Category: Lessons

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Consult-Liaison Education Lessons Medicine Systems

Have You Thanked Your Nurse Today?

As I noted earlier, hospitals permit around-the-clock observation of patients. If you don’t need around-the-clock monitoring, you don’t need to be in the hospital.[1. “But what about ‘social admits’?” you may cry. “They don’t need to be in the hospital, but we admit them anyway.” True. “Social admits” reflect the intersections of social policy, politics, health, economics, and the lack of resources. That topic is beyond the scope of this post.]

Who is doing this around-the-clock monitoring? Nurses.

Therefore, whether you are a patient or a physician, one of the best things you can do is get on the good side of the nurses.

If you are a patient, a nurse watches over you and your care. Nurses make sure that you won’t fall. They make sure they give the right dose of the right medication in the right route to the right person at the right time (which can be easier said than done). Nurses provide education about medicines, tests, and health conditions. They make sure you know what day it is, where you are, and who you are. (Also easier said than done.) They monitor your progress and try to ensure that your health only improves. Nurses can also page the doctor for you or your family. They can find out when you are scheduled to go through a procedure. They can find out what you are waiting for. Nurses advocate for you.

Sometimes it may seem like they’re not “doing” anything. They are. They’re keeping an eye on what is happening with your health.

If you are a physician, you must already recognize the value of nurses. (If you are a medical student or resident and have fantasies that, one day, you will be “running the show”, don’t be a fool: There is no way you could do your work in the hospital without the help of nurses.) Nurses serve as our eyes and ears. They tell us information about patients that patients themselves cannot or will not tell us. They do triage with us when we have multiple patients who are not doing well simultaneously. They tell us if someone is starting to look a lot worse… or a lot better.

While it is true that nurses provide around-the-clock observation of patients in hospitals, it is also true that nurses provide around-the-clock monitoring of doctors in hospitals.

Nurses know when doctors typically meet with patients. They know which doctors are more likely to spend time with patients and answer questions. They know which doctors work in collaboration with nurses and which ones treat them like second-class citizens. They know which doctors return pages promptly. Nurses quickly learn how to alter their approaches with various doctors to get work done.

This is yet another reason why, as a patient, you want to get on the good side of nurses. Nurses manage doctors. Skilled nurses will know how to work with different doctors to help you get what you want (e.g., answers to your questions, a meeting with your family, better pain control).

(Patients, you should also know that nurses also manage you. Nurses tell doctors which patients yell at nurses, which family members are berating them, which patients are trying hard to follow recommendations, and which family members left cookies and treats for them.)

Physicians, thank your nurses for helping you do your job better. Positive reinforcement and good manners go a long way. The more you acknowledge the skills and efforts of your nurses, the more they will want to work with you and make your job easier.

Patients, thank your nurses for watching over you. Nurses play an essential role in your care in the hospital. Be kind to them. The more you acknowledge the skills and efforts of your nurses, the more they will want to work with you to get you back to health as soon as possible.

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Education Lessons Medicine Nonfiction Observations Reflection

Cancer.

As a fourth year medical student I did my “sub-internship” in oncology. I hoped that this rotation would help me choose what specialty to pursue: internal medicine or psychiatry.

One of “my” patients was a woman with breast cancer that had spread to her liver and lungs. Fluffy brown hair fell to her shoulders. Wrinkles surrounded her puffy eyes that held jade green irises. Though she was in pain, she was patient and kind.

On the evening of her second day in the hospital, I came to her room and asked if there was anything else we could help with that day. Her pale, thin lips stretched into a sad smile.

“No, thank you,” she answered. “Have a good night.”

“I’ll see you tomorrow,” I said.

She was sleeping when I saw her the next morning, though awoke without a startle when I said her name. She kept her eyes closed as I placed the cool, metal diaphragm of the stethoscope on her chest and back. She murmured her thanks before I left her room.

As the attending oncologist, resident, intern, nurse, fellow medical student, and I approached her room later for formal rounds, she called to us.

“I can’t see!” she gasped. “I can’t see!”

We surrounded her bed and the attending began to ask her questions. He waved fingers in front of her face. He directed the beam from his penlight into her eyes.

“I can’t see! No, I can’t see!”

“But you could see yesterday, right?” he asked. She turned her head as if she was looking around at us, but her gaze was over our heads.

“Yes… but I can’t see now. Does this mean that I will never see my husband and daughters again? Is this permanent?”

I tried not to cry. The other medical student and the intern also looked away, their eyes welling with tears.

We learned later that the cancer had metastasized to her occipital lobe, the part of the brain that controls vision. Though her eyes were in good working order, the part of her brain that interpreted the electrochemical signals from her optic nerves was not. The cancer had stolen her sight.

You learn a lot of things in medical school: anatomy, physiology, pharmacology, and other concrete facts about human function. You also learn about human relations, communicating with people with different agendas, the system of health care, and other topics that fall under the “informal curriculum“.

You also learn how tenuous life is. You see women give birth to dead babies. You see children succumbing to cancer. Healthy adults get hit by stray bullets and drunk drivers. Heart attacks and strokes steal time and life away without making a sound.

You begin to recognize the blessings that you previously overlooked: I can eat all the cookies I want and I don’t have to take insulin. I don’t need a walker to get around. My fingertips and toes can feel the soft fur of a cat, the hot water coming out of the shower, and the zing of static electricity. I can breathe without difficulty and without having to lug an oxygen tank around. My arms and legs move when I want them to. My balance is intact.

You also realize, with some dread, that all of that can change in an instant. So you better enjoy the blessings while you got ’em.

My mother was sent to the hospital with urgency the day I returned to California to visit my parents. She was subsequently diagnosed with metastatic lung cancer.

I am grateful that I could advocate for my mother while she was in the hospital. I am also thankful that I could translate what was happening—not just from English to Chinese, but also from medical jargon to plain English—to my parents.

I was struck by the degree of confusion and uncertainty throughout her hospitalization. Things that I knew as a physician were not at all obvious to my parents. Things that I knew as a concerned family member were not at all obvious to the physicians.

I was and remain humbled.

As a consequence of this, upcoming posts will focus on how health care in hospitals work, what hospitals can do differently to help patients understand what is happening, and things that both medical staff and patients can do to make the hospital experience better for everyone.

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Consult-Liaison Education Informal-curriculum Lessons Medicine Observations

Informal Curriculum: Lesson 1.

It’s been over a year, but I haven’t forgotten about the Informal Curriculum.

The first recommendation in the informal curriculum in medicine, which I still believe is “paramount, the most difficult to define, and often challenging to implement”[1. It is no coincidence that a topic that is “paramount, … difficult to define, and … challenging to implement”, is also difficult to write about.] is to be a person.

What does this mean?

Be the best professional person you can be. Be a person who actively listens to patients, who shows empathy and emotions. Be courteous. Show humanity. Be a person.

Non-psychiatrist physicians seem to have an easier time with “being a person” than psychiatrists. Psychiatrists, as a population, can be weird. We can demonstrate exceptional skills at not being people. Sometimes we come across as intrusive, awkward, and odd.

I get it. I’ve had peculiar interactions with psychiatrists who knew I work as a psychiatrist. That might explain why the conversations were even more uncomfortable than expected. (Those are stories for another day.)

Do note that this recommendation exhorts you to be a professional person. This doesn’t mean that you tell your patients about your relationship or health problems, how crappy of a day you’re having, or why your political views are correct. That stuff makes you a person, too, but that doesn’t make you a professional person.

If patients are telling you things that worry them, be a person and acknowledge their worry. If they tell you something funny and it’s not inappropriate to laugh[2. Being a person does not mean that you toss clinical judgment and boundaries away. There are times when you shouldn’t smile and laugh, even if you want to. That topic is beyond the scope of this post.], smile and laugh. Talk with them like they’re people, not diseases or case studies.

Be a person.

Patients often want to share a connection with their physicians. Patients suffer and worry. They want to know that you care about their suffering or worry. That’s what actual people[3. Yes, there are anecdotes that people will share their woes with and find comfort in a computer program.] do: They care about the suffering and worry of others.

Be a person.

Why is this paramount? Why is this my first recommendation in the informal curriculum?

Because relentless forces exist in medical training and work that can transform you into a non-person.

You use words that most people don’t use. Most people don’t talk about MELD scores, Glasgow Coma Scales, or HIV classification systems. You see a lot of emotional and physical anguish. You see people who are ill. Sometimes they cry. Sometimes they scream. Sometimes you see parts of them that they will never see. Sometimes you see them die.

These are the things that can make you turn into a non-person.

So make an effort every day to be a person. If you’re not, none of the other suggestions in the informal curriculum will matter.

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Education Lessons Medicine Observations Reflection

On Being a Person.

Upon looking at me, there’s no doubt about it: I am Asian.

My ethnicity occasionally becomes a topic of conversation with patients. Some immediately ask me, “Yang… that’s Chinese, right?”

Others take a different approach:

“Where are you from?”

“Where am I from?” (This is meant to clarify the question, as it can mean different things….)

“I mean, where did your family come from? What part of Asia?”

Patients with significant psychotic symptoms occasionally start conversations with me like this:

“Konnichiwa! Ichiban? Teriyaki?”

or they might say things like this:

“God has a good recipe for kim chi. Do you want to know what it is?”

For the most part, it is completely clear that these conversations arise from benign intentions: Patients are trying to make a connection.

Even if I speak English with a perfect California accent or wear clothes that blend in with the fashion of Seattle, I cannot mask that I am Asian. It is a significant part of my identity and I bring it with me wherever I go.

While in training psychiatrists are often encouraged to present oneself as a “blank slate”. This psychodynaimc argument states that the more neutral you are—in speech, attire, manner etc.—the more you can analyze the “transference”, or what reactions (emotions, thoughts, behaviors) patients have upon interacting with you. These reactions are the grist for the therapeutic mill.

We, however, can never present ourselves as blank slates. Patients—people!—notice both what we bring to an interaction and what is absent. People might have opinions about my ethnicity, my facial expressions, the tone of my voice, or the scribbles I make during the conversation. They might also have opinions if I make few utterances, maintain an expressionless face, and answer questions only with questions (as demonstrated above).

Instead of being a “blank slate”, sometimes the best thing we can do as psychiatrists is to be a person.[1. To be clear, a psychiatrist should be a professional person; this is no time for sloppiness or disregard for a patient’s wellbeing and dignity. Being the best professional person you can be is still being a person.]

If people have relationship difficulties, we can be an actual person so that the patient can learn how relationships with people can be different. If people come to treatment because they have challenging relationships with themselves, we can be an actual person so the patient can learn how these views of self affect not only them, but also other people. If people have tenuous connections with reality, we can be an actual person who provides accurate feedback about “reality” (and make very clear that we’re not trying to steal their internal organs, etc.).

Being an actual person can be scary. We might worry what people (colleagues, patients, others) think of us. However, that vulnerability and authenticity we bring as people to the clinical interaction might be the most healing and inspiring to our patients.

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Lessons Medicine Nonfiction Reflection

A Dream.

A few days before I learned what happened, I had a dream about you. When I awoke, my heart felt like a bird flapping its wings inside the cage of my ribs.

The details had vanished. Only anxiety remained.

I gasped when I learned what happened. I suddenly remembered the little details, the things that never made it into the clinical notes: You liked your coffee black. You read the Wall Street Journal. You missed driving your sports car.

Where did you kill yourself? Did you get a motel room? Were you outside? What time of day was it?

You certainly planned this. When did you make the final decision? Did you waver? Did you want to waver?

They say that there are two kinds of psychiatrists: The kind who have never had a patient commit suicide, and the kind who have had patients kill themselves.

I now belong to the second group. We all join the second group at some point.

I wish you hadn’t killed yourself.

I thank you for what you have taught me, both in life and in death.

I wish you had the peace in life that you thought was only available in death.

May peace be with you now.