A Review of @danielleofri What Doctors Feel

When I started residency in July of 1999, I felt confident that I was doing my life’s work. I came to the hospital early the first morning. The chief physician brought me to the third-year resident who was covering the patients who would become mine. This was the resident’s last day of training. I will never forget the phrase my chief used when introducing him.

He said, “This is John. You’re taking his patients. Today is his last day of residency. He can’t be hurt anymore!”

My thoughts raced. What did he mean “can’t be hurt”? Who was hurting him? And why couldn’t he be hurt anymore? Unfortunately, I would eventually learn.

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In What Doctors Feel:How Emotions Affect The Practice of Medicine Danielle Ofri plays us like a celebrated cello concerto.

Piano

In the beginning she caresses the strings softly, piano. Her fingers dance around the definition of empathy . Her stories (the rape victim and the cockroach, the patient with ulcers incompatible with life)are the vibrato giving color and nuance. The pace is still humble, andante, as she asks if we can build a better doctor. This is Danielle the scientist. She delves into notable clinicians and teachers, and touches on studies of how empathy affects patient care.

Mezzoforte

The volume grows as we enter the chapter "Scared Witless". Here we encounter the complexities of physicians as fallible human beings. She struggles with her first chance to run a code, stumbles over a forgotten psyche consult, and trembles at a missed life threatening diagnosis of a pulmonary embolism. She describes the fallout of medical errors:

There's no easy answer about how to proceed onward in daily medical life with the ongoing churn of anxiety and fear, and certainly no research to guide us. Each doctor has to come to terms with it and negotiate an individual emotional armistice.

Forte Fortissimo

The thrum becomes loudest and most persistent In a "Daily Dose of Death". Here we meet Eva and learn of her heartbreaking experiences as a pediatric resident. Ofri transitions from the calm cool scientist to the impassioned story teller. Although the narrative is always controlled, the reader is punched in the belly by the raw staccato jabs. She follows with "Drowning" where we see the poor coping mechanisms Joanne (and so many other physicians) use to deal with burnout.

Finale

In "Under The Microscope" we come full circle with a discussion of malpractice and the physician psyche. Both the scientist and story teller intertwine. Piano, fortissimo, vibrato. We at last learn of the ultimate outcome for Julia, the heart failure patient, whose story meandered through the chapters and set the overall tonality.

We end where we began, not doctor and patient, but two human beings traveling the same lonely road.

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I only have a minor criticism for this wonderful book. My quip is that Ofri refuses (and this may be her true brilliance) to name the emotion that kept coming to mind as I read. She answers the question posed by the title with such words as fear, shame, grief and anger. Yet I can only imagine she purposefully uses pain sparingly.

Why?

As a physician, pain is the apparition that hides behind the closet door of my nightmares. Pain is what I felt when I told the three unsuspecting women that their father died knowing that I had fumbled in the ICU with the intubation. Pain is what drove my chief resident on my obstetrics rotation to break down after standing by helplessly as a mother stabbed in the neck, and her unborn baby, died. Pain is realizing that you are not the hero you hoped you would become, and that medicine is opaque, murky, and just plain messy at best.

The chief physician from my residency program had it all wrong.

I too felt at the end of my training that I couldn't be hurt anymore. I was drowning in the steely leather of self protectionism. But then in October of 2004 my world radically changed with the birth of my son. When I looked into his eyes looking back at me with complete trust, the barriers that I had erected since those horrible days of residency came down. I could cry again. I didn’t have to shield myself anymore. And I began to understand the meaning of empathy.

It is only when we allow the pain to flow through us unhindered and mix with the joy and awe, that we are truly free. Danielle realized this much earlier in her career then I did. Not only friendship and caring, but pain is the tie that bound her to her beloved patient with heart failure, Julia. In hurting she transcended the physical barrier and truly walked a mile in Julia's shoes. This may be the greatest gift that any doctor can give a patient. This is empathy, the jump that allows us to pass over "doctor" and become "healer"

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You want to know what doctors feel?

You have kindly read my feeble opinions.

You want a more nuanced and articulate view?

Read the book!

Departures And Arrivals

Thomas should have died long ago if not for a secret weapon.  Neither faithful medicines nor dedicated physician could battle the ravages of age and disease with the simple clarity of the love of his daughter.  Indeed, congestive heart failure and general frailty were no match for Leslie's unbending will.  She nursed him back from all exacerbations.  She slept by his side during every nursing home stay.  And she prepared his home triumphantly for each return to health even though he was getting sicker.

Her father's debility was in stark contrast to Leslie's own vigor.  She visited me occasionally for random colds and work related physicals.  Our contact was mostly limited to planning for the various hurdles her father was working to stumble over at any given time.  When it came to doctoring, he was my patient, she was more like a casual acquaintance.  Yet, as I was rounding the corner to enter Thomas's hospital room, it made perfect sense that the ER would call me.

There had been a car accident.  Leslie was in the emergency room. Dead.

A lovely bit of purity deep inside became black and sullied in those few moments in which I told Thomas that Leslie was gone.  It is in times like these that even the most religious curse their beloved deity, the faithless beg for prayer, and the mighty stumble.

Thomas stumbled.

The blood drained from his face, and the butterfly of life fluttered away from the cocoon of his still moving body.  He continued to breath.  His heart continued it's marathon march.  But the runner had become shoeless.  He lost his soul.

I sat with Thomas many times over the next few days.  I had few words of solace. As I held his hands, I voiced the bizarre thought that kept charging through my mind.

This is just like Leslie.  She probably wanted to go first to make sure everything was prepared for your arrival. 

He chuckled.  It was the last sound I heard leave his lips.  He died in his sleep a few hours later.

I'm not sure I believe in such things as heaven and pearly gates, but I like to imagine Leslie was waiting there for Thomas with open arms.

Ready in death as she had been in life.

Welcoming him home.

Why Doctors Lie

The oncologist shook his head as he walked out of the room.  He still held a paper towel in his hand which he used to wipe the last remnants of soap and water.  He tossed it into the trash, and looked in my direction.  We talked for a few moments.  The cancer was more widespread than originally thought.  The surgery exposed a belly full of metastases.  The options for chemotherapy were thin.

I entered the room with a heavy heart.  I sat next to the bed, and listened before beginning with a litany of questions.  The post operative pain was well controlled.  The patient had been informed of the diagnosis but still felt lost.  Her family watched hopefully, and measured each word as it left my mouth.  Their chins moved up and down frantically when I was hopeful, and back and forth soberly when I was not.

Before long, the conversation turned to prognosis.  The patient bowed her head and prepared for the answer. Every ounce of my soul longed to tell her that everything would be okay.  If only human will were the issue, I would explain how we could eradicate each cancer cell one by one.

And in that moment, I chocked on the truth.  I wished to give her the gift of hope, even though I knew it was false. It was not because it was easier, not because I wanted to intentionally deceive. In reality, I couldn't face my own frailty as a physician.  So many times we ultimately lose to diseases that are far too advanced or ingenious for our rudimentary knowledge.

I discussed the prognosis truthfully.  After answering their queries, I left quietly.

But I understand why physicians lie, why they embellish.

Even harder than telling someone they are going to die,

is seeing oneself without distortion in the reflection of the mirror.

Sacred Ritual And Twitter, Some Thoughts On @nprscottsimon Live Tweeting His Mother's Death

It was another perfect Los Angeles day. My family and I sat on the veranda of the hotel as the midafternoon sun cascased gently onto the shoulders of the onlookers. We collected in rows of chairs that were covered in white linen. The music marched forward, and the wedding party assembled cleanly in pairs of twos. We all knew what was coming next. Of course there would be some variation, but most have been through enough weddings to be familiar with the routine.

We use rituals to mark our sacred events: beginnings and endings, birth and death, and even marriage. We gather our loved ones, our communities, to celebrate or mourn with us. But as the bride and groom waltzed down the aisle at the end of ceremony with smiles on their faces, I scanned the reaction of the spectators. A number of them were hunched over their mobile phones. No doubt facebooking and tweeting. And I couldn't help but think for a moment about Scott Simon.

Many know that Scott recently made a splash in the social media world by live tweeing the death of his mother. At first, being a physician involved in hospice and palliative care, I wasn't thrilled with the idea. His tweets were authentic and brilliant, but while reading them my first inclination was to wish that he would put down his phone and just be with his family.

This wedding reminded me how profoundly we have been altered by social media. It has become crystal clear that our digital communities are just as important as our traditional, filial, and geographic ones.

Scott turned to twitter to share this sacred moment with his friends, family, and yes, followers. The outpouring of love, respect, and well wishing he received is exactly what one would expect at a traditional funeral but was more consistant with his digital reality.

Scott, I'm sorry that I originally doubted you. I have a profoundly different understanding of community after reading your eloquent tweets.

My deepest and most heart felt condolences to you and your family.

Regression To The Menial

I was far ahead of my time.

The cachectic middle aged man had been admitted to the hospital fifty times in the last calender year. The other residents and I joked that new graduates only truly became interns after they had Leon on their service. He suffered a range of chronic illnesses, mostly respiratory, that were overwhelming to his mentally challenged mind. He often would walk off the floor with discharge instructions only to appear in the emergency room minutes later complaining of shortness of breath.

I liked Leon. He was soft and gentle. His lack of mental capabilities only made his kindness more endearing. He was anxious about the outside world and preferred the safety of the hospital confines. And I couldn't blame him, to a homeless man on the St. Louis streets, our institution must have looked quite welcoming.

After his third hospitalization in as many days, I decided to take action. I gathered the patient's pulmonologist, primary care doc, and a bevy of clinic nurses together in a room to hash out this difficult case.

The pulmonologist retrieved his cat scan, and outlined the nodules and signs of emphysema. The primary care physician reviewed his compliance record. The clinic social worker and nurses attested to his housing issues. We worked together as a team. The group consensus was that his lungs were benign, and the best plan of care relied heavily on social intervention.

I left the room feeling like, for once, Leon had a concrete plan of action. I discharged him the next day confident that we could stem the tide of hospitalizations. From time to time, over the next few months, I patted myself on the back in recognition of the fact that Leon seemed to be nowhere in sight.

While strolling through the halls of the clinic during my third year outpatient rotation, I bumped into Leon, and almost didn't recognize him. He had gained fifty pounds. His emaciated figure filled out into more normal proportions. He smiled as he walked by and waved. Moments later, Leon's primary physician filled me in on his progress.

It turns out that Leon left the hospital the day I discharged him, and walked across the city to the emergency room of a competing hospital. He was admitted, and the attending physician called our institution. This physician listened to the details of our work ups, and was informed about our team discussion. He then decided it was all bunk, sent Leon for a biopsy of his lung nodule, and diagnosed him with tuberculosis. Leon was sent to a state facility for six months for monitored medication administration.

Leon thrived. He gained weight, his breathing improved, and he had been living out in the community for six months without a single readmission.

Now I know what you are thinking. Another case of a doctor warning about the diagnostic traps of not taking a frequent flyer seriously. But my point of contention is actually more about team based care. Ahead of my contemporaries, I used the group model, now lauded by healthcare reformers, to try to "hot spot" Leon.

The problem with team based care, however, is there is often a regression to the menial. Ideas and diagnostic possibilities on the periphery are inevitably homogenized or coerced to the center by other members of the team. Extremes are reasoned out, and often those who think out of the box are marginalized.

Specialty groups have an altogether different issue. Tumor boards and such often make extreme options more palatable. Last ditch and low probability chemo is bolstered by like minded individuals with well meaning intentions but often little clinical evidence.

It turns out that what Leon needed was not a team at all. His savior was a lone internist, weighing the clinical evidence carefully, measuring the pros and cons, and not being clouded by the faint murmurings of ineffectual group think.

Mental Calculus

He would describe himself as sensitive.  Not as in a lack of confidence, but more like able to tune into the feelings of the people around him.  It is probably why he became a physician.  A lover of math, he tripped on the mental calculus.  How many wins were needed to make up for each loss? How many lives would transform a death.  Even Michael Jordan missed a shot occasionally.  You can't tell me that Babe Ruth didn't strike out from time to time. 

He liked to daydream about powerlessness.  It would be so much easier if medical science were impotent.  He then could measure his worth in the warmth of a smile or the weight of a hand resting on a tired shoulder.  These were things he could offer without risk, without opening himself up to heartbreaking failure. 

He often pictured his own death.  Others fantasized about being met at the pearly gates by people they knew who had passed on: parents, friends, or lost lovers.  But who would meet him?  He had known hundreds, if not thousands who died.  He touched the acrid flesh, over and over again, uncovering physical and emotional pain.

He wondered if there would be a calamity.  His supporters would surely welcome with open arms and kind heart.  But what about those who were not ready to die?  They may shake their fists and scowl because he had not been enough.  A sort of scuffle would break out and opposing forces would clash.  Who would win?

But this was all just a dream, a confused, paranoid dream.   In reality there was no battle of judgement, no balancing scale.  And this was his burden. This was the thing he carried on his shoulders from day to day, week to week. 

This was the thing that pulled him back, that propelled him forward. 

Does Ezekiel Emanuel Think We Are Weenies?

Tilburt et al published a study in JAMA this week suggesting that physicians feel that other players (lawyers, insurance companies, hospitals, etc)  are more responsible than doctors for reducing healthcare costs.  Furthermore, they are hesitant to promote reforms that eliminate the current fee for service payment system. 

Although I would bet the no one would be surprised by these findings, a scathing editorial by Ezekiel Emanuel and Andrew Steinmetz caught my eye.  Before I get to the particulars, I would like to make a few (hopefully mostly uncontested) observations.

1)Physicians are some of the most educated, hard working individuals in American society. Very few professions require a four year doctorate, plus a minimum of a 3 year apprenticeship.  After finishing our training, we have long hours, take phone calls over night, and work many weekends. 

2)People, by in large, don't go to medical school to make a fortune.  There are many other professions that are more economically worthwhile with less debt incurred. Based on the GPA requirements, these applicants could likely choose almost any profession.  Medicine is a passion and calling.  Those who do not feel so drop clinical practice fairly quickly.

3)The daily job of physicians is to investigate, consider, and choose between incredibly complex and different avenues, and then take action.  We are trained to see the subtleties in both the written word as well as during patient presentations.  This is a thinking man's sport.

So when a large majority of educated, capable, and thoughtful people proclaim an opinion, one would think it would be wise to pause, consider, and evaluate before wholeheartedly dismissing the group as a bunch of weenies.  Unfortunately, Emanuel and Steinmetz think differently.  They proclaim:

The findings of Tilburt et al. confirm this ingrained human behavior by showing that physicians are hesitant, if not unequivocally opposed, to taking bold steps to re-engineer incentives in the system -- steps that may well have the most meaningful effects on controlling costs...

I couldn't agree more. Yes, thoughtful physicians who have been led astray before, are not jumping into the arms of governmental change.  Let us ponder a few questions.

1)Have any of the finished medicare demonstration projects ever had positive results?
2)Has pay for performance in the past, on balance, shown a financial or quality of care improvement?
3)Is there any proof that ACOs or PCMHs will improve the quality or cost of care?
4)How is the government doing so far at balancing the budget in general?

As physicians we learn to use scientific evidence to support our theories.  We have been burned time and again in medicine by using logic above data.  After careful consideration, moving forward "boldly" but foolishly may do more harm then good.  Ezekiel's fantasies about healthcare are unsubstantiated.  Show us the data, and we will follow willingly.

The editorial continues:

This is a denial of responsibility...Of course, physicians do not want to be blamed for the country's major problem. But can they really be both the captain of the healthcare ship and cede responsibility for cost control to almost everyone else?   Ultimately, what this survey tells us is that physicians acknowledge that health care costs are an issue, but they are not yet willing to accept primary responsibility and take definitive action to lead change.  The rejection of transformative, bold solutions to address the seriousness of the cost problem is indicative of much bigger problems ahead of we don’t start seeing more leadership from the physician community.

It's simple.  If you want us to be captain of the ship and take on all the responsibility, then you have to actually listen to our opinions.  Rehospitalization policies, pay for performance, and meaningful use are all untested ideas that have made both our and our patients lives miserable.  EHRs have never been shown to improve quality or cost of care.  Study after study is starting to show that rehospitalization rates are extremely difficult to modify.

Most importantly, our lives as primary care physicians have deteriorated greatly in the last two years.  The amazing amount of paperwork, the denials, and the computers are sucking our attention away from real life, difficult, patient problems.  Ask any patient, they will tell you that the office environment has deteriorated.

Finally, Emanuel and Steinmetz warn:

Unless physicians want to be marginalized -- unless they are willing to become just another deckhand -- they must accept and affirm that they are responsible for controlling healthcare costs.

I guess he doesn't realize that we feel as if we have already been marginalized.  But "deckhands" we are not.  If we decide decide to jump ship, whose going to steer the boat?

Maybe Ezekial Emanuel will.