I Wanna Hold Your Hand
Kendra Campbell -- A few weeks ago, I had an experience that has really stuck in my head. The resident and I were performing a painful procedure on a patient, and I could tell that he was really enduring a lot of pain by the grimace on his face. As I’ve done in the past, I instinctively reached out my hand and held his hand in mine. I allowed him to grip my fingers, and told him to squeeze my hand as hard as he needed to.
He started squeezing my fingers, and suddenly his face turned from a grimace to a smile. The change was rather startling, and so I jokingly told him that I’d never seen a patient with such a huge grin on their face while undergoing such a painful procedure. He smiled even more and said that it was because he was so happy to hold such a “pretty girl’s” hand. I smiled back, and soon the procedure was over.
I think it probably makes common sense that hand holding might bring some relief from pain. We all reflexively hold a child’s hand when they’re in pain. And I believe that even the most callous people might agree that there is something powerful about the human touch. Hugs are an even better example. I don’t know when the hug was invented, but I’m sure that it’s been around for quite some time. People of all races, ethnicities, and cultures seem to use the hug as a means of displaying affection. And while certain cultures might value human touch to varying degrees, I think we all agree on its significance.
One of the most well known studies on the power of touch and the importance of physical and social interaction is that of Harry Harlow. In his famous experiments, he allowed rhesus monkeys to choose either a cloth or wire ”surrogate mother,” both with and without a bottle of milk attached. Regardless of which mother had the bottle, the monkeys continued to choose the softer, cloth mothers. He also performed other controversial experiments, including ones where he deprived the monkeys of all physical or social interaction. The lack of physical touch produced monkeys with severe psychological pathologies, and in a few cases led to their deaths from self-induced starvation.
A study recently published in the journal Science also found some interesting results with regard to “warm hands and a warm heart.” The researchers found that if people were given something warm to hold, they subsequently described other people as having “warmer” personality traits, such as being more generous, more social, happier, and better natured. They also discovered that people who held something warm were more likely to behave in a friendly and generous way.
I’ve only begun to scratch the surface of the importance of the human touch, but you can see that the subject is much more than simply skin deep (pun intended). I tried to find some research that supports my anecdotal notion that holding someone’s hand who is in pain can serve to decrease their perception of the pain, but I was unable to find much research on this topic. Perhaps it’s a topic that will be further explored in the future.
But for the time being, I will continue to hold my patients’ hands. Whether they are in pain, or just very sad, or just very lonely, or even just very happy, I will continue to offer my hands to them. And hopefully when I need a hand to hold, someone will do the same for me.
It Has to Be Something Collective
Ben Bryner -- I've been reading Newsweek's gargantuan seven-part report of the 2008 presidential election campaign, written by five reporters who got unparalleled access to the campaigns in return for embargoing their reports until after November 4th. It's a terrific read, whether last Tuesday went your way or not, and it gives plenty of detailed description and analysis of the McCain, Obama, and Clinton campaigns. I hadn't been following the inside-baseball aspect of the campaigns, so the amount of discord within some of the campaigns was surprising to me.
But the most alarming aspect of the article was this quote from part two:
McCain loved the comparison. He began making guttural pirate noises, punctuating his jokes and one-liners with "Aaarrgh" and occasionally greeting reporters with this oddly cheerful growl.
I know, you’re thinking “I had no idea that McCain was a pirate!” Me neither. I thought I was paying attention during the race, but apparently not. Your reaction is probably one of the following: “I wish I’d voted for him instead of Obama!” or “I’m glad I voted for him, I only wish I’d sent him some more dubloons!” Or maybe you voted for Nader or you don’t care.
I am saddened that America missed a critical opportunity to elect a pirate, as swashbuckling transcends party lines. Who better to deal with the problems we face than a pirate?
OK, maybe there are some more qualified than a pirate to address economic problems. But pirates did develop a primitive form of catastrophic health insurance, so maybe we can learn a few things from them.
Actually, the part of the report I found most interesting was a transcript of a conversation between Obama and one of his advisers. Dismissing the idea that his individual actions would make a difference, he said about any effort that would seriously affect climate change that "It has to be something collective."
Although he was speaking about the environment, certainly the same is true about health care. As plenty of people have noted, our health care system is in trouble and is in need of radical solutions. I think there are some good suggestions out there. What seems most important to me, as Obama said, is that it must involve multiple parties -– in this case patients, providers, insurers are all going to have to work together.
Importantly, too, I think students must be involved in the decision-making process. After all, we’ll certainly feel the effects of these changes. For example, we need to push for debt relief to make it easier for more students to choose primary care or research-based careers. I think most of us in medical school understand that we will need to continue to be involved in the politics of health care issues throughout our careers. If we fail to work collectively (either because some of us don’t do our part and assume someone else will get involved for us, or because we students as a group don’t cooperate with other groups in joint efforts), it’s not going to work. As much as it pains me to admit it, the pirate’s hostile approach to solving problems (pillage, drink some grog, pillage some more, make those who don’t like it walk the plank) is not really what we need.
Like most people, I think I’ve been sleep-deprived pretty much since the start of my GCSEs when I was 15. I can’t blame it all on work; nights out and extra-curricular stuff probably have something to do with it!
But since starting uni, and especially clinical school, where life seems to happen at the expense of sleep, I’ve really learnt that sleep is somewhat optional.
I got called up at 7pm one evening and asked to go assist in an organ retrieval operation overnight. Not having put my name down for that day, I was not at all prepared and had stayed up later than was good for me the night before. It perhaps would have been sensible to get some sleep in the evening before the operation, but I was at my supervisor’s leaving party and didn’t want to go home. So I stayed up watching bad TV until midnight. And then went with the team to Oxford.
The retrieval went very smoothly and I was able to get very involved. After we got dropped back at Cambridge, I went straight to my (less exciting) lectures, finally going to bed late that evening. A couple of my friends have also done similar things, and most people who were undergrads at Cambridge have stayed up all night at a May Ball and then gone straight on to day-time parties. It wasn’t the ability to be awake overnight that surprised me, but the fact that I was able to function competently throughout it and then carry on the next day.
This must be trivial for most people, but it was a pretty big thing for me. I’d never pulled an all-nighter before this transplant and I’m pretty protective of my sleep normally! But ultimately, it must be mind over matter. In surgery, I had no choice but to be on the ball. I made a demand on my body and it responded. Undergrad was pretty mentally challenging, but I’m discovering the clinical school packs its punch in physical challenges. Bring it on! An education is not just in the facts you learn but also in what you learn about yourself, and that was a particularly satisfying lesson.
My Temporary Insanity
Jeff Wonoprabowo -- Right now I am writing this a few days before midterm exams. By the time this post goes live on The Differential, I expect I'll be in the middle of exam week. Exam weeks are never fun -- at least not for me.
Usually I'm pretty sleep-deprived during exam week. I stay up as late as I can trying to get that last bit of info to stick, wake up as close to the exam time as I can, take the exam, eat lunch, short nap, and repeat for the next day. It's not the healthiest way to spend a week. But then again, medical school isn't exactly the healthiest way to spend four years.
Occasionally, when the clock reads something like 2:30 AM, I find myself doing the strangest things. Well maybe I should say I find myself doing normal things at the strangest time of day. In the middle of cramming, I might get up, go to the bathroom, spray some shaving cream on my face, and start shaving. Another time, I started cleaning the toilet bowl in the early morning hours. I think I may have started vacuuming once.
Who does these things in the middle of the night? It's like I am suddenly struck by compulsions to do things I should probably save for later.
I would like to think that I only do these things because I am desperately trying to find a reason to take a break. I just hope these stress-induced episodes are not indications that I might be predisposed to some psychological problem.
Maybe I just need to do a better job of studying in the weeks before exams. That way, on the night before an exam, I can go to sleep by 10:00 pm because I am so confident in the studying I have already done.
So the prescription for my temporary insanity? Efficient, daily studying... Who knew studying could be therapeutic?
Vote for Health
Thomas Robey -- Did your man win? No matter your answer, there are more Americans this year than ever who can answer that question. There have been a few nods to this year’s election here at The Differential. If you’re from the US and reading this, you are probably in the voting demographic cited as having the most impact on this outcome. So if this was the first time you voted (no matter who you voted for), congratulations.
But waiting in line for three hours or slogging through pages of propositions doesn’t entitle you to complacency for the next four years. Whether in New York or New Guinea, the UK or the UAE, we medical students have our hands full with future careers in health care. If the stresses of caring for patients -– limited supplies, long hours, unintelligible reimbursement procedures, and the complexity of disease -– aren’t enough, take a moment to consider your patients. Issues such as limited housing, decisions between food and medicine, neglected diseases, and access to care transcend what we learn in medical school. These are in the academic domain of social and political scientists. They are also problems that outlast any elected official.
The transient nature of representative government makes health care issues difficult to address. The kind of quick fixes officials make to get re-elected may conflict with a cogent long-term approach. For a few moments –- in between debates about the war and the global financial crisis -– I heard talk about a plan to expand the American health care system to improve access for more than 40 million in the US who cannot pay for health care. I think I remember talk like that 15 years ago.
Politicians come and go, but medicine is a career for life. Many of us would rather name it a calling. Why not pick up the phone and call your representative to say, “I’m in the business of caring for the sick, and my company needs a bailout?” And after you get a canned response that health care is important to so-and-so, thank you for your vote, find an evening clinic that needs a volunteer provider. Maybe someday you’ll open your own clinic. Or consider malaria or dengue fever as a research topic. Or take a few more classes to get an MPH or other degree that will help you understand the health system so that you can take the next step of fixing it.
After November 4, 2008, there’s a lot of excitement around the United States, and the world. I’m afraid that response will fall into the category of patients we worry about the most: lost to follow-up.
When Burnout Leads to Suicide
Kendra Campbell -- A few months ago, I received a phone call that I’ll never forget. An obviously distressed friend and fellow med student was on the line. In between the sounds of sobbing, she related to me the most unbelievable truth. Another friend and fellow medical student was dead. He had committed suicide the night before. I nearly dropped my phone. I was, of course, in complete shock and didn’t understand what was happening. Time has passed since then, but the shock has still not faded. I can’t believe he’s gone.
Unfortunately, my experience is not all that unique. Many studies have documented the fact that medical students have higher rates of suicide than that of the general population. And guess what profession has the highest rate of suicide? You guessed it, physicians.
We have known for many years that medical students and physicians have higher rates of suicide. Studies have shown that psychiatrists, anesthesiologists, and emergency physicians, in particular, have the highest of all physician suicide rates. It’s been posited that this is because these fields involve incredibly high levels of stress, and access to drugs of abuse. For years, researchers have documented that depression combined with drug or alcohol addiction contributes to the likelihood that someone will commit suicide. And perhaps not surprisingly, the rates of depression and drug or alcohol abuse have also been found to be high amongst medical students and physicians.
A study recently published in the Annals of Internal Medicine has started to shine some much needed light on one of the variables involved with med student suicide. The authors found that one factor, in particular, was linked to the probability of a med student committing suicide. And guess what that factor was? Burnout. Should we be surprised?
I wrote an article last month that expressed my own feelings of burnout, and questioned whether or not torturing medical students was a valid method of education. I’ve since had even more time to reflect on these thoughts. I’ve also spent a good deal of time thinking about the death of my friend, and the factors that might have contributed to him making the choice he did.
Can I say that the pressures of medical school absolutely led to his death? Definitely not. But do I believe that the unbelievable amount of stress and pressure to do well in school contributed to his choice? Yes, I think I do.
Just today, I sat in an open discussion at my hospital, led by a senior physician. One student spoke up and complained about the fact that some residents and attendings had been very mean to him at times. He also mentioned the long hours, and the sometimes belittling treatment that med students receive. The physician's response? That’s just the way it is. That’s what he himself had to deal with to make it through medical school many years ago. And he said that when that student eventually becomes a resident or attending physician, he will also treat medical students the same way.
So, are we to believe that this is all simply a fact of life? Is this just the way it has to be? Is the stress simply inevitable? Are the resultant deaths also simply inevitable? Must this cycle of abuse continue, similar to the cycle of abuse in families?
I’m sorry, but I refuse to accept this as truth.
Ben Bryner -- If you're in med school or applying now, someone has probably emailed you this article by Dr. Pauline Chen in The New York Times about medical student burnout. (Or, if you're me, four people have done so -- are they trying to tell me something?) In the article, Dr Chen refers to a survey of medical students that showed widespread signs of burnout and a high incidence of suicidal ideation, as well as relating her own feelings of despair during medical school. It’s certainly an interesting topic and I'd like to hear some of my fellow bloggers' thoughts on it, too.
Burnout, as defined by Dr. Christina Maslach (who designed the Maslach Burnout Inventory to formally assess it) includes three elements: exhaustion, cynicism and feelings of inefficacy. It seems to me that med students are already at a disadvantage because of the third one; med school is a means to an end, a gateway to another training program where one will acquire the specific skills necessary to achieve the end goal (helping people). One of the hardest things about medical school is not being able to really help. By far the most satisfying experiences in medical school have been when for some reason I've actually been able to help someone, and the most disillusioning experiences have been when not just me but my whole team hasn't been able to help a patient. Most of the former experiences have been when I've sat down with a patient for a half hour or so and listened to their story, as time is mostly what I have to offer as a med student, and occasionally that does some good. Not much, but I've noticed I'm usually happier going home on those days.
As far as the latter goes, one experience I remember was during my cardiology rotation. One of my patients (meaning I'd taken his history, examined him and written his admission note; "presented" him to the team the next day; called and kept track of his consults; and discussed all of the above with the intern assigned to him) was about ready to go home. Mr. E had a previous diagnosis of aortic valve stenosis that was causing worsening heart failure. After much discussion and consultation, it was agreed that the risks of a procedure on the valve outweighed the benefit. The increasing workload facing his left ventricle as it tried to generate enough force to push the blood through a narrowing valve would eventually cause his death. He understood the situation and the bleak prognosis.
I brought my draft of the discharge paperwork to my resident so he could look it over. One of the sections in our discharge summary is the clinical course, or a summary of all the progress notes that covers everything that happened from the point of admission to the time of discharge. With patients who've been in the hospital for weeks, the clinical course can get out of control. Our EMR imposes a character limit on the note, which can mean going back over the note several times trying to tighten it up -- maybe the only time that editing skills come in handy as a medical student. But this time it was fairly brief; Mr. E had only been there a few days. As my resident read that section, he remarked, "Wow, we really didn't do anything for this guy." He didn't say it angrily or sadly or cynically, it was just a neutral declaration of fact.
It was difficult to realize that he was correct. It's always tough to give people bad news, but that's part of medicine; what made this worse than usual was the fact that he didn't get a new diagnosis or a new definitive treatment, just confirmation that he was going to die. If I had taken the Maslach Burnout Inventory that morning, I'm sure the answer choices to the questions that assess inefficacy wouldn't have been strong enough.
Since it was the weekend, I had time to sit down with Mr. E and his wife and talk as they waited for their ride. He was upset about having to take his last potassium tablet. He wanted to wait and take it at home. (I told him I certainly wasn't going to stop him.) Eventually we started talking about something else, about the things he was going to do that week and for the next few months. It wasn't enough to completely ward off feelings of burnout that day, but it was something.
When All You Can Do Is Watch
The only thing that’s going through my mind is “oh my god, he’s 19.” He got a brain tumour, and he’s only 19. The surgeon’s talking about excision and radiotherapy, and I’m trying to compose my facial expression into something less shocked.
The whole family’s there -– mum, dad and son. Their reactions are heart-breakingly middle-class. Sat in the middle, as though being protected, the boy writes down key words “glioblastoma” and “high-grade” deliberately on a small pad of paper. No doubt there’s going to be a lot of wikipedia searching later, trying to make sense of the crashing into their lives. The dad’s pretty steely but he’s no fool; he places his arm around his son’s shoulders. The mum’s the only one shedding tears actually, and she’s restrained about it.
I don’t think the news came as a shock to them. And they all know what the answer’s going to be when the son asks, “I’m training to be a pilot; can I still fly?” No. That’s what he writes down in response. Meticulously, he writes that damning word down.
He acts as though it’s no big deal, like he’s just been told he can’t eat broccoli again. He doesn’t even seem to hear when the surgeon tells him he might still be allowed to drive. A career over before it starts. A life over before it starts. That’s what I saw today. And that’s what got to me. Most of neurology and neurosurgery is a futile fight. You prove to the patient that their taxes haven’t been wasted because you can tell them exactly why they’re getting those pesky symptoms. But most of what you do seems like blowing into the wind.
And as a student, you feel sometimes that you’re not even doing that. I imagine it as being by the side of a road, watching a terrible accident unfold. And not only can you not do anything about it, but the victim can see that you can do nothing about it. I have never wanted to be out of the room during a consultation, but today would definitely have been a good day for the ground to open and swallow me up. Every now and then, one of the family members would make eye contact with me. And I would return their nod or faint smile of acknowledgement, hating myself inside for being there. Because this is a moment of grief, and one deserves the right to experience grief in private. Did they mind me being there? Probably not. Are these situations unavoidable? Almost certainly. But it doesn’t help to be there when all you can you can do is watch.