My patient died, yet this is how I find out?

As medical students and again as trainees, a lot of time is spent perfecting the art of breaking bad news. Many of us will have seen it done badly and as uncomfortable and horrible as those situations are, we remember them. Why? Because we absolutely swear never to do it like that.

Over the years, I have gained confidence in my communication skills. I know I can lead these difficult and distressing conversations but despite the experience, it never, ever, gets easier.

For each family, that moment is life-changing. The way in which you deliver that information has repercussions for the rest of their life: the words you choose, your tone of voice, the way you sit, your facial expressions… You slow down, you give them time, you listen, you offer them a shoulder, a tissue, a cup of tea… you do whatever you can to make a seriously shit experience just that tiny bit better.

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So why is it that we don’t do this for each other?

A while ago, I looked after a child who was normally fit and well. He had become ill very quickly. The team had worked hard, doing our best to keep him alive. By the time I went home that evening, the boy was doing better. I was exhausted and thankfully had a few days off after this. When I was next on the ward, I heard a couple of nurses talking as I wandered through. In and amongst what they were saying they seemed to be referring to a recent death. I enquired who they were talking about.

“Oh haven’t you heard, (….) died a couple of nights ago.” They were talking about the boy I had looked after; the one I thought had pulled through; the one who seemed stable… They went on to tell me the clinical ins and outs of the situation. I stood there feeling overwhelmed: deep sadness for him and his family, guilt, uncertainty, what if I had missed something. I started running things over, should I have done something different? And before I had time to begin to process this the ward round commenced.

This is not the first time that I have found out about the death of one of my patients like this: a passing conversation on the ward, finding a bed space unexpectedly empty, a conversation at handover in front of 15 other doctors etc. Finding out like this really disconcerts and destabilises me.

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Why is it that we spend years learning to break bad news to our patients in a sensitive and empathic way, yet when it comes to ourselves and our colleagues, there is very little thought put into how we discuss it. Losing a patient is challenging, no matter where you are in your career. It highlights our personal vulnerability: the sadness of losing of someone we knew well, a reminder of struggles in our own life, self-doubt and questioning of our practice, guilt, a trigger for mental health difficulties.  All of this is completely normal, yet somehow it is overlooked when we talk to each other.

Looking out for each other

A few years ago, I looked after a little boy with a long term condition. He frequently attended the paediatric ward and the staff had all got to know him well: hilarious, witty, cheeky, brave and truly inspiring. He was my favourite. A few months into my maternity leave I received a call from one of my fellow registrars. She thought I should know that this little boy had died a few days earlier. I remember holding my trolley tighter, tears rolling down my cheeks in the supermarket car park.

I look back and realise how much that phone call meant to me. I was able to grieve at the same time as everyone else rather than having to wait until I returned to work to find out. That colleague gave me permission to feel. We are humans after all. It is OK to feel.

So, maybe next time you lose a patient, think of a colleague who deserves to find out in a more sensitive way than overhearing something on the ward or realising there is a missing name on the handover sheet. Give them a ring, check they are OK. Allow yourselves to grieve the loss of a patient. #ItsOKtoTalk

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To admit or not to admit- That is the question (Part 2)

Does admitting vulnerability have to be a bad thing?

I remember a patient I looked after several years ago. She had been admitted to a general paediatric ward with the medical complications of her eating disorder. The idea of nasogastric feeding terrified her. She sat sobbing on her bed. Although I never needed artificial feeding when I had anorexia, I could totally 100% relate to what this girl was going through.

It was a strangely quiet night shift. I had the option of getting some sleep but instead I sat with the girl and we chatted. She cried- I held her. She talked- I listened. As I left the room she said “Nobody has ever got it like that before. Thank you”. The following morning her mother came to find me. She was so grateful for the time that I had spent with her daughter but she had seen through my empathy. “You understand in a way that others don’t, like you know what it is like. Have you had a sister with it or something?”

In that moment I didn’t know what to say. I worried I had crossed the boundary of professionalism, thought I would get into trouble. I don’t even have a sister… I could make one up…… But somehow honesty was the only way. And so I explained that I had suffered from anorexia as a teenager, that I had been in hospital for 3 months and that things had been tough. But I could also tell her that I had come out the other side and now had a healthy relationship with food. The mother looked at me and tears started rolling down her cheeks. I immediately regretted what I had said.  She unexpectedly leant forwards and hugged me. Into my ear she whispered “Thank you, thank you so much for giving me hope.”

Admitting vulnerability doesn’t have to be a bad thing.

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Opening up with patients

All too often in the healthcare sector, we refer to vulnerability as a negative attribute. We are expected to pick ourselves up, brush ourselves off and get on with things. Stigma silences us. In their study, Malterud and colleagues demonstrate that vulnerability can be beneficial in the doctor patient relationship.

Clearly there is a boundary when it comes to sharing our own struggles with patients. After all, we remain the professional in the relationship and as such, need to be aware of how the disclosure may impact on that. Revealing insecurity doesn’t have to be done by spelling things out though. Thoughtful questioning and understanding can be sufficient to help the patient feel valued.

However, opening up can leave us feeling exposed. I was convinced that I would get into trouble for my behaviour. I worried about it for days. What if someone at work found out? What if they thought I could no longer be a good doctor?

It turns out nothing happened. Of course it didn’t. I did nothing wrong. Being true to ourselves isn’t always such a bad thing.

To admit or not to admit- That is the question (Part 1)

 

Admitting vulnerability: never again

Ever since I was a teenager I have struggled with my mental health. I had an inpatient admission at the age of 15 with anorexia, depression and anxiety.  By the time I applied for medical school things had improved. Nonetheless, I divulged my history on the occupational health form sent by the university. I felt I should be honest and admit my vulnerability. The next thing I know, my place at medical school is in question and I am being asked to attend for an assessment the next day. Nobody at that meeting asked about my emotional well-being. Instead they weighed me, told me I had put on 17kg and therefore deemed that I was fit to be a medical student.

From that day onwards I knew that being honest about my emotional state was not an option and would jeopardise my career as a doctor. I went on to spend most of medical school expecting to be found out. Someone along the way would realise that I was “crazy” and would kick me out.

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“From that day onwards I knew that being honest about my emotional state was not an option and would jeopardise my career as a doctor.”

Speaking out at work

It is now well reported that doctors have higher rates of suicide than the general public. Devastatingly, several of those who resort to suicide have not received any professional help at all. So why is it that doctors struggle speak out?

Clare Gerada is known for her work on supporting the mental health and wellbeing of doctors. She speaks vehemently on physician suicide and advocates for reducing stigma.

There is something about seeking help as a doctor which instils a sense of failure, a fundamental weakness. I have written about this previously. Until culture changes amongst doctors, until senior physicians open up and set an example, we will continue to struggle on in silence. In response to this, the Doctors Support Network has recently launched a campaign encouraging senior practitioners to share their stories and demonstrate there is no shame in admitting that we need help. They also offer support and advice for struggling doctors. Worth a look.

Awareness around mental health and wellbeing in doctors is thankfully improving. The government has recently invested a large amount of money into improving the support offered to doctors returning to training. It is recognised that junior doctors take time out for a multitude of reasons (be it maternity/adoption leave, research, sickness, caring responsibilities etc). Training days on resilience skills and wellbeing, mentoring programs and improving training for supervisors are all examples of how we can work together to improve support.

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Having decided to speak out about my mental illness after things spiralled out of control last year, I realised that the greatest stigma came from myself. Only one person at work has responded negatively to my disclosure. Everyone else has been nothing other than compassionate and supportive. So maybe the first step in reducing the stigma is to admit to ourselves that we aren’t a failure, we aren’t weak. We are normal.

 

 

Medicine- vocation or job?

Medicine was a career choice that I made when I was nine. I had no doctors in my family. In fact I didn’t know that much about it at all, but somehow there was never another option. It was always medicine. And so, I did what I had to in order for that to happen.

At school I applied myself, worked hard and got good grades. At university I did the same. Medicine excited me. There was a passion that I can’t describe, a love of everything that it represented.

 

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This was my favorite outfit when I was about four or five!

 

After I graduated and began working on the wards, I maintained the same excited enthusiasm. I would happily pick up extra shifts, not for the money, but for the feeling of belonging to a team and pitching in. I genuinely enjoyed being there. I relished the relationships with patients and their families. It gave me a sense of purpose, of worth.

Over time, my experience in the NHS opened my eyes to a different facade of medicine. I am not naturally a leader, certainly not in a social setting, in fact I try to blend into the background when sitting around a busy dinner table. Somehow on the ward, that social anxiety completely dissipates. I become a leader and thrive on it. I strive to improve patient care, to support my colleagues, to teach the medical students. I am engaging and confident.  Well, I was…pexels-photo-875512.jpeg

The current climate of NHS began to grind me down. The hurdles, the barriers, the tick boxes. I was morphing into a service provider. My individuality was being stripped away. I felt more and more like a fish finger on a conveyor belt to consultancy.

The general negativity on the wards fueled my pessimism. The moaning, grumbling and reluctance among junior doctors and nurses were growing. There were significant rota gaps, an obligation to cover colleagues who were off and a sense of having to perform and behave in a certain way. As a thirty odd year old professional, I felt like a school child. Being a doctor no longer felt like a vocation or a passion. In fact I had grown to despise my job and everything about the system that I worked in.

I was burnt out. Worn out. Exhausted. Depressed.

A year later, as I embark on my return to medicine, I wonder whether I can reignite the passion, ambition and excitement that I used to have.

How much passion do you have left for medicine? Can being a doctor just be a job?

I broke

Three weeks today I return to work after a long period away. This wasn’t leave that I had looked forward to or planned. It was imposed on me by my health, or perhaps I should say my ill health.

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Back in June 2017 things had got pretty bad. In fact I hadn’t really realised how bad. It had all crept up on me insidiously. A thick dark fog had descended on the world. My soul, my passion and my enthusiasm for life seeped from my exhausted body. Yet my mind was racing, my thoughts so jumbled that at times that I could not make sense of them. I was worn out by the constant indecision, the questioning, the anticipation and anxiety. I felt like I was at breaking point but was compelled to carry on. Giving up work was not an option. In fact I despised myself for showing any sign of weakness; having time off epitomised failure as a medical professional.  People tried to tell me otherwise, but when it came to my situation, all I heard were empty words.

 

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There is a culture ingrained in medicine of not asking for help. Fragility and vulnerability are not desirable attributes in a doctor.  This misconception silenced me for years. I tried my best to be tough, to repeatedly pick myself up, dust myself off and crack on. So, when my psychiatrist advised me to take some time off work, I sat opposite him and sobbed. I was broken. I was a failure. My job had finally defeated me.

As I left my local GP surgery the following day with a sick note in my bag, all I felt was guilt. My colleagues, my patients, their families… nowhere in that moment did I think to spare a thought for myself. Medicine teaches us to be kind, empathic and caring. Maybe it’s time that we started to treat ourselves with that same level of compassion…

What do you do for yourself?