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.

The Trouble With "Traditional" Research and a Call to Action

What’s wrong with the following picture?

Two medical researchers at a major academic center collaborate to study disease X. They come up with the research question, design the project, obtain grants, and collect data. Their results are published in a scientific journal and presented at several medical conferences. Based on this first study, the researchers start another cycle of idea generation, data generation, and publication.

I presented this scenario to three Harvard medical students working with me in the ER. They all looked at me blankly. “I don’t get it,” one of them said. “Isn’t this the way research is done?”

That’s exactly the problem. This is “traditional” research, and traditional research leaves out one critical stakeholder: the patient. 

A few weeks ago, I had the honor of participating as a member of PCORI’s inaugural advisory panel on patient engagement. PCORI is the Patient-Centered Outcomes Research Institute, and is a new federal institute mandated to figure out how to meaningfully involve patients in research.

Some may argue with the necessity of such an institute. After all, isn’t research ultimately done to help patients? While grants and publications advance careers, few researchers go into such grueling fields to make money or gain fame. Isn’t research already serving the public good, which by definition is patient-centered?

But here’s another way to think about it. In “traditional” research, patients are subjects. Their sole purpose is to participate in research trials, and the extent of their decision-making is confined to whether to participate in the trial (let’s set aside, for now, the many throughout history who were subject to research against their will). Very rarely, if ever, do patients participate in the research design, data analysis, or result dissemination. Very rarely, if ever, do patients initiate the research and envision the research question itself.

Yet isn’t it the patient—the one with the disease—the most knowledgeable about what needs to be studied and how? No doubt, the researcher has irreplaceable expertise; but isn’t the patient also a vital partner in the process?

In this era of healthcare reform where the patient is finally recognized as a necessary stakeholder, the creation of PCORI is an attempt to shift the paradigm of how medical research is done. Rather than having patients as invisible, nameless subjects, PCORI requires them to be involved in the research design from the very beginning. Patients are expected to be equal partners in deciding what projects to fund and figuring out how to design studies with a patient-centered focus. They are expected to help figure out what’s important to study, and how to get out the results beyond the realms of scientific meetings and medical journals.

Much about this “new” concept of medical research is common sense. Most would agree that precious time and tax dollars should be devoted to what really matters to people. Yet, this paradigm shift is such a departure from traditional research that it is not without its doubters. Researchers not used to involving patients question whether they would be sophisticated enough to understand the research process. Patients, too, doubt whether they have the expertise required. Fueling this is mutual mistrust: will this new patient-centered approach derail existing research? Will patients end up being “used” for some nefarious ulterior motive?

As part of PCORI’s outreach efforts, it solicited applications for 4 advisory panels. Over 1,000 people applied—many of whom are representatives of patients and patient groups. Twenty-one of us were selected for the advisory panel on patient engagement, and met over two days in Washington D.C.

While many of us are optimistic and excited about the potential of PCORI, we also raised several questions, including:  

* How can researchers switch their mentality to become patient-centered such that they are not just simply checking a box to affirm that yes, patients are involved?

* How can PCORI itself ensure that it adheres to its goal of “research done differently” and go really tackle the concept of patient-centeredness?

* While it is admirable that PCORI has taken great strides to involve many patient advocacy groups, these groups represent only a small portion of patients. How can PCORI go beyond hearing the loudest voices—many of whom may also have their own motives—and really engage people?

* How will PCORI address issues neglected in traditional research that are vital to our healthcare, such as preventive medicine?

* How will PCORI really engage people around the country to come up with research questions and redirect priorities?

Recognizing that there is a fundamental problem with the traditional conduct of research is a critical first step to making change. PCORI has opened a door that’s been shut for far too long. It is now up to all of us—as physicians, researcher, and most of all, as patients—to ensure that medical research, and medical care, focuses on and originates from the patient.

Happy Nurses Week: A Tribute to Nurses

It was my first shift as an intern, and I was terrified. I was assigned to the “Fast Track” area of the Mass General ER—a section designated for those with straightforward issues: lacerations, sprained ankles, etc. Overnight, though, I would be the only doctor in that area. I’d been away from clinical medicine for nearly three years, and was terrified of what that Saturday night would bring.

My first patient proved my ignorance. Mrs. R was a pleasant woman in her sixties who had gotten her left hand caught in the car door and was feeling pain in her third and fourth knuckles. I’d ordered x-rays of her hand, which showed a small fracture, and I was trying to figure out how to make a splint.

“Doctor, you might want to take another look at her hand,” her nurse, Kelly*, said.

I ran to the room. Even from the doorway, I could see that Mrs. R’s third and fourth knuckles had swollen to twice their size. The ring finger was turning a dark red, almost purplish, color.

This was an emergency! I couldn’t believe that I’d forgotten to take the rings off before the x-ray, and now they were compromising blood supply to the fingers.

But what do I about it now? Mrs. R was in obvious pain, but she was also crying that these were precious rings, given to her by her late husband.

I grabbed an ice bucket and some water-soluble jelly. Kelly frowned. “How about doing a digital block first?”

Numbing the finger…. that sounded like a great idea. But alas, digital block, jelly, and ice did not do the trick. “Maybe it’s time we get the ring cutter,” I said

“How about trying the string technique first—have you used that?” Kelly suggested. No…. but she had, and we succeeded in getting the rings off, without needing to damage them, or our patient.

The rest of the night was a blur. I remember my hesitation at ordering any medication stronger than Tylenol, and even Tylenol itself (“for God’s sakes; mothers give it to their babies!”.) I remember my first car accident victim, M, an intoxicated young man who had been struck while walking across the street. He looked fine to me, but his nurse, Ann, didn't think so. He was sweating and looked confused, not drunk. “Let’s move him to another area,” Ann said. She was right—he turned out to have a bleed in his brain and a large femur fracture. Her clinical acumen saved our patient.

Thankfully, I have matured as a clinician since that terrifying first day, though the training process was not without its bumps and bruises. I and my fellow trainees frequently credit the attending physicians and senior residents from whom we have learned so much. This praise is deserved, but I also want to acknowledge another group of people who have instrumental in teaching and guiding us: the nurses.

Over the last four years, I have had the honor and privilege of working with and learning from the terrific nurses at Brigham & Women’s and Mass General Hospitals. Time and time again, these nurses have saved me from making mistakes, big and small. They have taught me clinical judgment and clinical skills. They have demonstrated true patient-centered care, and shown me what it means to really listen. They have inspired me to always be vigilant and always care.

In my second year of residency, my mother passed away from metastatic cancer. Before she died, she told me that she wanted to make sure I thank her nurses, because it was they who she thought really cared for her.

It was they, too, who cared for my family and for me. After we decided to withdraw her life support, I was wracked with guilt. It was what my mother had wanted, but kind of daughter was I to end my own mother’s life?

All the doctors had left. Her nurse, Andy, came to find me at my mother’s bedside. He told me about how he had to make a similar decision to allow his terminally ill wife to die. “It’s what she would have wanted,” Andy said. “You are carrying out her last wish, to die peacefully.” I will never forget his words and his kindness.

As I near the end of my training at last, I am reminded of the Hippocrates saying that the goal of medicine is “to cure sometimes, to relieve often, to comfort always.” This, too, I learn through daily example from the amazing nurses I work with.

Thank you.

* Names have been changed, though I very much remember—and acknowledge—the actual people involved.

Rebranding “Patients” as “Healthcare Consumers”: Tread with Extreme Caution

On Monday, I had the privilege of serving as the keynote speaker for an excellent conference in Boston. Empowering Healthcare Consumers: a Community Conversation brought together an impressive array of people to discuss how to improve healthcare through empowerment. In attendance were over 150 community leaders, clinicians, hospital administrators, insurers, advocacy group leaders, and patients.

Patients—or I mean healthcare consumers? The conference organizers specifically requested that I use the terminology of “healthcare consumer” rather than “patient” in my presentation. Several of the speakers before me made the point eloquently as to why: “patient” has the connotation of passivity, and people need to be active to take charge of their health. We need to be savvy consumers and do our own research into the cost and quality of healthcare, much the same way we would if we were shopping for a new car.

The new language made me uneasy. Don’t get me wrong; I am all for people being empowered in their healthcare (I write a blog and published a book on this), and for transparency and availability of information to make informed choices. However, I also believe that healthcare is a human right. A patient deserves healthcare as a right. But does a consumer?

Those of us in favor of universal access to care argue that healthcare is not a commodity like cars and TVs. Using the language of people being consumers could undermine this fundamental tenet. If you are shopping for healthcare in the same way you shop for your car or TV, this implies that you buy what you can. (Can’t afford a new Lexus? Buy a used Toyota. Maybe wait a year.) This doesn’t—and shouldn’t—work for healthcare. (Need heart surgery? Choosing the “discount” surgeon, or waiting a year, don’t sound like good choices.) Those who can’t afford healthcare are priced out of it, and healthcare is no longer a public good, like public education and clean water.

I also worry about effects of rebranding on the physician-patient relationship. What happens when the doctor becomes the hired consultant of the savvy shopper patient? Perhaps the doctor will be more responsive to consumer demands—but perhaps this doctor will also feel more obligated to give the consumer exactly what he wants, including unnecessary tests and harmful procedures. And will these physicians still retain their sense of social responsibility, when healthcare is reduced from societal obligation to personal choice?

An extreme version of patient-as-consumer can be found in China, where people routinely pay their doctors under the table as promise to receive better care, and patients—even those dying of stroke and heart attack—are turned away from hospitals if they cannot pay upfront for their treatments. The physician-patient relationship has broken down so much that doctors have been murdered by angry patient families.

In such a system where it’s every man for himself, it’s hard to convince people that healthcare is something we all have to safeguard. We already live in a society where many believe that more is better—at least when it comes to ourselves. When making healthcare decisions, few take into account the cost to society. Yet, healthcare is not a limitless commodity. There are efforts underway to think of the escalating cost of healthcare as we do global warming; these efforts will not work if we adopt the language of consumerism.

So what is to be done? Here’s a suggestion. Instead of throwing out the word “patient”, change what it means. Encourage people to become the educated, empowered patient, even, dare I say, the pushy patient. This is the patient who will make individualized choices about her health as an active and equal partner with her doctor. This is the patient who will ensure the best possible care for herself and, in so doing, catalyze reform of our healthcare system to one that values informed decision-making and reaffirms health as a basic right.

From the Frontlines: Reflections of the Boston Marathon Bombings

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“I have a recurring nightmare where I am performing CPR on a patient who turns out to be my husband.

Last Monday, my nightmare nearly came true.

It was 2:50 p.m., and the Massachusetts General Hospital ER was filled to capacity.

In the section where I was working, my patients were critically ill, with strokes, heart attacks and overwhelming infections. Even the hallways were packed with patients receiving emergency treatments.

A call over the loudspeakers announced that there had been two explosions. Many people were injured. That's all we knew.”

This is how last Monday began. The rest of my story, and my husband’s, is in my NPR piece.

It’s been a very long week in Boston.

I will write more of my reflections in the days to come, about destruction and terror, but also about collaboration and courage. 

Thanks to everyone for your support and well wishes during this trying time for our city.

12 Ways to Stay Safe in Hospitals

Hospitals can save you, but they can also harm you. In my last two articles, I discussed recent research that shows how medical errors affect one in three hospitalized patients, and the 10 types of errors that happen.

So how can you stay safe in hospitals? Follow these 12 life-saving tips:

#1. Never go alone. Always bring someone else—a trusted family member or friend—with you. That person will be your primary advocate, and can serve as an extra set of eyes and ears to help make sure you are safe. (This tip applies to routine doctors’ appointments too; always bring your advocate with you.)

#2. Determine, in advance, the goals of the hospitalization. Before you go to the hospital, ask your doctor why you need to be hospitalized. Is it necessary, or is outpatient care possible? What is the goal of the hospital stay? How often will that goal be assessed? Can you choose which hospital to go to, and when you should go? Rarely is the need for hospitalization so emergent that you can’t get these answers and discuss them with your doctor in advance.

#3. Prepare. Bring all the things you would normally bring with you to a doctor’s appointment, including a list of your medical problems and allergies. Don’t assume that the hospital will have your records. It’s very important to bring all the pill bottles that you take so that there will be no mistake about what dosage and how often you take your medications. Keep your main doctor’s phone number and your advocate’s phone number handy (though your advocate should be going with you to the hospital).

#4. Meet your care team. Find out who is in charge of your care: is it your regular doctor or a hospitalist doctor? Introduce yourself to her, and to your primary nurse. Meet the patient care tech, the nursing assistant, and the other members of your healthcare team. Tell them about yourself, and find about them. The more they get to know you as a person now, the more they will help to answer your questions later. Your advocate should also get to know your care team.

#5. Know who to call for help and how. Who will be the night-duty doctor and nurse, and how can you reach them? If you are in trouble, or if your advocate sees you’re in trouble, how will you get help? Many hospitals have a “rapid response team” or a “code team” that come to assist in emergency situations. Can your advocate activate this team himself?

#6. Ask about every test done. Don’t just consent to tests. They all have risks, so ask about them. Why is your blood drawn every morning—what is the purpose? Why are you getting the CT scan? You should discuss every test with your doctor in advance of doing them, and have a thoughtful discussion about risks, benefits, and alternatives.

#7. Ask about every treatment offered. If you’re being started on a new medication, ask about what it is, what the risks are, what the alternatives are, and why you need it. If you’re told you need a procedure, make sure you discuss it with your doctor.

#8. Keep a record of your hospital stay. Your advocate may need to help you with keeping a careful record. This includes your tests (make a note of what you get done and ask about the result), medications (write down when each medication is given and double-check it’s correct), and providers who come to see you (write down names of specialists and their recommendations). A detailed record helps to prevent mistakes, coordinate your care, and keep you on track.

#9. Attend bedside rounds. Doctors and nurses usually have rounds at least once a day to discuss their patients. Find out when rounds happen and ask if you and your advocate can attend. This is your time to find out what’s going on with your care. Prepare questions to ask during rounds.

#10. Know your daily plan. Rounds are a good time to ask about what is happening that day. Are you doing more tests? More treatments? Are you on track, or did something unexpected happen? When can you expect to go home?

#11. Keep your eye on infection control. If someone comes into your room, ask him to wash their hands. If someone is doing a procedure on you, ask her to follow an infection control checklist. Hospital-acquired infections kill 100,000 people every year, and you can help prevent them.

#12. If something isn’t right, speak up immediately. Remember that it’s your body and you know yourself the best. Get help if you develop new or worsening symptoms. Empower the person you’re with to speak up for you if you can’t.

All of these tips may sound like a lot of work, and you may be wondering why it’s your job to do all of this. After all, aren’t you the patient, the person who is feeling unwell and seeking help? By and large, doctors and nurses are well-meaning, and most of the time, the system is working well and you will get good care. However, mistakes do happen—and you and your advocate can help prevent medical error. Follow the tips above to make sure that you are safe and well during every hospital stay.