Wednesday, February 22, 2012

Role Model

As I am relatively new to the attending physician role, I am still getting used to the idea that my students and residents are watching me.  All the time.  Whether I am consciously teaching them something or not.  I put a great deal of thought and preparation into the didactic talks that I give them, the teaching points to bring up on rounds, and the formal feedback that I deliver.  But I am starting to realize that there are many dimensions to the team’s education that are more subtle.

When I am leading a team of residents and medical students, I am supervising their patient care.  They are absorbing knowledge about clinical judgment, the management of the diseases that we encounter, and integrating their scientific foundation with practical applications.  However, they are also learning the art of dealing with uncertainty and with the infinite variety of humanity.  I feel a responsibility for their clinical development and also their moral awareness. 

While I am on the inpatient wards, or in the residents’ clinic, everything that I do or say communicates something about being a doctor.  My tone of voice can convey respect or exasperation.  When I speak about disagreeing with a colleague, I can be collegial or unprofessional.  I am modeling attitudes for my learners, which may be subconscious to them (and to me) but nonetheless influential as they are growing into their doctor identities.

Sometimes it is hard to avoid mixed messages.  When I stay late at the hospital with my call team, I show them dedication to the job.  But do I also undermine the ideal of work-life balance?  When I admit to not knowing something, does it shake their confidence in me?  Or can we use the opportunity to look it up and promote life-long learning?

Even my lifestyle choices are under scrutiny.  My team knows what I get from the cafeteria or what I bring in for meals and snacks.  It actually motivates me toward healthier eating.  If I spend all day counseling others about their diet, I had better practice what I preach.

It is exhausting to be constantly alert, not only to the high demands of patient care but the role of teacher as well.  I need to keep in mind that my team of doctors-in-training is learning a science and an art at the same time.  They are figuring out how to apply clinical knowledge, analyze data, keep up with advances, interact with people, improve systems, behave professionally, balance their work and personal lives, and countless other complex tasks. 

They are learning through observation.  I must keep all of this in mind, as they are observing me.

Saturday, February 11, 2012

Death Scenes

My favorite death scene in literature is that of Kurtz in Conrad’s “Heart of Darkness”.  I am also fond of its parallel in the film “Apocalypse Now”, which is evocative in its own right.  Though not exactly a death scene, I greatly appreciate the death-discovery of Nastasya Filipovna in Dostoyevsky’s “The Idiot”.  That fine novel also includes my favorite fake-out death scene of Ippolit’s failed suicide. 

The winner for best-death-scene-in-a-short-story goes to Kafka’s “In the Penal Colony”.  This is one of my favorite short stories in general, with its fascinating combination of horror and mystical experience.  It speaks to the insight (or lack thereof) derived from suffering.  I have not seen any film adaptations of this story.  If my readers have, I hope they will let me know.

I also enjoy the seemingly random, senseless deaths of Vonnegut.  They are not exactly death scenes, as many of them occupy only a sentence or two.  They speak to the absurdity of life and death, but at the same time reflect a deeper humanity.  Each death is marked by a “so it goes” that strikes me as not quite as dismissive as it first appears.

What makes a literary death scene great?  I am sure that much has been written on this topic.  I simply offer my personal opinion.  I look for a death that is appropriate to the character, a fitting culmination of that person’s arc.  It must be dramatic and memorable.  It must express something in the human condition beyond that individual, something that all of us can understand, whether it repels or attracts us.

I often have occasion to contrast these literary achievements with “real life” death scenes.  Most of us probably wish for as little drama as possible in our own deaths.  A peaceful, dignified passing.  An expected death is preferable in a way, as it allows us to prepare, reconcile with others, plan for those who will survive us, and say goodbye to loved ones.  We may not be especially concerned with the human condition in general, but we do wonder what our own lives mean and what the next stage in our journey might be. 

As a doctor, I have witnessed quite a variety of “real life” death scenes.  Young people, previously healthy, with sudden, shockingly unexpected deaths.  Older people, well prepared and ready.  The drama of heroic efforts to resuscitate cardiac arrests.  The peacefulness of hospice deaths.  The despair, rage and turmoil of grieving loved ones.  Reconciled loved ones, singing hymns and comforting each other.  It is never as neat and tidy as it seems in books. 

Many of us will have no say in how our personal death scenes are written.  There is plenty of unpredictable risk out there.  But there are some things that we can do.  Avoid life-shortening behaviors.  Make advance directives, so that our end-of-life wishes will be known.  Reconcile with loved ones now, before it’s too late.  Reflect on mortality, faith, and the meaning of our lives. 

Friday, February 10, 2012

Saturday, February 4, 2012

You look too young to be a doctor

I walk into a clinic exam room or to a hospital bedside and introduce myself.  The patient looks me up and down and declares, “You look too young to be a doctor!”

There are many variations on this scenario.  Some patients state it as a question: “Are you sure you’re the doctor?”  Some try to guess my age, incorrectly.  Others simply give me a quizzical look.  I interpret it (perhaps over-interpret it) to be a judgment on my youthful appearance.  Behind it, I also see a judgment on my competence and authority.

I sympathize with the patient’s predicament.  He or she is coming to the doctor with a medical complaint or condition, seeking diagnosis, treatment and advice.  It may even be a life-threatening situation.  It is important for the patient to have confidence in the wisdom and experience brought to bear on the case.  I try to understand the patient’s vulnerability but, at the same time, I am bristling at the superficial prejudice that casts doubt on my credentials.

Another layer to my defensiveness is the impression that my female appearance is also working against me.  Although female doctors are becoming more common, it remains a challenge to gain equal status in a traditionally male-dominated profession.  I am sensitive to any suggestion that I am less worthy of the doctor role than my male counterparts.

Many possible reactions come to mind, when a patient remarks on how young I look.  I imagine the critical retort: “Well, you look old and fat.”  Or perhaps the affronted listing of qualifications: “I’ll have you know, I completed my medical training at prestigious institutions!”  Or the harsh reality check: “I may look young, but I’m your doctor, so deal with it.”  Or the facetious admission: “You caught me!  I am actually a college student masquerading as a doctor.”  Or the sarcastic comeback: “Oh, how insightful of you to notice.  You are the first person ever to bring this to my attention.”  Or the self-doubting crumble: “I guess I must be too young.  Maybe I should give up and go home.”

I know that none of these responses is the correct approach.  Simply ignoring the patient’s remark seems inadequate.  I consider a positive spin, such as: “I work out and eat right to stay young.”  I usually go for something more self-deprecating (and truthful): “I can’t take much credit for genetics.  My whole family is skinny and young-looking.”

I move on quickly to talk about the patient, instead of myself.  I do my best to build his or her confidence in me through our interaction.  As we get to know each other, my physical characteristics become less important than my intellectual abilities and emotional engagement.

The important thing, for me, is to figure out what the patient needs from the encounter.  My ego is secondary to discerning the patient’s insecurity and overcoming any potential barriers to a therapeutic relationship.