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Monday Jul 10, 2017

Support of Colleagues, Family, Friends Is Key to Resiliency

A recent post to this blog by Stewart Decker, M.D., beautifully addressed how his community pulled together to provide support after several residents and faculty members were injured in a bus crash, and how important that support was at a time of great vulnerability.  

[AAFP Director Carl Olden, M.D., with his mother, center, and her sister]

Here I am with my mom, MaryEllen Olden, center, and aunt, Elizabeth Gehrke. Mom passed away this spring.

Unfortunately, physicians in such difficult circumstances often try to go it alone, don't ask for help, try not to show weakness and lean on decades-old approaches to medical training that suggest the strongest iron is forged by the fires of making mistakes and learning from them alone.

A surgeon once told me that during his residency orientation, the chief resident instructed interns, "Call me if you're weak." I hope this is not the current mood of teaching physicians, but when I look at my colleagues trying to solve challenges with their electronic health records -- or I when look at quality-of-care issues in my hospital -- I don't see a willingness by physicians to seek help or show vulnerability. Unfortunately, I don't see physicians willingly offering assistance to others in a nonjudgmental way, either.

In an increasingly digital world, this lack of collegiality isn't likely to improve unless we make a conscious effort to address the problem. Physicians' relationships are mostly electronic, and the chances of two or more physicians involved in a single patient's care actually meeting in person to discuss a care plan; review transitions; and create a situation, background, assessment and recommendation communication(www.ihi.org) -- much less meet with the patient and family members -- are pretty slim.

This isolation and dependence on computers contributes to burnout. The AAFP is raising awareness about physician burnout and plans to launch an initiative to help physicians cope with burnout and address work-life balance in September during the Family Medicine Experience in San Antonio.

Because resiliency and burnout are such challenging issues for us as physicians, and because I can remember the names and faces of every one of the colleagues that I have lost to suicide along the way, this is a personal issue for me. We all face significant life challenges, and we get through them in different ways. Some of us need the support of our colleagues, family and our friends. Some rely on our faith or beliefs. Some may need a combination of these factors.

I learned my own lessons about resilience, vulnerability and accepting the help of others in the past 15 months. Here is my story.

A little more than a year ago, my mother scheduled an appointment to see her family physician because she felt weak and dizzy and was having difficulty keeping up with the physical demands of her gardening and full-time work as an accountant. At age 87, you might chalk that up to just getting older, but her longtime family physician knew not to take her complaints lightly. On warfarin for chronic atrial fibrillation, she was having low-grade intestinal bleeding and had become anemic. However, before moving directly to colonoscopy, a more thorough workup revealed a large adrenal carcinoma that already was metastatic.

My brother and I were invited to an appointment with my mother so we could discuss care options. Given the options of leaving the community for what would be a risky surgery and toxic chemotherapy versus palliative care at home, my mother chose the latter. She retired from her job but continued to garden and maintain her home. My brother and I both live nearby, as do all our children, so she had plenty of support. We knew her time would be limited, but she was determined to live life -- and die -- on her own terms.

Sadly, sometimes life gives you more than one great test at a time.

My wife, a fourth-grade teacher, had some particularly challenging students in her classroom during the past school year, and one evening she came home with a terrible headache. I checked her blood pressure, and it was quite elevated.

Susan sees one of my practice partners, and using our patient portal, she was able to schedule an appointment for the next day. At that point her blood pressure was mildly elevated, but better than the night before. She was due for a mammogram, so one was scheduled for the following week. That mammogram showed an abnormality.

In our patient-centered medical neighborhood, physicians are all linked by a secure texting system. I was able to text the radiologist (who also is my patient), who read her mammogram. He was out of town but he called his partner, who called us right away and set up an ultrasound-guided biopsy. Twenty-four hours after biopsy, we had pathology results confirming carcinoma.

I sent a secure text to my favorite general surgeon (also my patient) and we saw him in the office the next day. This was a Friday, and the next Tuesday my wife underwent lumpectomy and sentinel node biopsy at our hospital where, like on Cheers, everybody knows our names.

At 6 a.m. our time on that Tuesday, I called into the AAFP Board meeting in Leawood, Kan., to let everyone know why I would not be at the Board meeting or the AAFP Leadership Conference later that week in Kansas City, Mo. You see, we are family, and the prayers and support of Board colleagues are an important part of our resiliency. By noon Thursday, I was able to speak with AAFP President John Meigs, M.D., and let him know Susan had negative surgical margins and negative nodes. John sent us a video of the entire room at the conference cheering that news!

The following week, we had consultations scheduled with medical oncology on Monday and radiation oncology on Thursday. Then, at midnight Tuesday, I received a call from Lifeline. My mother had triggered her alert and they could not communicate with her. It is a five-minute drive to Mom's house, and -- it being midnight -- I did not wait for the one traffic light I encountered to turn green.

Mom was in bed, and she told me it was time. She had fallen but was able to get back in bed. She said she was ready to go and join Dad, who passed in 2006. I got her comfortable, gave her medication that our palliative care team had prepared and started calling family. We gathered kids, grandkids, and great-grandkids, and everyone got to see Grandma and get a hug and a kiss and say goodbye.

Thirty-six hours later, she peacefully passed in her own bed, exactly as she wanted. It was just before sunrise, and there was time to get the necessary things done before everyone had to get ready for their day's work.

After we dressed Mom in the outfit she had picked out for cremation -- and after the obligatory visits by the fire department, emergency medical servcies, police and, finally, the funeral home -- everyone headed off to start their days. Susan and I met with the radiation oncology consultant, where she had a CT, got her first-ever tattoos, and had the whole treatment course explained.

The following Monday, Susan had her radiation simulation appointment, where they took the measurements to set up a radiation therapy program. This was the first time I was not part of the process, and I admit I felt a little uncertain. But these were the same folks who had treated hundreds of my patients and my partners' patients for more than 30 years. Surely, they deserved my trust.

A week later, after the physicists had completed their treatment programming, there was a final run-through of the simulation and then the first of 20 radiation treatments. Susan still had the rest of the school year to finish and did not want to burden other teachers or lose ground with her students because state testing was rapidly approaching, so her treatments were scheduled around her class schedule. We timed the best route from school to the cancer center, and I planned my schedule so I could meet her every day for treatment even though I couldn't go in with her.

By the third treatment session there was a clear pattern. The radiotherapy reception staff saw Susan as she entered the building, waved her in, and she went right back to change and get treatment. I barely had time to read an email before she was in the lobby and ready to head back to school.

The 20th session came before we could blink, and it was all over. One week after Susan completed treatment for breast cancer, we celebrated our 38th wedding anniversary.

One of the final tasks we had related to these events was to clear out all of the flowers from our home. So many beautiful gifts had come from friends, co-workers and our AAFP family from the time of Susan's diagnosis and my mother's passing to Susan's successful surgery and the completion of radiation therapy that our home looked like a florist's shop!

In my role as the chief medical information officer and director of quality for our community hospital, I recently had the opportunity to have lunch with the new family medicine residents in our community program. I prepared for the meeting by reviewing the personal statements from their residency applications and decided that the best way to make our time together valuable for them was to talk about work-life balance, building resiliency, and recognizing the risks and symptoms of burnout and how to seek help.

I described the community of support and the culture of nurturing and safety that existed around them. Finally, I told them that if someone liked me stopped to ask, "How are you doing?" and waited for an answer, we meant it.

Carl Olden, M.D., is a member of the AAFP Board of Directors.

Posted at 10:30AM Jul 10, 2017 by Carl Olden, M.D.

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