Tuesday, 24 July 2012

If you do nothing else today, please share this message...

This letter made us cry. We feel there is no choice but to respond.

HEARTS in HEALTHCARE is an online community and a social movement to re-humanize healthcare and to strengthen compassion and caring.

Jane (not her real name) wrote to say why she wanted to join the community:

My name is Jane. I’m a healthcare worker in Mental Health. I work in a culture of cynicism, stigma and discrimination. People are overlooked and all that seems to be seen is their diagnosis or illness. I’m deeply saddened by what I hear from work colleagues for I feel like I’m on my own. I feel very lonely and feel like I’m in a desert, in other words a harsh environment. 

I value my clients, I love getting to know them and finding out what’s important to them. I love doing life with them, supporting where I can, and I value the quality of relationships I have with my clients. 

The other side is the contrast within my team, I see people making decisions with their  heads and distancing themselves from the clients. I have a vision that it could be so very different. I don’t know how to speak up, I’ve been quiet for too long and don’t know how to survive it, realizing I’m a sensitive person and seem to take on the disrespect and lack of value that I hear being spoken.

I go home and cry for what I’ve heard. I go home and think about what’s happened during my day and realize my team has barriers up and they cant connect with the clients because they are judging them instead of getting to know them and seeing the bigger picture. I then realize I’m putting barriers up with my team and don’t know who to trust. I feel I cant share with anyone because I hear how clients are spoken about with so little regard and realize my colleagues could just as easily speak of me in this detached manner.

I would like to connect with passionate people that are working with integrity and would be able to assist me have difficult conversations with my colleagues. Honest conversations that need to be spoken about. I’ve been thinking that I’m not trying to be popular, but wanting above anything to speak out about the harsh reality of their cruel words that confront me each day and how these spoken words are affecting the quality of care that they are being given. To speak the truth in love and still care about my colleagues and bring effective change to a dark place.”

If you have any family members or friends who require help from mental health services, you will share our concerns about this message. We have heard many others like it.

Please show your support for this courageous healthcare worker by commenting on this post or sharing it with others.

To learn more about HEARTS in HEALTHCARE see our short film.

In anticipation of our launch of the community, we are gathering the names of supporters here.

Friday, 8 June 2012

Hero doctors

In our weekly anesthesiology morbidity-and-mortality meetings, we swapped tales of derring-do. How, in the face of overwhelming illness or major injury, we somehow saved lives. We conspired to reassure ourselves that poor outcomes were not our fault.
While the details of technical care were turned over and dissected, the subject of our emotions, feelings, fears and vulnerabilities were off the table altogether. These are taboo subjects in the hospital medical culture.
I worked at my last hospital for eleven years. In that time, only once did I hear a senior doctor speak of personal vulnerability, openly, in front of others. He was an obstetrician and gynecologist who confessed to me in the operating room, in front of the nurses, that he hadn’t felt like coming to work that day.
The day before, a cesarean section had gone horribly wrong and the patient nearly bled to death. The surgical team fought for six hours to save her life, replacing her complete blood volume over and over. Eventually she stabilized enough to get her to the intensive care unit. This surgeon told me he was so traumatized by the events, he had just wanted to stay at home today, not operate on a list of gynecology cases.
In the last decade, that is the only time I have heard such a public confession of vulnerability from a senior hospital doctor.
Yet our failings and mistakes injure and kill patients every day. The accepted figure for the proportion of hospitalized patients, who are accidentally harmed in the course of healthcare, varies between 10% and 40% of all patients. Medical error is a leading cause of death.
This internal tension between our heroic, fearless ideal of doctoring, and the reality of so many patients that we cannot save, or we accidentally harm, is a source of tremendous emotional vulnerability.
But when we learn to bring open-hearted compassion to the care of our patients, we learn there is so much we can give beyond technical expertise and heroic doctoring.
It gives meaning and purpose to our work, even when our technical medicine toolkit is empty. With that deeper connection, we also begin to be kinder and more compassionate to ourselves. No need to be a hero.

Wednesday, 6 June 2012

Making time to care

‘Great interview, darling, but there’s one question you didn’t quite answer.’ My wife is my best coach. She thought the question about a busy orthopedic surgeon not having time to relate to his patients deserved a better response.

My interviewer, a psychiatrist, said he once accompanied a surgeon friend on his Saturday morning round of post-op cases. On the drive home, he challenged his friend with the observation that many of the patients were anxious and frightened. ‘You just ignored their concerns in the hurry to get the round finished,’ he said.

‘Yes,’ admitted the surgeon, ‘I know I’m not meeting all their needs but if I stopped to talk to them all, I wouldn’t have any time left for my family. What do you expect me to do?’

The interview was about compassionate caring. My first response to this question was the scientific evidence relating anxiety and stress to surgical outcomes. A skin incision takes twice as long to heal in stressed subjects. Moreover, stressed and fearful subjects are three times as likely to succumb to infection.

‘So it’s likely your surgeon colleague is creating extra work for himself when he ignores the emotional wellbeing of his patients,’ I said.

I then talked about the importance of investing a little time up front with each patient, to build trust and rapport. The doctors who are skilled at making this human connection save a lot of time. Plus it’s a more satisfying way to practice.

In my interview, I forgot about the research using video-taped interviews of doctor-patient consultations. Patients give us lots of cues about unanswered concerns. The doctors skilled at noticing and responding to patient cues had on average shorter consultations than those who brushed them aside. Responding effectively to patient concerns saves time.

By this time, I started to get off-topic in the interview. I didn’t get back to the reality of this orthopedic surgeon’s practice. Here are two better answers:

Dr Stephen Beeson, a family doctor in California, is one of the happiest doctors I know. His patients love him too – his patient satisfaction ratings are in the top 1% for the USA.

Beeson has an unusual practice: he gives his personal mobile phone number to every one of his patients. ‘Feel free to call me,’ he says.

Insane! Doesn’t he have a family life? When I tell my colleagues to give their personal phone number to patients, they think I am mad. Patients would never let them alone.

Actually, Beeson’s phone hardly ever rings. And when it does, it’s usually something really important. For his patients, just knowing he’s there, and that he cares, is enough.

Beeson is an outstanding physician leader. Many of the clues to his happiness are found in his book, “Practicing Excellence A Physician's Manual to Exceptional Healthcare”.

The secrets to happy and fulfilling medical practice are often paradoxical.

The more barriers built between doctor and the patient, the more they will demand of you. It’s as if you’re not really connecting, so patients remain unsatisfied.

My experience is that when you take down your barriers and defenses, patients made fewer demands on you, not more. And they’ll do a better job of helping themselves.

One final observation: Most orthopedic surgeons have massive incomes, compared to the national average. What would happen if my interviewer’s friend reduced his caseload and his income?

He could take every Friday off and not have to do a Saturday round. He’d spend more time with his family and would probably be a better, and happier doctor. He might even have time to talk to his patients.

Sunday, 27 May 2012

The patient and gentle invitation

Two years ago I was fortunate to spend five days at the Quest for Life Foundation and see the wonderful Petrea King at work. I joined a residential program with twenty others who were seeking peace, happiness and the healing of old wounds.
Many participants told horrifying stories of tragic loss, serious illness, violent abuse or other burdens that shaped their lives. I spoke of the trauma and brutalization I had experienced in my medical practice. What I learned from King was gentleness and non-judgment in the approach to peoples’ vulnerabilities.
My medical habits and expectations did not sit easily within a program that seemed so passive and so full of inactivity. The daily lunch break yawned from 1 until 3.30pm. At my hospital I usually grab a quick sandwich while working at my desk!
Each day began with an hour of relaxation and meditation. Our meals were prepared with seasonal organic food. Counseling and massage therapy were on tap. Slowly, day-by-day, the peace of the place dripped into you.
Petrea made no attempt to overcome resistance. In her infinitely gentle, compassionate and wise way, she simply bore witness to suffering. She invited participants to let go of past events and to stop fretting about the future. She called us all to “come to our senses” – literally to connect to the present moment through mindfulness and noticing our rich sensory experience.
As the days passed, I began despair that some of the participants would ever climb out of their anger, depression, anxiety, or self-loathing. One lady had spent four days curled up on the floor in a fetal position, hugging cushions. I wanted to push or challenge her.
But on the last morning of the program, she suddenly opened up like a flower. The transformation was complete – a new light in the eyes, a different posture and body language, and a remarkable change in her voice and her words. In that moment, I learned something profound about gentleness and non-resistance.

Alone with my shame

Every doctor has a case like this, where the guilt and shame burn on.
I was a new senior resident in anesthesia, rostered solo to anesthetize a patient for major vascular surgery. I’d worked in the hospital only a week and I didn’t know the surgeon or the operating room staff. I didn’t know where to find essential equipment and I was unfamiliar with local procedures and protocols. To make matters worse, all cases started late that day because the anesthesia department had a meeting.
My high-risk patient needed an arterial line, a central line and an epidural as part of the anesthetic management. I struggled with every procedure, wasting time. The waiting surgeon grew impatient, then angry, and stopped talking to me.
Both the surgery and the anesthetic went badly. The patient proved to have a sicker heart than pre-op tests predicted. I couldn’t control the blood pressure. The essential communication and coordination between surgeon and anesthesiologist was lost. The patient bled profusely. I struggled alone and didn’t call for help. Where I had trained in the UK, asking for help was not part of the culture.
In the middle of the day, one of the senior anesthesiologists stepped into my operating room. He said, ‘I noticed there was a new resident doing a major case alone so I thought I’d see if you needed help.’
He quickly realized I was in serious difficulty. He sent me out for a break and by the time I returned, he had greatly improved my patient’s condition. I was deeply grateful for his empathic support and practical help. While I was glad for my patient, I felt ashamed of my failings.
My patient went to intensive care and his condition gradually worsened. Every time I was on-call, this patient appeared on the list of acute cases for the operating room. I felt like he was haunting me. I took him two more times to the operating room for treatment of complications but his condition deteriorated. He died after a month in intensive care.
I’m sure it’s the worst anesthetic I have given. This patient’s death hangs on my conscience. I thought I was competent to do the case but have since come to understand that I was set up to fail on that day. No doctor could have performed well in those circumstances.
Experiences like this are traumatizing for the doctor, creating fear and vulnerability. Both my patient and I were abandoned by an unsafe system – save for my kindly rescuer. The patient’s relatives live with their loss, I with my shame.