Calling for empathy. At 3am.

4pm. Friday. Sunny afternoon in the last week of 2016.

I've finally settled into my comfortable desk, warm slippers and all, in recovering mode after my overnight shift. It's customary for me now to take a snooze a the hospital (about 45 minutes from where I live) after each night shift for fear of dozing off at the wheel on the drive home (almost happened a number of times). But that also eats into my post-night-shift free time. As I finished my work this morning at 9am (official off time was 8am but I'm used to staying an hour or two behind), I rolled into the springy squeaky hospital call room bed and snoozed unsoundly for about 4 hours. Then, feeling as if I'm utterly sick of the hospital by then, rolled out of bed to grab a light breakfast/lunch before driving home. It's usually late afternoon by the time I get to "catch up" on my life at home. Today, I felt the inspiration to restart my practice of blogging my random and impulsive thoughts (hopefully I can keep it up this time). Today the impulse was to write about empathy. Because after every night shift (or even after some quite testing day shifts), I felt I needed a kind reminder of how to be empathetic again as a doctor.

First off, it is intensely easy to lose empathy as a doctor, particularly with a role on the first line, such as myself as an Emergency Physician, as well as (my other hat), as a Family Physician. Your role as the first line of medical assessment means your time with each patient is diluted, because the key in your job is to push through high volumes of patients, efficiently, effectively, thoughtfully, and hopefully, caringly. Why is your empathy tested? It's easy to be empathetic to one or a few people. We all have kindness in us to give. But when you are seeing 20, 30, sometimes up to 40-50 patients a day (the former more in the ER, the latter sadly in the clinic), imagine listening to patients and patients' many questions and concerns, as well as often numerous complaints or expectations, while realizing you are well behind in the waiting times, and often when you are already utterly exhausted, usually more mentally but sometimes also physically. Last night, when I came on shift at 11pm, there were already about 20 people waiting to see me, many of whom have already been there over 2-3 hours waiting (the previous doctors were already working like maniacs to catch up, but holidays seasons has been often an haunting nightmare in the Emergency Rooms). Plus, usually around that time is a new flux of patient coming in to see the doctor, and I was the only doctor on staff from that point on all until 8 am the next morning. Heavy-hearted, knowing that all these patients are in for a long night along with me, scanning their sad desperate eyes hoping that I would call their name next, it is impossible not to want to rush to seem them all quickly. My friends know this. They know it's my nature not to relax until all my work is done. Seeing a waiting room like this literally eats me alive.

But it is this very notion to get through the list quickly that we, as doctors, must fight to resist. Because rushing though assessments put us at risk of mistakes and errors in judgement. And also, it eats into our empathy.

Some people are totally deserving of being in the Emergency Room. There is usually little difficulty in finding empathy for those people and their families. But many others do not seemingly seem they are in the right place for their concerns. And it is these patients, some of which have waited for hours just to get an question in for you, that you have to dig really hard to find empathy for. I try to remind myself, that if someone has waited 4 hours to see me, even if I truly believe they should not be there in the first place, they deserve at least a good few minutes of my undivided attention and care. More importantly, some of the hardest cases to deal with in the ER are patients to seemingly look well and have no right being in the ER, but yet actually presents with some pretty serious underlying condition that you better not miss and will only find if you are attentive enough. Finally, for both their benefit and mine, I think it is very important for patients to always end their encounters with their doctors on a good note. At the very least, even if I cannot immediately solve their problems (and this happens a lot in the ER), every patient should hopefully feel that they were listen to, that they had a small share of my time and attention, that their worries and their expectations and fears were voiced, and that, even if I have no direct solution, that I cared, and thought about how to help. It's like BayMax in Big Hero 6 (silly reference I know), hopefully they can all feel that they are satisfied with their care, no matter the outcome.

But it's not easily displaying all this, when you are mentally stretched to the limit with multiple things on your plates juggling numerous tasks and often overseeing a mixture of very sick patients to ones who don't seem they need any medical care at all. Those who work with me usually finds that I have a natural friendly and mild manner with patients. But those who know me have also seen me becoming blunt and short with patients when I am stressed. Especially at night, when the wait is long and the light at the end of the tunnel is far from reach, it's very easy becoming the latter. At times like these I try to remember something I learned from a preceptor who always seemed to be controlled and attentive in the most chaotic of environments. I remember asking him how he handed all the stress and distractions. He summarized his approach in one word, "mindfulness" (I actually wrote about this in a previous post I think but it's deserving of a repeated mention). In a zen-like appeal, he explained how he tries to practice mindfulness with each patient encounter, in that, during those brief moments with patients, he allows himself to ignore everything around him, and absorbs himself purely with that patient and his or her problems. It sounds easy, but its exceedingly difficult to achieve in a busy place such as the ED with many problems under your watch. But in those brief moments, I do believe he is able to almost find a little peace within him to reach further to each for each patient. It doesn't seem to take away from his decisiveness and efficiency, and I always remember him as a competent, effective, but very empathetic doctor.

It's easy to lose empathy for patients. It's easy to lose faith in people, when you see patients after patients, many of whom their names and characters get washed out among their medical complaints and symptoms. You start to forget they are people and not just names on charts, with families and loved ones and thoughts and worries and insights. You start focusing on the macro-management of the department, and lose sight of the micro-management of each person. I truly think this is one of the biggest challenge as a doctor. To both be an effective macro and micro-manager. To maintain a certain degree of care, in your voice and in your manners, even if you know truly well that you could care no more. But it's important, not entirely for you in that moment, but for the patient who has so much bottled inside them when they made the decision to come and sit through the hours of wait just to see you for their concerns.

Last night went by, thankfully, with somewhat smooth efficiency. I was mildly rattled by the end of my shift when I was pretty exhausted to have a fresh heart attack patient rolling in at 7:30am (I've not had a break since I started at 11pm, and towards the last hour of your shift is when you really hope nothing "bad" happens so you can quietly tuck into the "night" when your replacement arrives at 8). Thankfully, the nursing staff worked efficiently with me to help manage this patient effectively to get the care that he needed. I don't mind these cases honestly. They are why we have the department open 24 hours a day. I always tell patient never ever apologize for coming to the ER for chest pain. It's what we do and we do very well. Hopefully this man recovers well.

Long post. My apologizes from rambling on in my state of post-night-delirium. But hopefully I'll get in the habit of posting again soon. Mostly, if anything, just as a constant reminder to myself of how to be decent.

One challenge at a time...

It's only been a couple of weeks since returning to work from my short break, and already the intensity and the stress of working in the ER is hitting me.

It's been amazingly busy in the ER lately, at both hospitals where I work. I think that's the expected flow of things in the winter months, particularly at the new year, when doctors are often away, flu bug hits, and patients travel and pick up new diseases.

It's been disheartening and often very discouraging, when I'm already maxed out in my mental abilities, working non stop as fast as I can to move from one patient to the next, while making sure I take my appropriate time and attention with each patient to make them feel like they got their fair share of my care, and to make sure I don't make mistakes or overlook anything in the midst of all this chaos. But the waiting room keeps piling up, and I keep falling behind, and they keep coming. And keep coming. And coming...

This made me think of one of the more favorite movies I watched recently, Matt Damon's the Martian. In the movie Matt's character got stranded on Mars and had to engineer his way to survival and to a eventual unlikely rescue. He encountered endless bad breaks, each one seems insurmountable, but yet he motored through, created a solution, and lived on. Towards the end of the movie he became a professor and answered a question from a student of how he got through his predicament. His answer was, "just focus on solving one problem at a time."

When the world seems crumbling towards you, if you start looking at all of the problems that are coming, you will feel defeated, you will feel there is no way out.

One problem at a time. That's all you can focus on. That is the only solution. Do each problem justice, focus, treat it as the only problem of concern right now, deal with it fully, then move on. That is all you can do. That is the only way to hack away at it.

It's a difficult but high level task to master. As a ER physician, part of your job is to maintain control of your department and manage resources, beds, nursing efforts, and patient flow accordingly. Never must you lost touch with the current activities and demands of your department. It is much like a general in battle. You job is to maintain a pulse on all corners, and be the first to know what to do to keep the department afloat. Having said that, you never lose sight of your primarily obligations, and that is your patients, each and every one of them, when they are sitting before you. In that moment, you learn to shut it all out, even for 5 minutes, and make them feel like it's just you and them then. You give them all of your attention, you try to think of what it is best for them. You deal with their problem.

One problem at a time.

Yesterday I had a very difficult shift. Because I was sick. I couldn't sleep the night before. I woke up with chills and rigors and vomited and almost fainted during my morning shower. I thought about not going in but by that point it was impossible to get a last minute replacement on an early Saturday morning shift. I took 5 minutes to down some warm fluids and half a cup of greek yoguart. Then drove on to work. I thought about the day ahead of me. It felt taunting.

Then I remembered Matt Damon's Martian. One problem at a time. At this point, my first problem is getting to work on time, and arriving safely.

45 minutes later, I arrived at the parking lot of my hospital. I gave a sigh of relieve. First job done. I'm here. On time. I can do this.

I walked in, asked my nurse for an anti-emetic for myself, then picked up my first chart.

I got through the day. Focusing on one patient at a time. Luckily the department was manageable. And I think I did a good job with them all yesterday. I was so relieved when my shift was over. I was so exhausted. But I got through it. Thinking about the Martian.

Today I'm off. Just woke up from a 12-hour sleep. I'm feeling better. Hopefully this will past swiftly before my next shift tomorrow.

One problem at a time.