Treating Patients, Not Textbook Illnesses

I think it's often too easy for a medical student to have idealistic notions, saying that he would be able to be different from the others. I think it takes a continuous effort for someone to stay aware of his own growth - to not bend in to the system and conform, but to realize what it means to one's own personal growth. It takes self-evaluation, self-reflection and mental strength.

From some articles and blogs I've read, some complain about how medical school forces them to become sociopathic - it forces people to value grades over compassion, emotional detachment over empathetic pain. It's not hard to see why.

I believe that the real reason why some doctors stay compassionate while most of the others don't, is simply because they don't see the value in compassion. Some doctors even have to be constantly reminded that they are treating patients and not diseases.

Some doctors learn how to be charmingly deceptive - in their medical rotations, they learn how to be chameleons, saying things to please their superiors. To be fair, I don't think this merely exists just in the medical profession, but in nearly every other profession, especially in businesses. Wherever they are people and hierarchies, these behaviors exist.

Some doctors play "hot potato" - tossing patients from doctor to doctor, not really caring about the quality of life of the patient. Even if they did, they followed "textbook" protocols. Gosh. While there might be certain 'instructions' that can help to demonstrate compassion... No! Humans connect heart-to-heart. That's what makes us warm-blooded humans.

Then there are the doctors who learn 'professionalism' - to learn how to cover your legal ass. It's definitely tough - having studied and incurred financial and time costs, then having to be sued by patients and their families because you forgot to mention that one side-effect. This is an article that shows how pharmaceutical reps learn how to manipulate doctors to prescribe more of their drugs and earn more money for their companies. For example:

Most physicians deny their professional integrity can be “bought” by something as trivial as a cup of coffee or a free lunch. In this paper, we review the social science literature arguing that “gifting” physicians in this way is, in fact, a highly successful method of boosting drug sales..... Even small gifts produce in their recipients a disproportionately powerful willingness to reciprocate in some manner.

And I don't blame them. It's basic psychology - Reciprocity is listed as one of the 7 principles of persuasion, as written by Robert Cialdini in his famous book.

The dark reality is that there are a huge number of people in the world (being realistic and not a negative nelly) who being humans, are subject to human psychology. In fact, many people even use these psychological principles when interacting with others, usually unknowingly. As a result, these professions have come up with the holy grail of getting to places: Connections.

I don't see any bad in connections. I only see the bad when people approach others without the genuine sincerity of connecting as a human. I believe every human being has their own inner need to stay connected and socialize - to have someone else understand them better. It's tedious to keep treading on their toes around the world. Connections - well, you make them when you really want to know a person as a human better. Don't make it a tool!

The worst thing is that most people wouldn't want to acknowledge that, nor will they realize how they're developing sociopath tendencies. One thing is because they don't see the value in retaining their humanity - They don't have a strong, resolute goal that they are willing to sacrifice their own life for.

I think however, that doctors must learn how to retain their humanity. All of these happen because they attach their identities to things that do not matter. I personally value my own principles over anything else. I'm a Buddhist, so my aspiration of course, is to conform to the Noble Eightfold Path.

Nothing will shake my resolution: To exercise Right Speech, Right Action and Right Intention. To act from the heart, regardless of anything. Even if it takes me my entire life, I will accomplish what I want to do. Even if it doesn't happen, I feel that my passion will be able to fuel the passion of others. To lead by example is the greatest teaching.

What else is there to fear, except to die? I don't fear death. I only fear a life that hasn't been lived well.

I feel that it is ultimately up to the individual to change things. If an individual is reactive and mutable, they would conform to such an environment. But if an individual comes from a sense of knowing who they are, with firm principles, with deep self-awareness, then I trust that our inner wisdom would allow us to be better doctors simply because we truly want to help humanity.

It's not about whether you're a doctor, a businessman, or any kind of profession. I think the saying is true:

If you really want to know a person's character, then treat him like a tea-bag and put him in hot-water. Then you'll know exactly how strong they are.

When I was in the army, there were tons of people who stuck up to superiors. Granted, there were good superiors but most of the ones I had were nasty. When they were wrong, I stood them up. Well of course, I'm a human being. I'm not the model, robotic soldier who should follow orders and not question things.

I think one of the most powerful ways that a doctor can learn to treat patients as the humans they are - is to practice loving-kindness meditation every single day without fail. To acknowledge that people are as they are - Nasty as they sound, nasty as they act, horrible as they may seem - To learn how to forgive and set down the pain. To not carry the memories and traumatic incidents over.

To live in the moment, afresh, every single second.

Being alive is already a phenomenal miracle.

I swear many problems in the world arise simply because people become unconscious and get carried away either by the environment, their bodies, their emotions, their perceptions, their thoughts, etc.

Isn't it dangerous to have a doctor who is unaware of their own state?

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Foolish Compassion and Physician Burnout

One of the biggest problems I've been trying to solve is the idea of "compassion". To some, people think that compassion encompasses simply doing everything that you can to empathize with a person and then doing all you can to help them. However, we need to take a self-check sometimes and understand that wisdom must go along with compassion for it to be effective.

For example, if one is compassionate towards a drug addict, and gives him drugs to alleviate his withdrawal symptoms, simply because you are empathetic, then this is absolutely foolish. But if someone never had medical knowledge, then they wouldn't understand the implications of their actions. Therefore, one of the most powerful things that any compassionate act must have is wisdom.

To be wise, one must understand what the consequences are, or at least what direction such an action will lead to. To put it in metaphor of parenting, one cannot be too indulgent a parent, nor too authoritarian. Instead, one must be able to balance emotion and logic, so that the compassionate act becomes one that truly helps the person. In the same way, a good doctor must be able to learn how to exercise true compassion.

One of the biggest things I've seen and heard from doctors, is the question of physician burnout. It's not an easy thing. In fact, it's been proven statistically that 33% of all physicians in the world, regardless of location or specialty, experience burnout (That's every ONE out of three!)

For one, the stress comes from the huge responsibility of directing the course of a person's life and health, while managing the emotions that arise from it, and also within physical restraints such as the lack of time, overloading pressure as well as the shortage of staff.

Add to that the hectic call-days, the short recovery periods, and nearly a decade of working through the lower ranks of being an MO and HO - and you get a burnt-out physician, with what we call "compassion fatigue". It's even normal to hear phrases like "working like a dog", "a slave's life", "my biggest regret", etc.

And you can't blame them at all! Because it really is true. The medical life isn't as smooth-sailing as anyone might think. It's only for those who have chosen to dedicate their life towards serving suffering patients.

But I feel that like all problems, there is always a root behind it. While we cannot change the tides and waves of the ocean, a skilled boatman can certainly navigate his way through the storms. What exactly would help a doctor retain his compassion, while working with vibrance & expectation, looking everyday forward to serving the medical field?

We can't change what we can't name.

-- Dr Bliss 

 If we are not aware and cannot see it, then we will miss it. There are many ways to look at how someone moves towards burn-out, and the very first thing is to take a look at its symptoms, as recorded by the Maslach Burnout Inventory (MBI):

1. Physical Exhaustion: Working long-hours end-to-end, or having somatic stress. 
2. Depersonalization & Emotional Venting: This includes a form of distancing away from the patients and situation, erecting an emotional barrier between doctors and patients, also known as compassion fatigue. It happens when doctors start to use sarcasm and non-compassionate terms to describe patients, usually as a group-venting session. They say things like "My patient is a bunch of *&^%*&".
3. Loss of Purpose: Doctors start to question if their work even makes a difference (more prevalent for females statistically).

In other words, we could also summarize them as Physical, Emotional and Driving Needs. But the red-alert is usually Cynicism, Blaming Behavior and Venting, along with a drop in both physical and emotional energy.

I read about this very useful analogy, which is to treat our energy levels as a Bank Account, instead of a Battery, because batteries die when they run flat. However, we are definitely able to function even at 0% - we just continue to accumulate charges. 

We can't give what we don't have - so we need to exercise wisdom to build up our own physical, emotional and driving balances. 

The causes of burnout are as follows:

1. Patient Care: This can range from simple things to very traumatic events, which may need narrative medicine (which I will do on this blog). It can be really crazy and tragic things that you see in your workplace, which can leave a scar on you. Let's face it - Nobody wants a health problem, neither do their families.
2. Career Stresses: Relationship with your colleagues, superiors, etc. Job-related stresses like 
3. Life Outside Medicine: This comprises relationship problems, financial issues, family issues, or things that can happen outside, catching you off-guard. Sometimes things can happen at home which make it difficult to "recharge" at home.
4. Unhealthy Conditioning: We learn these conditioning archetypes in the training of medicine, being conditioned to be like that...
   1. The Patient cannot always come first - When you are not with the patient, doctors must focus on their own lives - Don't be a workaholic.
   2. By trying not to show weaknesses, it forces people to ignore them, making them unaware of pain.

I also feel that doctors should take care of their own kind - not just patients. It's a collaborative effort, and we need to look out for everyone else on the same mission to help others - nurses or medical assistants, etc. By helping everyone out, it generates a helping and supportive culture, which is a far healthier working environment than one where doctors are constantly thinking that burning out is part of the work - it shouldn't be! 

In fact I'm starting to think we actually need doctors for our doctors. Who's going to take care of doctors if they cannot take care of themselves? Doctors think they are superheroes just because they can save others. But I find that a reckless thing - More will suffer if a doctor goes down.

True compassion is taking care of yourself FIRST, then allowing yourself to be a good presence to the patients. In the same way, the Buddha said that one should focus on enlightening oneself, then enlightening others naturally as a consequence. You can't save a poisoned victim if you're already ticking with poison in your blood.

Insanity is doing the same thing over and over and expecting a different result.

-- Albert Einstein

Doctors know that they are being burnt out. But by using short-term strategies like patient venting is not a good way - in fact, it exacerbates the contrast when they move away from venting into serving the patients. The burning out shows.

Some of the strategies to prevent burnout are as follows for doctors:

1. Become aware of your emotions. Lower your stress at work, increase your recharge at home. 
   1. Stress comes as a consequence from the inability to manage the physical, emotional and spiritual. You cannot directly manage stress. Therefore, learn how to be aware of the physical, emotional and spiritual, then apply strategies to relieve them.
   2. All suffering comes from a form of attachment, stress is this friction. One must become aware and be a witness, and understand that all bliss comes from within us.
2. Make yourself and family a priority. Again, it is not about selfishness, but seeing the larger picture. A happier doctor makes for better healthcare. We are humans, not robots. 
3. Ask for help when you need it. It's not weakness, it's recognizing that you are human and the needs of your human body. Conversely, ask your co-workers: "What's going on at home?" and let them know that you are there, even if they resist it.
4. Have an ideal job description. Always know what you want. What are the overlaps between an Ideal Job description and the current Job? What are the things you can work towards? What would I change to increase the overlap?
5. Differentiate Dilemmas from Problems. Problems have solutions, but dilemmas don't necessarily do. You can't find a one-step solution for a dilemma, it is about finding the balance point. A strategy is multi-stepped. Also, a tracking system is required, where there is tweaking so that we can move towards the ideal point.
6. EMR (Electronic Medical Record). Learn how to be a Power-user. Only put something in the chart if they fall within these 3 categories:
   1. Continuity: Can someone else pick up the chart and take over where you left it?
   2. Billing: Did you put enough in the chart to charge to the insurance
   3. Cover your legal part: For malpractice coverage
   4. Make Templates for "repetitive things": Take half an hour to make a template, once a week.
7. Optimum Time Management. Keeping a form of structure will allow you to meet commitments and have more time to yourself.
1. Paper Calendar. Every week, put your workouts, date nights (twice a month) and destress sessions. Ask your family/loved ones to put them in as well. Then scan them into the phone.
2. Say "No" when appropriate. Use the Paper Calendar as a reason. Practice a phrase to say "no". 
8. Compartmentalize Home vs Work. Take off the 'white coat' when you go home. Do boundary rituals: Visualize pulling out the key to "work" while exhaling when you step out of your car. 
9. BID Huddle: You're never too busy to huddle. Grab a schedule, pre-plan the day together with everyone else. Know which patients need pre-planning - troubleshoot them before they break out. How to schedule empty slots? Use the opportunity to build the team and show gratefulness (Check in: How are you doing?). Talk about something outside of work and make it a supportive culture.

[Work in progress...]

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Goals for my journey in medicine

We all start off as wide-eyed medical students with an aspiring wish to make a difference with medicine, but as the years go by, some lose the luster in their eyes, beginning to regret their decision.

This is not an unfounded reason, because a road like this is not an easy one - Doctors are simply put, overworked to the point that they are exhausted and drop completely down to the bottom of Maslow's pyramid of needs - Where sleep itself is threatened.

One of the aims of blogging my journey is to use this blog as a way to revitalize my own dedication to this field, where I set my own life on the line so that I can serve to take away the suffering of everyone else. One of the greatest things that make doctors do the work they do is job satisfaction - to know that what you have done has indeed made a difference.

The second aim of this blog, is to document my journey for many reasons - For one, it serves as a way for me to document my insights as I navigate the medscape, and it would be a refreshing way to look back and see how far I had gone. Also, I wish to let my loved ones know that I am going at my very best for my life's purpose - I want them to inspire them to do the same regardless of what they do - I want to let them know that I am happy doing what I am doing.

The third reason is for me to consolidate my thoughts, as I tend to sort my ideas better while talking about it. I'd love it if you had some comments for me.

This is not going to be some jolly ride - it's going to be a ride straight through chaos, but heck, it's the process that matters. It is the process of heating that allows the molding of metal. Similarly, it is only going to be in heat where one learns the ropes.

As one of my favorite people says - Productive suffering.

So open your eyes real wide and swallow my little blog nuggets. :)

I don't know what the future holds, but I want to learn how to live with enlightenment. I want to learn how to become a better doctor - I want to be a better human being - I want to emerge with wisdom.

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Dr Bliss checking in

I was always thinking of launching a blog series on my medical journey, while reconciling it with my own philosophies, ideals and beliefs. Someone special suggested it again, and I thought, why not? Let's go ahead with it!

So checking in with the first post, 

Peace!

Dr bliss signing out ;)

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