Tag Archives: Health

Quandaries of Liver Transplant

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In the US about 10% of those on the liver transplant list die prior to transplant and over 20% are removed from the liver transplant list after being listed1. The hospital where I’m completing residency is a major liver transplant center. While living donor liver transplant is an option for some people, the patients I take care of are awaiting a liver donation from someone who died and donated their organs to others.

The patient was the color of a yellow highlighter. Perhaps you think I’m exaggerating that a person can be so yellow – I’m not. People turn bright yellow when their liver fails. The color comes from a pigment called “bilirubin” that the body can’t eliminate easily when the liver is sick. The patient’s eyes gazed off into the distance, into the future, or perhaps they gazed into nothing. They told me their name and answered questions, reassuring, but the slowness of their speech hinted at how sick they were. They were under my team’s care as we did the workup to determine if they were a liver transplant candidate. To be a transplant candidate patients must go through a thorough social and medical review to ensure they have the social support needed for post-transplant recovery and that they have no other medical conditions (like cancer) that would disqualify them from being a liver transplant candidate. If deemed a candidate for transplant, then a patient will be placed on the liver transplant waiting list (“transplant list” for short) which means they can receive an offer for a liver when one becomes available.

The workup of the patient the color of a yellow highlighter was ongoing. People whose livers have already failed are in a precarious state. They are at risk of confusion from toxins building up in their blood because their liver doesn’t filter the blood anymore. They are at risk of infection which can quickly kill them because without the liver working properly their immune system is weakened. They are at risk of both bleeding and forming clots. (Yes, these are opposite problems, and a failing liver puts one at risk for both through several complex mechanisms.) When the liver fails it disrupts the fluid dynamics of the body. Blood and other body fluids pool where they shouldn’t which can lead to swelling in the abdomen (and other places like the legs) and possible damage to the kidneys, heart, and/or lungs. In short, when the liver fails it causes just about everything else in the body to fail too.

When someone needs a transplant, it becomes a race to see if death or transplant will come first. The workup is prescribed. We hurry to send off the tests and complete the exams and procedures that the patient needs. Besides the workup, there are other barriers to liver transplant. For example, there is no road to transplant without health insurance. Just as there is no road to transplant if patients do not have friends or family to take care of them after their transplant. One also must have stable housing. Many people are not placed on the transplant list because they are disqualified or die along the way. Those who do make it on the transplant list frequently don’t survive until transplant. Livers are scarce. When a patient is on the transplant list, they are waiting for a person to die who has a liver that matches their body. Not any liver can be transplanted into any person. The liver and person receiving the liver must match so that the body of the person receiving the liver doesn’t reject it.

There are many people who need livers. When a liver becomes available who gets it? The answer is a combination of luck, being the sickest, and being the best match for the organ (like having a matching blood type and being the right size). Is it fair who gets a liver? Unlikely. There are race and gender disparities. Geography matters in terms of access to organs. Many patients never qualify for the transplant list because of the social determinants of health including problems related to poverty and lack of social support.

I thought of the patient the color of a yellow highlighter as I left the hospital for the day. No one could predict what their outcome would be. Even though experience and science told me the odds were against them, I hoped they’d get a new liver and recover well from the surgery. After all, I went into medicine not because I thought all outcomes would be happy but because I wanted to help people fight for the best outcome they could. Getting a liver transplant and having it work was the best outcome for this patient; it was the outcome the patient was fighting for. I came to work every day to help them survive until transplant. It was a big task, but few things are more motivating than the chance to help change another person’s life for the better. No matter what happened, I was grateful to be on the patient’s team. Grateful they trusted me to help support them through this challenging stretch of their life. Grateful we can transplant livers – giving hope for a new life in a situation where death used to be the only outcome.

  1. Annual Data Report of the US Organ Procurement and Transplantation Network (OPTN) and the Scientific Registry of Transplant Recipients (SRTR) from HRSA: https://srtr.transplant.hrsa.gov/ADR/Chapter?name=Liver&year=2022

About Those Weight Loss Drugs

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Several friends asked my opinion on a group of weight loss medications called “GLP-1 receptor agonists” like semaglutide (Wegovy). Specifically, they asked me: 1) Are these drugs cheating? and 2) Will these drugs worsen stigma and mistreatment of people who live in large bodies?

These questions are hard to answer concisely. I am going to try. I will first clarify several concepts then answer each question individually.

4 Foundational Concepts

1) GLP-1 receptor agonists aren’t a silver bullet. They can have serious side effects including severe nausea and vomiting, kidney injury, gallbladder disease, and pancreatitis. Some people who try these medications can’t continue them given the side effects they experience. Another challenge is that GLP-1 receptor agonists can be too expensive for patients to afford because insurance companies don’t always cover them and there is no cheap generic version available in the US.

2) BMI (body mass index) compares a person’s weight and height as a tool to understand if their weight has a negative impact on their health. It is flawed. BMI was developed using mostly data from white men. Half of my patients aren’t white. Another half of my patients aren’t men. So, the BMI brackets of “underweight,” “healthy,” “overweight,” and “obese” don’t perfectly describe most of my patients because they aren’t white men. BMI is also flawed because it does not describe body composition (fat vs muscle vs other) which is relevant to how weight affects health. As such, BMI is complex to interpret when someone does not fall at one extreme of the scale. Despite its flaws, BMI is helpful when used with other information (like waist circumference, labs, vitals, history, etc.) to understand how a person’s weight affects their health.

3) Obesity has a specific definition based on BMI and several other factors. The most basic definition of obesity is a BMI ≥30 kg/m2.

4) Obesity is a disease with a multifactorial cause. Obesity is NOT caused by weakness or lack of self-control. There’s growing information about the genetic and environmental contributors to obesity. Additionally, there are certain medications that some people need to live given their other health problems that contribute to weigh gain. Like many other diseases, personal choices can contribute to the development of obesity. Personal choices, however, do not define or explain obesity completely.

Are these drugs cheating?

No. GLP-1 receptor agonists are useful because we know that weight loss is more effective with them than with diet changes alone. GLP-1 receptor agonists are ONLY approved for weight loss in people who have obesity or people who have a BMI ≥27 kg/m2 with a condition that is likely a complication of their weight like diabetes, high cholesterol, or high blood pressure. Weight loss in these populations is important because it will improve their overall health and, importantly, lower their risk of heart disease. Heart disease is the leading cause of death in the US so it’s serious.

Note that GLP-1 receptor agonists were first approved to treat diabetes (regardless of a person’s weight) and continue to be used for that purpose. These medications are also recommended as part of the treatment of chronic coronary artery disease in specific situations.  In other words, not everyone on a GLP-1 receptor agonist is taking it specifically for weight loss.

Will these drugs worsen stigma and mistreatment of people who live in large bodies?

They shouldn’t since they are proven treatments for specifically defined diseases (just like most other medications we use). Subjective judgements of body size that classify people as having a large body aren’t good predictors of people’s health status. It’s important to realize that what societies and individuals consider a “large body” is often based on cultural and individual beliefs and is variable. When looking at weight from the medical perspective, we use specific objective data like BMI and other medical information (like body composition, labs, and vitals) to estimate how likely a person’s weight is to negatively affect their health.

While not all people with large bodies (from the perspective of society) have obesity or negative complications from their weight, some do. If my patient’s weight negatively impacts their health, it’s my job as their primary care physician to include weight loss as part of their medical plan to help them live a long and healthy life. Weight loss medications are one tool in the toolbox.

My goal is to treat people with compassion and respect. I believe that if I continue to strive to practice medicine that is fair and kind regardless of my patient’s body size, I can help reduce the stigma placed on people with large bodies. GLP-1 receptor agonists can help people with obesity lose enough weight to lower their risk of developing heart disease and other complications associated with obesity. The opportunity to help people achieve their best health is one reason why I went into medicine. I’m excited that we have the GLP-1 receptor agonists and will continue to recommend them when medically indicated.  

References:

StatPearls, “Glucagon-Like Peptide-1 Receptor Agonists”: https://www.ncbi.nlm.nih.gov/books/NBK551568/

Cureus, “The History and Faults of the Body Mass Index and Where to Look Next: A Literature Review”: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10693914/

Clin Med, “Causes of obesity: a review”: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10541056/

New England Journal of Medicine, “Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes”: https://pubmed.ncbi.nlm.nih.gov/37952131/

CDC, “Heart Disease Deaths”: https://www.cdc.gov/nchs/hus/topics/heart-disease-deaths.htm#:~:text=Heart%20disease%20has%20been%20the,excessive%20alcohol%20use%20(2)

Tell Me One Fun Fact About You

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It can be anything. Your favorite vacation, a hobby…

“I’ve been to 157 US cities.”

“I love my grandchildren. I like to facetime them.”

“I have a mermaid tail. It’s pink and purple.”

“I have a wife and kids waiting for me at home.”

“I liked to play basketball as a child.”

“I care about people.”

“I used to ride in the rodeo.”

“My favorite place to vacation is the Caribbean.”

“My son recently got married. I don’t like my new daughter-in-law.”

I look at hundreds of labs values a day. I review vital signs, recorded bowel movements, and urine output in milliliters for all my patients daily. I place orders and write notes. I answer a nursing question about every 6 minutes during the busiest part of my day. I discuss every patient with my supervising attending. I discuss complicated parts of my patients’ treatment with my senior resident. I coordinate with nutrition, social work, physical therapy, occupational therapy, speech, and numerous others to ensure patients are taken care of while they’re in the hospital and safely discharged. I examine every patient every day and if their status changes (like their blood pressure drops) I re-examine them. I do more, but this paragraph is already too long.

The constellation of the medical workup I order, medications I prescribe, and information I gather about my patients’ symptoms are how I figure out what is ailing them and how to treat it. As you can imagine, when so much of my energy is focused on sorting through data, it’s easy to forget that under all the data I collect are people.

The best doctors I’ve worked with each have their own way of reminding themselves that they are caring for people not just treating vessels of illness represented by labs, imaging, and physical exam findings. And, within the past few months, I decided to develop my own method as I plan to be among the best doctors. It’s tricky because as a doctor there isn’t time to learn many of the details of our patients’ lives. There is time to learn something small, however, if I prioritize it.

My way to learn something about my patients as people is to ask about something nonmedical. My phrasing is, “Tell me one fun fact about you. It can be anything, such as a hobby or a favorite place you vacationed.” I’ve learned about the most amazing people this way.

The above simple inquiry has made all the difference in my practice as a doctor and my ability to endure the hustle that is inherent to residency. It’s easier to arrive at the hospital 6 days a week by 6 am (and leave often more than 12 hours later) when I’m showing up to help someone with family and a mermaid tail to go home to compared to showing up for a pile of numbers representing blood counts, vital signs, and urine volume.

It’s the people who are the patients who make medicine different from any other profession where people aren’t the subject. And it’s the people who have shared their fun facts with me who continually remind me why I entered the medical profession and where I’m going with it. And for that, I am most grateful.

Hey Doctor!

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I got in the hospital elevator. One person was already in it – a maintenance guy by his uniform and the fact that he had a ladder in hand. Before I’d decided if I was going to say “hello,” he declared joyfully “Hey doctor!”

I glanced down at my badged (“doctor” was written on it in capitalized black letters on a yellow background larger than anything else on the badge). I looked around the elevator…yep just me and him…he was definitely talking to me. I said, “Hi!”

“Did you have to look at your badge?” he asked in a voice cracked in the way voices are when a laugh is bubbling up. We both burst into laughter.

I’ve been a practicing doctor for 5 weeks. While I feel ready and excited to be a doctor, the title is still new and I’m learning the role. Some patients and non-doctors take the title seriously and some don’t; however, when you ARE a medical doctor, the title comes with some weight as you know exactly what responsibility is behind it.

As part of my residency training, I work in a primary care clinic where I have a group of patients for whom I’m their sole primary care doctor for the duration of my residency. This means I’ll see them when they have a new issue and I’ll also manage their health maintenance. Primary care is about tackling health challenges before they become health issues and preventing people from experiencing life-threatening events and worsening health if possible. It’s arguably the most important part of the healthcare system even though it gets the least recognition, compensation, and emphasis in our corporate/profit-focused US healthcare system.

My first week as a primary care doctor I ordered a cholesterol panel (a blood test) for one of my patients. They had obesity and chronic pain. They hadn’t had their cholesterol checked before and at their age and BMI (body mass index) I wanted to see if we needed to start a cholesterol-lowering medication to reduce their risk of heart disease. During our appointment, the patient and I had a lovely conversation about their life and the changes they’d made to improve their health. I was inspired by them because it was clear that they were motivated and dedicated to their health – they had made diet changes and were finding ways to fit exercise into their routine despite having housing insecurity and struggling to make ends meet. 

The cholesterol panel came back several hours after the patient’s appointment had ended. I looked at the numbers and panicked. How do I interpret these numbers? I asked myself. This patient was relying on me to evaluate their lab results and provide recommendations on lifestyle and medication use. It was a big burden. I read some medical resources then, based on what I read, decided that their cholesterol was okay given their other heart risk factors. They didn’t need to start a new medication. I sent them a letter with the normal result.

Even after I sent the patient a letter about their cholesterol, panic lingered in my toes. Had I interpreted the results correctly? Would I need to call them back and tell them I was wrong, and we needed to do something different? Had a missed an opportunity to help them protect their heart?

Over the next week I researched more about cholesterol panels and then talked to my supervising doctor about the topic. In the end, I confirmed that I had made the right decision for this patient. I also learned there is a calculator I should use to determine patients’ risk of heart disease and the benefit of starting a cholesterol-lowering medication.

Soon interpreting cholesterol panels will be easy and fast. But the first time I did it for a real patient (a real person) was exciting and nerve-wracking. Just like being called “doctor” in the elevator this week required a little extra processing to realize that I was the doctor being referenced. I know I won’t have to check my badge for much longer to confirm my profession. I’m excited to grow into the person who can respond without pause to “hey doctor!”

Maintaining the Body/Mind

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In zooming around healthcare settings, I’ve noticed that many people approach illness as a weakness or a betrayal of their body and mind. I’ve even noticed myself having a similar feeling occasionally when I must visit my own doctor. This way of thinking is like how I think about my car: I expect my car to get me from A to B every time I ask it to, with minimal effort on my part, and no upkeep.

To further outline the analogy between bodies/minds and cars:

  • The hospital is to the body/mind as the auto shop is to a car after a crash. If something gets damaged, we usually must fix it to run again.
  • The primary care setting is to the body/mind as an oil change, tire change, and alignment are to a car. For optimal performance, we must continuously do some upkeep and occasionally get a tune up.

As we examine the analogy between cars and bodies/minds there is an essential difference. If we have the money, we can buy a new car periodically to avoid all the upkeep that inevitably comes with the wear and tear of use. However, we each only get one body/mind and, therefore, not even money can spare us the required upkeep that comes with the wear and tear of life.

Considering that we each only get one body/mind and life is hard, I’d like to propose the viewpoint that going to a primary care provider isn’t a visit with the enemy. It’s not intended to be a place of judgement or punishment. Instead, think of primary care appointments as tune ups that include chatting with an expert on the human body/mind. In this chat, we can uncover what aspects of our body/mind are optimized, what aspects aren’t optimal, and how we each can make our body/mind run better. By optimizing our body/mind, we may prevent many diseases from occurring (prevention is better than treatment, why get sick if there’s a way to avoid it completely?). 

In a similar fashion, no one wants to stay in the hospital, but needing the hospital isn’t unique; it’s part of the human experience in places where hospitals exist. Hospitals can save lives and fix big health problems. They might not be the most pleasant places, but without them we might not get the care we need to recover when things in our bodies/minds break. If we can think of our hospital care team as a bunch of people on our side who are looking out for our bodies/minds, it might make the whole experience a little better.

 Just as we know our cars require a certain amount of upkeep, I challenge all of us to remember that the body and mind also require a certain amount of upkeep without considering a need for that upkeep a shortcoming.

Heartbroken

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Tears fell down their cheeks. There was a long pause. “My heart broke and I’m just having trouble processing that,” the patient said. They’d been hospitalized for a heart attack several months earlier. I was seeing them at a primary care visit long after discharge. On paper they were recovering well, but they didn’t feel that way. They felt broken.

This interaction resurfaces in my mind periodically because it shows a side of illness that isn’t often seen in the hospital (where I’ve spent most of my time training). This patient had experienced an acute illness (heart injury). They had recovered their functionality. By medical definitions, they were a success story. Yet, they were miserable. How could that be?

In medicine we organize diseases into buckets with specific treatments and endpoints related to the organs affected by each disease. For example, this patient had a disease of the heart which might include endpoints like their ability to tolerate exercise or their heart rhythm. These endpoints are a simplicity required to synthesize something as complex as the human organism. However, as this story shows, looking at only specific endpoints can lead to missing things related to the illness that aren’t listed as clear endpoints to track. In the case of this patient, the heart is connected to the brain which is an organ of personality, mood, and feelings (among other things). While the functionality of this patient’s heart met all medical endpoints, their mood/feelings were severely affected by the experience of surviving a heart injury.

This patient’s experience reminds me that the diagnoses we make and interventions we do have lasting impacts on patients. Remembering this motivates me to provide information and support that I think will empower patients in their processing of what happened to them while they were hospitalized. I often wonder what conversations this heartbroken patient had with their care team while they were in the hospital recovering from their heart attack. Was there anything that their care team could have done differently to lessen the patient’s distress after discharge or was the patient’s feeling of heartbrokenness inevitable? I’ll never know the answer.

With this patient’s experience in mind, I try to ask myself if there is anything missing or left unclear before I discharge a patient. Healthcare is far from perfect (it’s quite broken actually) yet, even in a broken system, we can choose to communicate and help as best we can.

Listening in Medicine

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This patient was always cheerful. Despite approaching a month in the hospital. Despite extensive injuries for which they required multiple procedures, surgeries, and a long course of antibiotics. Every time I checked in, they had a visitor, were listening to mass, or were simply doing life things.

One day when I stopped in, the patient was different. Still as pleasant as ever, but their cheer was guarded. I noticed that their voice was heavier. That their eyes were drooping at the edges. Their smile seemed more effortful. “Is everything okay? Are you okay?” I asked. In the minutes I was with the patient, I asked these questions periodically. Interleaving with the normal questions about signs and symptoms and physical exams I needed to do. I’ve learned that if you create space for things that haven’t been said to be said, sometimes patients share what’s bothering them and you can do something about it.

I paused as I was preparing to leave and asked one more time if the patient was okay. They started crying. I waited. “It’s just I haven’t seen my children. I miss my children,” the patient said. I’d come to learn that they had two young children who they hadn’t seen since their admission. They video called them but, obviously, that wasn’t the same as seeing their children and giving them hugs.

Since COVID, hospital visitation policies have become more restrictive. There are reasons for these restrictions, however the unintended consequence is patient social isolation which is bad for patient mental health to put it simply. At the time when I was seeing this patient, the hospital I was in was not allowing children to enter the hospital as visitors. Rules, though, usually have exceptions. I spoke with the nursing staff, as they steward hospital floors, and they were able to arrange for the patient to see their children.

This patient interaction reminded me how listening is critical in medicine. The hospital is a difficult place to have a good conversation as patient. The hospital is confusing and foreign to most people; there are unintentional power differences that exist as medical knowledge and understanding are uncommon among those who didn’t study medicine; there are many faces with different roles in the hospital so it’s impossible to keep track of who is the right person to ask for what; and the hospital is busy and short-staffed, so healthcare workers are doing their best but they are always running behind. Given these barriers to communication, the burden falls not on the patient but on their care team to ensure that time to hear patients’ needs is made. To do this doesn’t necessitate longer patient interactions, necessarily, but it does necessitate listening for more than reports of a fever or bowel changes.

It can be hard to listen for things that don’t directly relate to changing a patient’s care plan. Yet, patients are more than carriers of disease and, therefore, to best support them in their journey to better health we in healthcare must listen to all ailments. Sometimes we can lessen a burden and sometimes we can’t. Arranging for a parent to see their children after weeks in the hospital is something we can solve easily. I was glad I was able to help this patient see their children, but I wondered how long the patient had suffered from missing their children. Perhaps, if one of us from their care team had listened more carefully earlier, the patient wouldn’t have had to wait almost a month before seeing their children. To me, it seemed unreasonable to add the burden of missing loved ones to this patient’s burden of healing from an accident that had almost killed them and injuries that would likely change their life. Being sick is hard enough; let us in healthcare not forget the human things, like social supports, that can help make healing less daunting. 

Burnt

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Her hands had become so numb she could no longer administer the eyedrops that kept the pressure in her eyes from getting too high. If her eye pressure got too high, she’d go blind. So, her eye doctor said she needed surgery if she couldn’t use the eye drops. There were two surgical options. One surgery would take an hour and she’d leave the operating room able to see. One would take 3 hours and she’d leave the operating room blind, requiring 4-6 weeks of recovery before her vision would return. She was lucky because she had family who already helped her a ton because her other health conditions had made independent living hard for her. For some reason, the insurance would only cover the 3-hour surgery that would leave her blind for over a month. The holidays were coming up. The family members that took care of her had kids. She refused to make them care for her while she was blind over the holidays. She postponed the surgery. Would she go blind before she could get her surgery? Is this the healthcare system we want?

~

The patient wasn’t COVID vaccinated. “What will you do to treat me if I get COVID?” she asked. I thought about the patient a resident had told me about. That patient had been dependent on family for care. His family didn’t vaccinate him. He got COVID. He came to the emergency room with trouble breathing and then went to the intensive care unit. He lived on the intensive care unit for a year. Eventually, his healthcare team cut a hole in his neck to put a breathing tube in because he needed it. They did everything they could to keep him alive. The resident said when the patient first came to the emergency room, he was a happy, funny soul. The patient lost his happiness slowly during the year he fought to breath. After a year of an entire hospital trying keep him alive, he died. When exactly did avoiding sickness fall out of favor? Do you ask what firefighters will do if you set fire to your house or do you make a concerted effort to not catch your house on fire knowing that firefighters will do their best to stop a fire if it occurs but are limited because fires are destructive and destroy houses and the people who try to stop them?

~

The patient asked, “Why are so many doctors retiring?” I wondered how he didn’t know the answer to that question already. It seems so obvious. Then, I realized he was not a medical student. Being a medical student is to have a front row seat for observing the current state of healthcare. What had I seen? Why did it seem perfectly logical to me that so many people were retiring from healthcare even as I was striving to make it my career?

Not just doctors and nurses, but everyone in healthcare seems to be retiring…

We report our COVID cases. Our COVID test rates. Our COVID survival rates after hospital admission. Our COVID deaths. Who was there to perform those tests, to care for those people when they came to the hospital, and to close the curtain when the ventilator wasn’t needed anymore? Healthcare workers. But, they were also there for all the other things too. The heart attacks. The stomach pain. The broken bones. The cancer. The normal healthcare screenings. They were there when people looked for help with their depression and their anxiety. Healthcare workers’ hours increased. They worked the job of two, three, four, and five people because the hospital was short-staffed before the pandemic hit. Again, healthcare workers were already working long hours and doing the work of several workers before COVID came. Then healthcare workers got sick. And the ones left standing worked for their sick colleagues, worked for themselves, and worked for the staff who were missing before the pandemic came. Wages stayed the same.

Housing and food got expensive for everyone, including healthcare workers. Healthcare workers missed the same performances, social events, and restaurants that everyone else was missing. Life got more expensive because everything including industry was disrupted by COVID. Healthcare wages stayed the same. Healthcare workers got sick. Sick leave was used up. Shifts were harder because healthcare was short staffed and there were more patients than before. And the patients were dying. And insurance didn’t want to pay for the treatments that patients needed, not that that was new, but it remained disheartening. And there was the need to wear masks at work. And to put on goggles and gowns and for healthcare workers to take extra time to protect themselves from infection. There was the risk of bringing COVID home after working in healthcare. Wages stayed the same.

People got sick. And healthcare workers got tired. Wages stayed the same. Hours were long. Vacations couldn’t be taken like they used to be taken. And just like their patients, healthcare workers got sick, tired, depressed, and anxious. Staff shortages increased in the hospitals and clinics.

People denied that COVID was real. People invented vaccines that helped prevent COVID infection. People refused to get vaccinated. People complained about wearing masks. People got tired of social distancing. People got sick. The intensive care unit was full. The psychiatric ward was full. The cardiac ward was full. Alcohol use disorder, diabetes, high blood pressure, and all the other medical conditions that always exist marched on because they don’t stop during a pandemic. Healthcare workers shouldered the workload of several workers each because some of their colleagues had left, some had died, and some were sick. Wages stayed the same.

In such an avalanche, how long would you have waited to change careers? For many, the answer was between 1 and 2 years.

~

There is always hope and healthcare has been grounded in hope since the beginning. But as a student so excited to become a physician I know that change must happen if hope is to materialize into lives saved. And for my sake and all the people who might need the hospital or a clinic in the coming years, let’s not make it take a healthcare collapse before we seriously consider how we might improve and restructure our healthcare system. I’d very much like some seasoned healthcare workers who are not completed burnt at my side when I start practicing as an independent physician because experience is gold in medicine. I’d also really like to have enough staff to care for patients without having to burn myself and burn my colleagues with the weight of too many lives in each of our two hands.

Surgeons

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I sat waiting for the surgeon I’d work with to arrive at the hospital. Being a medical student involves a lot of waiting. On the wall across from where I sat and next to my surgeon preceptor’s office was a wall of fame, of sorts, of surgeons gone by. The black-and-white photos caught my attention because every single surgeon depicted there was a white male. The irony was that most of the surgeons I would come to respect in the weeks to follow would fit neither or only one of the “white male” descriptors. The surgeon I was waiting for, for example, was neither white nor male. She would single-handedly show me what it meant to be an excellent surgeon.

The operating room is cold. The lights are stark. If you are helping with an operation you “scrub in” (which involves washing your hands in a special way and putting on sterile gloves and a sterile gown). Once scrubbed in, you maintain sterility the entire procedure which includes only touching sterile things and keeping your hands in front of you and between the level of your bellybutton and chest. Bathroom breaks and snack breaks aren’t an option for medical students in the operating room, so I tried my best to do those things before entering the room.

Once the patient is settled on the operating table, they’re put to sleep by anesthesia.  As soon as it’s confirmed that the patient is asleep, their eyelids are closed with tape to protect their eye structures and a tube is placed down their throat to help them breathe.

While the patient is asleep surgery unfolds. All surgeries are done with a team of people, the surgeon is only one member of that team, and the surgery is not successful without every team member. The patient is covered with drapes except for the area where the operation will occur. This is interesting because the humanness of the patient is lost. Their body becomes a workspace once the drapes are placed. It may sound disrespectful, but it isn’t. Rather, the drapes are meant to protect the sterile workspace and maintain patient modesty.

Surgeons are the artists of medicine. Much like carpenters and painters and jewelers and other craftspeople they make their living by using their hands. The difference, however, between surgeons’ hands and carpenters’ hands, for example, is stark. The surgeons’ hands are soft and their fingers nibble while the carpenters’ hands are rough and their fingers strong.

Surgery is all about feel and dexterity. Surgeons tie knots with thin thread to keep arteries from bleeding. They sew with curved needles using plyer-like instruments. During surgery, it’s the surgeon’s hands that impress. Their fingertips can feel the difference between disease and health in tissue. Their hands can somehow hold more tools than you thought possible.

Ask a surgeon about surgery and about the operating room and their eyes become bright. They smile. They draw pictures and use their hands to describe structures. They talk about the neat surgeries and bodies they’ve seen. They talk about how many operations they’ve done. Surgeons are like artists. They love their craft and exude a love for their studio (the operating room).

I would eventually join a surgery led by the surgeon I had waited for by the surgeon wall of fame. A resident and I were helping her. The resident was soon to finish and become an independent practitioner. The surgeon was busy operating; I was holding a camera (used to see inside the abdomen); and the resident was doing something else to help the surgeon. “People will not take you seriously because you are a small female,” the surgeon said to the resident. “Don’t be disheartened. Respect is earned.” The surgeon would go on to discuss the importance of appropriate financial compensation for your work and doing excellent work. I would hear this message about differences and respect several times during my surgery rotation. I would feel why multiple women ahead of me thought they needed to tell me and my colleagues this information. Yet, it wasn’t new information because I, like most others, didn’t make it through my 20s without learning how my different identities help and hinder me.

There are many things that you could die from if it wasn’t for surgeons. But, as lifesaving as surgery is, it is also fraught with risk. Your surgeon can kill you. Having life and death literally in one’s hands is not a light matter, and you see its weight on the shoulders of surgeons when you work with them. The riskiness of surgery is also why the road to becoming a surgeon is a long, hard one. It involves many years filled with unfortunately long workdays. Apart from a grueling training marathon, surgeons have high personal standards for their work. High standards coupled with hard training leave many surgeons with a robust ego.

Egos aren’t all bad. You want a confident, proud surgeon. This is because you want someone who is very good at what they do and who takes pride in their work to operate on you. However, egos can be detrimental too. Too much ego can lead to poor listening skills, lack of self-reflection, and a complete disrespect for others. High-quality surgeons are confident because they are good at their work and love it, proud because they save lives, and humble because they know they are human and will make mistakes. The best surgeons are not only confident, proud, and humble but also curious. Curiosity makes the best surgeons because they not only love operating but, also, dig to the bottom of their patients’ stories, investigate thoroughly any mistake or less-than-perfect outcome, and keep up on the latest research and recommendations in their field.

On our last day working together, the surgeon that made me understand surgery had time to sit with me in her office by the surgeon wall of fame. She gave me some advice and her philosophy on medicine. “It’s nice when patients appreciate your work. You saved their life. But, they don’t have to and that’s not why I do it. I like to help people,” she said. The conversation continued for a bit. “People talk about quality of life. I don’t think it’s fair to say that you don’t want to do surgery because of the quality of life. Quality of life is something you make. For example, right now I pick up lots of call [24-hour shifts]. I do it because I am well compensated but, also, because it is good experience. I like to help people… I like having the cases [surgeries]… But, I won’t pick up call forever. Right now, it makes sense… It’s all about tradeoffs. You can work less and then you make less money… You can set the terms of your work,” she said.

As I left the hospital after my last day working with her, I thought about the surgeon I’d worked with. She was a calm and patient teacher – something that is rare. She had saved many lives. She had seen the inside of the body many times. Her hands could tell the difference between a fat glob and a cancer by feel alone. I’d seen her talking to patients with a patience you don’t find in all surgeons. I’d seen her interacting with all levels of hospital personal with a respect and kindness that was genuine. I’d heard her talk through her clinical reasoning; it was thorough. I’d seen her do surgery; she excelled. She was exactly what I’d call an excellent surgeon. I would have no hesitation sending my patients or family to her because I knew she’d treat them well and operate with precision. She was the first surgeon to go on my mental surgeon wall of fame. After that first day waiting outside her office, I’d decided to construct my own wall of fame (for surgeons and other types of physicians) because the one I’d seen in the hospital was outdated.

Autonomy In Medicine

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Set Up

I’ve been thinking of patient autonomy and the humanness of physicians a lot recently. In my short time training to be a doctor, I’ve had many experiences that have brought these topics to light. Here are a few examples:

  • An attending physician told me he usually first recommends pills to women seeking birth control because he believes that women find it reassuring to have their period every month. Odd perspective as my experience as a woman is that some women find periods reassuring and many find them annoying. Odd perspective as my short time in his clinic showed implant and injectable birth control methods as the most common forms of birth control requested and used by patients. Odd perspective as research has shown LARC (which include implants and IUDs and NOT birth control pills) have greatly decreased unwanted pregnancies because they’ve removed the mishaps of having to remember to take a pill every day. Medicine is complex. It requires both keeping up with research and checking your personal beliefs at the door. The approach I’ve seen most physician take when discussing birth control is to outline the different available birth control options so patients can decide themselves which is best for them.  
  • I overheard an attending physician talking to a resident physician about a D&C they did recently. A D&C is a procedure that can either be used to end a pregnancy early on or clear a miscarriage that occurred early in pregnancy. The patient these physicians were discussing had the procedure to end pregnancy. The resident physician stated that she thought the patient was looking for validation from the attending physician for choosing to have the procedure. The attending physician shrugged. I (medical student) asked what the attending physician had told the patient. The attending physician said, “She doesn’t need to give me a reason for the D&C. I told her she doesn’t need to give me a reason to terminate the pregnancy.” I found this statement to be a powerful example of approaching medicine without imposing personal beliefs on a patient.
  • An attending physician walked out of a patient room and told me the patient’s problem was that she was naïve. This was his reaction to the patient (a pregnant woman) planning to visit friends/family in another city while in the third trimester of her pregnancy. The patient had gained too much weight during pregnancy. She also had high blood pressure at this appointment. When asked the patient described improving her diet. The physician laughed at her when she described eating salad. In self-defense, the patient then described eating very healthy-sounding salads. The patient’s trip would delay the follow up blood pressure reading the physician wanted by two days. The physician did not explain why he was concerned about hypertension specifically in the last weeks of pregnancy. I wondered why he didn’t recommend that the patient monitor her blood pressures with a home blood pressure cuff and bring in a log of her blood pressures when she was able to schedule her next appointment. It seemed the risk of delaying a blood pressure reading in the clinic by two days might be outweighed by the benefit of social support during the final weeks of pregnancy. I questioned the choice of “naïve” as his diagnosis. Why should she know about preeclampsia if he didn’t tell her? Naïve is a loaded term and isn’t one I’d be quick to use to describe a pregnant and uninsured woman with friends/family in multiple cities. Medicine is a team sport. Patients are the captains and physicians are the coaches. It’s important to remember that the patient is part of the team and that while they don’t bring medical knowledge, they do bring life knowledge.
  • The patient told the attending physician that they stopped their antipsychotic medications. The physician recommended that the patient continue taking their medications. The patient refused. The attending and the patient came up with a plan to watch for warning signs that the patient’s psychosis was returning. The patient continued to attend group therapy even though they stopped their medications. This allowed the group therapist to send a community crew out to the patient’s home to check on the patient when that patient showed psychotic behavior at the online group therapy session. The patient did not self-identify that their psychosis was returning. However, because they continued to attend group sessions they were still connected to care and were brought to the emergency room before their psychosis led to self-harm. I found this case an excellent example of a physician respecting autonomy while also trying to prevent serious health outcomes for her patient.

Reflection

Medical school, residency, and being a physician teach us to solve complex problems. They teach us the complexities of the human body and how to cure diseases and treat symptoms. They teach us to think critically and sift through data efficiently. They provide us with guidelines and treatment recommendations. But, medical school, residency, and practicing medicine don’t and can’t teach us the complexity of each patient. They can’t give us the ability to foresee the future or understand patients’ life goals better than patients do themselves. And, despite our great knowledge as physicians, we can’t (and will never) have all the answers. Despite extensive training, medical research, and detailed guidelines medicine is still decided by humans (yes, physicians are just humans) and is (therefore) based partly on intuition, experience, and practiced guessing.

In medicine we are fixated on being right. Our goal is to reduce suffering, cure disease, and help patients navigate illness. And while as doctors we strive to cure, as humans we know that life can be more complex than curing. As humans we know life is paired with death. As humans we know not all questions have an answer and not all problems have a solution (at least yet). And as humans we know that health, sickness, healing, recovery, pain, and death are individual experiences that share commonalities across individuals but (ultimately) are unique experiences that each person endures differently.

In my short time in the hospital, I’ve already observed patients losing their autonomy. I’ve seen patients’ wishes ignored and explanations of why skipped or glossed over. I’ve seen us (medical experts) angered when patients don’t follow all our recommendations, insulted when we’re asked why, and forceful that our way is the only right way. And I’ve seen patients suffer. I’ve seen patients suffer taking our recommendations and I’ve seen them suffer when they refused our recommendations. And while suffering seems to be a part of some points in all lives, it also seems that sometimes in addition to our patients suffering we (physicians) push our patients to accept a treatment plan that is discordant with their values and life goals. It seems sometimes that we add to suffering by piling on shame or judgement.

In medical school, in residency, and as physicians we are taught to find the truth and to be right and to be directive. We are taught to recommend the best medicine has to offer. Yet, the best options based on evidence are not always the best option for an individual patient. And even if they seem right, the best options are not foolproof. The best options are based on probabilities, percentages of effectiveness and likelihood of reducing disease or preventing further harm. Probabilities are helpful, but they are not certainties.   

I’ve been thinking of medical recommendations and patient autonomy and the humanness of doctors because medicine can be hierarchical. It can be rigid with the attending physician setting the law; a mix of other players like nurses, medical students, and resident physicians in the middle; and the patient disempowered.

There are more cases than I presented above that I’ve experience which illustrated the complexities of patient autonomy and the humanness of doctors. Medical school is a whirlwind of learning. What I’ve come to discover, however, is that all the learning isn’t strictly medical. I’m also learning how I’d like to conduct myself when I’m an independently practicing physician, the ethics of medicine, and the challenges of working in a field where the outcome is dependent on the efforts of all team members.

As I reflect on the hierarchy and the complexity of medicine, if I could hold one piece of advice for myself as my training continues it would be to ensure my understanding of medicine is excellent while also remembering that patients are autonomous individuals. This advice reminds me that my job is ultimately to help people navigate the complexities of health and illness. This advice acknowledges that patients can say “no” and that the “why” is just as important as the “right answer.” This advice helps me to remember that my patients and I are a team. And just as I can decline or refer a patient to another physician if I am not comfortable with a patient’s request, my patient can also decline my recommendations or seek the medical expertise of another.