 It’s easy to live with success. However, in the context of medicine, success can be dangerous because it makes us complacent and less self-critical.
It’s extremely important, yet incredibly difficult, to admit to our mistakes and try to learn from them. As a young doctor, you can’t risk being completely honest with yourself because a certain degree of blind self-confidence is necessary in order to keep doing your job and learning. We hone our skills by making mistakes. However, they’re extremely hard to swallow. In fact, you develop something referred to in psychology as “cognitive dissonance” where you recognize two contradictory thoughts, and applied to decision-making the term is demonstrated when part of you knows that your choice was probably a mistake and part of you denies it. There’s also an obligation to tell your colleagues about your errors so that they don’t make them. Consequently, there’s pain in being a physician and it’s even more painful if you’re a nice doctor. Therefore, the art of medicine is finding a balance between compassion and creating distance in your relationships with patients. You have to be detached and scientific, yet caring and compassionate, but the more you care the more it hurts when things go wrong. With practice, you get used to these challenges, but you still suffer and you still feel bad about it, especially when patients die. Somehow life goes on though. If you don’t take on the difficult cases you won’t become a better physician. Eventually, you learn to live in a permanent state of slight anxiety. Most doctors are young and healthy and don’t really understand what it’s like to be a sick patient in hospital. It’s often only when physicians become patients that they say, “I never realized what it was like.” Perhaps hospitals would be nicer places if more doctors had personal experiences with health and many of us should probably listen to our patients more. We’re all frightened about losing our health and physicians know what can go wrong. With experience you become more philosophical and as you age you also become wiser. In fact, there’s a common saying in medicine, “It takes three months to learn how to do an operation, three years to learn when to do it and 30 years to learn when not to do it.”
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 Is burnout a negative outcome on its own? Or, is it a surrogate outcome? Do we care about burnout because of how it affects patient outcomes and patient satisfaction? Or, is it something to worry about on its own because of the distress it causes practitioners?
Perhaps the answer lies in a combination of all of these questions. Although I learned a great deal in medical school, burnout, resilience and their interaction with empathy wasn’t something I think I learned enough about. In the theoretical understanding of burnout, there’s a clear link with how we understand empathy. However, there isn’t a lot of literature discussing the connection between them. We know that burnout is associated with attrition—people burnout and they leave medical practice. It’s also associated with medical errors, or at least perceived medical errors—people who score highly on burnout ratings also report themselves as having made more medical errors. Moreover, burnout is highly associated with the patient’s sense of their interaction with the doctor. Or, in other words, their satisfaction with the process. As a medical student, I remember thinking, ‘That looks scary. I hope I’m able to do it and still be active and healthy.’ Perhaps it isn’t perfect, but the three-factor model of burnout has been a helpful tool in clinical practice. It considers emotional exhaustion, depersonalization/cynicism (you start treating other people functionally (e.g. as objects as opposed to complicated human beings)) and a lost sense of personal effort (you start feeling like your work isn’t making the difference you wanted it to). Empathy isn’t necessarily something that drains you emotionally. Nevertheless, it requires emotional resources. It demands that a certain amount of energy be present in order to do it well. When people in the medical profession are rushed, or thinking of someone in terms of a disease process rather than a person who is experiencing distress, those concerns serve as barriers to empathy. It’s the pressures of the work environment and often the lack of time that clinicians actually have. In medical school, it’s also the sheer volume of information. It gets easier once you master the medical science of the treatment and management of the patient. However, at a time when you’re literally just trying to remember, ‘What does hypernatremia mean?’ ‘What causes that?’ it’s not easy to attend fully to the person in the room with you. Then, once you start treating patients, how do you know if you’re being empathetic enough, or too empathetic? [This post was written by Clea Machold and Valentina Ruiz Leotaud]
It’s hard to believe that it’s our last day in Jordan. After celebrating World Mental Health Day (usually Oct. 10, however, delayed this year) at a five star hotel in the heart of Amman’s business district, walking some of our favourite streets seemed like a good idea. Little did we know that the apartment-downtown route we were so proud of figuring out, actually amounted to it taking three times as long as it should to walk downtown. The combination of speaking only a few words of Arabic, our most polished of which is shukraan (plain thank you), and the fact that the locals don’t use street names at all, makes getting directions challenging to say the least. To further complicate things, shmal, Arabic for north, is used by Jordanians to mean left no matter where you are. Today, after letting the route itself decide our way, we discovered that once you get to Rainbow St., which is a left, a right, a left and another right away from our apartment, Amman’s downtown core is only a left, a right and another left from there. Ironically, this epiphany only occurred to us after almost a month of it taking half an hour to walk downtown. Not only did we walk this in 40-degree heat, we also braved it in the pouring rain. The worst part? We kept forgetting specific turns, so we usually had to retrace our steps and make sure we didn’t miss the landmarks we had decided were important for us: Africano pet shop, staircase with trash, Housing Bank, cute coffee shop, umbrella alley. Despite our well-developed system, we still had to ask for directions every time. "You know Hashem Restaurant?" was the ‘answer’ we usually got as intended to reach any spot on the crowded Prince Mohammad St. As it turns out, we had actually passed by that place several times without realizing it. It also just so happens that it’s one of the best places to have falafel in Amman -just saying. Our enroute anecdotes could go on for many, many lines. We bumped into a guy who took us to a tourist-trap cafe, we had a spices shop owner laugh at us because we were only buying 10 gr. of cinnamon (in the end, he just gave it to us for free), we posed for a photo with local kids at the Roman Amphitheatre who found us 'interesting'... We’re definitely going to miss you Amman. We are going to miss your people and their teachings -with actions rather than words- about hospitality, generosity and looking at the bright side of things. But, we’ll be back… There are still many stories waiting to be told, and others that require follow-up from us. On top of that, we still have to find a place where they assure us that their falafel only contains chickpeas with zero flour, so Clea can have it, and we still have to find someone who invites us to try some homemade mansaf, so Valentina can taste it one more time to make sure she really likes it, since even some Jordanians don’t. So, see you soon Amman! C and V Our reporting trip to Jordan is the first time I’ve ever covered stories in a language I don’t speak or understand. Pretty much all our interactions are in Arabic.
I am getting really good at reading peoples’ facial expressions and interpreting their verbal queues so that I can react appropriately, but it’s more challenging than it sounds. Despite the fact that Hala is fluent in Arabic and English and translating on the spot whenever she can, misunderstandings often occur due to cultural differences. One of the stories we’re reporting on is about mental health. Covering it with the depth and detail we’re striving for involves asking sensitive questions and responding compassionately. Sometimes our characters, the ‘sensitive souls’, laugh at times I might expect them to cry based on the English translation of the question Hala is asking in Arabic. Sometimes an answer that I think will be a few words ends up being half an hour long. Although Valentina and I understand more now than a month ago, there is still something missing. This is partly because of an unnatural delay; it’s harder to connect with your characters when you don’t understand most of what they’re saying in the moment. I’m listening to the voices I’m hearing carefully, concentrating on how people are speaking, not just what they are saying. I’m listening to the rhythm of their speech, focusing on how the pitch of their voices rises and falls. I’m listening to the music they make. In journalism school, I remember one of our professors telling us that radio is the most intimate medium. Now, I understand why. We have been invited to several special occasions in and around Amman.
The first was a bus trip to Ajloun Castle, also known as Qa’lat ar-Rabad, a 12th-century Muslim castle in northwestern Jordan. On the way, we stopped in Jerash, the capital and largest city of Jerash Governorate, 48 kilometres north of Amman, towards Syria. This journey is one I won’t forget. Here, people are generous and sincere. So far, the only nuisance is that I’m celiac. This means I can’t eat gluten, and I’m quickly learning that breads and pastries are staples in the Arabic diet. Another integral part of the traditional culture here just happens to be offering your guests food, and it’s considered rude when it is refused. It’s for this reason that Hala continually finds herself trying to explain why I basically can’t eat anything I’m offered. The last stop on our way home from Ajloun was a homemade, picnic dinner. Cucumbers were the only dish where I could say, “Ne’am min fadlik,” followed by, “Shukran”. Forty kilometres outside of Amman, a cup of yogurt spilled, completely drenching my left-pant leg. After two interviews, three cab rides and several phone calls the next day, we were looking forward to a traditional, Arabic wedding in the afternoon. Since our hostess was running late, she decided to take a shortcut that I wasn’t aware of. Suddenly, we were in the left lane of the highway driving against the clearly painted, pristine white arrows on the pavement. “Hala, we’re driving the wrong way,” I said. “I know, we’re taking a shortcut,” she said calmly, as if driving the wrong way on the highway was a completely normal occurrence. Another thing about driving here is the honking. Certain common patterns exist, including double, triple and ultra long beeps, although I haven’t decoded their meaning just yet, other than to signal grievances about someone else’s driving. These honks are usually followed by forceful hand gestures. We eventually made it to the wedding, recording equipment intact, and ready to celebrate. Valentina and I had never been to an Arabic wedding before. Then, a huge slice of gluten-rich, strawberry, sponge cake appeared. A short while later, its chocolate counterpart arrived. It is 1:50 a.m. at the Queen Alia International Airport in the arrivals hall. Ahmed, a dark-skinned, middle-aged, stalky man of average height is wearing jeans and a collared shirt. He speaks only a few words of English and is waiting for me with a smile on his face and a large, white sign that reads, ‘Clea Machold’ in black, block capitals. As we walked to the parking lot, Ahmed started pressing his car remote key anxiously. He forgot where he parked. He laughed as he kept pressing the remote to find the car, which lit up when he pressed the buttons. “Don’t worry, I will find,” he said. There were cars everywhere, but Ahmed wove his way to the exit and onto the highway in no time. With the windows down, a pleasant breeze swept through his four-door, white sedan. Despite not signaling and driving between lanes, there were no accidents, not even any close calls in fact. When we arrived at the apartment, Hala and Valentina greeted me excitedly despite being jetlagged and exhausted, having only arrived a few days earlier. Our hugs were viciously interrupted by the screams of two cats in heat that appeared at our front door. We spent Wednesday exploring the hilly, narrow streets of Amman. Colourful, intricately embroidered, long dresses were on sale in many shops. Honking horns, the imam’s call to prayer and voices speaking Arabic filled the air. Then, we found our way to a local bookstore. The owner recognized Hala from their last meeting 10 years ago when she lived here. His contagious laughter shook the bookshelves and our spirits. He served us Iraqi tea to celebrate the reunion. Using Suhad’s (Hala’s mom) hand-drawn map, our next stop was the Al-Husseiny Mosque. Then, we took a taxi to Bünn Izhaiman, a 122-year-old local coffee shop. On the way, the driver pulled over and ordered a coffee to go. Turns out that coffee's flavour can be enhanced with coal as Hala translated his words in real-time. As evening approached, the three of us girls crammed into the back seat of the third taxi that day with five full shopping bags. The ride home was chilly as the sun set over the city. A flashing, red light emanated from the spot where the car beside us was missing its gas cap. Recently, a conversation with an 83-year-old man reminded me that aging citizens feel largely ignored by our society.
"Have you ever noticed that seniors are invisible?" he asked. As I thought about his question, its truth struck me. We think others basically see us how we see ourselves. However, there's a drastic difference. The more we age, the wider the gap becomes between our own sense of self and the world's. How many of us look in the mirror and think, 'That's not me, not the real me, not the person I know.' This 83-year-old man is a proud physician. "Now, when people meet me, they bend down and call me 'dear,'" he said. "They ask, 'How are we doing?' Even the correct pronoun has been lost to me, and the singular erased." Or, they don't bend down at all, he continued. "They talk to my children, or my carer. The nurses and doctors I have come to love in the hospital, which is where I spend a lot of my time these days, are the people who sit beside my bed, call me 'doctor' and see beyond my wrinkles, white hair and vulnerability," he said, adding that, "They're still respectful and attentive." Occasionally, I catch myself saying that my mom 'was' beautiful, when in fact she still is. Or, that my dad 'was' clever and kind; as if the aged become ghosts in their own lives. Sometimes, when people describe their parents, they use words like 'naughty' and 'silly,' as though they’re speaking about young children. Similarly, we often say, 'I love children' and 'I love old people,' denying them their individuality and fitting them into categories. If we're lucky, we grow old. Yet, our culture negates old age; we speak of 'them' rather than 'us.' This 83-year-old man is aging. Nevertheless, he still represents all the selves he has ever been; the stubborn child, the independent young man, the husband in love, the doctor, the father and the grandfather. He characterizes all of us. We all strive to be recognized. We all endeavor to be seen as unique individuals. Let's start with how we look at the world by seeing others as we wish to be seen ourselves and making what is invisible visible again. Founded in 1995, the Ontario Medical Association’s Physician Health Program, or PHP, helps doctors with alcohol and drug addictions.
Dr. Sam Smith, not his real name as we agreed to protect his identity, started attending the PHP in 2010 because of a marijuana addiction. A practicing family physician now, he celebrated six years of abstinence in February. When Smith started residency in 2010, he was referred to the PHP because of a question on his application for licensure with the College about previous problems with alcohol, or drugs, which he answered ‘yes’ to. In fact, Smith was given his medical license on the condition that he enrol with the PHP. “Most people would just answer ‘no,’” he says. “All through medical school I evaded the truth about how much I was using when I was flagged for failing exams. That question about substance use on the residency application gave me a chance for a fresh start by being truthful. I was told by the PHP that it was ‘refreshingly honest’ [because most] people don’t come into recovery until they’re discovered,” says Smith. “Either they’re caught taking drugs from work, or they’re hung over, or intoxicated, or they get a DUI, or a colleague will call the PHP, or the College, [to] make a complaint.” Although a proactive process in the end, getting here has been a long journey for Smith. “In Ontario, the usual [agreement] with the PHP is five years,” he says. “For most people, they recommend urine monitoring, seeing an addiction doctor and sometimes a psychiatrist as well. They also generally recommend an in-patient treatment program and attending Caduceus, a group of health-care professionals with addictions.” Smith says it has been a positive experience. He has a new contract now, after moving to another province, and will be finished mandatory monitoring soon. As with many physicians in recovery, however, Smith intends to continue his addiction treatment afterwards. “The overwhelming thing for me in my recovery was someone [who] said, ‘You have to give up control to get back control,’” he says. “Over time, I really learned what that meant, which was that when you’re in active addiction, or even recovering, but still trying to do everything on your own, or do things your own way, it can be really problematic.” Smith considers the PHP’s support instrumental in his successful recovery. “It’s been really helpful for me to have the PHP to say, ‘No. This is what we want you to do. We want you to have all these things in place to keep yourself and the public safe in case you relapse,’” he says. Based on Smith’s experience, one has to buy into the program, by trusting the people who are there to help you. “For the first time in my life, I had all these different areas of support and fail-safes to protect me from using, [which] really, really helped.” The statement, “I wish I had cancer,” recently reminded me of the film Still Alice, based on Lisa Genova’s novel, and dementia’s lonely journey.
This is because these are also the words of Dr. Alice Howland (Julianne Moore), a linguistics professor at Columbia University, when her neurologist (Steven Kunken) diagnoses her with early-onset familial Alzheimer’s disease. She celebrates her 50th birthday with her physician husband, John (Alec Baldwin), and their three children. During a lecture, Alice forgets the word “lexicon.” Then, she gets lost on campus while jogging. As her illness progresses, she becomes unable to deliver focused lectures and subsequently loses her job. Alice gets lost looking for the bathroom in her own house and soils herself. She fails to recognize her youngest daughter, Lydia (Kristen Stewart), after watching her play performance. Later, Alice visits her eldest daughter, Anna (Kate Bosworth), in the hospital to meet her newborn twin grandchildren, but doesn’t recognize her. Anna tests positive for the Alzheimer’s gene. Her unborn twins test negative, as does her brother, Tom (Hunter Parrish), a junior doctor. Lydia declines genetic testing. Alzheimer’s is not only a disease of the elderly. The younger-, or early-onset type, affects those less than 65 years of age. In fact, up to five per cent of the over five million Americans with Alzheimer’s have the early-onset form, according to the Alzheimer’s Association. That’s about 200,000 Americans. Many are in their 40s and 50s. They may have careers, families, or even be caregivers when Alzheimer’s strikes. Last week, one of my patients expressed memory concerns. After a series of other tests, I eventually asked him to draw a clock, a common method used to assess baseline cognitive function. When he tried, he realized he couldn’t do it. Then he said, “I wish I had cancer. People wear pink ribbons for you when that happens.” A moment of realization for both of us, this reminded me how lonely illness is. Losing one’s mind is a journey we largely walk alone. Perhaps it’s because we’re often as afraid as our patients. Rarely do we ask, ‘What is it like?’ Or, ‘How does it feel?’ Questions considered common practice with cancer, diabetes, or heart disease. Similarities exist between helping people manage mental illness and other chronic medical conditions, such as high blood pressure, or Type 2 diabetes. Nevertheless, psychiatry is different to other medical specialties. One reason for this is that patients’ intentions and progress tend to be less concretely defined. In the case of hypertension for example, reducing one’s blood pressure to 130/80 is a tangible target. In the context of advanced Type 2 diabetes, making lifestyle changes to avoid losing one’s foot is a specific goal.
With diseases like anxiety, depression, bipolar disorder, or schizophrenia, however, treatment is less black and white. Medication often plays a significant role. Nonetheless, as with all drugs there are side effects, and compliance is a common issue. For the most part, it’s a question of helping people maintain their optimal level of functioning, and major improvements are relatively rare in the field of mental health. Assessing suicide risk is another important consideration in psychiatry. Often, all I do is listen. Most psychiatric patients don’t progress the way ‘getting better’ is traditionally defined and measured. Huge accomplishments are somebody saying, ‘Do you remember suggesting making a list and crossing things off as I got them done? That changed my life.’ Or, someone with a long history of recurrent hospital admissions, because of repeated suicide attempts, who hasn’t been admitted for a year. Sometimes, it’s as though people find themselves in a fog. Over time, usually after several years in fact, trust and rapport are established. Eventually, there might be an opening in that fog, which we try to seize. “Don’t use your influence until you have it” has been invaluable advice thus far. |
AuthorDr. Clea Machold Archives
March 2016
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