Tag Archives: People

Remarkable People

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Movement at the periphery of my vision caught my attention as I sat at a stop light on my way to work. The movement was a person standing on the sidewalk. Perhaps they were dancing in their mind. Their movements were rhythmic but not in the way most people move to a beat. Something was wrong. Then I realized they were foaming at the mouth and a string of drool hung from their chin. Their eyes were open, but I wasn’t sure they saw the world around them. The explanation didn’t take a medical degree to deduce: Drugs. Likely cocaine or another stimulant. Opiates make people sleepy, not interested in dancing on a street corner.

That day in clinic I had a new patient scheduled who hadn’t been seen by a doctor in several years. The patient was young. They had a history of substance use disorder. The last notes in our system, from several years prior, said they’d stopped using drugs. Previously, they’d used almost every class of drug: alcohol, tobacco, cocaine, benzos, and opiates. As I waited for their appointment to start, I wondered how they were doing, now years later.

The patient entered my clinic calm, clean, and collected. They were articulate and respectful. They had cool hobbies including gardening and beekeeping. “Last time you saw us, you hadn’t used drugs for a few years. Is that still the case?” I asked.

“Yeah, I don’t use drugs anymore. Haven’t for years. I still smoke cigarettes though,” the patient said.

The conversation about their health unfolded. I looked at my computer to go through the never-ending reminders the healthcare system required me to complete with my patients. The reminders for the current appointment included cancer screening and offering nasal naloxone (maybe better known by its brand name “NARCAN.” It’s a nasal spray that reverses the effects of opiates and, if given soon enough after an overdose, saves lives).

“I know you said you don’t use drugs, but I have a reminder here for naloxone. Would you like free naloxone just in case?” I asked.

“No. I’m good. I used to have it. It saved my life twice…and I saved the lives of two other people. I had a friend that said over his time, he saved 60 people with NARCAN,” the patient said.

“I’m glad you were able to do that. I’m glad you’re still with us,” I said.

I finished going through the reminders. We finished our appointment. The patient was healthy and didn’t even need any blood tests.

I thought about the patient as I walked to my car. Beekeeping is awesome. I hoped I’d get back to gardening someday too. As I put my car in reverse, I remembered the person I saw foaming at the mouth on my drive to work. The contrast between the person I saw on the street corner and my patient that day was stark. The contrast reminded me how life is nonlinear. I thought about how the patient had saved their own life and the lives of two others. The patient I’d seen was a remarkable person. The phrase popular for healthcare workers during the COVID pandemic came to mind, “Not all heroes wear capes.” I decided the phrase was accurate but needed modification. Perhaps a better phrase for remarkable people in the world is, “Not all heroes wear capes, but they have baggage and have learned to carry it with grace.”

I hoped the person I saw dancing to drugs and foaming at the mouth would turn down a different road in life. Maybe that person on the street corner would someday tend their own flowers and suck honey from honeycombs too. Maybe the person I saw on the street corner had saved a life right before I saw them. Maybe their life had been saved by an unknown remarkable person. Afterall, the only thing that makes people remarkable is what they’ve done. Every day each of us can decide to do something new. Every day we can evolve and refresh. That’s the most exciting thing about life: The only constant is change.

Knowledge

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“People believe shit and don’t believe sense,” my supervising doctor said. The comment was in reference to patients who believe remedies without any evidence to support their efficacy will treat disease better than medicines which have robust research behind them proving they work. It wasn’t a comment saying patients shouldn’t believe or do whatever they want, it was a comment that each of us should challenge ourselves to investigate the facts behind claims. It was a nod to science – the scientific method designed to prove that observations are (or are not) significant.

Perhaps the statement wouldn’t have caught my attention in a different era, but with the state of current affairs it did. These days there are attacks on science. There are TV stations and online blogs calling themselves “news outlets” yet report nothing but opinion, and poorly informed opinion at that. There are threats against the true investigative journalist; stories based in research.

Current affairs. The thought that one can simply say whole groups of people don’t exist and think they’ll disappear…or assume they don’t have a right to be who they are. The assertation by certain politicians that experts know less about their industry than folks who never studied it or never worked in it. The propaganda that people who move from one country to another didn’t do so in good faith, didn’t have a dream for a better life, and weren’t needed in the country where they arrived. The dangerous opinion that one’s beliefs are the only beliefs; forgetting that we’ve proven time and time again that all humans are fallible and that diversity of thought and world view make our species stronger.

The ability to think critically and analyze the validity of people’s claims is a form of power. It’s powerful to set one’s emotions aside and examine the truth behind one’s feelings. With a critical approach we can gain knowledge, not just vibes. With knowledge we can grow and change. We can learn to better understand those different from us rather than expect everyone to be like us. We can embrace diversity. We can embrace transitions from one identity to another. We can include everyone. Knowledge helps us understand that prohibiting words like “diversity,” “transition,” and “inclusion” won’t make people who live those realities disappear and is a form of coercion and censorship. 

“People believe shit and don’t believe sense,” my supervising doctor said. I laughed at the comment because in the context it was funny. But it wasn’t funny when I thought about how many people have, do, and will suffer because powerful people are unwilling to believe sense. Unable to hear reason. Disinterested in knowledge. We can’t change other people, but we are responsible for ourselves. I challenge you to look for sense, not shit, when making your decisions in every facet of your life. If each of us challenged ourselves to do that, the world would be different from what it is today.

Positive Transformation

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The first time I saw the patient, they weren’t sure if they wanted to take the medications I recommended for lowering their cholesterol and blood pressure. Primary care appointments are conversations. My assessment of their health after reviewing their labs, vital signs, and story suggested that making lifestyle changes (like more exercise and diet adjustments) and starting a few medications would help the patient be healthier and reach their goal of living a long, healthy life. I explained the reasoning behind my recommendations and the patient agreed to think about them. We planned to continue our discussion of possible medications and lifestyle changes at future appointments. As I like to remind my patients, it doesn’t help anyone if I prescribe them medications they won’t take. I’d rather have an honest conversation about the medications I think would help them but only prescribe the medications the patient would like to try.

Primary care is proactive. In other words, the goal of primary care is to prevent the development of disease in the first place or, if a disease is present, to prevent its progression. Contrast primary care with the reactive approach of hospital medicine. The goal of hospital medicine is to treat disease that is unstable or so far along in its course that it can’t be safely managed outside of a hospital. We know we can help people live longer, healthier lives when they have good access to primary care. However, the challenge with primary care is that often the interventions it promotes don’t create visible changes in the present.

For example, people generally don’t feel any different if their cholesterol is high or low. However, we know that high cholesterol over time can lead to clogging of arteries which, in turn, can lead to heart attacks, strokes, and blockages in arteries that feed the legs (causing pain, poor healing, and tissue death). If a patient has high cholesterol and chooses to lower their cholesterol through diet, exercise, and (possibly) medications they are taking important action to prevent heart attack, stroke, and the other complications of clogged arteries. Yet, it can be hard for people to find the motivation to change their lifestyle and (possibly) take medications every day when those changes don’t change how they feel, and the health benefits are intangible (though very real).

I saw the patient who agreed to think about my medication recommendations many months later. They had lost weight and looked more muscular. They’d revamped their lifestyle – they started a balanced exercise program at least 3 days a week and minimized sugars and carbohydrates in their diet in favor of lean meats and vegetables.

“I’m ready to try the cholesterol-lowering medication,” the patient said, bringing up the topic before I did.

It was a complete transformation. “What motivated you to make all these changes?” I asked.

“I decided I want to live a long time still. I have things I want to do,” the patient said.

I found myself smiling long after the patient left. Many people struggle to make all the changes that this patient had to support their health. Yet, this patient had taken their health into their own hands. And, while I’ll never be able to say exactly how their actions changed the course of their life, every bit of research suggests these choices would shape the patient’s future. They’d lowered their probability of dying from heart disease or stroke. They’d lowered their risk of developing heart failure and diabetes. And such a positive transformation, though rare, is the dream of primary care.

Hospital White

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The stretcher looked different from the 100s of others I’d seen. It was empty and it had an unexpected metal bar at the head of the bed. I glanced in the room outside which the stretcher had stopped. On the bed was a white bag, zipped up, and just the height and length of a sleeping human. I realized the stretcher was there to take a body to the morgue.

Death has been present on many of my hospital shifts – especially in the ICU (intensive care unit) where this sighting occurred. Yet, until this moment, I hadn’t seen the patients who died taken out of their rooms. I’d pronounced them dead. I’d seen patients’ families crying at bedside. I’d seen the closed doors with butterflies on them marking that someone was dying or dead. I’d seen the strangely empty and freshly made beds where those who had died once lay.

The body in the white bag was lifted onto the stretcher. White sheets surrounded them. Then they were wheeled to the morgue – their family wouldn’t see them again. Of course, the person’s soul was gone well before the body was put in a white bag. Off to a better place. If nothing else, watching many people die has made me certain there is a soul which leaves when death calls. To where the soul goes after death, no one knows.  Long ago, I decided to believe souls always go to a better place when the body dies. No one can prove my theory wrong, so no need to worry about the journey of souls.

The sighting of the white bag made me sad. It wasn’t the kind of sadness that made me feel like crying. It was more of a sinking feeling placed on top of an already crummy night. Heaviness on the chest and shoulders. We had multiple sick patients. My co-resident had pronounced dead a patient almost every night that week. Somehow, he’d gotten that burden. I had not pronounced anyone that week; I was caring for people who were staying alive (for the time being). It was night shift, making the already dreary worse. A string of unpleasant nights with one-way transport of white bags out of the ICU. Some of these nights were so busy we only just managed to do the things most necessary. Our patient list was younger than it should have been. It’s easier to accept death when people have lived a long life. Of course, there were a couple happier cases; those patients would make it out of the ICU and then the hospital.

I don’t think one can ever get used to witnessing death. One can come to peace with it. That’s what I’ve done as my years in medicine accumulate. There is an intrinsic link between life and death. The two cannot be separated and are not whole without each other. In the US, black usually represents death. In many other places, death is represented by white. The more time I spend in the hospital, the more I think white is the most representative of life’s end. Hospital white. A blank sheet. All the shades of light together. The absence of physical color. It seems fitting that death is represented by light and not physical being.

The image of the white bag lingered in my mental peripheral vision for the night. I didn’t know anything about the person whose body was in the bag. Sometimes, one doesn’t need to know the details to understand. Death is like that. Simple once it happens. How we arrive at death is what is complicated. Everyone eventually arrives there at their own time and in their own way. Death is one of the most unifying features of being human. But that doesn’t make it easy. Some things are never easy.

The Stickiness of Capacity

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“It’s my religion, my decision!” they yelled as the elevator doors closed, the climax of their escape (though no one was stopping them) from the hospital. They often spoke in rhymes. Where they would go and what condition they’d be in when they got there were mysteries. They’d been in the hospital for almost 2 weeks as we tried to find a safe place for them to discharge to. Their house was in such disrepair that their electricity had been turned off because leaving it on was a fire hazard. They’d had frostbite before, and winter was near. Their mental state was such that we did not believe they could make safe decisions for themselves. They had no way of getting home without our help. Despite all these features they were not in immediate danger of harm and so we had no legal grounds to keep them when they decided they were ready to leave the hospital. We tried to convince them to stay, but they would not listen. They were ready to leave; they wouldn’t wait for us any longer, not even to arrange a ride home. We were worried that they were leaving without a safe plan, but the US medical system is not a jail system. Except for several clear situations, our patients are free to leave the hospital whenever they please even if their doctors think it’s a bad idea.  

Capacity, a patient’s ability to make informed decisions about their healthcare, is more complex than one might think. It’s grounded in the ethical principle of autonomy, which means that patients have the right to decide what happens to their bodies. To understand the complexity of capacity requires at least some understanding of the history of medicine and how we conduct medicine today.

Medicine was paternalistic historically (and in some places it still is). It also wasn’t, seemly, originally centered on doing what was best for patients. There are classic examples of medicine’s unpleasant history, among them: the Tuskegee Syphilis Study, Henrietta Lacks’ stolen cells, stealing corpses to supply cadavers for anatomy labs, and the history of insane asylums. Given its concerning past, there are strict laws outlining which patients can be kept in the hospital against their will and for how long. There are also laws ensuring patients are informed about the risks and benefits of their healthcare and allowed to decide if they would like to pursue or decline tests and treatments their doctors recommend.

When a patient doesn’t have the ability to make their own decisions (for reasons such as acute illness or chronic conditions like dementia) we say that they “lack capacity.” In such instances we identify a person who can legally make decisions on their behalf. Capacity is decision dependent – so a patient may have capacity to say they don’t want to eat lunch but lack capacity to decide to undergo vs. decline a life-saving surgery. Capacity also can be fluid, so perhaps an acutely ill person doesn’t have capacity initially but as they start to recover, they regain capacity. For patients with conditions like dementia, often capacity is never restored if lost.

In tricky cases like the patient described above, the healthcare system can do less than you might think. We can easily treat acute illnesses that are a complication of a patient’s confusion (such as frost bite) but we have few ways to help avoid frost bite in the first place. Hospital social workers can help find nursing facilities to offer at discharge, but seldom can we force patients to go to a nursing facility if they don’t want to go. It’s also worth noting that we do not have the ability to find housing for people experiencing homelessness – so unless they need a short-term skilled nursing facility at discharge, we often have no choice but to discharge patients experiencing homelessness back to the street once they’re medically stable.

In these circumstances, sometimes those of us in healthcare are left with unsettling discharges either because our patients discharge even though we don’t think they’re ready or because we discharge them to the street (or to an unsafe home). In the case of the patient who yelled “It’s my religion, my decision!” as they made their dramatic exit, the patient declined our safe discharge ideas. Even though their medical decision-makers agreed with us, no one could force the patient to do something they did not want to do. After discharging the patient, we (their care team) found ourselves keeping an eye out for them as we drove to and from work. Our plan was to call Adult Protective Services if we saw the patient – because we all knew they had no way to get home. We couldn’t force them to wait for a ride and they had no money for the bus. We also weren’t convinced they knew how to get home. We all suspected they’d end up wandering the streets. As I drove on the lookout, I was reminded how limited our healthcare system can be. I was also reminded that balancing patient autonomy and medical beneficence is not always easy.

Lost in Delirium

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The patient was sick. On death’s door kind of sick. They were a nice person – treating all the hospital staff with respect. Saying “please” and “thank you.” Cracking jokes even though they were ill. They were articulate. Earlier in their hospital stay we’d discussed God. They believed strongly in the power of God. The patient explained that they were at peace with their life and were ready to join God whenever he called.

Then one night the nurse found the patient completely naked in their room. At that time, the patient couldn’t remember their name. The nurse was able to redirect them, remind them of their name, and put them back to bed. They were embarrassed by the events the next morning. In the morning, they seemed to still understand what was happening around them.

The next night they became confused again. But, this time, they weren’t better by morning. As the days unfolded, they were usually able to tell me their name. They’d lost track of why they were in the hospital or what the plan for the day was. They didn’t know the month or the year. At times they seemed more lucid and at other times they were so confused that they believed they were on a business trip. Occasionally they were angry. But, more often, they looked scared. They were easily frightened because they didn’t know where they were or what was happening to them.

This patient was a classic example of delirium. Delirium is a state of confusion that waxes and wanes. It occurs because of the unfamiliarity of the hospital setting, the disruptive nature of hospital activity, and the stress of being ill.  Every patient in the hospital is at risk of developing delirium during their stay. Some people are at greater risk of delirium – elderly people, severely ill people, and people with underlying brain illness.

Delirium is complex from a medical standpoint. We try to prevent it but everything about the hospital promotes delirium – from frequent sleep disruptions to the unfamiliar setting and faces of the hospital. Preventing delirium involves encouraging family members to visit, minimizing overnight wake ups for medical care (vitals, blood draws, meds, etc.), and frequently reminding patients of where they are and the date. We try hard to ensure lights are off at night and lights are on during the day (and window shades open). Despite precautions, delirium can still develop. The challenge is that we have no good treatment for it. Overcoming delirium involves the same strategies as preventing it and treating the illness that brought patients to the hospital in the first place. Another difficult aspect of delirium is managing it when it causes patients to become agitated.

When patients are lost in delirium they don’t act as they normally would. They are in a state of confusion. They may scream and cry not because they are in physical distress but because they don’t understand what is happening. They might fight hospital staff or try to run away. They might become dangerous to staff or other patients. They might refuse the medical care they need to get better. Sometimes to keep a delirious patient and staff safe we need to use sedating medications. But sedating medications can prolong delirium. It’s a tricky situation.

Delirium is one of those conditions that takes up a lot of my time as a physician and consumes nursing time but is little-known among people who don’t work in healthcare. In the short term, it can negatively impact patients by making it difficult to care for them. In the long term, it may impact patients’ cognition.  

Everyone should know about delirium because the best way to prevent delirium has nothing to do with medicine. Delirium is most successfully prevented by having family/friends at bedside. Patients who have frequent family/friend visits (ideally daily for multiple hours) while in the hospital are less likely to develop delirium. The reason family/friends are so important is that they are familiar faces. They can help patients keep track of night and day. Family/friends help keep patients’ minds engaged in conversation, games, and other shared activities. Engaging the mind helps keep it from getting lost in delirium.

In the US, it is fascinating how many patients don’t have family members or friends visit while they’re in the hospital. There are many reasons for this, but two important ones are the American focus on independence and our geographic distance from relatives. Many Americans can’t help that they live hours from their family (and even their friends). But, in an era of electronic connectivity, don’t forget that your loved ones need you. Try a voice or video call. Call or visit even if your loved one says they’re fine. Your support might be the reason your loved one remembers their name the entire time they’re in the hospital. And that, though seemingly small, might make a world of difference in their recovery.

Is It Luck? Is It Privilege? Or Is It Something Else?

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She was in my thoughts more than I expected for how little time we’d spent together. She and I crossed paths while I was volunteering for a local organization. We were born the same year. Yet, she was born in Afghanistan and I in the US. She can’t read any language, as she reminded me, women are not allowed to attend school in her country. As a US physician, I’m among the most educated in the world. She has multiple children. I have none. We do not speak any common languages. Despite the differences, I noticed a few commonalities between us beyond our birth year. We are both married. We are both women. We both drink tea.

Soon after meeting her, I read updates in The Economist about the Taliban. Summarized, the Taliban issued more limitations on women in Afghanistan. It is so difficult to be a woman in Afghanistan that the EU has made being a woman from Afghanistan a criterion for asylum – no other qualifications necessary. 

Yet the horrors that I’ve heard about Afghanistan and the complex interconnected history of the US and Afghanistan are not how I want to know this Afghan woman. Life has taught me that the stories the media tell are not the stories of individuals. The negative thoughts and the sadness I have about how different my life is from this Afghan woman I know originate in my biases and my ignorance of her.

I do not know enough to guess what she thinks or feels about her history and her future. I do not know her story while living in Afghanistan. I do not know her story of coming to the US. I do not know what she thinks of her life in the US.

We were born the same year. Was it luck, privilege, or something else that I was born in the US and she in Afghanistan? How can one compare two lives so different? What does she think about when she has a quiet moment? What does she dream of? What does she enjoy? What makes her happy?

I interact with many people who have different backgrounds and cultures. But this woman and I seem even more different than most people I encounter. The Peace Corps taught me that difference is not better or worse just different. It also taught me that what I believed to be laws of humanity were theories – theories with counter theories, and most importantly, not proven to be true or correct. I know this Afghan woman and I have more in common than I can see now while also acknowledging that our views of the world are likely as different as views can be.

As I write this post, I wonder if I will ever have the chance to learn more about her. I hope so. I have grown most profoundly when given the opportunity to learn about new cultures and about new people. It is the diversity of humans that makes us so remarkable. And while I imagine her story is one marred with sadness, I know she has things she is proud of, moments of joy worth remembering, and stories of success. I hope that someday she can choose which stories and things I know about her, rather than my limited knowledge of her culture fabricating a story of her. Reality, I’ve found, is always sadder and more beautiful than imagined worlds.

I’m grateful that being born in the US allowed me to become a doctor and choose my own path. I hope that the US is as generous to her, whatever her hopes and dreams upon coming here are. The future is one we are each molding in our own way. Be it luck, privilege, or something else clearing the path.

Meeting in a Common Place

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Over dinner with a non-medical friend they said, “Even though I will inevitably have a heart attack [in relation to their love of ice cream], I’d rather enjoy a short life than live a long miserable life.” They brought this up even though I hadn’t made any comments about health during our meal. I’ve noticed that since becoming a physician family and friends make comments like this about their lifestyle with a frequency that surprises me. It seems that they feel guilty or defensive because they think I might be judging or evaluating the healthfulness of the life they lead. 

Perhaps more important than highlighting that I don’t judge my friends’ lifestyles just because I’m a physician is pointing out that in my role as a physician, I also do not judge my patients’ lifestyles. Society likes to use guilt to control people and create hierarchies of worse and better. Many health and physical attributes have been used to define people as better and worse. The list of such attributes is long; several common examples are weight, cholesterol level, blood sugar level, and brain functioning. Despite this societal tendency, guilt and creating arbitrary lists of good and bad don’t help achieve health, so they are not part of my practice as a physician.  

My job, especially as a primary care physician, is not to make my patients feel guilty or inferior. My job is to help my patients increase their chance of living a long, healthy life. Health is defined, in my mind, as a physical and mental state where a person can do the things they want to do with as little suffering as possible. My goal is to help my patients avoid suffering, illness, and pain from medical conditions and physical injury. Especially in the primary care setting, I provide my patients with recommendations to optimize their health. But my recommendations are recommendations – they are not law, and they are nonbinding.

Science continues to investigate what the optimal lifestyle is to ensure that one avoids illness and lives a long time. Yet, while we know many things, we don’t know what the perfect lifestyle is. Further, research can not account for the complexity of human experience. It is absurd to think that all people can live the same lifestyle. Individuals have different access to resources, different preferences, different priorities, and different realities. There is simply no universal fit for lifestyle.

When I discuss lifestyle with my patients my goal is not to make them start a different life. My goal is to identify reasonable adjustments that have a high chance of improving their health. For example, I might ask a patient about their typical diet. As I learn about their diet, I might offer education tailored to specific goals – such as reducing salt to help control blood pressure, strategies to ensure a stable weight or weight loss, or adjustments to prevent diabetes. I try to identify realistic adjustments because unrealistic suggestions are not likely to happen (by definition). For example, some of my patients only eat out. In those cases, rather than telling them they need to start cooking, I ask about the menus at the restaurants where they frequently eat and offer suggestions to optimize their health based on the menu choices they have. I might ask patients about exercise, tobacco, alcohol, drugs, sleep, stress, and any number of other things. The process remains the same for each: 1) Where is the patient now? 2) Is there some optimization that can be done? 3) What are the small steps and adjustments that can help my patient reach that optimization?

As a physician I meet my patients where they are in terms of their health goals and health situation. I see our relationship as a partnership where I’m an expert and they are advice seekers. Just as people hire financial advisors as experts and planners for their personal finance, physicians are experts and planners for lifelong health. As a physician I relay what research has shown is important for health; help my patients make decisions about specific medications, procedures, and tests; and form a plan for how my patients might optimize their health.

To my friend who thinks everyone who eats ice cream will have a heart attack – that simply isn’t the case. To my friend who thinks a heart attack is trivial – I’ve met hundreds of people who have had heart attacks and even those who survived were changed forever. So, in a general sense my response is, why not consider a middle ground where one can have ice cream and not have a heart attack? Curious how to do that? Consult your primary care doctor; she’s an expert in health and you hired her to help you reach your health goals.

Reading the Crystal Ball I Don’t Have

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“Will I make it until then?” the patient asked. They were referring to the cancer treatment which was their only chance at long-term survival. Their cancer was everywhere yet, likely, treatable and maybe curable…but only if they got treatment. Their social situation created roadblocks. To be approved for chemotherapy in our medical system they had many hoops yet to jump through and hills to climb.

“I don’t know. I hope so,” I said. My answer was genuine.

The patient signed. They closed their eyes for a long blink. They looked down. They slumped in their chair. Their stuffiness (from lymph nodes so large it was hard for them to breathe) made their breathing loud. The room felt small.

“You’re strong. You’re a fighter. You told me recently you wanted to do everything you could to beat this. We are trying to get you there,” I said. These were truths but they didn’t mean much.

This post could easily be about the inequities of our healthcare system. This patient was a victim of those inequities. But whether everything is going right or going wrong, the truth remains that neither I nor any physician know the future. We have probabilities and expert opinions to guide us. We have previous similar patient cases and the risks/benefits of medications and other treatments to consider.  But as much information as we have, we do not have a crystal ball that tells us exactly what is to come. We make educated guesses which are often right but also have a higher-than-desired chance of being wrong.

What is to come, the outcome, is exactly what my patients want to know. And, if I were in my patients’ shoes, that is what I’d like to know too. When thinking about my patients’ futures, I try to balance hope with reality which (for me) manifests as honesty. If I’m worried, I say so. If I’m confident in their chance, I say so. And, if I’m unsure then I will explain the contrary things I’m considering and why I’m undecided.

I didn’t know if the above patient would make it to chemotherapy. The oncologists (cancer doctors) were not offering this patient treatment when the patient and I had the above conversation. The oncologists felt that the patient had too many other things going on to start chemotherapy. Chemotherapy is hard to endure. One must be physically strong to survive it. One also requires lots of social support.

“We are trying to get you treatment. Remember the next steps we talked about?” I reviewed the follow up appointments and things lined up for the patient before they saw the oncologists.

The patient nodded. They looked out the window. “I’ve been here [the hospital] so long,” they said. They’d been in the hospital for about 6 weeks.

“I know,” I said. “You still have a long road ahead.”

I wish there was a crystal ball like in fantasy books that would reveal my patient’s futures. But part of life is not knowing exactly where it’s going. Part of being a physician is becoming comfortable with uncertainty. Perhaps that’s one reason why physicians study for so many years. Day by day my predictions about my patients’ futures are more informed and more often correct. But, on the opposite end of the spectrum, even the most seasoned physician is sometimes wrong about a patient’s future.

When the patient and I had the above conversation, their survival was unlikely but possible. The sliver of hope that remained is why I reminded the patient that they had told me they wanted to fight their cancer. That is also why, when the prediction is tragic and my patients say they believe in miracles, I say “I hope you’re right.” No physician wants their sad-outcome predictions to come true. Yet, we are obligated to provide our best guess even if it is bad news. As physicians we also plan for all the likely outcomes.

While I reminded the patient of their desire to fight, I also reminded them that if things changed there was an alternative option called “comfort care*.” I reminded them that they could change their mind about their goals at any time. I reminded them that we (their care team) were here to help them on their journey regardless of where it led them.

The only certainty about my patients’ futures is that their care team will be there no matter what. And while patients’ care teams change with work shifts and specialty, the purpose remains the same: to help as the unknown unfolds. Being a physician hasn’t given me a crystal ball to see the future. But being a physician has given me hope. While there are illnesses no human body can overcome, the body is incredibly resilient. Further, the human soul is a force of bravery and grace even when faced with insurmountable challenge. And when I witness these human strengths, my faith in life is renewed.  

*Comfort care is end of life care where the focus is treating symptoms rather than prolonging life. For example, if a patient has anxiety, then we will treat it; or if they have pain, we will treat it. Comfort care is offered to patients who have conditions that will kill them and either there is no treatment or the patient declines treatment. In comfort care we don’t treat chronic conditions such as high blood pressure or diabetes because the focus is to make the patient’s remaining time as comfortable as possible rather than trying to make them live as long as possible. Comfort care is the type of care that people receive in hospice. Hospice is end-of-life care for people whose life expectancy is 6 months or less. Comfort care is not about hastening death, but it is possible that people will die sooner on comfort care than with traditional care because the goal is no longer to cure illness.

Stand Up for Yourself Sister

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“Stand up for yourself sister…because if you don’t stand up, no one will.” This was the theme of my thoughts as I walked home recently. I’d learned this lesson over a series of experiences, most significantly the Peace Corps and the 20ish jobs I had before medical school. It’s a skill improved with the help of pivotal women throughout my younger years who showed me how to advocate for myself (not just others). And it’s a skill I’m always improving.

Medical school forced me to practice standing up for myself over, and over, and over again. Medicine isn’t designed to be kind to its trainees. The journey to doctorhood is fraught with unpleasantries. A self-aware and self-confident person can minimize these annoyances if she chooses to face them and address them as they arise.

“Stand up for yourself sister” had popped into my mind after chatting with a younger co-resident who described several instances where she was asked to do work that wasn’t her responsibility by senior trainees and didn’t feel comfortable saying “no.” These instances were like the time in medical school when I found one of my classmates in the hospital hours after her work was done because a resident asked her to do a non-medical errand (meaning it was a personal favor and had nothing to do with the student’s learning). The student had also not felt comfortable saying “no.”

In both of the above cases, if the junior trainee has said “no” to their superiors they would have been in the right and may have prevented their time from being wasted. Further, both cases were examples of misconduct by the senior trainees as defined by the governing bodies that oversee medical trainees. Because of the hierarchy of medicine there are clear guidelines of conduct designed to protect junior trainees from abuse by senior trainees and physicians. The above cases were not reported to governing bodies.

Weird and questionable situations arise all the time. What I’ve learned is that being confident to say “no” is important. It is possible that there will be ramifications when one says “no,” but if one is in the right it is often worth the risk. Further, reporting unreasonable requests to the governing powers in our institutions is another form of self-advocacy that has the added benefit of helping to prevent others from being put in similar situations in the future. I don’t think it was coincidence that the two above examples happened to female trainees.

America calls itself “land of the free and home of the brave.” I find this tagline misleading. One reason is the different way many fractions of America raise their women and men. Even in a place that screams equality as its core value, many American sub-cultures (including my own) teach their boys to be confident, embrace conflict, ask for things, and demand better. At the same time, these sub-cultures (including my own) teach their girls to be cute, create harmony, strive for pleasantness, advocate for others (especially the weak), and be tactful. The lessons we teach girls are fine except they don’t cultivate the skills girls need to stand up for themselves the way the lessons we teach boys do.

American women from these subcultures are then at a disadvantage in many situations including when they negotiate employment contracts, ask for promotions, and define boundaries in relationships. Of course, many girls and women learn to negotiate and advocate for themselves anyway. But, what I’ve noticed, is that these skills aren’t default from culture in America like they are for men. Many of the women I know who stand up for themselves are self-learned after facing challenges or inequitable treatment next to men. A lucky subset of women are great self-advocates because other women took the time to teach them (despite American culture) in the hope of sparing them some frustration.

There are women who never find a way to feel comfortable standing up for themselves. I feel for these women because I know what it is like to be averse to conflict and scared to speak up. I know what it’s like because that is the default American subculture from which I come. But, like I told my co-resident, we can learn new skills and grow our personalities if we choose to do so.

I’m thankful I invested in cultivating my ability to self-advocate. American women are often amazing advocates for others (such as their children, their parents, their patients, their friends, and many other groups) while being uncomfortable advocating for their own needs. But, advocating for oneself is just as important as advocating for others. There is no reason to believe self-advocacy is a fixed ability or a trait only man can have. Even as I write this, I’m still not as good at self-advocacy as my husband is. Thankfully, I have many years left to practice… You better believe I’m striving for self-advocacy excellence.