There Are No Words

Picture Credit (John Moore/Getty Images)

“…if we forget, we are guilty, we are accomplices.

“we must always take sides. Neutrality helps the oppressor, never the victim. Silence encourages the tormentor, never the tormented. Sometimes we must interfere.”

“When human lives are endangered, when human dignity is in jeopardy, national borders and sensitivities become irrelevant. Wherever men or women are persecuted because of their race, religion, or political views, that place must- at that moment- become the center of the universe.”  

Elie Wiesel 

Over the last few weeks, I read the news. I saw the pictures. I agreed with the outrage expressed in op-ed’s, evening news and twitter feeds. I shared and voiced my thoughts and opinions on the heinous actions of my government, separating in traumatic fashion children from their parents. My thinking brain has been shocked, horrified and outraged and did not have to stretch far to appreciate the parallels to the Japanese internment camps.

But my heart remained protected, wrapped up and insulated using the same tools I use to manage the emotional burden of caring for the critically ill.

And then I heard the tapes from Pro Publica.

I can only imagine the trauma that those children and their parents are enduring. I’m sure it falls far short from reality.  Although I cannot draw a direct comparison,  I do know how I felt when I was separated from my child in a way I never hoped to be.

I ached in a way I had never ached before. The weight of worry in every breath. Fear of the unknown fueled racing thoughts. My vision blurry and tired from holding back tears. My hand constantly drawn to my chest near my heart, pulled by a force from my core. A place I have felt only a few times before. This place inside, beneath skin and bone, ached with such weight and depth that it often forced me to the floor in attempt to ride out the waves of pain rolling through me.

I was overwhelmed and felt helpless. Yet I knew where my child was and who they were with. I knew those people cared.

Now, imagine you’re five years old in a foreign country with a foreign language. Cold concrete floors partitioned by chain link fences all around. No parent to squeeze hard and cling to. No family member to hug and hold, to feel their strength and resolve as an answer to your overwhelming fear. Only uniformed strangers with weapons at their side or tin foil blankets to turn to for any potential warmth.

There is no insulation from their cries. And there shouldn’t be. If you have not heard the tape, I ask you to listen.

Immoral. Unconscionable. Heartbreaking. Traumatic. Terrorizing. Those words, as strong as they are,  are insufficient to describe this current horror. There has already been too much rhetoric and not enough action. So I am going to do what I can do.

I am writing. I am donating. I am calling. I will vote in September and will help as many others in my community and neighboring states to do the same.

There are plenty of organizations that need your help. There is a need for lawyers, translators and donations.  Here is a link to a website at SLATE written by Dahlia Lithwick and Margo Schlanger. They are continuously updating the page with places that are helping in this battle.

Not much more to write. It’s time for me and my family to act. I’m asking you to act as well and share what you are doing. I’ll be sharing here over the next few days what my family chooses to do.

Together, we can be better than this.

 

 

 

 

 

 

Top 5 Lessons Learned for the New Interns

Welcome new PG-1’s! One day you wake up a medical student. Then by the afternoon you are a MD. A few short days later, you are now in the hospital no longer looking for someone to co-sign your orders in the EMR.

It’s a crazy time, full of excitement as well as an inordinate amount of stress.

My list is not for your first day of the first week. But maybe bookmark it for after you get your sea legs under you. After you know where to park the car and where to get that much needed cup of coffee. This is for after you figured out how to login to the EMR and PACs system and know the pattern (or lack thereof) to your days on your first rotation. Then, come back here and re-read. When you have the bandwidth to actually process. There are many pearls out there for new interns. There are handbooks, pocket guides along with Twitter full of words of wisdom. The five I have written about here I think will serve you well as interns and beyond.

  1. Don’t forget the chief complaint.

My closest calls and near misses over the years have been when I neglected to pay adequate attention to the patient’s chief complaint. They may be in florid heart failure with a pulse ox of 70% and not making any urine. But all they care about is the pain in their calf. While I am placing them on non-invasive positive pressure ventilation, nitro drip and Lasix, two hours later I find them in the OR for compartment syndrome. Their chief complaint may not be at the top of YOUR problem list, but it is at the top of THEIRS. It may not always end up being a life or limb threatening process, but then again, how do you know if you don’t check it out. Always respect the patient’s chief complaint.  If you do not bother to pay attention and address it, what else is your patient telling you that you are not hearing!

2. Ask that question!

If you are uncomfortable asking as an intern, how will you do it when you are an attending? I will let you in on a little secret. We (the attending’s) do not know what’s going on all the time. But I do know where to go to get help. What resources I have in the form of other colleagues, partners, consultants, etc. You are not expected to know everything. Definitely not as an intern. But we doctors can be an interesting bunch. We often feel like imposters, especially early in our training. That we do not belong. Yet we have pride and ego that compete with our feelings of insecurity.  This is an awful construct to have in your head.  Break it. Ask the question. I am willing to bet someone else on rounds has the same one. By asking, you encourage the next person to speak up. By sharing what you do not know, you foster an environment that encourages learning and is better for patient care. More importantly, you will recognize that this doesn’t stop after intern year. Welcome to being a life-long learner

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3. Approach with caution the patient with psychiatric illness.

It’s hard when the patient’s history of mental illness gets put up front during sign-out from the ED or on your chart review. Our biases often kick in whether we intend to or not. Often the patients ability to give a good history and report symptoms accurately gets called into question and their voice gets tuned out in the shadow of their mental illness.  Patients with mental health issues can just as easily develop physical illness. Which often in turn leads to exacerbation or decompensation of their underlying psychiatric diagnosis. Too often we dismiss out of hand their complaints or the “pan positive review of systems”. It is hard when someone’s psychosis or mania or anxiety is raging to discern what is the truth. But be disciplined and approach all patients with same level of concern.  Don’t stop listening and tune the patient out. That abdominal pain, even though it is the 5th time they have been to the ED, can still be an appendicitis. 

4. Don’t fear the family.

I remember dreading walking into rooms with family members. They were more able in body and mind to ask questions and were not so easily dissuaded by my quick in and out of the rooms trying to get thru my morning pre-rounds. I feared them. Not just because of the time they took that I did not have, but also, I felt they would expose me for what I was. An imposter. Unable to answer their questions, I feared more what they made me think and feel about myself.

They fear too. They worry about their loved ones. They are confused, out of place, disoriented and are trying to advocate in the best way they know how. Don’t fear them. Lean into them. Sit down. Answer questions even if it means saying you do not know. Start getting comfortable with diagnostic uncertainty and being able to talk about that with patients and families. Honesty combined with empathy goes a long way towards building trust and confidence.

5.   Recognize wins.

I have written about this before in  another post  10 Tips For New Interns For Surviving and Thriving in the Intensive Care Unit  but I think its important enough to include here as well. Learn to retrain your brain. As physicians, we tend to focus and dwell on what went wrong. The challenging patients and families. Frustration over missing labs or delays in imaging. The complications of our interventions. The bad outcomes. The deaths. This is where our brains go when we are most tired and beaten down after an exhausting and non-stop twenty-four hours. But in doing so, we miss out on celebrating our wins. We successfully shepherd so many patients through the treacherous and complex world of medical illness.  Treating a “routine” COPD exacerbation and managing them through their hospital stay to discharge without any drama or significant adverse event is no easy task. But we fail to value our role in this as a win. It is viewed as a baseline expectation. We need to learn that there is nothing given about a patient’s course. If we blame ourselves for the bad, then we must take credit for the good. We focus so much on what goes wrong or in our perceived failures to help or heal our patients we end up ignoring all the positive around us.

Best to all the new interns on the start of a new journey. Exciting times lie just ahead. If you enjoyed this post and want to hear more thoughts on medicine and work-life balance, please sign up to follow this blog!

The Nocturnists and the Healing Power of Storytelling in Medicine

A few years ago, I stumbled upon the Moth Stories.  Originally based out of New York, but now in cities around the country, people would come together at a venue to share and listen to personal stories based on a theme for the evening. Ten people, randomly selected one at a time, would go up on the stage and tell their story. I went to one in Chicago a few years ago not quite sure what to expect, but my experience was profound. There is such intensity and intimacy created by sharing such impactful and vulnerable moments to an open and receptive audience. I had the opportunity to share my own Moth Story  (which you can see here) at one of these events. I gained tremendous personal incite preparing my five-minute story. I also realized, telling my story in front of several hundred people without any notes was more stressful than running most ICU codes.

It is no surprise that this format translates so well to the medical world. In 2015 a second-year resident at UCSF, Emily Silverman, after seeing the Moth Stories herself, started The Nocturnists, a similar storytelling event but geared for the medical community. The program has grown over the years in the San Francisco area and there have been shows in Boston and this fall, New York City. Emily just completed the first season of The Nocturnists Podcast, which I finally, over the long weekend, binged on.

Each of the thirty-minute episodes, start with a ten-minute story, recorded live from one of the stage shows. The rest of the podcast is an interview between Emily and the storyteller, further unpacking their themes, taking a deeper dive into a range of topics:  The dehumanizing aspects of residency training and the impact on both doctors and patients, the competing roles physicians face providing hope versus reality, the anxiety of running a code and other procedures for the first time, the loss of autonomy for our sick patients and the impact on the doctor-patient relationship, end of life issues and advanced care planning, EMR’s, the opioid crisis and more.  Each of these vivid and personal narratives, through the voice of the storyteller, contain multiple themes that will feel familiar, formative and universal for almost all  health care professionals. For those whose lives are outside of medicine, the access “behind the scenes”, not just to the story but to the mindset and thoughts of the storyteller themselves, make the listener immediately invested and connected. Almost every story resonated personally; except for the one where the morgue refrigerator broke down one night, challenging the problem-solving ability of an administrator on call. You are going to have listen to episode #8 to learn more about that one.

The medical themes I have been writing about here on my blog; burnout, demands of residency training, dealing with and end of life issues, formative moments in the life of physicians, are all brought to vivid life in these wonderful and powerful stories contained in the podcasts. Just hearing them alone in my car all weekend long, has helped me feel more connected to the medical community at large, which I believe is the most valuable component of the Nocturnists. A lot is being written about “Narrative medicine” and the power of  stories to help our patients and ourselves; injecting some much needed humanism into the medical workplace. When people, with their varied backgrounds, have the opportunity to share their stories with each other out loud, the healing power of connection comes alive. I do not believe it is a coincidence that the growth and success of the Nocturnists comes at a time when physician burnout and frustration is at an all time high.

I invite you all to check out the podcast on Itunes or Stitcher and listen. I look forward to season 2, and hopefully for The Nocturnists to make their way to Chicago sometime soon!

Anyone who has appreciated my writing, will definitely find these podcasts  well worthwhile and thought provoking.  I look forward to the day the Nocturnists come to Chicago!

Balance 2.0?

So, a wannabe author/writer walks in to a writer’s conference…

Sounds like the beginning of a not very funny joke.  But, that was me earlier this month as I attended the Harvard’s Writing, Publishing and Social Media Conference for Healthcare Professionals.  Quite a busy three days. Started at 7AM and  finished after 8PM. A lot to learn and absorb: Improving writing style, understanding the publishing and self-publishing landscape, using social media effectively and with purpose.  During the three days, met some great people that I now know in IRL (in real life).

There were so many take aways but a few things did strike a chord and stand out.

  1. This blog is “static.” Once or twice a month I write something. Probably a little too long and a little too moody (more on that in a minute). Right now, it’s really a one-way communication between myself and you the reader. I would like there to be more engagement and build on what I have started. I would like to provide more content that hopefully YOU the reader find either useful and interesting or entertaining.

 

  1. So I am asking you, the reader, what more you would like to see? How can I  make this more of a two-way conversation? I am looking to post:

 

  • Shorter thoughts and musings on life and themes such as burnout.
  • Write on End of life issues / advance care planning / introduce thought leaders and game changers in this space
  • Timely topics of the day.
  • Interesting book reviews or articles in paper or journals on critical care, end of life care, burnout.
  • Guest bloggers with strong clear voices on interesting and important topics.

 

  1. The last part that threw me for a loop was how morose or weighty my writing must feel to most people. I often dismiss as a joke, when my long-time friends send me a text checking in to make sure I am ok after a typical post. During the conference, it was commented on that IRL I seem different than the “voice” that comes across on the blog (ie: I have a sense of humor, funny/sarcastic and quite social instead of morose, melancholy, moody or morose)

So, to be brief, my BLOG and website is a work in progress (similar to my life in general). But I hope to grow it into something more.  So maybe call it Balance Redux, or Balance 2.0

Come to think of it, lets get this conversation started.  Thoughts on a new name? Anyone….