Monthly Archives: December 2023

Sights Set on 2024

Posted on by

Stopping by Woods on a Snowy Evening

By Robert Frost

Whose woods these are I think I know.  

His house is in the village though;  

He will not see me stopping here  

To watch his woods fill up with snow.  

My little horse must think it queer  

To stop without a farmhouse near  

Between the woods and frozen lake  

The darkest evening of the year.  

He gives his harness bells a shake  

To ask if there is some mistake.  

The only other sound’s the sweep  

Of easy wind and downy flake.  

The woods are lovely, dark and deep,  

But I have promises to keep,  

And miles to go before I sleep,  

And miles to go before I sleep.

2023 was a year of change. My themes of focus were quietness, absorption, and forward movement. I wrapped up medical school, moved halfway down the East Coast, and started residency. Despite all the professional development, I enjoyed a 7-week adventure in Puerto Rico, visited Paraguay, hiked the 33 highest peaks in the Catskill Mountains of New York, and undertook other small hiking/traveling/outdoor excursions as the opportunity arose.

Residency leaves me tired and overworked, but my progress toward becoming the doctor I wish to be is rapid. On one hand, Frost’s line “miles to go before I sleep” is a literal interpretation of what I expect 2024 to bring professionally. I have many professional goals which will march along as the days pass. On the other hand, the “stopping by woods on a snowy evening” part of Frost’s poem (pausing in an unusual place), resonates with me as I think about my personal goals and themes for 2024. As I set my sights on 2024, three themes are on my mind: quietness, pause, and connectivity. It’ll be a year where I focus on personal health.

Quietness

This was also my first theme in 2023. I’m carrying it forward both because I think it is of utmost importance and because I still have growth to achieve in this area. Being a doctor and learning to become a better doctor involves constant stimulation and 1000s of decisions daily. Adult life is full of challenges including finances (bills and earnings), home management, and unexpected disruptions like illness. With so much happening, I find that it’s easy to get lost in the hullabaloo and lose track of my inner calmness. As the unexpected challenges of 2024 unfold, I will continue to cultivate my inner quietness because I believe it is at the core of resilience and central to success.

Pause

Related to quietness, my second theme is pause. As the hustle of life unfolds, I easily forget to stop to appreciate small and large successes and delights. In 2024, I will take time to pause so I can absorb the joys of life. Focusing on joy will train my mind to see the positive and diminish the negative.  

Connectivity

The aspect of connectivity I plan to focus on in 2024 is the mind-body connection. My medical training has been extremely demanding in multiple ways. I have watched my health decline as the doctorhood quest unfolds because of my schedule, external pressures of doctorhood and the healthcare system, and the stress of my work. While my medical training will remain vigorous throughout 2024 and beyond, in 2024, I plan to focus my free time and energy on re-cultivating my physical wellbeing. This focus on physical health combined with my focus on quietness and pause will strengthen my mind-body connection. I think cultivating my own mind-body connection will ground me as I seek to connect with my patients, colleagues, family, and friends.

More Than Half the Days

Posted on by

It was a regular primary care visit and my patient felt well. I clarified several of their questions about how to take their medications properly and why some of the medical treatments we’d prescribed them were important for their overall health and life expectancy. The conversation flowed. They were engaging and exuded positivity.

It came to the part of the visit when I went through my system-generated reminders based on the patient’s medical record (topics and screenings I was supposed to review at certain intervals with my patients as their primary care doctor). Among the reminders was a depression screening questionnaire which was due.

“How many times in the past two weeks have you felt like you would be better off dead? Options are ‘not at all,’ ‘several days,’ ‘more than half the days,’ and ‘every day,’” I said.

“More than half the days,” the patient said. The questionnaire was 9 questions long. By the end, it was clear that the patient had untreated depression. Interesting how the first part of our appointment didn’t suggest depression. To uncover the patient’s depression required additional, and specific, evaluation.

“Tell me more about what you mean by these feelings,” I said walking through their answers to each of the questions on the depression screening questionnaire.

The patient would go on to describe living alone with no friends or family nearby. No activities outside the home. A lifetime of being socially awkward – preferring to be alone because of the awkwardness. Feeling as though they had a hard time connecting with people. “I thought it was just normal for someone my age,” they said, referring to their feelings of sadness and thoughts of death.

How common is depression? Is it normal to be depressed? What exactly is the difference between the medical definition of depression and a transient dark mood?

A lot about being a primary care doctor is brainstorming solutions to life’s persistent problems. Sometimes there are medications that can help, but usually the non-medication interventions and lifestyle changes are just as (or more) important than the medications.

The patient and I discussed how to take their antidepressant correctly (they were already on a medication for depression, but they were not taking it daily as intended due to confusion on how it was designed to be taken).We discussed exercise classes to strengthen the mind and body and to create an avenue to be around other people sometimes. We discussed hobbies and activities that brought them joy. We discussed what might be normal for their age.

This patient was motivated. Perhaps they could find a path to better mental health. It would take time. The brain is the hardest organ to heal. To help ease the journey, my clinic had all kinds of mental health resources (including exercise classes) patients could use for free. When we finished our visit, I walked the patient over to the mental health team’s office attached to my clinic. The mental health team would share with the patient additional resources beyond those offered by primary care such as individual and group therapy sessions.  

The statement, “more than half the days” would resurface in my thoughts for weeks to come. Not because it was unusual, but because depression is so common. I’ve known how common depression is since I entered healthcare. But, for the first time, I have the chance to help some patients find a path to healing now that I’m a primary care physician. Of course, the clinic where I work is special and has more mental health resources than most primary care clinics in the US.

What would I have done for this patient and others like them if my clinic was not set up to help people with mental health challenges? What if there were no therapists, wellness classes, or psychiatrists on staff to help any patient who came through my door? What if this patient had to wait for months before they could be seen for their mental health concerns?

When the phrase “more than half the days,” crossed my mind I thought about the 1000s of people walking around feeling they’d be better off dead more than half the days of their lives. I thought of the probability of there being time during their regular primary care visit to be properly diagnosed with depression. I thought about the probability of their primary care clinic having the resources needed to help them if their depression was diagnosed. The math suggested that many people’s depression would go undiagnosed or, if diagnosed, untreated because many people couldn’t access the treatments they needed. To be profitable primary care appointments get shorter and shorter, with many clinics scheduling appointments that are 20 minutes or less. The length of the appointment doesn’t factor in the complexity of the patient even though as patients become more medically complex, a 20-minute appointment becomes more absurd. Between health insurance access issues, healthcare costs, and healthcare professional shortages many patients don’t have access to medications, therapy, and other mental health treatments that have been proven to work.

Healthcare in the US has so much opportunity for improvement it’s maddening. No setting reminds me of this more than primary care. No disease category reminds me of this more than mental health. The better I know the US healthcare system, the less hopeful I become that it will ever serve all people. But sometimes there are little micro settings where all the resources a patient needs are there if they choose to use them. This patient was in that situation and, so, I was hopeful that they’d find a future in which they felt better off alive than dead more than half the days. I was hopeful that they wouldn’t die by suicide.

Depression can be sticky and hard to overcome in the best circumstances. But depression, like all diseases, is more likely to be cured when the patient can access the best treatments. The more I learn about healthcare, the more I believe everyone should have access to the best treatment for the most common conditions. And, currently, that is not the reality in America.

References:

Maybe Tomorrow

Posted on by

“Maybe tomorrow you can be discharged,” the doctor leading my team said to the patient. I’d lost track of how many days in a row he had said that.

The patient had cancer and was undergoing treatment. Did you know that chemo is poison? We use it hoping to destroy cancer before we destroy the person who has the cancer. Chemo saves lives. Chemo causes all kinds of side effects. Chemo often works. Chemo doesn’t always work.

This patient was neutropenic which means that they had no white blood cells to fight infection. No white blood cells to fight infection means even the wimpiest infection could kill them. To avoid death by infection, they needed to stay in the hospital for IV antibiotics and monitoring every time they had a fever.

We couldn’t find the cause of their fever. No source of infection. 24 hours without a fever, “Maybe tomorrow you can discharge, you just need to be 48 hours without a fever to go home,” my supervising doctor said to the patient.

The patient’s red blood cell count dropped so they needed a blood transfusion. Were they bleeding? “Maybe tomorrow you can discharge, if you don’t need another transfusion.”

 They also had a rash. Was that from chemo, cancer, or something else? It was a really uncomfortable-looking rash. Blisters and red all over their torso. “Maybe tomorrow.”

The “maybe tomorrows” dragged on. All the patient wanted to do was go home. They wanted to have some control over their life. They wanted to feel the breeze on their cheeks. They wanted to live. They wanted to see their friends and family. But cancer is a tricky beast. It takes one’s freedom and lands one in the hospital more days than anyone would ever choose.

But, at last, tomorrow did come. We were all happy when the supervising doctor said the patient could leave the hospital. The patient was excited to go home. No one mentioned that it was only a matter of time before they’d be back to start another string of maybe tomorrows. Sometimes there’s no point in saying things that everyone already knows. No need to speak the unpleasant into existence. It will come when it comes.

The patients and families on the cancer wards are among the strongest people you’ll ever meet. Their strength is like the endurance of ultramarathoners, not sprinters. Their strength is one of days running into weeks running into months. Counting the years. Their strength is one of setbacks and small victories. Of bodies changed and freedom lost to be reinvented. Their strength is keeping hope for tomorrow while knowing that it may never come.