Four Years Later: Reflections From the Last Day of Residency

On July 1^st, four years ago, I walked through Mass General and Brigham & Women’s Hospitals with an odd mixture of fear, relief, and excitement. Now, as I leave the hospital after my last shift of emergency medicine residency training, I am filled with a similar hodgepodge of emotions and reflections.

#1. “You were terrified of being a doctor!” I mentioned this article to the attending who oversaw my first shift as a newly-minted doctor. That day is forever etched in my mind; did he remember it? Much to my great embarrassment, he chuckled and said, of course. “I kept telling you not to worry if you don’t know something, but you were scared of everything!”

Though I knew that I was there to learn, it took me a while to get over my insecurities about not knowing so that I could focus on learning. And the learning was everywhere—on every single shift, I learned from great clinicians not just about diagnosis and treatment, but also important lessons on how to lead a team, how to teach, and, most importantly, how to help people who come to us in their time of need. I’ve been incredibly fortunate to have learned from many colleagues along the way, including the amazingly skillful and compassionate nurses at Brigham & Mass General. As my mentors say, it is called the practice of medicine for a reason, and we should embrace, rather than fear, the learning.

#2. “Mistakes will happen.” Every doctor has made a mistake some time in her life. Whether it’s a technical error (i.e. inserting a long IV into an artery rather than a vein), a systems error (i.e. ordering a medication for the wrong patient), or a communication error (i.e. angering a patient or colleague), all of us graduating residents will have made some kind of error. I myself made all three of these errors, and more.

With the volume of patients we will see throughout our careers, being the cause of medical error and interpersonal conflict is a terrifying and humbling thought. A wise physician said to me that just as residency is the time to learn how to practice medicine right, it’s also the time to learn skills like how to disclose mistakes to patients, and how to deal with conflict. “Don’t shy away from difficult situations,” he told me. “Put yourself in the middle of them to see what others do, and then develop your own style.”

#3. “That man has a name, and it’s not ‘the chest pain in room 8.’” As busy residents with long to-do lists, we often fall prey to the tendency to dehumanize our patients and brand them as chief complaints to quickly decide their disposition. On the surface, this might appear to save time, but dig a little deeper, and such algorithmic, depersonalized medicine results in unnecessary tests, misdiagnosis, and worse patient experience.

Furthermore, practicing cookbook medicine is not why we chose to become doctors. My work became much more meaningful when I made a commitment to connect with each patient, no matter how busy I am. I learned that the “old guy with dementia” was a world-renowned philosopher, that the “the onc patient with fever and neutropenia” had ten children with her preschool sweetheart. As physicians, we are privileged to hear so many stories from so many people. Cherish this gift we’re given to share in our patients’ rich lives. Our healthcare system isolates patients and disenfranchises families; we have the power to practice real patient- and family-centered medicine.

#4. “Residency is hard, and you have to take care of yourself.” My best friend from medical school, who had just completed his pediatric residency, warned me about this before I started intern year. How right he was. Work hours may have improved since our forefathers trained, but residents still work a lot and are exposed to high-stress situations with life-and-death consequences. Studies have shown that rates of depression and burnout increase sharply during training, yet the “hidden curriculum” of medical training still favors bravado over openness. Residents are taught to “suck it up” instead of talking about difficult situations and taking care of ourselves.

This is not the way it has to be! I learned this lesson the hard way during second year of residency, when my mother died. I suppressed my emotions rather than seek help, and saw how easy it is to feel isolated. Fight this impulse and stay connected. Find peers you can reflect with and openly speak about your experiences. Nourish the other people in your life and recognize their critical role in helping you through this process. For me, it was my wonderfully supportive husband and my friends who sustained me and kept me grounded. Make time for these people in your life. I cannot think of anyone who regrets the time spent with our loved ones and laments, “if only I spent that day reading one more research article!”

#5. “Emergency medicine is a phenomenal field.” The first grand rounds lecture I heard as an intern was by Dr. Larry Weiss, then President of AAEM. He spoke about how emergency medicine is an ideal specialty for advocacy: as the frontlines of medical care who interact with every aspect of the healthcare system, we are the most well-positioned physicians to advocate for our patients, our communities, and our society. We see the problems with public health—smoking, obesity, gun violence, etc. We see the problems with under-, over-, and misutilization of healthcare. And we have the ability and power to act on these problems every day.

In my fourth year of medical school, I selected emergency medicine as a specialty because I wanted the ability to treat any patient, anywhere. Being one of the emergency providers who took of care victims of the Boston bombings made me grateful for my training and for the skills I’ve learned along the way. We in emergency medicine have the incredible opportunity to utilize our training to do what we love while making a difference to improve care for our patients and to transform our healthcare system.

What else can I say about these last four years? It’s been a rollercoaster ride. Now that I’m about to embark on the next journey as an emergency medicine attending physician, health policy professor, and Director of Patient-Centered Care Research at the George Washington University in D.C., I am filled with exactly the same emotions of fear, relief, and excitement that I came to Boston with. I have learned so much from so many incredible people along the way, and will forever be indebted to the amazing attendings, residents, nurses, physician assistants, and other colleagues at Brigham & Mass General Hospitals.

Now, what will the next years bring? I’ll be on leave for the next month, but stay tuned for more dispatches and reflections, soon to be from the nation’s capitol.

8 Ways to Care for Elderly Loved Ones in Assisted Living

This is a special guest post from contributor Krisca Te.

When the time comes to move a loved one to an assisted living facility (ALF), it can be an emotional period for everyone involved. While it’s undoubtedly the right thing to do when they are no longer capable of living on their own, it is inevitable that some negative feelings will surface. 

On your own end, there may be feelings of guilt that you aren’t taking your parent or grandparent in yourself, while for them it means the beginning of the end of their independent lifestyle and will require some pretty big adjustments.

I experienced this firsthand when the time came to move my grandma to an ALF. She had always been very active and independent; she loved playing golf on the weekends, meeting up with friends for bridge games and hosting elaborate dinner parties.

However, as she got older, it gradually became more and more difficult for her to climb up and down the stairs and get around the rather large home where she lived alone. On one occasion she suffered a fall and injured her ankle; luckily it wasn’t too serious, but it did lead us to reevaluate her situation.

When we brought it up with her, she was naturally very distraught at the thought of leaving her home and insisted that she would never move to an ALF where as she put it “everyone was just waiting to die.”

Eventually we suggested that she come along and have a look at some of the places in our area, just to get a feel for what they were like.

Once she saw the facilities, met some of the residents there and talked to the staff, she actually began to warm up to the idea of moving to a smaller place where she would have more help, and also more opportunities for socializing. 

She has since moved to an assisted living facility nearby and although it certainly hasn’t been an easy process for her, she has managed to readjust and is still enjoying most of the same activities she did when she lived in her own home.

I’ve learned that although you can’t change your loved one’s circumstances, there are things you can do to help them through the transition. The most important thing you can do is to simply be there for them and give them your support when they need it.

The following are some of the things that helped in our situation, and hopefully they will be helpful to others as well.

1. Deal with any feelings of guilt first. If you’re feeling guilty about placing your loved one into assisted living, it’s important that you are able to work through those feelings before you move forward as these feelings could negatively influence your loved one’s transition period.

Keep in mind the reasons why you initially decided that moving your parent or grandparent to an ALF was the right move and remember that it will benefit their health and well-being.

2. Talk through any concerns well in advance. If your loved one has any concerns about the move or about what will happen to their current home or belongings once they move, it is important to go over these concerns long before you being any other preparations. Find out what they are worried about and then work towards coming up with solutions that will put their mind at ease.

3. Visit the ALF with them a few times before the move takes place. Most of us are more afraid of what we don’t know than what we do, so taking your relative to visit the facility and acquaint themselves with the grounds, staff and amenities can do a lot to ease their worries and help them adjust more quickly.

Go to a few meals, talk to other residents and familiarize yourselves with the grounds and layout of the facility so that your loved one knows what to expect.

4. Keep in touch as much as possible. During the first few months or even year of your loved one’s transition into assisted living, they will likely be feeling vulnerable and insecure in their new surroundings. Knowing that they can count on your support can go a long way in helping them to adjust. Make regular visits and when you can’t come in person, be sure to phone them or send a little note so that they know they haven’t been forgotten.

5. Help them make new contacts and get involved with activities. Elderly people can often become shy when placed in a new environment and may turn down suggestions of activities or social gatherings. However, getting involved with others in their community and making new contacts is an important part of the adjustment process.

If they seem reluctant to participate, try accompanying them to some of the planned activities and gatherings so they don’t feel too intimidated. There is bound to be some activity your loved one is interested in, whether it’s art, book clubs or music lessons.

6. Don’t coddle. Showing support is important, but make sure you give your parent or grandparent the space to be independent as well.

In the first few days, for example, you may want to visit every day to make sure they know you haven’t abandoned them, but as time goes on, it’s better to space the visits out a bit more so that your loved one doesn’t become too dependent on you.

7. Set up their new living space with familiar furnishings and personal effects. Most elderly people are quite attached to their belongings, and parting with them can be very stressful. Obviously, they will be moving to a smaller environment, so not everything can be moved with them, but incorporating as many of their favorite objects like armchairs, beloved knickknacks and photographs can give the new place a familiar feel.

8. Form good relationships with the staff. You may not always get straight answers from your loved one about how they are doing and whether or not they are adjusting well into their new home, so forming good relationships with the staff can help you stay better informed of their progress and any issues there may be.

Krisca Te works with Open Colleges, Australia's leading provider of TAFE courses equivalent and aged care training. When not working, you can find her on Google+ or spends the day with her baby boy.