks its members to leave aspects of themselves behind. The course explores this idea, what Carl Jung called the “shadow.”
“Everybody’s given a box of crayons and a big piece of paper like in first grade and they are asked to draw a picture of the parts of themselves they feel they can’t bring into their work as doctors,” explains Joseph O’Donnell, a Senior Advising Dean at the Geisel School of Medicine at Dartmouth, who has taught the course for more than a decade. First-year students do the exercise alongside doctors who have been practicing for decades. “Then everyone holds up their picture. You see ‘curiosity,’ ‘love,’ ‘compassion,’ ‘kindness,’ ‘creativity.’ And people say, ‘I thought I was the only one experiencing this.’ ”
The session on grief and loss is among the most powerful, adds O’Donnell. “Students and faculty are asked to become still and quiet,” he explained. “They’re asked to think back to a time when they experienced a loss, and remember the feelings, and think about what someone may have done that was helpful, or unhelpful.”
They write it down. Then the students are asked to say what was helpful. “You hear things like: They held my hand. Gave me a hug. Brought me food. Sat silently and listened.” For unhelpful, you hear things like, “They said, ‘I’d better leave you alone” or “You’ll be fine in no time.’”
When O’Donnell graduated from medical school in 1973, there was no place to discuss such matters openly. “It wasn’t safe to say, ‘I’m really bothered by what I’m seeing today.’ You just took care of it. You read the scientific articles, but you put your heart and soul aside. Here you are allowed to bring those things to the forefront in a valid way with colleagues who are esteemed.”
Dean Parmelee, the Associate Dean for Academic Affairs at Wright State University, who has taught the course for several years, recalled an incident shared by a fourth-year student who had been part of a team when a baby was stillborn.
The mother was 16 or 17 years old and she was with her boyfriend, he recalled. There were some psychosocial issues. “After the delivery, the student said, shockingly, everyone just left the operating room,” said Parmelee. “He was the only person left and the only sound was the air-conditioning and the ventilation.” The mom had started to cry; her baby lay still on her abdomen. The boyfriend was crying, too. The student said nothing. He simply reached out and took the mother’s hand and with his other hand he reached out and took the father’s hand, closed his eyes and stood there with them for a few minutes crying silently together.
“The student said that if he hadn’t taken the course, he would have left the room like everyone else,” added Parmelee. “Or he might have said something like, ‘You’re young, you can have another baby.’ ”
“Instead,” commented Remen, reflecting on the story, “he offered them and himself the healing of a common humanity.”
This is not how doctors are accustomed to managing grief and loss. “We intellectualize it, minimize it, become numb to it,” O’Donnell said.
There is an enduring belief in medicine that if you feel strongly it will cloud your judgment. But research indicates that emotional attunement can improve critical thinking, decision-making, and the ability to act quickly in crisis moments.
Moreover, we need to feel to connect with other human beings. “If patients see that you care, they can trust you enough to tell you the truth and are more likely to follow your advice,” observes Remen. Parmelee, who has been an expert witness in malpractice cases, has found that most cases boil down to physicians “not really listening or making themselves available emotionally for a patient.”
And then there is the simple truth that buried feelings don’t just go away. “When I took The Healer’s Art, the session on grief and loss brought up a whole period in my life that I must have tried hard to not think about,” recalled Parmelee. “I was totally unaware of its continuous impact on me, and how much was still there after more than 30 years.”
In medical school, students rarely hear their teachers speak this way. Brent Aebi, a third-year medical student at Wright State University, said that hearing veteran doctors speak about their struggles helped him to see a path forward that felt right to him. “I saw that you don’t have to become hardened,” he said.
The same holds for peers. The combination of hyper-competition and self-doubt in medical school can work against the development of supportive relationships. “This way of listening to others’ stories is not present in the normal medical training,” observes Rhianon Liu, a third-year medical student at Johns Hopkins School of Medicine. “And it showed me that the most important protective mechanisms are the relationships we build with our classmates and faculty.”
Indeed, the importance of listening comes across as one of the course’s biggest lessons. “Students comment that they never realized how powerful silence is in communication,” said Parmelee.
For O’Donnell, who oversees oncology at the Veterans Administration Hospital in White River Junction, Vt., the course has helped him learn to listen more deeply. “I hear themes I might have missed before,” he says. “Not just the symptoms, but the story — how scared the patient is that this ache might mean a recurrence. It brings you back to taking care of people. Because the world isn’t made up of atoms. It’s made up of stories.”
The Healer’s Art is an entry point: an attempt to anchor a cultural shift in medicine. Some students who have taken the course have formed groups so they can continue to uncover the meaning of their work after the course ends. They are building an alternative socialization process. The Institute for the Study of Health and Illness also helps doctors, nurses and other health care professionals form groups dedicated to “Finding Meaning in Medicine.”
But the course and similar programs need to be given much higher priority if we are going to attack burnout. “Because it has strong links to the quality of care,” says Dr. Shanafelt of the Mayo Clinic, “promoting wellness is a shared responsibility of individual physicians as well as the hospital or practice group.”
However, if hospital administrators are going to allow doctors to cut back on “productive” activities so they can take time to focus on self-care, he adds, “We’ll need to provide hard evidence for people making financial decisions that this is a good investment.”
For doctors, this investment could mean the difference between succumbing to burnout and finding ways to practice that deepen their sense of purpose. “When doctors learn to read the affective domain, they are shocked to discover that they have gone right past experiences of profound meaning without seeing them,” says Remen. “They say, ‘I was colorblind.’ Medicine offers you a front-row seat on life. Meaning is all around you. When you can see it, it gives you a sense of gratitude for the opportunity to do this work.”
Every day, we are reminded that the health care system is in crisis. We are going bankrupt. There are too many lawsuits. We practice defensive medicine. We restrict access. But surveys of doctors indicate a problem that penetrates much deeper than this. Today, almost 50 percent of doctors report symptoms of burnout — emotional exhaustion, low sense of accomplishment, detachment.
Countering doctor burnout with a refresher course on the capacity to heal.
Medicine is facing a crisis, but it’s not just about money; it’s about meaning.
We often think of medicine as a science, and many doctors do come to think of themselves as technicians. But healing involves far more than knowledge and skill. The process by which a doctor helps a patient accept, recover from, adapt to, or endure a serious illness is full of nuance and mystery. I was often moved by how much my father-in-law — an actor who died from a form of leukemia — drew comfort and even inspiration from the relationship he had with his hematologist (who requested a Shakespeare recitation at each visit).
Great doctors don’t just diagnose diseases, prescribe medications and treat patients; they bring the full spectrum of their human capabilities to the compassionate care of others. That is why doctors, upon entering the medical profession, speak noble words like the Declaration of Geneva (“I solemnly pledge to consecrate my life to the service of humanity…”) or the Oath of Maimonides (“May I see in all who suffer only the fellow human being.
Yet by then, considerable damage has already been done. Nearly half of medical students become burned out during their training. Medical education has been characterized as an abusive and neglectful family system. It places unrealistic expectations on students, keeps them sleep-deprived, overstressed, and in a state of fear of making mistakes, and sends the message that doubts or grief should be kept to oneself.
While the training formally espouses the ethics of empathy, compassion and altruism, doctors and researchers say that the socialization process — the “hidden curriculum” — teaches something very different: stay detached, objective, even a little cynical. Five out of six doctors say that medicine is in decline and close to 60 percent would not recommend it as a career for their children.
As administrative and documentation burdens have exploded in the past three decades, doctors find themselves under pressures to work as quickly as possible. Many have found that what is sacrificed is the very thing that gives meaning to the whole undertaking: the patient-doctor relationship.
“These high levels of distress, depression, loss of satisfaction, fatigue, and burnout have big repercussions for quality of care,” explains Dr. Tait Shanafelt, director of the Mayo Clinic Department of Medicine’s program on physician well-being. It leads to medical errors, substance abuse, and doctors quitting — something that a country with an aging population and a shortage of doctors can ill afford.
How could we help medicine overcome its own illness?
That’s a question that has occupied Dr. Rachel Naomi Remen for decades. Remen is a clinical professor of family and community medicine at the U.C.S.F. School of Medicine and the director of the Institute for the Study of Health and Wellness, at Commonweal. Over the past 22 years, she has been advancing a powerfully subversive addition to the medical curriculum, a course called The Healer’s Art.
For the first six years, Remen taught it with 10 friends, all community physicians drawn from outside the school. She was half afraid that her dean would discover it and throw her out. But gradually, the course began to spread by word of mouth, to two schools, then four, then 16, then 25. It is now taught annually at 71 schools in the United States (half of the nation’s medical schools) and schools in seven other countries.
More than 1,600 students take the course each year and about 13,000 have gone through it. And while it is described as a simple elective — a 15-hour course given in five three-hour sessions — many of the doctors who teach it, and the students who take it, see it as part of a movement. In evaluations, large majorities of students say the course fills a gap in their medical education. It helps them to feel more committed to medicine, more supportive of their classmates, more confident that they can be good doctors, and more clear about what they can personally offer patients. More than 95 percent of them say they will recommend it to other students.
“What our students say loud and clear is this course helps to keep their spirits alive as they go through the training,” explains Nancy Oriol, dean for students at Harvard Medical School.
Remen’s life has been shaped by her own experience living with illness. By her own admission, she has not been well for 60 years. When she was 15, she was diagnosed with Crohn’s disease. She underwent nine major surgeries and took large doses of steroids daily for 15 years. “My doctors told me I would be dead by the time I was 40,” she says with a laugh. She’s now 75 and has been a doctor herself for 50 years.
After medical school, on her first day in training as an intern, a 3-year-old was brought into the emergency room after a car accident. The doctors were unable to save the child’s life. Remen accompanied the chief resident as he met with the parents to inform them that their child had died. When they broke down, the sadness was too much. Remen found herself crying, too.
Afterward, the chief resident took Remen aside and said that her behavior had been highly unprofessional.
The message stuck. By the time Remen was senior resident, she hadn’t cried for years. That year, another child, a baby, was brought into the hospital after drowning unattended in his bathtub. The doctors were unable to resuscitate the baby. This time, Remen was the one responsible for informing the parents that their only child had died — and as they held each other and fell apart sobbing — she stood silently by in her white coat, maintaining her professional distance. After a while, the baby’s father, with tears running down his face, apologized. “‘I’m sorry, doctor,’ he said. ‘I’ll get a hold of myself in a minute.’"
How had she become the person a grieving father apologizes to? This is a common outcome of the hidden curriculum.
The Healer’s Art is predicated on the idea that medicine is an ancient lineage that draws its strength from its core values: compassion, service, reverence for life and harmlessness. When students and doctors connect to these values in a community, they derive meaning and strength, and can “immunize” themselves against the assaults of the medical curriculum and even the health care system itself.
To help people tap into these deep currents, the course is delivered in an unusual manner. Students and faculty members meet together in small groups in the evenings, participating side by side as equals. There are no experts, no hierarchies, no wrong answers; anyone may speak about his or her experiences or simply listen.
It begins by reminding people that it is not by chance that they are in the room. “We ask: ‘How old were you when you first realized that the needs of a living thing mattered to you?’” says Remen. “For most doctors and students, the impulse to respond to the needs of others, plants, animals, insects, and even people, goes back to early childhood, sometimes as far back as they can remember.”
Remen recalled a student who told the class that his mother used to bathe him in an old claw-footed bathtub. “At the end of his bath, she would pull out the stopper, reach behind him and get a towel, sit him on her lap and dry him. One day he stepped on the drain and it was sharp — there was pain and blood — and his mother said, ‘Never stand on the drain again.’ A few weeks or months later, as he was waiting for her to dry him, he noticed the water circling the drain as the tub emptied. He remembered how sharp the drain was and worried that the water was being hurt. After that, when his mother pulled the plug, he would drop his washcloth over the drain to protect the water.
“This is magical thinking. He was probably about 3,” said Remen. “Now he is a pediatrician and he brings the same intention to make a difference in pain and suffering to his little patients himself.”
Every culture approves and disapproves of different qualities. As the price of admission, medicine implicitly asks its members to leave aspects of themselves behind. The course explores this idea, what Carl Jung called the “shadow.”
“Everybody’s given a box of crayons and a big piece of paper like in first grade and they are asked to draw a picture of the parts of themselves they feel they can’t bring into their work as doctors,” explains Joseph O’Donnell, a Senior Advising Dean at the Geisel School of Medicine at Dartmouth, who has taught the course for more than a decade. First-year students do the exercise alongside doctors who have been practicing for decades. “Then everyone holds up their picture. You see ‘curiosity,’ ‘love,’ ‘compassion,’ ‘kindness,’ ‘creativity.’ And people say, ‘I thought I was the only one experiencing this.’ ”
The session on grief and loss is among the most powerful, adds O’Donnell. “Students and faculty are asked to become still and quiet,” he explained. “They’re asked to think back to a time when they experienced a loss, and remember the feelings, and think about what someone may have done that was helpful, or unhelpful.”
They write it down. Then the students are asked to say what was helpful. “You hear things like: They held my hand. Gave me a hug. Brought me food. Sat silently and listened.” For unhelpful, you hear things like, “They said, ‘I’d better leave you alone” or “You’ll be fine in no time.’”
When O’Donnell graduated from medical school in 1973, there was no place to discuss such matters openly. “It wasn’t safe to say, ‘I’m really bothered by what I’m seeing today.’ You just took care of it. You read the scientific articles, but you put your heart and soul aside. Here you are allowed to bring those things to the forefront in a valid way with colleagues who are esteemed.”
Dean Parmelee, the Associate Dean for Academic Affairs at Wright State University, who has taught the course for several years, recalled an incident shared by a fourth-year student who had been part of a team when a baby was stillborn.
The mother was 16 or 17 years old and she was with her boyfriend, he recalled. There were some psychosocial issues. “After the delivery, the student said, shockingly, everyone just left the operating room,” said Parmelee. “He was the only person left and the only sound was the air-conditioning and the ventilation.” The mom had started to cry; her baby lay still on her abdomen. The boyfriend was crying, too. The student said nothing. He simply reached out and took the mother’s hand and with his other hand he reached out and took the father’s hand, closed his eyes and stood there with them for a few minutes crying silently together.
“The student said that if he hadn’t taken the course, he would have left the room like everyone else,” added Parmelee. “Or he might have said something like, ‘You’re young, you can have another baby.’ ”
“Instead,” commented Remen, reflecting on the story, “he offered them and himself the healing of a common humanity.”
This is not how doctors are accustomed to managing grief and loss. “We intellectualize it, minimize it, become numb to it,” O’Donnell said.
There is an enduring belief in medicine that if you feel strongly it will cloud your judgment. But research indicates that emotional attunement can improve critical thinking, decision-making, and the ability to act quickly in crisis moments.
Moreover, we need to feel to connect with other human beings. “If patients see that you care, they can trust you enough to tell you the truth and are more likely to follow your advice,” observes Remen. Parmelee, who has been an expert witness in malpractice cases, has found that most cases boil down to physicians “not really listening or making themselves available emotionally for a patient.”
And then there is the simple truth that buried feelings don’t just go away. “When I took The Healer’s Art, the session on grief and loss brought up a whole period in my life that I must have tried hard to not think about,” recalled Parmelee. “I was totally unaware of its continuous impact on me, and how much was still there after more than 30 years.”
In medical school, students rarely hear their teachers speak this way. Brent Aebi, a third-year medical student at Wright State University, said that hearing veteran doctors speak about their struggles helped him to see a path forward that felt right to him. “I saw that you don’t have to become hardened,” he said.
The same holds for peers. The combination of hyper-competition and self-doubt in medical school can work against the development of supportive relationships. “This way of listening to others’ stories is not present in the normal medical training,” observes Rhianon Liu, a third-year medical student at Johns Hopkins School of Medicine. “And it showed me that the most important protective mechanisms are the relationships we build with our classmates and faculty.”
Indeed, the importance of listening comes across as one of the course’s biggest lessons. “Students comment that they never realized how powerful silence is in communication,” said Parmelee.
For O’Donnell, who oversees oncology at the Veterans Administration Hospital in White River Junction, Vt., the course has helped him learn to listen more deeply. “I hear themes I might have missed before,” he says. “Not just the symptoms, but the story — how scared the patient is that this ache might mean a recurrence. It brings you back to taking care of people. Because the world isn’t made up of atoms. It’s made up of stories.”
The Healer’s Art is an entry point: an attempt to anchor a cultural shift in medicine. Some students who have taken the course have formed groups so they can continue to uncover the meaning of their work after the course ends. They are building an alternative socialization process. The Institute for the Study of Health and Illness also helps doctors, nurses and other health care professionals form groups dedicated to “Finding Meaning in Medicine.”
But the course and similar programs need to be given much higher priority if we are going to attack burnout. “Because it has strong links to the quality of care,” says Dr. Shanafelt of the Mayo Clinic, “promoting wellness is a shared responsibility of individual physicians as well as the hospital or practice group.”
However, if hospital administrators are going to allow doctors to cut back on “productive” activities so they can take time to focus on self-care, he adds, “We’ll need to provide hard evidence for people making financial decisions that this is a good investment.”
For doctors, this investment could mean the difference between succumbing to burnout and finding ways to practice that deepen their sense of purpose. “When doctors learn to read the affective domain, they are shocked to discover that they have gone right past experiences of profound meaning without seeing them,” says Remen. “They say, ‘I was colorblind.’ Medicine offers you a front-row seat on life. Meaning is all around you. When you can see it, it gives you a sense of gratitude for the opportunity to do this work.”
Sunday, September 16, 2012
Musings on a night call
I wonder at which point in life people start becoming mean. How does someone one day decide to live for himself at the expense of another fellow human being? Does he suddenly wake up and realize that everyone is doing that and therefore he should do it too?
If I were a patient I think I would really hate the way I was being treated. I never ever know what is going on. People are ordering tests on me without telling me what for, I never know what doctors are thinking when they talk to me in very vague non-committal terms, I never get to see a good summary of my medical condition, I never understand the true situation when I have to wait 1 day doing nothing to go for a scan, I never see my doctors for more than 10 minutes a day. I think the strangest thing is random people popping up throughout the day to ask me weird questions (have you farted today?) and how I am without introducing themselves.
Random thoughts post surgical call. Sigh.
If I were a patient I think I would really hate the way I was being treated. I never ever know what is going on. People are ordering tests on me without telling me what for, I never know what doctors are thinking when they talk to me in very vague non-committal terms, I never get to see a good summary of my medical condition, I never understand the true situation when I have to wait 1 day doing nothing to go for a scan, I never see my doctors for more than 10 minutes a day. I think the strangest thing is random people popping up throughout the day to ask me weird questions (have you farted today?) and how I am without introducing themselves.
Random thoughts post surgical call. Sigh.
Thursday, July 28, 2011
Tough luck
I remember what Jon Chan wrote about the internship resounding very clearly within me, "it's the same feeling that I got at the start of M3 (Surg) - I half don't know what's going on, I'm worried because this is the rest of my life, and I'm scared because I don't know how well I'll do."
Magic moments. Of all the patients that I've encountered, I will remember Mdm T our hamster lady who was labelled as "bedbound" in the nursing home, but was reviewed by the in-house physiotherapist and found to be able to walk 50m assisted! I will remember sitting by Mr S's bedside at 4am in the morning looking at his right knee stump, watching him grit his teeth in pain from arthritis, and ask him for permission to take his bloods. He then nods with resignation, and I am glad to succeed with one try. Then there is Mdm R who came in rather drowsy and uncommunicative, and left being able to smile and wave at me when I walk by. Not forgetting Mr P, who in the midst of his chest pain and breathlessness, says "I will fight till the end!".
Over the weeks at work, discussion of NTU graduates and peers in other industries earning twice, thrice, or even ten times the salary of doctors dominated conversations. In school, we trumped them with our As, for what? Now they're owning us with their salaries. I learnt about the ROAD specialities - top earning sub-specialities with minimal effort that are most highly sought after in post-graduate training. Radiology, Opthalmology/O&G/Orthopaedics, Anaesthesia, Dermatology. Most of these conversations ended with lamentations at the fate of doctors. I should have never become a doctor. Tough luck. Most of the time, I had little to contribute. What was I to say? I have never experienced bearing the responsibility of answering non-stop calls to do changes at 3am in the morning. I have never felt the panic before a desaturating patient. I have never received a payslip that is far below what I expect for the work and hours that I put in. Who knows what I will say 5 years down the road, when I am weary and tired, have to do full calls, and feel under appreciated by the system?
In some ways I feel fearful at this fate that I'm heading for. Who knows what lies ahead? What did we sign up for? Surely nothing less than a lifetime of loving another.
Thursday, July 21, 2011
Failures
Medical school has truly failed when a moderate pleural effusion secondary to metastatic lung CA is diagnosed only on CXR and every case note entry says "Lungs: clear".
Friday, August 20, 2010
What should doctors tell young people who want to study medicine?
By Dr Martin Young
Every now and then a young person approaches me for advice on studying medicine. The majority are extremely bright, capable and enthusiastic semi-adults, with strong desires to change the world and to ‘make a difference.’
I was once like that, once upon a time, long, long ago……….
I have wanted to be a doctor for as long as I can remember. At a very early stage in my life, as soon as I could walk and talk, I also wanted to be a Royal Marine. As an adult I got to be the closest equivalent to both I possibly could be. But the reality of being a fighting soldier – yes, a doctor and a fighting soldier (South Africa was a crazy place in those days)– was more in line with my expectations than those of being a doctor. Even while growing up I had a keen sense of what the military expected of me, and what it would do to me in return. For the realities of practicing medicine I was, and probably still am, completely unprepared.
Part of the problem is that in the 30 years it has taken me to ‘arrive’ as a specialist surgeon with my own practice, medicine has changed completely, and not for the better in my opinion. It is just not a ‘comfortable’ profession anymore, because of the outside influences of managed healthcare, litigation, health economics and others. Helping people, and curing some of them, is still a big plus. It is the other ‘stuff’ that goes with that that has become difficult. The level of frustration is getting so high it is almost part of the daily job description.
So, when young people approach me asking if they can job-shadow me for a while, I have to watch myself very closely in trying to give good, solid advice that will not put them off, but at the same time, not help steer them careering into a profession for which they may be both ill-suited and ill-prepared.
These are a few things I tell them, I hope with a sense of reality, tempered with awe of the incredible responsibility:
Every now and then a young person approaches me for advice on studying medicine. The majority are extremely bright, capable and enthusiastic semi-adults, with strong desires to change the world and to ‘make a difference.’
I was once like that, once upon a time, long, long ago……….
I have wanted to be a doctor for as long as I can remember. At a very early stage in my life, as soon as I could walk and talk, I also wanted to be a Royal Marine. As an adult I got to be the closest equivalent to both I possibly could be. But the reality of being a fighting soldier – yes, a doctor and a fighting soldier (South Africa was a crazy place in those days)– was more in line with my expectations than those of being a doctor. Even while growing up I had a keen sense of what the military expected of me, and what it would do to me in return. For the realities of practicing medicine I was, and probably still am, completely unprepared.
Part of the problem is that in the 30 years it has taken me to ‘arrive’ as a specialist surgeon with my own practice, medicine has changed completely, and not for the better in my opinion. It is just not a ‘comfortable’ profession anymore, because of the outside influences of managed healthcare, litigation, health economics and others. Helping people, and curing some of them, is still a big plus. It is the other ‘stuff’ that goes with that that has become difficult. The level of frustration is getting so high it is almost part of the daily job description.
So, when young people approach me asking if they can job-shadow me for a while, I have to watch myself very closely in trying to give good, solid advice that will not put them off, but at the same time, not help steer them careering into a profession for which they may be both ill-suited and ill-prepared.
These are a few things I tell them, I hope with a sense of reality, tempered with awe of the incredible responsibility:
- Unless you really, really want to be a doctor, have no other alternative in mind, are willing to do as much as it takes to get into medical school, even if it means getting another degree first, don’t even think of it. The novelty of being ‘doctor’ wears off a lot sooner than you may think.
- If you are bright enough to get into medical school, you are bright enough to do any other job or profession, and to be a success at it. With something tangible to show for that success. But if ‘success’ is defined in your mind as financial wealth, choose another easier route! Or redefine ‘success’ in your own mind, leaving out the fast cars and fancy houses.
- Medical school is going to drain your resources, and put you five years behind your peers in earning potential.
- Being a doctor may leave you physically, emotionally and mentally exhausted for long periods of your life.
- The establishment takes the brightest and most enthusiastic of a country’s youth, loads them with debt, and then pushes them into a workplace which is invariably understaffed, ill-supervised, overworked and underpaid. For years at a time! Are you prepared to go through all that?
- Take a look at the doctors around you and how they practice medicine. In ten years time everything will have changed dramatically. No one can really say whether or not for the better.
It’s not all bad:
- The highs in medicine can be very high, bordering on euphoria, at a challenging job well done.
- You will never be short of a job somewhere. It may not be the job you wanted, or where you want to be, but there will always be work for you.
- You can take your qualifications and experience with you anywhere you go.
- Other jobs may have diminished appeal after being a doctor, somehow lacking in relevance.
- You have a wide range of options within medicine itself, so careers can develop in different directions at different stages. Which is a good thing.
When I have had the opportunity to say these things, my young would-be doctor may look quite thoughtful or even apprehensive. Many tell me that they never realized that there was a dark side to being a doctor. I refer them to other sources, websites and blogs like this one, and wish them all the best of luck.
How many have I seen come back to me as qualified doctors? I’m still waiting…….But I know of one who became a water sanitation engineer.
In terms of ‘saving lives’ and ‘making a difference’ he probably has the edge on all of us!
Tuesday, June 15, 2010
Sunday, May 9, 2010
Sunday, April 25, 2010
The Other Side
Today I finally experienced what was on the other side. Beyond the green sliding doors that bring in people who experience severe, retrosternal, crushing chest pain, polytrauma and the collapse cases, I saw real people, real life. The Resuscitation Room is like a haven. A haven for medical professionals I mean, but unfortunately not patients. It has restricted access, meaning no relatives are allowed in (or if allowed, only 1 per patient) unless under special circumstances. Doctors and nurses work without being under the scutiny of emotional friends, angry parents or agitated spouses. What we do, we do it in the best interest of the patient, but we by no means have the ability to bring the dead back to life.
So over the past 3 weeks, we've seen a handful of collapse cases. Most collapse cases refer to someone who has suffered an injury which has resulted in inability of the heart to pump sufficiently. This results in the absence of a pulse, and an indication to commence CPR to maintain circulation and most importantly blood supply to the brain. The previous cases that we've seen were typically a result of a massive heart attack. Having seen a couple of similar patients and dealt with them, we were familiar with the management algorithm of these patients. Their modes of presentation were generally the same.
Two of them came in last night, one just after another. The typical medical student reflex to be involved in resuscitation kicked in, and we all took turns to perform CPR. After a few cycles, there were intermittent period of a returning pulse that would drop after a few minutes. The poor prognosis just became more evident. Then, I noticed the doctor in charge leaving to speak to the relative of the patient.
I'd never seen the doctor speak to the patient's relatives before (I don't really know why) so I decided to accompany the doctor this time. I need to learn holistic management, I thought to myself. However, the moment I stepped beyond those green sliding doors, I felt a great sense of fear. I saw the patient's wife, alone and anxious. She was the one who saw him collapse, called the ambulance, and waited for 25 minutes by his side until the sirens finally drew close. Death comes quickly.
The doctor spoke with her and explained the situation, leaving messages in between the lines, each sentence to prepare her for the worst, yet most probable outcome. No one can prepare for the loss of a loved one, regardless of how ill the patient has been for the past months. Composed to distressed to teary eyed to uncontrollable sobbing. Death is shocking.
Can you help me doctor? Please? Can you just try to revive him even if for a while? I've heard of this expensive injection that you can give? Please?
Even the most wealthy and educated are not spared from the trauma of death. 30 minutes later, we announce the passing away. There is more sobbing, and even more sobbing. Amidst it all, there is admin work to be done, papers to be signed and phone calls to be made. Death is troublesome.
As I returned back to the Resuscitation Room, all had returned to normal. The nurses were sorting out inventory, doctors doing administrative documentation and the medical students fussing over plug setting and history taking. Where is all this in the grand scheme of things?
A husband, a father, a son lost. Their lives will never be the same again.
Now listen, you who say, "Today or tomorrow we will go to this or that city, spend a year there, carry on business and make money." Why, you do not even know what will happen tomorrow. What is your life? You are a mist that appears for a little while and then vanishes.
James 4:13-14, NIV
Saturday, August 1, 2009
The Magic of Medicine
this week was rough. i started out thinking to myself, look i've got 4 more weeks to end-of-posting-test, time to buck up and not be stupid anymore. chiong where possible. i was just close to printing out a big sheet of paper which said THINK. DON'T BE STUPID, because that was how i'd been feeling through the past 6 weeks. day in day out i did my thing - go see the patients, attend my tutorials, practice, present and come back to study through what i've seen. by thursday i was tired and sleepy, but still trying to chiong and staying till 7pm on friday.
friday was a scary day. we had a tutorial with Dr Suresh and had a pseudo mock test which Z and M underwent whilst the rest of us watched. i thought they did ok, at least that's pretty much what i would have done in their circumstances. but guess what, the comments we got were "you're just close to passing" and "you already did xxx and if you just did xxx you would have failed immediately". demoralized x10000. EOPT = major fail.
but then K told me something whilst on the car back on friday, which i think ought to be shared with all those who are going to pee in their pants from EOPT syndrome. if i may rephrase it - "you know, i think if i did something so terrible during EOPT that the examiners decide to fail me, then i think i'd rather fail now and keep retaking till i get it right, lest i do it again next time and end up killing someone." i thought it was particularly insightful because it captured the essence of our exam, to prepare us for compentency as doctors and not just to get through an academic level.
Dr Suresh talked to us about the real world during our tutorial. the real world where real people function under real circumstances, not like in our exam where the patients are primed, told what to say and we are so eagerly trying to rehearse and prepare ourselves for the ideal patient with the perfect signs and symptoms. in the real world, patients lie, they come with 1 out of 25 signs, they are in denial, they don't take the correct medicines. in the real world, people die.
we had a fantastic geriatrics tutorial with Dr Lim WS on thursday. he told us about being doctors with a heart, and he quoted Edward Livingston Trudeau's "To cure sometimes, to relieve often, to comfort always". and whilst it doesn't come as anything mindblowing or new to us, i always find it inspiring when people who have been in the profession for so long can still hold true to such beliefs. they always tell us about how doctors become jaded and angsty from the workload, how the profession is unrewarding and demands more than you can give. but coming from The Wise Sages, it's an equivalent of a been there, done that.
Medicine is magical, and slowly but surely things are falling into place. right now we have but a pile of jigsaw puzzles thrown at our feet, and we slowly pick up the pieces to put them where they belong. the good physician first looks for the obvious abnormal looking corner pieces, then work from the peripheries towards the centre, finally hitting the heart of the puzzle where you should already have an idea of what the clinical picture is like. everything fits, the picture is complete and the puzzle solved. but that is not the end of the story, because we deal with humans, not cardboard. there is the dimension of thought and emotions that we have only just begun to discover...
press on friends! be real :)
friday was a scary day. we had a tutorial with Dr Suresh and had a pseudo mock test which Z and M underwent whilst the rest of us watched. i thought they did ok, at least that's pretty much what i would have done in their circumstances. but guess what, the comments we got were "you're just close to passing" and "you already did xxx and if you just did xxx you would have failed immediately". demoralized x10000. EOPT = major fail.
but then K told me something whilst on the car back on friday, which i think ought to be shared with all those who are going to pee in their pants from EOPT syndrome. if i may rephrase it - "you know, i think if i did something so terrible during EOPT that the examiners decide to fail me, then i think i'd rather fail now and keep retaking till i get it right, lest i do it again next time and end up killing someone." i thought it was particularly insightful because it captured the essence of our exam, to prepare us for compentency as doctors and not just to get through an academic level.
Dr Suresh talked to us about the real world during our tutorial. the real world where real people function under real circumstances, not like in our exam where the patients are primed, told what to say and we are so eagerly trying to rehearse and prepare ourselves for the ideal patient with the perfect signs and symptoms. in the real world, patients lie, they come with 1 out of 25 signs, they are in denial, they don't take the correct medicines. in the real world, people die.
we had a fantastic geriatrics tutorial with Dr Lim WS on thursday. he told us about being doctors with a heart, and he quoted Edward Livingston Trudeau's "To cure sometimes, to relieve often, to comfort always". and whilst it doesn't come as anything mindblowing or new to us, i always find it inspiring when people who have been in the profession for so long can still hold true to such beliefs. they always tell us about how doctors become jaded and angsty from the workload, how the profession is unrewarding and demands more than you can give. but coming from The Wise Sages, it's an equivalent of a been there, done that.
Medicine is magical, and slowly but surely things are falling into place. right now we have but a pile of jigsaw puzzles thrown at our feet, and we slowly pick up the pieces to put them where they belong. the good physician first looks for the obvious abnormal looking corner pieces, then work from the peripheries towards the centre, finally hitting the heart of the puzzle where you should already have an idea of what the clinical picture is like. everything fits, the picture is complete and the puzzle solved. but that is not the end of the story, because we deal with humans, not cardboard. there is the dimension of thought and emotions that we have only just begun to discover...
press on friends! be real :)
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