Role Model, Part 2

This week, I have been thinking a lot about great teachers I have had in the course of my medical training.  The doctors I worked with in Bangladesh inspired me to go to medical school in the first place.  I saw the exciting work they were doing clinically and also the patient education they were engaged in, training students, and teaching local community leaders about public health.  They empowered me as a learner by being open to my questions, generous with their time and attention, including me in what was going on through language translation and through thinking aloud so I could follow their process.

Other models have included my clinic mentor during residency.  He helped motivate me to consider primary care and clinician-educator careers.  He shared many of the qualities of my mentors in Bangladesh: openness, generosity, transparency.  In addition, it always impressed me how happy he seemed.  Even when we were dealing with clinical and social disasters, difficult patient situations, time pressure, and so on, he was committed to the learning opportunity.  I sensed that he was essentially optimistic about people.  He could meet them wherever they were and find some way to help, with the implicit understanding that everyone could do better, everyone could improve.  Somehow he found the right balance between challenge and support for each patient, student, and resident.  And he truly seemed to enjoy it.

I want to have the skills at teaching that I have seen in my role models and have it be something that I love doing.  Teaching is sometimes undervalued in academic medicine, since it generally does not bring in any clinical revenue or research funds.  But good teaching is the foundation of all other academic activities.  It has the potential to be very fulfilling, when you can see someone else benefit from your influence. 

As an educator, you can make a difference not only to the individual learner, but to every learner that person has in the future.  Role models form part of a chain in passing down knowledge and also personal and professional values, qualities, and aspirations.  I want to be part of the chain that has come down to me through my mentors and their mentors before them, which now rests with me to carry forward.

Match Day

Today is a big day for medical students.  All over the U.S., you will gather together to receive mysterious envelopes that notify you of your fates.  Your fates have been generated by a computer (which I imagine looking like Hal from 2001: A Space Odyssey) that is charged with correlating students’ lists of preferred residency programs with programs’ lists of their preferred students.  This impersonal match-maker determines where you will work, train, and live for the next several years.  For many, the decision means moving to another state, uprooting families, deciding whether to break off relationships or continue them long-distance.  The downstream effects on lives and careers are impossible to predict.

Does any other job search work this way?  If so, I am not aware of it.  It seems truly bizarre to be handed an envelope that tells you where you will be for the next 3-5 years.  It is not a complete surprise, since you submitted your rank list for consideration, but you have no way of knowing in advance where you stand in your desired programs’ estimation.  The system was developed in the interests of fairness and transparency, but it still strikes me as an odd method of staffing the nation’s medical centers.

Another unusual element to this process is that there is no room for negotiation.  You accept the conditions of your employment and training without question.  You have been selected for 80 hour work weeks; working nights, weekends, and holidays; low pay and high debt; and very limited control over your life.  But you are so happy to be selected that you do not dwell on these details.  Also, you have spent the last four years working hard with no pay at all, so any step up feels like a major improvement.

I remember my own Match Day fondly now.  I recall the excitement, rather than the anxiety.  I received my first-choice appointment, which probably influences my perception of the experience.  It was fun to be with my whole class at a decisive moment in our lives.  I am sure that many of you have festivities planned to celebrate (or commiserate) this weekend.  Do keep in mind the advice that you will probably be giving to others for the rest of your career: to celebrate responsibly.     

Night Shift

I was counting down the hours until the end of my shift.  I only had three out of thirteen left when one of my patients started to have chest pain and trouble breathing.  Why couldn’t this have waited just a little bit longer? 

I was covering 20 patients on 3 floors of the hospital and admitting 5 new ones by myself.  I did not know any of them before that night and likely would never see any of them again after I handed them back to their primary team in the morning.  So far, I had been too busy to eat or sleep but without any major crisis.  Around 5 am, I started to hope that it would slow down enough to let me run to the cafeteria for some breakfast.  Instead, I had chest pain to deal with.

The sign-out sheet told me that she had metastatic lung cancer and had recently been treated for pneumonia.  Past notes in her record told me that she had been seen by palliative care and a goals-of-care debate was ongoing.  Looking at her told me that she was frail, emaciated, both acutely and chronically ill, and in distress.  She was clearly in pain and anxious, with fast and shallow breathing. 

I did what was medically necessary to stabilize her and try to diagnose why her condition had changed.  I gave her oxygen and treated her pain.  I obtained and analyzed an ECG, arterial blood gas and chest x-ray.  Meanwhile, I was also fielding calls about other patients and their anemia, pain, itching, nausea, constipation, loss of IV access, desire to talk, desire to leave against medical advice, desire to eat in spite of being scheduled for a procedure, and everything else that comes up on cross-cover.

I dealt with all of these immediate issues, more or less successfully.  What I regret about busy shifts is being unable to deal well with the human dimension.  My contact with each patient was superficial.  I did not have a chance to get to know people.  My woman with lung cancer made it through the night, which is important.  Her urgent physical problems were addressed.  But she had deeper emotional needs that I could not meet.

What she needed was someone who knew her as a person.  Someone who could offer her comfort in a time of pain and fear.  Not someone with 25 other patients on her mind, counting down to the end of a shift.  

Difficult Questions

“How do you find the right balance?”

When a medicine intern asked me this question, I must admit that I was not sure what to say.  She was talking about the balance between caring too much and caring too little. 

When you care too much about your patients, you risk distress from bearing the burden of their disease, pain, and eventual deaths.  You may use up your emotional reserves and become burned out.  As with any strong relationship, you risk getting hurt.

When you care too little, you fail to provide people with the comfort and support that are part of the healing process.  You may also feel unfulfilled, unable to truly engage with your work.  You protect yourself, but risk becoming hardened or cynical.

Both extremes are problematic, but how do you find the middle?  In medicine, we are used to quantifying variables.  Every lab value has a normal range.  It is relatively straightforward to tell when an electrolyte level is too high or too low, run through possible explanations, and provide treatment to correct it.  When a normal range cannot be measured, we feel distinctly uncomfortable. 

The appropriate balance of caring is subjective and dependent on the circumstances.  It is also a challenge that is never solved.  We can continue to reflect on it long after our formal medical training is complete. 

I let the intern know that I am still working on this balance myself.  My tendency is to err on the side of caring too much.  I am willing to take the risk of distress, if it means that my patient gets the benefit of feeling cared for.  But in order for this approach to be sustainable, I have to make sure that I also have the means to decompress and recharge.  I have to be ready to be emotionally available for the next patient as well.