Above and Beyond

It has been a scary, painful, difficult week, which began with 30+ hours of labor followed by a C-section.  I have been dealing with all of the challenges of being in the hospital as a patient for the first time (that I remember), recovering from surgery, and caring for a newborn (also for the first time).  Along the way though, I have had several moments, which I want to highlight, of the staff showing compassion and respect for me as a person, above and beyond the excellent medical care that I received.  I would like to thank:

The OBGYN, who kept me well informed about what was going on.  One of the scariest things is not knowing and letting your imagination run away with you.  When a decision had to be made, she explained the options and the implications of each one, as best they could be predicted, and gave me space to talk to my family too for support. 

The anesthesiologist, who kept me updated during the surgery, when I could not see because of the drape.  I have seen C-sections performed from the other side and know what the steps should be.  He also wrapped towels around my arms when I was shivering and let me know that this too would pass.

The post-partum night nurse, who was always positive and upbeat and never made me feel like I was bothering her, even when I was calling in the middle of the night.  Taking the baby to the nursery for a few hours, so we could get a little sleep, was much appreciated.

The day nurse, who was kind and encouraging, when I was having hormonal crying spells.  She reassured me that it was normal to feel overwhelmed at first and everything would be okay.

Everyone who let my husband know that he was doing a good job too.  Several nurses and the lactation consultant all remarked on this.  Maybe they tell every dad that he’s the best dad on the floor.  But they noticed the way he changed the diapers when I was still unsteady on my feet, the way he fed me and helped me drink while I was nursing, and the way he stayed with me and supported me through the whole process.  He certainly did not feel like he knew what he was doing, so I was glad that so many people with baby expertise could tell him that he was actually a gold-star daddy.

We are all doing much better now, settling into our new life at home.  Yes, this is hard work, but a great blessing too.  And it was good to see from the patient side how a little humanism can go such a long way in helping people to feel cared for.

Being the Patient in the Triad

Usually I am the Preceptor/Teacher in clinical settings, supervising a medical student or resident in their interactions with a patient.  I have the challenging and rewarding task of making sure that the patient is well cared for and that the learner’s needs are also met.  I am still working on the art of gently guiding learners while preserving their relationships with their patients.

Recently I had the relatively new experience of being the patient in a patient-student-preceptor triad.  At my OB appointment, a medical student was practicing how to check fetal dopplers and fundal height, supervised by the nurse-practitioner.  Overall, he was doing it correctly but I could tell that he would benefit from some direction on positioning.  I did not tell the student that I was a doctor, since I thought it might make him nervous, and I did not want to correct him myself, in case that would undermine his actual supervisor.  So, I kept quiet and observed.

The NP did an excellent job of showing him how to improve his technique, not only explaining what to do but why, and sharing expertise in a constructive way.  I am sure that this student has had plenty of experiences in his training when he was either ignored or completely crushed by criticism.  It was great to see him get some good teaching.  I was glad to provide him with a learning opportunity and also to learn something myself from a role model in precepting.

Happy Thanksgiving!

I have a lot to be thankful for and would like to take some time on this beautiful fall day to remember that.  I have a place to live and food to eat.  I can meet my basic needs and also the higher-order needs that we have as humans: for self-expression, community, and meaning in life. 

I am thankful for fulfilling work.  Yes, medicine is hard.  But it’s an honor to take care of people, to listen to their stories, to learn something new every day, and to work with amazing colleagues from so many different disciplines.  In academic medicine, I also get to teach new doctors the art and science of this vocation and add new knowledge through research.

I am thankful for my family and the love and support we share for each other.  Thankful to be adding a new baby to the mix soon.  And thankful that this pregnancy has been uncomplicated so far, at least in physical terms.  Juggling personal and professional lives is a complication of its own, which will only become more challenging.  We all have to figure out how these two realms can be complementary, rather than in conflict.  I am glad that Baby will have the role models of a working mother and a dad who excels at the manly duties of childcare. 

I hope that you also have a lot to be thankful for today.  I know I tend to forge ahead without always pausing for reflection.  It is good to be reminded not to take things for granted.

Baby Belly

Some of you may remember my post about my medical school reunion and the impressive number of babies my classmates had produced, despite working in the high-pressure field of medicine.  Now it is my turn to contribute.  I am due in December!

One aspect of the pregnancy experience that has been especially strange to me is the amount of interest it draws from others.  I am a rather introverted person, not used to calling attention to myself.  Now that my belly has reached very obvious proportions, random strangers will ask me when I’m due and if it’s a boy or girl.  Though I am still rather startled to be addressed by people I don’t know, I take this in the friendly spirit in which it seems intended.

I recently completed some intensive weeks of work in the hospital and was even more surprised at how interested patients were in my belly.  I was there to help them with their medical problems, not to talk about myself.  But almost every patient who was alert and oriented asked me about it.  Rather than being a distraction, it was actually a refreshing addition to the conversation.  After a serious discussion about challenging clinical issues, they could focus on something optimistic.  Everyone wished me well.  I even got a hug from a patient’s mother.

I had expected mixed feelings from my clinic patients, since it will be an inconvenience to them when I am out for several weeks on maternity leave.  Instead, it has been heart-warming to see how supportive they are.  Patients with complex problems and chaotic lives of their own are inquiring after my health and genuinely excited to talk about babies.  It has brought us closer together and allowed them to open up more about their own families.  The clinic staff could also focus on the inconvenience of my scheduling, but instead take the opportunity to share their parenting stories and advice.  I am thankful for excellent, understanding colleagues, who can help out while I am temporarily away.

Of course, it is difficult to do my demanding work when I am more tired than usual.  I put off taking care of myself until after I have taken care of everyone else.  I can’t deny the mental, physical, and emotional strain of being a pregnant doctor.  But there is also a benefit that I had not anticipated in brightening the day for patients and their families. 

Guest post

Hi everyone!
You can check out my guest post on KevinMD.

New Link: Hospital Drive

It’s time for another new link!  I have added Hospital Drive, a literary journal affiliated with the University of Virginia School of Medicine.  I love this journal, not only for my UVA nostalgia but also for the depth and variety of creative work on the themes of illness and healing.

They have included one of my poems Furniture Magazine in their summer issue.  This was written in response to receiving a catalogue in the mail full of glossy photos of home interiors.  I was struck by the juxtaposition with the stack of medical journals I usually receive and, even more so, by the contrast between my experience of human reality and this idealized artificial world.

Enjoy! 

Precepting

It was a challenging transition, when I shifted from being a medicine resident to supervising medicine residents.  There is much to be said about this shift (and similar shifts of ever-increasing responsibility at various stages of doctors’ training).  The aspect on my mind at the moment is the role of clinic preceptor. 

When I was new to the role and new to the clinic, I was paired with a more experienced preceptor.  He showed me the practical details: how to do the billing sheets, how to use the computer system, where things were located, which clinic staff could help with different problems.  He also modeled how to structure a visit: the resident goes in to see the patient, comes out and reports to the preceptor, then they go back in together. 

This was practical guidance in the sense of figuring out how to use the time, keep up with multiple residents, and incorporate teaching into a high-pressure environment.  But it went beyond what to do, pointing at why to do it a certain way.  There were attitudes and, in fact, a philosophy to it.  For example, he encouraged the residents to do their presentations in the patients’ presence because he believes in including the patients in decision-making.

There are so many delicate balances in precepting.  How to give residents the right amount of autonomy versus support.  How to tell what they know and what they don’t know.  How to teach them the answer but more importantly how to find the answer and how to handle situations in which the answer is not established.  Making sure that the patient is well cared for and the resident is too.  I observed him navigate these waters with insight, subtlety, and integrity.  I could tell how deeply he cared about getting to know patients as people and about instilling those values in the residents. 

The residents’ clinic can be an overwhelming place.  Patients usually have multiple serious medical problems and a host of psychosocial problems, which make management even more difficult.  Residents are torn between their clinic and hospital duties and other competing demands.  However, it is also a setting that allows for more continuity than inpatient rotations and gives residents a chance to be people’s primary doctor.  There is potential for empowerment, fulfilling relationships, and a lot of learning. 

What I had not realized before was that this potential extends to the preceptors as well.  The endless variety of humanity and ever-changing field of medicine allow us to learn something new every day, even when we’re the “senior” supervisors.  In addition, we have the privilege and delight of observing the residents over time, as they develop in their professional roles.  Having a co-preceptor to debrief with can make us more aware of these processes and mindful of both the residents’ growth as doctors and our own growth as their teachers.

Vanity

I received something curious in the mail.  It appears to be a brochure for “America’s Top Physicians” offering a variety of plaques that can be ordered and engraved with your name, sponsored by the “Consumers’ Research Council of America”.  If this is a legitimate organization, someone please let me know.  I doubt it though.

It reminds me of mailings that I used to receive from a vanity press.  They lost track of me after I moved (or realized I would never give them money and dropped me from their list).  I forget their exact name now, but it was something very similar, like “America’s Top Poets”.  Their letters would claim I had been selected to submit my work to an “exclusive” anthology, which would give me the recognition that I “deserved”.  Their true agenda, as far as I could tell, was to induce people to buy the anthologies.  The quality of your work did not really matter, as long as you were willing to pay to see it in print.

Now I seem to be on the mailing list of the doctors’ equivalent of a vanity press.  I am offered the opportunity to buy “Honors of Distinction and Excellence”.  The options are quite amusing in their extravagance.  I could get one that looks like a fake magazine cover or one that resembles a diploma.  I can’t decide if my favorite is a huge crystal cup on a pedestal, a silver globe, or an engraved glass plaque standing between marble columns. 

I had a laugh at the pretentiousness of all this, and the shallow ploy to extort money from doctors.  It also gave me pause, though, to think how vulnerable we might be to this kind of vanity.  As doctors, we are used to being high-achievers and received academic awards throughout our education.  Once we get out in the world, that phase is over, for the most part.  In practice, there are no more mentors or supervisors looking over our shoulders and telling us when we are doing a good job.

On days when we are worn down by the less satisfying aspects of medicine, we may start to feel underappreciated.  Maybe a fancy award is just the thing to cheer us up.  But what does it mean?  If it’s not an honor that is earned, but a purchase that is marketed to us, what is the point? 

I will stick to the internal reward of knowing that my hard work is helping patients.  It may be less tangible than a “distinguished ebony piano wood plaque with a sculpted three-dimensional plate” that is “laser engraved with your personal information regarding your accomplishment”.  But it is much more valuable.

Three of my favorite things

I have been away from the blog for a few weeks, due to travel and the crush of work that comes before and after any attempt to get away.  I attended the annual COMET conference, which one might think is an astronomy event but in fact is an academic meeting on the subjects of Communication, Medicine, and Ethics.  It gives me a chance to go beyond my usual sphere (dominated by medical professionals) and meet social scientists, linguists, and other researchers who share my interests and approach them from a different perspective.  It is a truly international and interdisciplinary experience.

The conference reminded me how central communication is to the practice of medicine and how important its ethical implications can be.  No matter how reliant we become on blood tests and fancy imaging, the tasks of eliciting and interpreting the patient’s story remain the key to diagnosis.  Explaining the diagnosis to the patient, negotiating a treatment plan, and answering questions are equally vital duties of physicians. 

Our education tends to focus heavily on the clinical decision-making that occurs within the physician’s mind: weighing evidence, drawing conclusions, and discerning how best to proceed.  The step of translating this medical knowledge into a form that is understandable to patients receives much less attention.

We may assume that talking to patients is the easy part of medicine.  However, this is often not the case.  We forget that our jargon is a foreign language to most people.  We overestimate how well we are understood.  Patients may agree with what we say, not because they really do but because they are afraid to speak up or ask questions. 

Medical encounters are a prime setting for misunderstandings: two (or more) people who do not share the same vocabulary or frame of reference, with an unequal power dynamic.  Furthermore, in medical encounters, misunderstandings can be particularly damaging.  These conversations are fraught with peril.  Bad news broken badly can make an already difficult situation much worse.  Patients’ concepts of their illnesses, treatment options, and prognosis may have a profound effect on their lives.  But their physicians may be oblivious to the subtleties of tone and word choice that convey meanings, which may or may not be intended.

What we say (and how we say it) has the potential to do much good or much harm.  I am encouraged to see the breadth of research being done in this area, but there is certainly a great deal more to do.  How healthcare professionals do communicate, how we should communicate, and how to teach ourselves and our trainees to do better, are questions that merit attention.