Thank you for being a good doctor.

So apparently it works.

Two days after I posted my last post on trying to maintain compassion, empathy, and respect no matter how difficult some patient encounters were, I received a positive encouragement that this was indeed a worthy goal to achieve on every shift.

I was finishing up another tiring shift, hiding in a corner as I usually do trying desperately to finish my charts while avoiding any further eye-contact with any living creature, when a familiar voice came from just around the corner.

I looked. A scruffy-looking man with messy hair and worn down face stared down at me.

"Oh by the way, sorry to bother you, but I just want to say thank you for being a good doctor to me yesterday. I know I was being difficult, but thank you for looking after me...".

My heart melted. My defensive posture gone.

"Nono, I'm glad to see you doing better. How are you feeling?"

"Oh a lot better now, thank you doctor..."

I smiled. And broke up eye contact soon after and briskly returned to my charts. But I felt happy.

He was indeed very difficult the day before. Had it not been for my earlier reminder for myself to be nice against all odds, I very well could have casted him aside. Even had I treated him correctly medically, I would have given him the cold shoulder. He was loud, obnoxious, demanding. He was moaning and calling out such that the entire department could hear him. Sure he might have been in pain, but so many more tamed souls would have simply suffered in silence, or at least asked for help in a more respectable manner. He wasn't even from our region. I was working in Maple Ridge; he was from Surrey. His "relatives" merely decided to drive him here and simply dropped him off. The night before, apparently he was at a different hospital at New Westminster, likely in a similar unpleasant manner, and likely somewhat deserving so that he got the cold shoulder from other ER docs there and left without getting much attention. Today, he was coughing, he was complainting of nausea, he was retching badly and kept calling out for pain meds or other requests. Yes those might have been legitimate request, but comparatively he really wasn't that ill to demand that much vocalization. He has a history of substance use, which no doubt contributed to his difficult character. All my nurses hated dealing with him. Most were dead set on not having me admit him to hospital under any circumstances. Had it not been my worry about his vomiting potentially causing an esophageal injury and that he likely won't be very compliant with any outpatient treatment I bestow on him, I also might have leaned towards discharging him. But I softened. Objectively, he deserved a stay. So I kept him, and quickly apologized to all my nurses for leaving them with most likely an evening of endless demands and moans.

Obviously, in this case, I guess I made the right call.

Lately I have been feeling rather blessed. I had recently got a new condo in an area I've been longing to move into. I've been excited at the prospect of a new home, and new furnitures, and a new living style. While I continue to live a very very modest lifestyle, I have no doubt numerous luxuries easily among my reach. I choose to live somewhat under my means merely as a form of discipline, and because I continue to practice sound financial judgements and planning. But, sometimes, by allowing myself to enjoy a certain luxury, I also allow myself to remember how blessed that I am. Sure, my job is tough, and I honestly feel that every dollar I earn is by trading a little bit of my health and livelihood (there has been many studies on the negative health effects of doing shift work as well as working in a high risk environment such as the ER). But, simply being in the position to work for this type of living is a tremendous privilege. And the more I am aware of my comfortable lifestyle, the more I can see the vast contrast in many of the patients whom I see every day.

As I mentioned in my last entry, in the ER we treat many of the most vulnerable people in our region. Most of these are unpleasant characters that, one could argue, might have found themselves in those situation by their own doing. However, in our society, very often once you are down, no matter the reason, it is very difficult to get back up. These people are difficult for us to treat, and often their actions don't make it any easier. But I try to remember, that no matter how challenging the interaction might be, they are the one who are in need, and I am the one who gets to get into my car and drive back to the comforts of my home at the end of my shift. No matter what, I am the one who has more to give than they do, and it is my job to do so.

I will not be perfect. There is no way I can keep up this positive attitude through out my working career. It is likely that within the first 30 minutes of my next shift I will lose all this perspective. But I will try to remember it as much I can. And the look on the face of that despicable man, as he was thanking me, would serve as a very clear reminder that it is all worth trying.

Compassion, Empathy, Respect.

Some of the most difficult lessons in my job are also the most easily forgotten ones.

No matter how much you set out to start your shift with lots of positive energy and compassion, after going through a bunch of patients in a high pressure and time constrained environment, very soon all of that is gone. You become short, blunt, angry, ever more frustrated when you pick up the next chart. It also doesn't help when the next chart you see has a complaint that should have no place being in the ER. Medication requests, chronic pain issues, simple skin infection, a cold.

You look around the waiting room and there are people waiting upwards of 4 hours. There are kids crying 2 hours into their stay. There are people with broken bones, some of them still waiting.

And you have to deal with medication freaken request? (Of course these are triaged lower accordingly, but you would eventually have to see them nonetheless, and that still makes other people who are already waiting wait ever longer...).

How can I possibly not lose my cool in that moment?

I have, of course. I show them a stern face. I lose my usual friendly smile. I deliberately take away my bedside manner. As a form of protest. You should not be here. You are making other people wait. It is unfair to them.

Of course, all that is reasonable in this context. But this is also when things can be missed.

No, nothing bad happened fortunately. I am writing this purely as a reflection after a series of busy shifts and with my patience wearing ever so thin with quite a few of these seemingly "unnecessary Emergency visits". I was growing increasing frustrated. But I also realized I was getting increasingly blunt. And that has to stop.

I have to remember. In the ER we deal with some of the most vulnerable patients out there. And many of them know that they probably shouldn't be there. Many of them, in fact, are quite apologetic, even embarrassed, when they are finally seen. They know the landscape. They know long ER wait time is a wide spread issue.

But, problems big or small, they are probably all there willingly waiting, sometimes upwards of 3-4 hours, for one very simple reason. They are desperate. They are scared. They have one thing on their mind making them tough it out until they see me.

After a few of these busy shift, I have to be honest I felt slightly regretful that I lost my cool a few times. No I didn't act out against the patient. I just lost my empathy towards them. I lost any compassion for the seemingly minor problems they present with. In some cases, I lost respect for them as a person.

And that's a line I should not cross, no matter how tired, how busy, how frustrated I am on shift. But it is not one that is easy to remember in the heat of the moment, for an emotional person such as myself.

Every patient, problems big or small, deserves a certain degree of empathy, compassion, and respect. Even if they honestly have no right being there. Those are their given rights that they shall receive.

After a tough overnight shift I had last week, when I was physically and mentally drained, I had a moment of reflection. Quite often, it is hard for me to offer them everything that they might want on their visit. No, I will not fill that narcotic prescription you are seeking. No, you do not need an urgent CT scan now. No, you do not need to stay in hospital for this, in fact it's better for you to be at home. No, I can't do anything more for you today.

But while those other things have financial and opportunity costs to the patient or the system, giving compassion and respect is free. At the very least, that's what I can offer to them. That's what anyone shall always offer, to be honest.

I'll be be first to admit, and I think any doctor will say the same, that after working in medicine for a while, especially in the high stressed environment that is the ER, you start to lose a bit of humanity. People are simply another chart, another headache, another number. You try to keep your department afloat by being efficient, organized. You focus on flow. As one doctor puts it, you learn how to "move the meat".

When patients are reduced to that singular impression, you lose sight that they are, well, people.

Family medicine taught us well to focus on four factors, called FIFE: Fears, Ideas, Feelings, and Expectations. Those are what we try to flush out during any patient encounter.

When I first started working in the ED, I thought those four mental checklists are extremely applicable and important. But I'll be honest, even only after a few years, I have very often completely forgotten about them.

But no. They are people. They are not meat. Do not lose my humanity in this job.

Before my shift last night, I took a moment and recycled these three words in my head. Compassion, Empathy, Respect. I told myself I will excise all of them on every patient, no matter how busy it is.

Simply an hour into my shift, I already found it difficult to maintain that mindset. But I remembered, and continued to practice it. In the end, I felt good about my shift, and it had nothing to do with the type of cases I had treated.

In medicine we spend hours keeping up with medical knowledge and newest research and advances. Eventually those technical aspects are simply second nature. As we get older and become more seasoned as physicians, I think some of the most difficult lesson has to do with maintaining our humanity. How to not lose our kindness. How to not lose ourselves.

That, perhaps, is the ultimate life long lesson, and one that we need frequent reminders almost every day when we head to work in order to maintain. That, to me, is some of the biggest challenge in medicine.