10:56 – The Minute a Patient’s Life Ends and a Medical Student’s Life Changes

By Rachael D’Auria

The hierarchy in medicine, dark humor used to cope with difficult patients, and embarrassment of not knowing answers to endless questions being thrown your way are some of the many horror stories students above me have attempted to prepare me for. However, no amount of preparation could prepare me for witnessing my first death.

As I watched the residents add notes to patients’ charts, an announcement over the loudspeaker made all the physicians abruptly look up from their computers. “A 79-year-old male is being transported to the ER in a full code.” Immediately, residents, nurses, and attending physicians started prepping the trauma bay, as I, a rising second-year medical student doing clinical research in the emergency department, attempted to stay out of everyone’s way. I squeezed myself into a corner of the trauma bay and made sure I was not blocking any important machinery. The trauma bay erupted with activity as EMS workers rolled the patient into the room while administering CPR and rhythmically squeezing the ventilation bag. He was quickly moved onto the trauma bed and the CPR machine continued chest compressions. The patient’s wife sat near the room’s entrance as the team administered epinephrine, calcium chloride, and bicarbonate while attempting to intubate him.

Every few minutes, a nurse called out “pulse check,” and the resident briefly turned off the CPR machine. The room held its breath with anticipation for a returned pulse, but the resident would respond, “No pulse.” Every time I heard this, my spirits declined as I stole a look at the patient’s disappointed wife. I watched the patient’s wife text family members, the physicians’ hopeless looks after administering another medication, and the machines showing no cardiac movement. After 50 minutes of the pounding CPR machine attempting to revive this patient, the resident and attending talked to the patient’s wife and described what they had done and the poor prognosis. Ultimately, they turned off the CPR machine and called out, “10:56,” and silence took over the room. While I have seen family members in open casket funerals and cadavers in the anatomy lab, I had never witnessed someone pass away before 10:56 a.m. on that Monday morning. The nurse called for a moment of silence to appreciate the valiant efforts of the team, and then the medical team filed out of the room and carried on with their day.

I felt noticeably sad for the remainder of my shift as I grieved this patient I had never met. I felt guilty for feeling this way as his wife held his hand to say her goodbyes because I played no role in his medical care nor did I know this patient. Even though the medical team carried on with their day seemingly unaffected, I imagine many of the caregivers in that room felt the aftereffects of witnessing a passing of a life throughout the rest of their day. As I processed the passing of this man’s life, I realized the importance of building an emotional attachment to patients and allowing myself to address my emotions no matter the duration of a patient interaction or my role in medical care. I will carry this lesson forward in my medical education, as I inevitably am forced to cope with countless tragedies.

 

Rachael D’Auria is a second-year medical student at Drexel University College of Medicine. She is passionate about bioethics and hopes to continue researching ethical dilemmas occurring in patient care settings throughout her clinical years.

In the Defense of Plastic Surgery as a Feminist Choice

by Anu Antony

 

I am a plastic surgeon, a profession that involves understanding women’s aspirations not only in the corporeal sense, but also being cognizant and mindful of their psyche – the inner thoughts and feelings that drive them to choose plastic surgery.

While choosing plastic surgery can be an empowering undertaking, many women still harbor feelings of guilt. Will their friends and family will think they have succumbed to societal pressure to look a certain way?

Remarkably, many women can feel guilty even when they are getting breast reconstruction surgery after mastectomy. Reconstruction surgery is now widely accepted as a medical treatment for cancer patients – although the breast once removed is not a functional organ like a kidney or liver. I’ve even been told by other medical professionals that I am a “real doctor” because breast reconstruction surgery is my specialty. But a generation ago, even breast cancer patients seeking reconstruction were chastised for seeking procedures that were considered superficial and unnecessary.

Changing attitudes were reflected in 1998 when the Women’s Health and Cancer Rights Act (WHCRA) legalized the right for patients to seek out breast reconstructive services and have those procedures covered by insurance. Perhaps the fact that insurance provides this coverage as a medical necessity gives many patients comfort they are not seeking superfluous cosmetic procedures.

But women seeking other kinds of plastic surgery often still don’t receive the same empathy that my breast reconstruction patients receive. I am wondering if we can broaden this conversation. Might plastic surgery become a right for women to choose?

In my conversations with patients, I hear patients express their desires. Some wish to restore that which cancer took away. Some want to defy their genetics. Others want to undo the effects of pregnancy on their body. I have yet to hear a woman say she is acquiescing to a societal demand for perfection.

To take the “defy genetics” notion a step further, consider gender confirmation surgery. Kaitlin Jenner and others like her have highlighted the plastic surgery procedures they have undergone to live as transgender females. Surely, an understanding of “the why” of a transgender woman is complex, but in a more conceptual sense might be ascribed to an assimilation of their internal conflict with their external selves. This driving pressure to physically change comes from within rather than an external pressure from society to become a woman.

To be sure, as plastic surgeons, we must balance expectation with reality, and the delivery of surgical procedures is as much of an art as is understanding our patients. If exercised judiciously, plastic surgery is intended to improve the quality of life for patients – it is not intended to win the battle of aging or establish cultural norms.

Choosing plastic surgery may not necessarily be an internalization of societal values, but rather stem from agency of the individual. In social science, agency is the capacity of individuals to act independently and to make their own free choices. Thus, the stigmatized interpretation that individuals seeking plastic surgery have internalized societal pressure may be inaccurate. Instead, we may consider another construct inclusive of authenticity of the individual and comprehend that the reasons why women choose plastic surgery most often lie within.

Even for breast reconstruction surgery, the research has borne out that restoration of the breast means the restoration of psychological well-being, not the restoration of the ability to breast feed. Agency in this forum and a woman’s right to choose breast reconstruction surgery post-mastectomy might be considered the direct result of one’s inner Freudian id seeking to restore its psychological self.

Those opposed to aesthetic plastic surgery might consider a nature versus nurture argument. Must we choose to embrace our genetics or do have the power to decide who we are? Perhaps we can remove some of the guilt and understand that plastic surgery can be a source of empowerment whether to treat a congenital birth defect, acne scars of youth, disproportionate breasts, or a tendency to retain weight in certain areas. Can we remove the blame and the unconscious shaming of individuals and understand the decision to choose plastic surgery through a different lens? This is a historical time in the US, where there is a lot of intolerance. However, we are a country founded on choice.

The crux of the feminist movement centers around having equal rights and opportunities – having choice. Being a plastic surgeon has allowed me the opportunity to give women choice: the right to choose who we are in society, have control of our bodies, and what we look like in the world. While some of my most satisfying work to date has been in reconstructing women after breast cancer, I would like to take a moment to encourage tolerance for all. Each of us is on a different path and while we may not all choose the same journey – we can choose understanding.

Anuja (Anu) Antony, MD, MPH, MBA, FACS is a Professor and Vice Chair of the Department of Surgery and Chief of Breast Reconstruction and Medical Director of the Division of Plastic and Reconstructive Surgery at Rush University. Dr. Antony is a Public Voices Fellow with the Op-Ed project and an accomplished writer, researcher, and speaker who lectures nationally and internationally about plastic and reconstructive surgery.

On the Eve of a New Year

By Hedy Wald

Looking back, looking forward. It’s what we do on the eve of a new year. 24 hours away from a fresh start, resolutions, inspirations, and even some trepidations . . .  2020 sounds like science fiction and yet, here we are.

Social media is gushing with good wishes and plenty of party hat and heart emojis. @pranaysinha summed it up nicely: “Hope, love, and gratitude.” And following the Dalai Lama on Twitter can make your day; @dalailama: “I believe that if we make an effort to develop peace of mind within ourselves and cultivate a proper appreciation of the oneness of humanity, we can create a happier, more peaceful world. What we need is common sense-the positive use of intelligence-and warm-heartedness.”

So it’s not all party gaiety, it’s also serious contemplation of where we’ve been, where we are, and where we’re going. Resonates for me with the Ten Days of Repentance associated with the Jewish new year . . . reflect, look inward before looking outward – apologize, improve, be kind.

So many parallels to our vision for humanism in medicine. And for the work we do in medical education.  It’s about doing the work of a physician but it’s also about being a physician1 –how do we cultivate a prepared heart and mind for the inevitable complexities? Ethical vigilance? Values? Moral integrity and resilience? And when we close that exam door and are face-to-face, heart-to-heart with that vulnerable, suffering human being and/or family caregiver, how do we bring intentional presence2 to that sacred space with readiness to receive and hear the narrative, readiness for responsibility?Read More »

Virtue and Suffering: Where the Personal and Professional Collide

By Lauren Rissman

A distraught, exhausted mother asked through her tears, “Doctor, what would you do?” The palliative care, neurology and pediatric intensive care team sat in silence in the cold glow of fluorescent light. At that moment, I felt a zap of pain to my heart. It was sharp, followed by a lingering ache. It was visceral and unforgettable.

The mother asked again. As a team, we discussed with her the uncertainties in prognostication. Sometimes kids get better, and sometimes they don’t. After a cardiac arrest, it can take weeks for kids to regain function, if at all. This question was not mine to answer, but rather use it as a stepping block to evaluate a family’s hopes and expectations for their child and their future, as a family.

“He loves The Lion King,” she explained. Though her son had a traumatic brain injury and was receiving multiple sedating medications, she thought it was important for The Lion King to be playing in the background, so her son could enjoy it. But, within 10 minutes of the opening credits, he had had another episode. She described the episode as arm stiffening, and then demonstrated what she had observed. One arm, over her right ear, reached for the sky. Her left arm hung down by her side, fingers pointing to the ground. She arched her back and turned her head. She paused and then began to cry. “I don’t want him to be in pain,” she explained.Read More »

“I Shall Be Released.” Restorative Justice Techniques Can Address Healthcare Burnout & Attrition

by Jay Behel

Burnout, provider dissatisfaction, and attrition remain at near-epidemic proportions among healthcare providers. A 2017 survey found that 39% of physicians reported significant burnout, and nearly a third of physicians were contemplating leaving practice in a 2012 survey.  Nurses seemed to be faring better in a survey released earlier this year with only 15% reporting burnout. However, 41% reported feeling disengaged from their work.

The myriad wellness programs launched to address these problems have disproportionately focused on private, individual aspects of wellbeing like diet, fatigue, and exercise offering similarly individual solutions like yoga and meditation.

Missing from the strategy to help healthcare providers is a coherent plan to address the systemic, communal factors underpinning the crisis, namely the disengagement and isolation fostered by our mechanized and monetized healthcare environment.

While they’re often reserved for use in criminal justice settings, community-building and conflict resolution practices rooted in the philosophy of restorative justice offer a remedy for the alienation of the contemporary healthcare provider and, perhaps, our entire healthcare system.

I began looking for ways to introduce RJ practices at Rush Medical College in Chicago after attending a training in California.  While the whole experience had a powerful impact on how I think about my work as a healthcare leader, I was most struck by the flexibility of the circle practices—their ability to make space for the silly and the serious, for simple connection and complex problem-solving.  I was also impressed by the speed and apparent ease with which participants, myself included, made themselves vulnerable and voiced hard truths.

Following this experience, I brought training to our campus, and our student leaders subsequently held a series of restorative justice circles to address tensions over a curricular transition. Participating students expressed their needs and, ultimately, reaffirmed their commitment to respect and care for one another. After the circles, the number of students reporting peer conflict and incivility dropped.  Moreover, several students noted that the experience of sitting in circle completely changed their sense of the learning environment and their place in it. One student noted: “I feel that I have gained social capital knowing that there is a community of peers I can reach out to whenever I need support.“

Rooted in indigenous traditions, restorative justice (RJ) is a theory that emphasizes building community and repairing harm through cooperative processes that include all stakeholders.  RJ practices convene groups of people to engage in meaningful dialogue about substantive issues that impact community and individual functioning. These processes can help a group identify and gain mutual understanding of both the personal and collective sources of disconnection, create the conditions that incentivize growth, and build or rebuild trust.

One essential RJ practice is the community-building circle.  A circle is usually convened around a desire to both build connections and address tensions and conflicts disrupting the group’s ability to fully function as a community. Guided by a trained circle-keeper and structured around the use of a talking piece, community-building circles provide safe, inclusive space for the revelation of issues both large and small, personal and universal.

More fundamentally for the healthcare space, RJ, particularly circle practices foster the personal connection and humanistic values that brought most people to the field in the first place. Healthcare institutions in New Zealand and Australia are leading the way in employing restorative practices.

Integrating these practices certainly requires an up-front commitment of time and money, and RJ-driven culture change takes time and inevitably involves some moments of painful self-examination at both the personal and institutional levels.

Nevertheless, the pay-off over time, in reduced attrition, increased provider satisfaction, and better patient care, would greatly outstrip the initial investment. And, in an industry that has become so focused on efficiency and metrics, RJ may be key to building capacity.

While these practices alone cannot repair our fractured healthcare landscape, they do offer a roadmap by which providers can navigate the terrain with their souls intact.

 

Jay Behel, PhD, is Associate Dean of Student Affairs and Assistant Professor in the Department of Psychiatry and Behavioral Sciences at Rush Medical College in Chicago.  He is a Public Voices Fellow with the OpEd Project.

Speaking of Addiction…

By Meaghan P. Ruddy

When we speak of addiction, there is a lot we can say. We can talk about stigmatization, how stigma is a mark, a signifier of something often associated with shame and disgrace, which in turn are responses to things deemed problematic by dominant cultural narratives. We could focus on historical usages of stigmatizing practices, how we come to know disgrace and feel shame by observing how others, particularly those who are in helper roles, respond to our marks, and how all of this negatively impacts healthcare. And we could, as we often do, speak about it from the safe, professional distance of the theoretical.

But there is a simpler truth here.

It is the truth expressed by the civil rights movement, the equity in marriage movement, and women’s suffrage. It is the truth that fuels both political correctness and the fight against it. It is the truth that language matters.

Think about it. If it didn’t matter, we would never take offense, never laugh at a joke, never tear up at a well-delivered line in a film or speech. No one would bristle at terms with historically racist or fascist overtones.

Yet, we do.

Healthcare has made some progress but our work is far from over. The person-first language movement has done a lot of good; even the CDC-recommended terms of use for people with disabilities. Even the word healthcare is a relatively new and welcome reframing away from the silos implied by medical care, rehabilitation, nursing care, etc. The harsh terminology that was once part and parcel of “clinical-speak,” handicapped, gomer, diabetic, depressive, has largely been abated or is at least on the way out. There has been wide-spread recognition that these are people first, conditions second.

Except. Except for one challenging, and unfortunately swiftly growing population.

Addict.

Drug-seeker.

Yeah, but c’mon, someone might say. They are seeking drugs. They’re a huge problem! They should know better.Read More »

“You will be alright” – A Doctor’s Reflection on the Power of Hope

By Mahboobeh Mahdavinia

Alanna and Anthony are not yet ten years old, but they have been to the emergency room more times than most adults. Every few months since they were babies, their parents have raced them to the hospital for asthma attacks, superinfections of their severe eczema, or food allergy reactions. They each have been intubated twice in their precious few years of life.

But for the last year, Alanna and Anthony have not had to come to the ER in crisis. Instead, their parents have brought them to see me in my allergy clinic for scheduled medication shots and follow-up visits. I consider Alanna and Anthony a success story, or at least the start of one. But most hospitals would not – and neither would insurance companies.

The truth is, Alanna and Anthony have missed multiple appointments, and consequently missed almost half of their shots. Other patients I see have similar spotty records. Administrators who oversee my clinic have pointed out the large cost of no-show appointments. When inconsistent patients do come, their appointments often go overtime, creating conflicts with nursing and staff schedules. Some other hospitals and  clinic administrators would almost surely have come up with plans for dismissing Alanna and Anthony from the practice. However, we have all come to the agreement that we should do whatever it takes for them to stay as long as they choose. Read More »