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Monday Jan 08, 2018

Physician Authors Offer Prescription for Self-reflection

There are a lot of areas in medicine that we have to explore and develop skills for on our own. We are trained in palliative care and hospice, taught ethics and instructed how to deliver bad news, but none of the coursework or even the clinical rotations prepare us for the toll these relationships and end-of-life discussions will take on us as physicians.

[person taking a book from a shelf of books]

The biggest area physicians are left to explore alone is our own morbidity and mortality. Sadly, we often fail to prioritize ourselves.

I can remember as early as my intern year looking for books, conferences and other physicians to answer this need -- basically, anything that I thought could help me navigate the complexity of grief, death and how to maintain resilience. The biggest hurdle during residency for most people is the lack of time to do anything but residency. This was especially trying for me because I had a family I wanted to spend time with when I wasn't at the hospital.

An article published in the Saturday Evening Post in 2013 started to scratch the surface. "How Doctors Die"(www.saturdayeveningpost.com) by Ken Murray, M.D., explored the difference in end-of-life care that doctors provide for patients versus what they ultimately choose for themselves when faced with the same clinical scenarios. But even this article failed to deliver the emotional complexity I sought. It was an important piece of the puzzle and it helped me process the ethics of the end-of-life decisions we as physicians help patients and families make, but it didn't address our own limitations or mortality.

During the past year, after finding ways to better manage my time, I finally made my way through a stack of books I'd been accumulating, and they were exactly what I needed.

The first one I tackled was In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope by Rana Awdish, M.D. The author does a wonderful job of dissecting the patient experience from her perspective as a patient in her own ICU.

In rural primary care, I sometimes take for granted the relationships I have with my patients, especially the more complicated ones I see often. When you see a patient frequently, it is much easier to understand their priorities, what motivates them and what they fear. That level of understanding and rapport is often missed in both critical care and inpatient settings for multiple reasons, but Awdish provides insights into how that gap can be mended. She came frighteningly close to dying more than once and shares the lessons she learned in a form other physicians can benefit from because few of us will experience what she and our patients have.

The deepest dive into one's own mortality is When Breath Becomes Air by Paul Kalanithi, M.D. Kalanithi, like Awdish, wrote about struggling with continuing to work in a rigorous clinical setting while feeling truly awful. I've written previously about what drives us to work when we are sick, but these two physicians took it to extremes, learned from those experiences and tried to change that culture in their own ways.

Kalanithi had to develop what I'm sure was an embarrassing and raw display of humble honesty in the operating room when he needed assistance, something we are all reluctant to do in health care, but need to be better at. There are too many important lessons in this book to boil it down to one overarching message, but what I think we all owe Kalanithi is to read this book and appreciate his respect and interest in mortality and work-life balance.

The sentence that I recall over and over again is the moment when one of Kalanithi's attendings tells him he likely needs to be at home more, to which Kalanithi responds in a way only a dying neurosurgery resident could: by saying that the attending should likely spend more time at home, also. Point taken.

So many people had recommended I read My Own Country: A Doctor's Story of a Town and Its People in the Age of AIDS by Abraham Verghese, M.D., that I had developed an annoyance with the idea of the book. It was described to me as a book about an infectious disease specialist who uncovers a gay community in rural Appalachia, but I'm so glad I finally read it because that is not what it is about. This book is about feeling isolated as a physician (despite being around other physicians) and providing rural primary care. From now on, I will recommend that every student who rotates with me read this book.

Verghese dedicated himself to not only caring for, but truly getting to know, dying patients and their families. He could have easily sat in his office following CD4 counts, but instead he did home visits, outreach and research, and put up with now unimaginable levels of adversity because of the disease his patients had.

His book is about HIV and AIDS during a time when we knew very little about the disease or its transmission, let alone any possible treatment for it. Every patient Verghese cared for was going to die -- soon -- and he felt the weight of that burden accumulate on his life as a physician, husband, son and father. And although I was disappointed by the last chapter (when he leaves rural Tennessee), it was probably exactly the lesson I needed.

All three of these books are extremely different, written by different types of physicians who had vastly different experiences. Kalanithi died. Awdish almost died (a few times), and everyone but Verghese thought he was going to get AIDS from a patient and die.

Thankfully, all three physicians put their observations and feelings into words. Although for different reasons, they all felt they were failing their patients at times, they all felt they were disappointing their families, and in strikingly different ways, they all questioned their profession. They all reached a point of having to choose between continuing an unsustainable clinical practice, stepping down or changing practice settings. They all struggled with the desire to maintain direct patient care even when it seemed physically and/or emotionally impossible. They were all forced to envision the world around them without them, and then were able to incorporate that introspection into their professional and personal lives.

We shouldn't have to face death to make reasonable lifestyle decisions, but often that seems to be one of the only successful motivators. Hopefully, we can learn from the reflections of others and begin a sea change of self-reflection that results in more reasonable and sustainable decisions for ourselves.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.

Posted at 04:24PM Jan 08, 2018 by Kimberly Becher, M.D.

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