Brutal, Baby...

We’ve just finished the third of three difficult tests a week apart. This is supposed to be the hardest segment of the hardest year of med school. So, we seem to be done with this hard part. Hopefully, I passed. This last test was very challenging to say the least. Right now, I am studying. What else would I be doing? I am attempting to finish material for next week, read ahead. - Is this what the rest of school will be like? Probably not. I think this is just them placing us on a three-legged stool and kicking one leg out from under us, so we have to grab hold and become engaged in the process of 'active sitting'. The objective is to keep us in the game. They want us to have taut muscles, pumping hearts, thoughts and focus on the stool. They want us to tend to the important details of learning rather than being sidetracked by other people and events in our lives. We can always get up and leave, but we know that we must sit in order to learn and reach our final goal. We must stay the course.

On Purpose

One of our instructors in the Living With Life-Threatening Illness class indicated that people have hope as they die because they feel they have a purpose in life. So, I looked up the meaning of purpose in my dictionary. The definition revolves our desire to intend to do something, or it refers to a reasonable, rational end to an act, a creative effort, or use. Also, when we have a purpose, we are determined - resolute even - in achieving a practical result, effect, or advantage. It speaks to imagination, design, and forward thinking. It also speaks to a need of the ability to think. And, as far as we know, of all the things in this universe, only humans can do that.

So, I applied this definition to our purpose on earth. It had to have reasonable, rational intent. And, since we didn’t place ourselves here, as best we can tell, it had to originate from somewhere outside of us and our present understanding. And, indeed, any purpose we may have would have to be tied to our ability to think and understand. Understanding would have to be part of what we call purpose. It would also follow that learning, in order to gather understanding, would be part of being able to have the intent to do. Our purpose, then, is also tied to our learning.

We are certainly learning from the time we are born – to eat, stay warm, get along – to survive in general. We protect ourselves, our things, our children and people we care about, our systems of behavior and codes of conduct. These things help us live better, longer. We survive. But, so what?

I wondered if we are learning the wrong things. Nothing of this life remains, does it? What could possibly “remain”? And, if it remains, where and in what condition does it do that? Good question.

The things we take to survive (food, clothing, shelter, reproduction) cannot be tied to our purpose because they do not exist beyond our life here. Earthly survival cannot be tied to our purpose on earth unless it is tied to a survival beyond this existence. Of course, we may have no purpose. But since I have hope (purpose), I write this paragraph. Hmmm, how circular… or how obvious.

Our ultimate purpose, as revealed in death, cannot be to take. It can only be to give and to learn from the experience of giving. Indeed, we have a tremendous capacity to have and then give away over the course of our lives. Problem is: we don’t. We focus on present survival for the most part. Hmmm.

So, if we give away our things and ourselves, what would we learn? If we give up this life, what are we giving it to and why? Purpose predisposes us to consider a design and intelligence outside of our understanding – something beyond and outside of this life. Seems logical. And, in order to have a larger purpose, we have to believe in something we can’t see or understand from our current perspective. We have to use our minds as we are convinced of something beyond our birth and death. We have to rationally consider the finite and the potential of infinite.

Our purpose will certainly be determined in the things we are convinced of. The most hopeful thing I can possibly rationalize is that something exists outside of this life. Something I cannot see or understand but that is no accident. Since purpose includes intent and thereby thought, my purpose must include something that thoughtfully created us. And, that creator (to personify) clearly thinks and acts well beyond my ability to understand or comprehend in any more than very basic ways from this point of view, and this creator chose (intent) to create us in our present condition. We all must be logically intertwined in a larger purpose that we are hoping to truly understand. Indeed, our dying would be part of our collective purposes and, given that death is beyond our control, we know that we have far less control over our lives than we imagine.

Now, you may say you have no purpose. You could hold tightly to every earthly thing to have nothing when you die (because nothing truly matters). Or you could take the chance of having a purpose and having everything (whatever that may be) when you die. If you are right, we both have nothing. If I am right, our creator will explain to us more clearly why expressions of giving were so important. And, our creator will explain to us why taking was so useless.

Seems I can only win here. At least in the long run. I wonder how long I’ll live after I’m dead. Hmmm.

Creating the Invisible

Reflection for the body donor service:

One of the jobs I’ve had in life was to teach. During my education, I learned that there are many ways to learn, and I even learned how I learn best. I know that I assimilate understanding if I can pick up an idea, twirl it around, and see it from different perspectives. I gather knowledge best when I can touch the object I am discerning and feel its borders, comprehend its density and texture, and place it into a frame of reference for future application.

The special gift offered by the gentle persons who taught us anatomy will spread out like ripples in a pond of giving. They made a choice to open our eyes and minds in a way that no one else could. We will hand their choice back to the world in the form of clarity, perspective, truer judgment, and a common desire to give ourselves away.

When we leave this earth, I hope we will leave it having given away as much as we possibly could have. I hope that what persists in our physical absence will be the same kind of reminder that these people have provided us: a reminder of what lives on. I hope we have the courage to create what does not go away.

One Day Closer to Death

Started a new class this week called Living With Life-Threatening Illness. In this class we visit with and learn from patient-teachers who are in the end-stages of life and then share our experiences weekly in groups.

On this first day we met to learn more about the course, to meet one another and to discuss our motivations and reasons for being there. At the halfway point, we broke into smaller groups and sat in a circle, so we could all see one another. The group leaders asked us to describe in more detail any events in our lives that had caused us to be interested in end-of-life care and in wanting to be part of the class. The instructors told their stories and several others also told theirs. As I began to speak, my brain disengaged and my heart began to speak as memories flooded my conscious awareness. Thoughts bounced from one to another, completely out of chronological sequence. They all seemed to be emotionally tinged as the pump had been primed by the moving stories of others in the group.

I must have perceived that gathering and room to be a safe place since we were advised that shared information must remain confidential. I trusted them because they trusted me. I gave them glimpses of deaths I had been near and how they had impacted me. I told them about how I want to help people die with some comfort and dignity, with joy and clarity. I told them I want to discuss death and make it a part of life that we accept and embrace with less fear and more understanding. My voice broke as tears flowed. I can’t completely say why I felt so much emotion. I suppose I’ve seen so many people die with so little fanfare or so little care. I would like to help people know they are loved before they leave this place. I suppose that’s not an easy thing for some people to hear or believe. Too bad you can’t just come out and say that as a doctor. We have another job to do. That one takes precedence. Professional distance and objectivity have their value. There are some things that most patients simply aren’t looking for in doctors. Family, friends, clergy, counselors and advocates fill those roles.

But we can help to get this right. We can learn what works and what doesn’t. We can learn how to listen to patients' needs as they encounter an end to their path here. They can choose how those days will be spent. Maybe they will believe in an afterlife. I believe in a purpose and existence far beyond this one. I know what I know. I have experienced what I have experienced. My faith runs deep.

Will be interesting to see what I learn here – about how people approach death and how we can improve that experience, about skills that I can obtain in order to facilitate their final moments, about what lies inside of me that has been shoved into long-forgotten corners.

To Tell the Truth

Thesis: Being truthful with our patients is a necessary part of being a physician.

As physicians, we have a “duty to inform” our patients of their conditions, outlook and possible cure. This may be an implicit requirement or an explicit legal requirement depending on the laws in the state in which we practice. As physicians we are legally expected to tell the truth as we understand it and allow patients adequate information in order to make intelligent choices about their care. More importantly and beyond any legal mandate, telling patients the truth simply demonstrates respect for them and in doing so we create a covenant of trust with them that is central to the practice of medicine. Should individual patients prefer to receive less information about their health scenario or choose to assign their autonomy to others, we can always modify the amount of information we convey to them but never the quality.

When our patients are not told the truth, they are, by definition, uninformed and may not seek care. They may very well fail to receive necessary attention because they are unaware of a problem and will have no incentive to correct it. As well, they might make decisions in their lives that would be very different had they a clearer understanding of their overall health picture. Also, many patients are comforted in having a name assigned to their condition, and not knowing all pertinent information in their case may add anxiety and tension to their decision-making due to a sense of uncertainty. Indeed, persons who are not made aware of health problems are not afforded the opportunity for personal growth as they make choices about how they will receive their medical information and allow it to impact their families. And, without stretching our definition, withholding information from patients could be construed as a deception which would undermine their trust in us and in the medical profession, in general.

So, telling the truth is simply a high ethical standard we maintain as physicians - but we and our patients realize other valuable benefits as well. As stated above, our goal as physicians is to engender the covenant of trust we establish with our patients as central to the practice of medicine. It is plainly the most respectful and legally proper, and financially responsible mode of behavior. Additionally, however, we know from our PCM course material that telling the truth has been shown to cause patients to follow their care plans more closely, decrease patient pain when they have a fuller understanding of their health status, and improve health outcomes as patients are more fully informed. Telling patients the truth also has been shown to increase patient satisfaction in that they feel trusted and a partner in their own health care and makes patients less likely to change physicians when we allow them to participate in decisions about their care. As the final trump, telling the truth has even been shown to decrease malpractice claims.

Truth-telling should plainly be a habit any future physician practices without hesitation. It may require some effort as we consider specific legal requirements and individual cases, but we should always be attempting to tell the truth well as we are able and at every patient encounter. If we are not able to do that, it’s time to pursue another line of work.

The Art of Acceptance

Question: How will I incorporate and be understanding of persons with different cultural perspectives who come into my practice?

After a PCM presentation highlighting a Chinese naturopath and an M.D. having a mostly Hispanic patient population, I asked myself the question above. Our reading indicated that 70-90% of patients manage their sicknesses outside of the realm of formal healthcare and that our individual cultures play a powerful role in how we care for ourselves. Specifically, our material describes folk remedies that exist in all cultures and which vary tremendously from one culture to the next. So, how can I learn and apply knowledge of complex, culture-based care?

I think the answer consists of two parts: Gaining practical, on-the-ground experience and through independent study. Before I can do either, however, I must realize who my patient population typically will be or could potentially be as I begin to interact with them. I will likely have easy access to this information if I join an existing group practice or hospital. Or, if I begin a solo effort, other local providers or the community composition in the location I select will provide the initial profile.

As a first effort, I will need to read all I can discover concerning the cultures I expect to encounter. Each patient will present with different concepts of family, ideas of social justice, hierarchies among relatives, decision-making authority, folk remedies, and how they will approach their healthcare based on the cultural solutions they are familiar with and of which they are convinced have value. I will need to understand what each patient truly believes will make a difference for them and whether it will truly improve their health. Of course, much of the reading will be found in medical journals – and much of it will not. It may be uncovered in cultural periodicals, stories of persons who live in or originate from those worlds, and articles that describe their practices and beliefs as written by persons who are members of the fold. I will simply have to devote a good deal of my personal time to learning about my patients and until I have a firm grasp of who they are and what they believe will impact their health.

As a second means of learning, I will need to gather information directly from the patients themselves. Since this learning will occur one patient at a time during individual encounters, it will transpire at a much slower rate, but, as I am attentive to each person, I will steadily acquire this understanding. It will require a humble attitude that allows me to hear, and I will have to be open to new ideas and accepting of habits I don’t understand. I will need to inquire consistently as to their ideas and cultural remedies, and seek nonjudgmental compromise as we work together in their plan of care. Indeed, as indicated by Dr. An, the naturopath, some persons believe that the body only heals itself, and we merely need to attempt to get out of the body’s way or remove any impediments to the body being able to heal. And, as long as their methods are not deemed harmful, it may be best to negotiate a treatment plan whereby patients pursue their chosen remedy in addition to any I may deem beneficial or necessary. Possibly, their positive belief and outlook may make a remedy worth pursuing.

As I progress through medical school I will likely gain valuable insight into many cultures and practices. There will always be more to learn. I will continue to seek out new information and clarify my understanding of every culture I encounter. And, as a generous side benefit, my patients will educate me about new cultures in depth, and I don’t even have to purchase a plane ticket. Nice bonus.

Hearing to Heal

Question: How can I communicate with patients so they feel heard, cared for, and cared about?

I consider this question in response to the woman who addressed our PCM class and who told the story of losing her material goods and livelihood due to a husband’s financial dealings and a precipitating stroke. On that particular afternoon, we were hearing how people deal with acute illness and life crisis issues as this woman described the painful interactions she had with busy doctors who left her feeling distant and unheard.

As I listened, I wondered something to myself. What would happen if patients could write their own notes in their charts about how they feel, what their symptoms are, what they think might be wrong with them, and what we (doctors) should do about it? I began to wonder how much of that note a doctor would actually “hear” and take to heart if it were written in that sacred space and whether they would truly believe their patient’s opinions mattered. The truth is we mostly only allow patients to interact with us on our terms and in our official spaces which doesn’t seem to be a way to place them at ease or engender their trust. To do that I believe we must be partners with them in their care and understand them as they present themselves. While we are trained to approach medical problems from an evidence-based perspective, we can never truly have an “understanding-based” perspective until we include in it the expertise that each patient possesses of their own condition and history.

When I finally enter a practice of my own, I will spend much of my time listening to, encouraging, and negotiating with patients as I come to terms with their worlds and seek cures for their ills. Patients can help me do all of these things. One of the ways the woman described above communicates with her doctor is to write notes in advance of her visits, so she can present a complete list of her concerns when she arrives. Her doctor suggested she do this. Of course they aren’t placed in the chart, but, since she has difficulty remembering her symptoms and collecting her thoughts while she is in the room with him, it effectively allows her to feel that she provides all relevant information to her doctor, and she feels like it is an important part of her being heard - of her story being told. The lesson for me is to be aware of what a patient is capable of and aware of how they will communicate with me. I need to find ways, if they are lacking, of being able to communicate well with patients. It can only give me better information to make a more appropriate diagnosis and allow me to have a sense of where patients are at in order to understand them as “whole” persons.

Here are some additional relevant gleanings that I learned from my favorite family practice physician, Dr. Jeff Stoessl at Salem Clinic in Salem, Oregon:
· Sit down
· Don’t stare at the computer when in the room with a patient
· Don’t look at papers, books, or charts except as a quick reference
· Be 110% focused on the patient - nothing else matters right then
· Look patients in the eye when you both talk and listen
· Politely let them know what you are doing – communicate what is occurring at the time
· Allow patients time and space to think

It sounds obvious, but it comes down to a moment-by moment choice. We must choose to care and listen to every patient. We must choose to act in order to make a difference. We must choose not to be paternalistic or arrogant or the keeper of knowledge. We must convey to patients that we have an interest in their lives and that we care for them as whole human beings. Every encounter is a chance to get better at these things. I can’t wait to try them out.