Preserving the Humanity of Patients and Physicians

Everyone knows that life in the E.R. is fast-faced, extremely busy, and ever-challenging. When things get crazy, it becomes habit for busy physicians to see patients as “the chest pain in room 6” or “the broken wrist in the hallway.” We turn people with their amazing lives and fascinating stories into a nameless number and a “chief complaint”.

It’s a practice that’s easy to justify—after all, taking a long time with one patient can delay care for all the other people who are waiting to see us. However, the story of the patient, the story of why he is there, and the context of his illness—these are all critical to us taking care of him.

Learning our patients’ stories also makes our professional life that much more fulfilling. Last moth, I was supervising an intern, who saw a patient that she was confident she knew what to do with. “Room 8 is an old guy from a nursing home with dementia, who was recently here for pneumonia. He comes in with altered mental status and a cough. He is confused, has a fever, his lungs sound junky. I’m going to get a chest x-ray and do an infectious workup. He probably has pneumonia, and will need to be admitted.”

That sounded like a straightforward plan to me. It was a busy day, and I went into see this “old guy” who probably had pneumonia. I introduced ourselves to a woman in his room, his daughter, who was holding a book. It was on love: the metaphysical interpretation of love.

She saw me looking at the book. “Have you ever read it?”

I shook my head. “Well, it’s my father’s book,” she said. “It’s been printed in 100 countries.”

Indeed, this “old guy from a nursing home” was one of the foremost experts on the philosophy of love. He had had a phenomenal career, filled with interesting adventures. The daughter was one of many people who made up his loving family—they were more than happy to tell me about him. In a few minutes, I had learned so much more about him as a person, and as a patient.

How often do doctors find out, really find out, about our patients? Well, here’s how NOT to find out. Ask: “Do you have chest pain? Shortness of breath? Abdominal pain?” These yes/no questions may seem important to us as we check off a list that doctors feel compelled to ask, but they don’t tell us anything about who is the person in front of us. We have no idea of the careers they devoted effort to, accomplishments that they are proud of, and goals that they strove for.

As I think back to the most memorable moments of my medical training, what stands out aren’t the never-ending lectures, or heroic surgeries, or terrible traumas. What I remember are the people I met and their stories.

I remember Sharon, a lady who was dying of cancer. Her husband showed me a picture of the two of them when they were both three—they had met in a sandbox 80 years ago, and had been inseparable since then. I remember Fan, a middle-aged man who was so serene after a serious car accident that resulted in tetraplegia. I later found out that he was a Buddhist monk, one of the most revered in Asia. I remember Sydney, a drug addict I saw as an intern who returned two years later saying that he was now totally clean and running a recovery program for teens. These are the stories I cherish, of the patients I have been privileged to care for.

Physicians, nurses, and our team of health professionals are part of a humbling profession, an incredibly rewarding one, where we are honored to meet people from all walks of life. Instead of shying away from this task and turning people into a compilation of their symptoms, we need to embrace the gift that our patients are giving us. We should ask our patients about themselves. Not just what pain they have, or do they have this symptom or that symptom, but ask them who they are. What they do. What drives them. What makes them happy. Not only will it add so much depth and accuracy to their diagnosis and their care, knowing our patients will make doctors happier people—individuals who are more attuned to the humanity of our patients, and ourselves.

This column is modified from an article published in the American Academy of Emergency Medicine’s magazine, “Common Sense”. I explore these ideas and more in my new book, When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests.

Physician, Seek Help--Don't Just Heal Thyself

In my second year of medical school, I attended a reading by Dr. Abraham Verghese, a physician, writer, and humanist. He had just written a book, The Tennis Partner, that was about his friend and then-medical student who lost a slow battle to drug addiction and mental illness. The book was about how their relationship developed—and how he found out about his friend’s problems, then failed to act on it. The reading was poignant because of his obvious emotional involvement, and because the topic hit close to home.

How many of you know medical students, residents, and doctors-in-practice who have been depressed? Who have thought about harming themselves or tried to numb their pain with alcohol and narcotics?

Studies have shown that physicians have a far higher rate of depression, substance addiction, and suicide than the general population. Medical students start out with similar mental health profiles as their age-matched peers. During medical school, one in four medical students become clinically depressed. One in ten entertain thoughts of suicide. Despite their ready access to healthcare, physicians-in-training seek help with lower frequency than other young professionals.

Researchers have come up with various hypotheses to explain these findings, including social isolation during training and greater tendency towards perfectionism. In a New York Times op-ed, surgeon-writer Dr. Pauline Chen discussed the problems with the “survival of the fittest” mentality that is prevalent in the medical profession. While in training, who wants to be the “weak” person who seeks help? Who wants to admit they want more support than someone else, or burden others with time off or shifts to cover?

I faced this issue myself in my second year of residency. My mother died after a long battle with cancer. She had fought it for years with surgery and aggressive chemotherapy until finally she was in remission. Then, during my internship year, we found out that the cancer was back. The last few months of her life were filled with terrible suffering. She fought despite the pain because she wanted to make sure my then-16-year old sister was OK. Finally, she agreed to enter hospice care, but she never quite made it home. She died in the ICU, at age 54.

As much as my family was prepared for her death, and as much as it was welcome because it put an end to her suffering, it was a very difficult time for us. Coming back to work was much harder than I expected. Every cancer patient or critically-ill patient reminded me of my mother and her last days. I cried after every shift. I was on an emotional rollercoaster: things would seem to be getting better, then an issue with my family, or a patient, or a patient’s family, would set things off, and the rollercoaster would come crashing down.

My experience is a pretty specific example of grief and bereavement, but I think the lessons I learned are applicable to other physicians who are coping with their own challenging situations. I share them with you now:

1) Accept the support of family and friends. This may seem obvious, but I made the mistake of shutting people out and burying myself in errands and busywork just to keep occupied. Thankfully, those closest to me didn’t allow me to isolate myself, and I learned that losing ourselves in our training is never a good solution. It may temporize the pain, but will only serve to alienate us from those who care about us.

2) Ask for help. This could be as simple as letting your school, program or hospital know of your need for time off. In my case, I didn’t tell anyone in my residency when my mother got sick. I wish I had, because I would have been able to spend more time with her in her final months. When she died, I even resisted taking time off. In retrospect, I came back to work too soon. I thought I was being strong and wanted to prove—most of all to myself—that I could do it. But the result was traumatizing to me, and I probably ended up delivering less than ideal patient care. There is really no shame in admitting that we need help, whether it’s help for specific things like covering shifts, or if it’s referral to a counselor or support group. Both Dr. Verghese and Dr. Chen wrote about how silence is what leads to deadly outcomes. “Physician, heal thyself” is a mantra that fosters bravado, not compassion.

3) Recognize and help address challenges that others around us are facing. Prior to my experience, I hadn’t realized how prevalent depression and addiction are in our profession. The Tennis Partner describes a very plausible scenario that could happen to any of us. After all, if one in four of all physicians-in-training are depressed at some point in their training, it’s likely that a couple of our friends or colleagues are having problems at this moment. As physicians—indeed, as humans—we have a duty to make sure that those around us are OK.

So do your part. On a personal level, reach out to your friends. If you suspect they are in trouble, reassure them that you’re there for them and that it’s OK to seek help. Make use of student support services in your medical school or hospital. Start your own support groups if none exist. In my residency, I helped to start the Emergency Medicine Reflection Rounds (EMRR) where residents meet to discuss personal reflections and give advice and support for each other. EMRR has been successful so far, and the feedback we’ve received reinforces the importance of establishing and fostering community. 

Medical training is not an easy process, but we are not alone. We can each do our part to preserve humanity, promote wellness, and approach each other, and our patients, with respect and compassion.

Parts of this article have been published in AAEM's Common Sense magazine and on Medscape.  I welcome your feedback and comments on this blog post.

In Honor of July 1st: a Reprieve to Intern Year

Today is July 1st, a monumental day in academic centers around the country. It is the day when newly minted medical schools put their new M.D. to use as interns, when interns become junior residents, when junior residents become senior residents, and so on and so forth. In honor of today, I am reposting an article I wrote two years ago, at the end of my own intern year. This was initially published in AAEM's Common Sense magazine and on Medscape.

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“Excuse me… um… how exactly do I order the Tylenol?”

I look up. In front of me is a young man wearing a pressed shirt and striped tie. “I’m Ben,” he says, introducing himself to me as an intern on his very first day of residency. It’s not really statement that needed to be said; none of us would have mistaken him for anything but. How to order Tylenol is a seemingly self-explanatory action, but last year it was me asking that question. As I lead him through the order entry system, I reflect on the past year. How have I grown in this notoriously grueling yet life-changing internship year? What advice would I impart to the new cohort about to impart on this same journey?

Clinically, I am stronger than I was a year ago. Clinical training in a supervised setting is indeed the purpose of residency and why tens of thousands of young people in the prime of our lives devote many long hours to our hospital. Internship is all about becoming more comfortable with management of everything from routine urgent care presentations to medical resuscitation of very sick patients. Throughout this year, I’ve seen my classmates and I progress from asking “what next” to thinking through and acting on most treatment decisions ourselves. Part of that clinical development is knowing how much more there is to learn, and it remains daunting and inspiring to see that, as much knowledge and skills as we have gained, there is still a long way to go.

Professionally, I feel more comfortable in my role as clinician and resident physician. I remember on my first day of internship practicing my introduction in the mirror. “Hello, I’m Dr. Wen, your doctor,” didn’t seem quite right. Too curt, yet oddly redundant. “Hi, I’m Leana, your doctor.” Not right either. Too informal. “Nice to meet you, I’m Leana Wen, one of the doctors.” OK, but who are the other doctors? The struggle with something as basic as introducing myself is symbolic of my biggest challenge in intern year: feeling at home as a resident. Our training is at two main hospitals and two other affiliated sites. Not only were there dozens of residents and attendings and literally hundreds of ED nurses to meet, each month was a different rotation with more new people and new ways of doing things. It took me until the end of intern year to feel at ease with my colleagues. Being part of AAEM-RSA has been instrumental for me to feel at home in my specialty—now, not only do I know my 60 co-residents, I am connected with thousands of residents across the country.

Intellectually, this has been a year of alternating disappointment and growth. So much of medical school was about memorization and pattern recognition; I was afraid that residency would teach more of the same. I did not want to be an automaton who did nothing more than input data and run algorithms like a “Choose Your Own Adventure” book. EM, perhaps more so than other fields, has the potential to turn into an algorithmic exercise. However, there are plenty in our field who believe that EM is far more than figuring out a disposition. As my mentor, Dr. Josh Kosowsky, likes to say, EM is the modern home of diagnosis. What other field presents so many diagnostic puzzles in any given day? Checklists have their place, but algorithms should never replace the art of healing. One of my most valuable lessons this year, one that has kept me intellectually challenged and emotionally engaged, is to make sure to hear each patient’s story as their narrative, not just as a chief complaint followed by yes/no answers.

Personally, one of the battles each of my classmates has struggled with is finding balance. Internship is pretty far from a “normal” life: it throws off anyone to work under fluorescent lights for six days a week, to eat nothing but hospital food for three meals a day, and to not see family and friends for a day and a half. Our days are so long that by the end of a shift, it’s often hard to find energy to do the things that used to make us happy. Yet, as busy and as tired as we get, we shouldn’t make residency just about working, sleeping, and eating. I’ve watched each of our classmates emerge from survival mode to making time for the things that matter to us, from training for triathlons to watching sci-fi flicks to getting a scuba-diving certificate. As for me, I’m ballroom dancing and playing the piano again, and a much happier person for it.

Despite finding better personal balance, one of my classmates said during our end-of-the-year intern retreat that he wasn’t sure he liked the person he was becoming. This resonated with all of us. In intern year, each of us can recall instances when we’ve become more abrupt with family, short with sales clerks, perhaps impatient or even disdainful with patients. However, as difficult as our lives may be at times, as grueling as it may be to work night shift after night shift, we cannot lose track of our fundamental purpose of being healers and advocates for our patients. It’s a profound privilege that we have to take care of patients in the time of their greatest need. It’s a profound honor that families place care of their loved ones in our hands.

“That was an awesome day. Thanks for showing me around!”

I smile. It’s the end of Ben’s first shift. His hair, impeccably groomed ten hours ago, sticks out in the back and strands point towards the ceiling. His face bears the telltale imprints of mask and eyeshield. His blue tie is flecked with blood. (I feel sure that from now on, his attire will consist of scrubs.) I wonder what Ben’s reflections after intern year will be. I know that he, too, will develop clinically and grow into his professional role. I hope that he finds his intellectual pursuits rewarding and his personal balance satisfying. Above all, I hope he retains his humanism, his ideals for why he chose to enter this healing profession of medicine.