“Today is your real orientation and I promise, we try to be efficient.”
I nodded my head in appreciation as the hospitalist administrative coordinator picked up a folder with Dr. M neatly scrawled on the right hand corner.
“First things first, here’s the important checklist stuff. This is the envelope for the “fun fund” – we all pitch in for birthdays, anniversaries, baby showers and whatnot. Because God knows we need things to look forward to!
Here are all the login codes and how to look at your schedule. And finally, here are the things I need your signature for.
Let’s start with this one – this tells the state that you’re a medical certifier for when you pronounce someone dead.”
As she passed over the paper nonchalantly, flashbacks to my first day of residency caused a fluttering in my chest. Hopefully my first day as a hospitalist wouldn’t be as eventful…
You never forget your first
My first day of residency was actually a night. Since I had been a med student at the same institution, the scheduling powers that be thought it fitting to start my intern year on a string of 7 nights. Although I was still essentially useless, at least I’d be less likely to get lost in the stairwells.
Despite this leg up on my other co-interns, the transition from med student to intern felt much different than I had anticipated.
The power to put in orders = terrifying.
The expectation that I was supposed to actually know something = spine-chilling.
The ease of going to the bathroom in your short white med student coat vs a real, long doctor coat??
Now that was something no one tells you about.
As I stood in the tiny bathroom stall trying to figure out how to shimmy out of my brand spanking new, blinding white coat while not hitting the toilet or C diff covered floor with the lower hem, I realized another dilemma – there was no hook to hang this on! How was I going to hold the coat up plus keep the scrub pants off the ground while fighting the 2 pagers and phone from dragging the belt line down?
This is all part of your training, M. Today is day one of developing a bladder of steel. You’re just not allowed to pee anymore.
As I walked away from the restroom contemplating my first decision of residency to abandon the very basics of self-care, my pager went off.
“Rm 524 dead, pls come to pronounce. Family here.”
Quickly scanning my patient list, I breathed a sigh of relief – this one was expected to pass. I hadn’t killed anyone… yet. Calling my resident, I updated her of the news.
“Ok.. did you pronounce him yet?”
“No.”
“Well, make sure you get all the paperwork and fill it out. Don’t worry about the death summary – the day team will take care of it tomorrow.”
“Ok… good to know. But, um, here’s the thing… I’ve never actually pronounced someone before…”
A momentary pause, followed by an unmistakable sigh of exasperation.
“Well, you know what dead is, right? The heart stops beating, the patient doesn’t breathe and there’s no response to pain. It’s impossible to miss, and you literally can’t mess this up. He’s dead, remember?
As heat flooded from my neck into my cheeks, I mumbled a word of understanding and hung up.
Note to self: find smarter sounding ways of asking dumb questions. Also, what is this? An actual blush? Another first, M.
Walking to the room, I envisioned my plan of action:
- Listen for the heartbeat while looking for any signs of breathing
- Check for a pulse
- Painful stimuli: sternal rub or push down on the nail bed forcefully
- … was I supposed to check for pupil constriction to light? Would that freak out the family at the bedside to see someone peel back their loved one’s eyelids to reveal a vacant stare where there was once life? Would that freak me out?
Getting closer, I could hear the tell-tale signs of crying bouncing down the hallway corridor. “Family here” didn’t even begin to describe the hordes of people that were spilling out of the room. I counted 10 just outside the doorway, and as I stepped through the threshold, at least 20 tearful pairs of eyes turned to see who this stranger was, interrupting their attempts to comfort each other.
“Hello, I’m Dr. M.”
A petite woman who clearly carried the authority in the room parted the sea of people to stand in front of me.
“I’m Y’s daughter, and it’s very important for us to know the exact time my father died. I know you’re about to declare time of death, but we need to know the actual time he died for our religion.”
“Ok… I will have to look into that for you.”
Was that the right thing to say? When in med school did they give us the tools to learn how to deal with this?
Making my way to the bedside, I tried to go through my process I had rehearsed in my mind:
- Listen for heartbeat while looking for breath sounds →
- How long do you listen for?? No one prepares you for what it’s like to listen while 20 family members are wailing in your ear. Nobody prepares you to do this while everyone’s eyes in the room are trained on you. Just slowly count to 10…
- Check for a pulse →
- No one adequately describes the cognitive dissonance that happens when you touch a warm, pulseless dead body that once housed life for 80+ years. He was there, and now he wasn’t.
- Push down on the nailbed →
- I watched as the pink blanched out from my thumb as I pushed down as hard as I could on his. But when I let go, the pink returned while his did not. I didn’t remember that being taught to me in med school…
Time of death
8:34 pm. Less than 2 hours into my first day of residency.
As I scuttled out of the hospital room, I enlisted the nurse’s help to determine the actual time of death per the patient’s daughter’s request. This was important for her family for whatever reason, and if this was the last thing that was going to give her closure, that’s what I was going to do.
10 minutes later, my resident found me hunched over a telemetry strip with the nurse as we looked at the last heartbeat before the EKG flat-lined.
“What are you doing?”
“We’re looking at the time of death since the patient’s family requested to know the exact time.”
Puzzled, my resident looked over at the nurse.
“It’s something to do with their religion – that’s what they told me,” the nurse said.
Shaking her head, my assigned mentor said to me,
“Pretty soon you’ll learn to wait until the family’s gone or else you’ll end up spending way too much time in there. You can’t help him anymore, M. And there are plenty of other people who need our attention. Like the new admission I have for you.
Let’s go.”
I want to help people
As I see med students’ anticipation rising for Match Day this Friday, I wonder if they wrote the same thing I did on my personal statement, if they said the same things in their interviews → I want to go into medicine because I want to help people.
8 years into this career, I wonder when help turned into a diagnosis/treatment algorithm:
- Hypertension → lisinopril
- Hyperlipidemia → statin
- Heart failure exacerbation → lasix
Isn’t spending the extra 10 minutes to help 30 people achieve closure after the death of a loved one also helping people?
Or is it not truly helping people if we can’t toss them a pill or do a procedure to make it all better?
Did we really help someone if the encounter is non-billable?
Now looking back, I realize day one of residency started the erasure of tending to another person’s humanity.
Welcome back
I’ve spent the last 3.5 years trying to regain my footing – to be the compassionate doctor I had initially envisioned myself to be. To remember that we help people, not problem lists. To listen and be present because often times healing only starts when people feel seen and heard.
As I scribbled my illegible signature to enlist as a medical certifier, I wondered how long it would take for me to harden again.
Because as shocked as I had been at the callousness of my resident on that first night, within a year I found myself saying the same things.
I waited for family members to leave first because, well, efficiency. I didn’t intentionally carve out the time for my interns and med students to take the time to debrief after a bad outcome. If any wayward tears made their way out, I’d tell them to take 5 minutes, collect themselves and come back because there were other people who needed our help. And if those people died, we’d just move on to the next person.
How long will it take before I find myself peering around the corners of a hallway, waiting for crying family members to leave so I can just get on with my day?
What do we become when we forget helping people necessitates us seeing their humanity and sitting with them in their pain?
What happens when we’ve become so uncomfortable with others’ humanity that we forget to tend to our own?
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This video has been making the rounds on the internet and for good reason. It speaks to what I talk about in today’s post → It’s Not Burnout, It’s Moral Injury. Take a look!
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Photo taken of layering hills at Dog Mountain, WA.
As always, great writing and story-telling. It’s definitely a problem when we become more focused on efficiently treating a problem list as opposed to humanely helping people. I’m glad you rediscovered humanity. Thank you for sharing this story 😀.
Thank you for reading 🙂 I think that’s part of what I disliked about my IM training – us internists are all about our 25+ deep problem lists, otherwise we don’t feel like we’re doing our job!
I’ve never had to do this. In residency there was always someone else more senior and now I don’t spend time in the PICU.
This hardening is somewhat necessary otherwise we will fall apart and can’t do the job that needs doing. But how do we do both the job at hand and keep us connected to the people we are helping?
We have completely unqualified people (our senior residents) doing the brunt of teaching the interns how to manage the stress and anxiety of being doctors. Those seniors are already exhausted and most probably learned terrible habits and methods for dealing with the stress from their seniors. And the cycle continues.
Absolutely.. we need to address the failings in our training system. You’re right – it is necessary to steel ourselves to be able to do what we do, but what is lacking is allowing ourselves the space and time to let the armour down and digest what’s happening to ourselves emotionally.
If we don’t start modeling and teaching this to our new doctors and med students, the cycle will only continue.
I still remember my first patient death, a ninety-something man on hospice. I recall being bear hugged by his stricken sixty-something son, who despite the fully expected course of events, had no words for the loss of a lifetime.
We got absolutely killed yesterday in the ED. I ate lunch at 10 PM while finishing charts. Intubated a catastrophic bleed. Transfused an active bleeder. Both anticoagulated. Could barely keep up with help.
Got home to find the entire household asleep. Irony being, every time my eyes shut I’m back in the thick of a horrible day in the department, so instead of sleeping I’m trying to read away the residual restlessness. Thanks, I needed this.
Moral injury is the perfect term, and Zubin (a med school classmate!) a very talented spokesman.
With gratitude,
CD
That sounds horrific. Being back in the hospital, it’s been a little frightening to see how I’ve been able to get back into the swing of things with such ease, to be able to shift from encouraging family members to change code status on their dying mom and then immediately running off to put out the next fire.
It’s much easier for us keep things in check while we’re at work and as long as we’re moving – it’s the quiet moments that get you. It’s when you realize you can’t just leave the white coat at the door, when you can still feel the blood on your hands despite washing them a thousand times.
I’m glad this post was able to serve as a distraction for you and I’m so sorry you had a bad day. Take care of yourself.
M
What a way to kick off a career in medicine. Yeah, medicine seems to make you dehumanize things for the sake of efficiency and not getting caught up in emotions. Definitely not the rosy picture of what a doctor was when you were in grade school thinking of this career.
Absolutely. This is the stuff they don’t tell you about. On one hand, it’s necessary for what we do – we can’t be caught up in the emotions all the time and we have to dissociate to do our jobs. But I do regret the lack of mentorship and conversations I could have had to help me figure out how to do this well without losing my soul.
I absolutely love the imagery in this post – the bathroom scene? Priceless. Should resonate with anyone who has ever worn the long white coat.
As a resident running my inpatient team, I was ruthlessly efficient. My mantra to my interns and med students was, “It’s all about me, guys. Make my life easier so I can make your lives easier and we can all get out of here while there’s still some sunlight.”
But then I remember an interaction I had with my team after visiting with a lovable elderly woman who was likely to die of her disease. We’d been following her for about a week or so, and she was determined to get better and go home. I sat down with her and had a heart-to-heart, explaining that I didn’t think we could turn her situation around, and it was time to start thinking about hospice-type options.
She was relentlessly optimistic about her chances, so we did a lot of joking around with each other, while I tried to inject some reality here and there. It was this delicate dance of broaching reality while not crushing her spirit.
I didn’t think that much of the whole interaction until we walked out of the room, and my med student looked at me with awe and said, “That was AMAZING.” The team was blown away that I could have a conversation about this woman’s impending death, while simultaneously laughing with her.
The point being – I’m awesome. No, seriously. The point being: you will say and do things in the course of your ruthlessly efficient day that have a tremendously positive impact on the people with whom you interact. And you might not even realize when you’re doing it. So just remember that when you’re feeling dehumanized.
Of course you’d be able to weave in a story of how awesome you are with some words of encouragement 🙂
I suppose you’re right… the small gestures that we make over the course of the day often go unnoticed by us.
Maybe we all just need someone following us at all times to tell us how awesome we are, although there is a risk of someone trying to buy our love and affection with empty compliments 😉
M,
Good post. Hope the new gig goes well. I am not sure there is much hope for the system to be humanized. It is the natural result of a reductionist approach to the care of a human being. The fee-for-service model breaks into billable chunks. Apparently, in French medical training the first things medical students learn are presentations and constellations of symptoms, not the microbiology and physiology of the human body.
I think that is telling. It takes a whole person to tell you what they are feeling. As long as we think of human beings as the constituents parts of a biological model, we will think that once the heart stops, our job is done. In that model, we miss that human beings are social animals, and our social structures write tomes in our biology. As long as the system ignores it, it is doomed to dehumanization and inefficiency.
I think the only salve for a humanist minded doctor is time away from the system. Otherwise, we are constantly fighting to maintain our humanity against a system that doesn’t even have to try to take it away. We (and in turn, all our mentors and teachers) are bound to lose.
I can’t believe I’m saying this because I am NOT an optimist, but I still hold some hope that healthcare will change for the better. Maybe change is not the word for it.. I think alternatives will start popping up like DPC that will subvert the system.
The problem with that though is people need to be willing to risk doing something new like that, and I’m not there… yet. But who knows? In 2 years at the end of my contract, the world may look entirely different.