Saturday, December 18, 2010

Moments & "thank you"s

This past week was a wild one; somehow the last week before the holiday break always is.  I could barely catch my breath, it seemed - the office was veritably hopping with patients, which meant busy patient sessions for me and busy precepting sessions with the residents.  Throw in a Joint Commission visit to our hospital and Family Health Centers, and I am most glad this work week has come to a close.

My lifelines during that hectic week came from rather unexpected places.  First, one of my resident advisees wrote me a lovely Christmas card thanking me for my support and also gifted me with a bottle of wine.

Then, I received a Christmas card from a patient that I would not have expected such a token from.  She frequently misses appointments and, when she does come in, I rarely get a sense of success in collaborating on her complicated medical and social issues.

Finally, I was privileged to attend the faculty development fellows' annual holiday luncheon.  I definitely enjoy teaching precepting, health behavior theory, and presentation techniques to the fellows at scattered points throughout the year, but I'm not convinced that I am contributing enough to justify my attendance at this lavish meal.

There is a line from Sondheim's musical "Into the Woods" (which I was lucky enough to be in while in college) - "Every moment is of moment."  How many moments with patients, with learners, with colleagues did I experience in this last week?

To have even a few such moments from the past year recognized was incredibly heartwarming.  While I never want to fall into the trap of expecting such recognition - and, thereby, making that the focus of my ambition - it does feel good to be acknowledged.

The sincere generosity that these three happenings demonstrate certainly reflect more powerfully on the givers than on me, though.  Those kindnesses, those little bright spots of light, made the grind of a hectic, overwhelming week more bearable.

Now I have to wonder - where can I spread a little light?

Thursday, December 9, 2010

Supporting our colleagues through the "hurts"

I was sitting on one of the hospital's nursing units having a difficult telephone conversation.  Anyone working nearby could have easily discerned the situation from my end of the call:

Patient's family member wants to keep aggressive care going for a comatose, terminally ill family member against the best advice of the medical team.

Having never had to make such a decision in my own life, I am left to imagine how heart-wrenching it must be for the family.  But the ICU team and specialists caring for the patient are in agreement -- this patient will not recover.  The only question is under what circumstances this patient will die.

I tried to hear the family's wishes and concerns with an open mind.  I tried to compassionately share my opinion about the extremely low probability of any meaningful recovery.  The ICU team had hoped that my rapport with this family would lead to a plan to withdraw care and permit a peaceful death; their conversations with the family regarding plan of care had resulted only in increasing hostility. The family member I spoke with was similarily adamant.  The family will not accept any outcome short of a full recovery, I was angrily told.  They expect this patient to walk out of the hospital as he/she was before, healthy and vibrant. 

Being shouted at, with the clear implication that my judgment is unsound and my caring most deficient, was unpleasant to say the least.  I hung up the phone and put my head into my hands.  A resident sitting at the work station next to me commented, "that sounded tough."  I shared the brief details of the situation and my sadness at this patient's fate of futile tubes, IV lines, and machines.  The resident asked some thoughtful questions about making end-of-life decisions, and we conversed for a bit.  An attending nearby commented, "sounds like the family's just not ready yet."

"It just feels like...if I could have found the right thing to say, the right way to say it, that maybe the conversation could have gone better," I responded.  I didn't mind the eavesdropping at all.  I had that deep, hollow feeling that comes into the pit of my stomach when a patient or family encounter doesn't go well, and it felt good to be able to share even a little of that with trusted acquaintances.

I dutifully delved back into the electronic records of our current inpatient team, signing off resident notes, looking at new labs, checking my outpatient in-box.  I tried, unsuccessfully, to convince that deep, hollow feeling in my stomach to go away.  Several minutes passed, and my empathizers drifted off to their other tasks. 

Or so I thought.  Another colleague had been quietly working at a nearby computer station.  He walked up to me and said something along the lines of "listen, I couldn't help but overhear what happened on the phone, and I heard you beating yourself up about it afterward.  But, it sounds to me like you did the best you could.  I heard what you said to them, and it was totally appropriate.

"Some things you just can't change," he continued.  (How many times have I said that to residents or medical students?)  "You did the best that anyone could have done."

The deep, hollow feeling began to lose its grip on my GI tract.  This colleague recognized my suppressed agony and perceived a responsibility to respond to it.  With just a few kind and thoughtful words, he helped me to regain perspective on the situation.

How often do we physicians, thoughout our day-to-day lives, suffer these little (and, sometimes, very big) hurts?  Sometimes we share them with each other, but sometimes we don't want to bother anyone.  Sometimes we're too ashamed at our real and perceived failures. 

I am grateful, today, that someone recognized and responded to my little hurt.

Tuesday, December 7, 2010

Back on the inpatient service again

It's another week supervising the inpatient resident service for your intrepid academic family medicine blogger.

I find my inpatient weeks to be among my most demanding as an attending.  To do my job well, I need to:

  • speak with and examine every patient on the service daily
  • carefully review all lab, path, micro, etc data
  • ensure that each patient's plan of care is appropriate
  • review all resident documentation for quality and accuracy
  • facilitate daily team round patient care discussions
  • directly observe each member of the team (students, interns, senior resident) as they evaluate a patient 
  • provide feedback to each team member regarding his/her clinical performance
  • provide feedback to the senior resident regarding team management and leadership
  • discuss residency and career issues with any family medicine-interested med student
  • problem-solve challenging patient and family situations
  • problem-solve any resident/team cohesion issues (rare, but it has happened)
  • attend to each team member's emotional needs (any burn-out? need support after a tough case?)
  • ensure that residents are not violating work hour regulations
  • sign every H&P, progress note, and discharge summary - and document my own thoughts
  • and, of course, teach medical management of the inpatient
I'm sure I could come up with more, but those of you non-academic-medicine people probably get the idea.  :)

This week, I have the added pleasure of working with one of our faculty development fellows, helping to teach him how to do all of this...and, of course, supervise his efforts and provide him with feedback as well.

It's always a fast-paced and interesting week.  I really get rejuvenated by watching our outstanding residents grow while grappling with challenging situations.

One of our interns led a family meeting today for a patient who is on a ventilator and has made it explicitly clear that he doesn't want to live that way any more.

Another successfully built rapport with the initially intimidating mother of an adult son with special needs.

Our visiting medical student led a behavioral rounds interview with a patient admitted with hyponatremia (low sodium) and seizures likely caused by excessive alcohol intake.

And, the fellow and I today worked to build an alliance with a frustrated patient's wife, unhappy with the "condescending" (her descriptor) manner of the many care providers she has interacted with.  Her husband is obese, and she feels that he is being unfairly treated because of his size.  With a lot of validation, empathy, and summaries, we tried to give her a safe place to vent her fear and anger, and we worked with her and her husband to come up with a treatment plan agreeable to all.

From these and so many more moments, the ultimate challenge for me is choosing what to focus on as a teacher.  Every single one of these episodes is positively overflowing with teaching opportunities - pathophysiology (the processes in the body responsible for disease), diagnosis, management, and, so importantly, demonstrating caring for patients and their families during the terribly stressful time of being hospitalized.

There's only so many hours in the day, though, and only so much capacity to absorb and process information at one time.  Halfway through my third year as faculty, I am feeling much more comfortable with these decisions, but sometimes I still worry that I am neglecting something that should be important.  That my assessments of my learners will miss some important deficiency.  That we will all overlook some critical detail - or make some critical mistake - that could have devastating consequences for a patient.  I like to think that the worry keeps me on my toes, at least.

So, toes, rest up tonight.  Tomorrow's another big day...