THE SURGICAL CONUNDRUM

Chatting with some med students, a good question was raised: how do we, as doctors, deal with the emotional baggage we encounter in our profession? It’s high stress, we see disturbing things, and sometimes we make mistakes that can result in harm to patients. The pressure and responsibility can be very hard to handle.

These stresses, if unmanaged or poorly managed, can carry severe consequences for physicians. Burnout is rampant among docs (and trainees, too). Doctors have high rates of divorce, substance abuse and have the highest suicide rate of any profession.

A normal day at my job is hard: I’m running nonstop for 8 to 12 hours, I’m constantly interrupted, I have patients making demands of my attention and empathy, I’m saturated with information and need to make rapid decision without adequate information, and I know that if I make an error or miss some important piece of information, the human, professional and financial consequences can be disastrous. It’s a pressure cooker.

And that’s a day where things go well. A bad day can be very bad indeed. Sometimes it’s just the emotional strain of dealing with particularly difficult patients. Maybe you go through a run of giving out terrible diagnoses. Maybe you deal with the death of a child. Or a patient who pulls at your heartstrings in some unique and personal way. Maybe someone dies on you unexpectedly. Worse, maybe someone dies on you and you’re not sure if it was your fault or not. Perhaps you know you made an error, and that you’re going to have to face accountability for it.

These are the days that drive physicians over the edge. I’ve had them, and I remember them so vividly even years later. There was the one lady with a gallbladder attack on Thanksgiving, many years ago. She had classic signs and I saw gallstones on my bedside ultrasound. She crashed and died right in front of me from a ruptured thoraco-abdominal aortic aneurysm. Her abdominal aorta had looked normal on my scan; the aneurysm was in the chest and ruptured into the thorax, which is very unusual. That didn’t make it any easier to go home and sleep that night.

So I guess my take on the question is not how do we deal with the psychological stress but how should we? I am not an expert, but here are my thoughts.

The first step, which most practicing professionals have already accomplished, is to learn what is called “professional detachment.” This is an unnatural skill in which you must suppress your innate sympathy for the suffering experienced by a fellow human being, pain which you may be personally inflicting. The first time you stick someone with a needle, it’s probably as traumatic for you as for the patient. More advanced applications involve you ignoring someone’s pain or personal tragedy while trying to figure out the hidden life threat. This is a necessary skill if you are to function in the medical environment.

Another way to think of the same skill is to maintain a sense of distance. Remember, an older teaching physician once told me, the patient is the one with the disease. This helps you remember that the patient’s condition is not your doing (usually) and their outcome, if negative, is the result of their disease and not necessarily a reflection on your care.

While this detachment is useful and necessary, it can be maladaptive if taken to extremes. First of all, as a physician you do need to express empathy and compassion. It’s part of the job. But the emotional demands will be overwhelming if not governed in some fashion; we have limited capacity for caring. My solution is to dole out my compassion and empathy in measured doses, as appropriate to the case and my own mental state. This is not a license to be callous and uncaring in other cases, but rather to be polite, professional and reserved, emotionally.

Furthermore, you need to understand that the professional reserve does not equate to repression of emotion. You suppress it, in the moment, set it aside to get the job done, but that doesn’t mean it never happened. For minor stuff it probably is okay to suppress it & forget it. But the bad things — they won’t go away on their own, but will fester and bubble up at the most inopportune moments. You need to take some time, when appropriate, to unpack the experience and re-live the emotions to deal with them. Maybe it will be just turning the case over in your head the next day. Maybe it needs to be more immediate. We’ve sent docs home after bad pediatric arrests when it was clear they were so upset they needed some time. It’s essential, in any case, to explore the disturbing feelings so you can come to a resolution and move on.

Many institutions will have formal critical incident debriefings for the entire team, for particularly awful events. While this doesn’t need to be performed formally for routine events, it’s a good idea to informally debrief with a trusted partner, superior or mentor. Talk through the case, review the medicine and the science, review your actions and outcomes, and your emotional response to the situation. It is helpful to do this with someone you respect, so he or she can give you valuable feedback. This can be over coffee or a beer or three; possibly better that way.

There can be a lot of shame involved when there was a bad case, even when well-handled, but especially so when you know that you made an error or may have. A lot of docs like to bury these as deep as possible. But these in particular are helpful to talk about, and the more publicly the better. This is not easy, but can be invaluable. We instinctively shy away from openly talking about our mistakes, but when you do you will probably receive a lot of support from your colleagues, many of whom have done the same or understand that “there but for the grace of god go I.” An additional benefit is that your mistakes may have been due to a system error or a cognitive bias and by reframing the discussion in an educational light, by seeking out the root causes, you can improve the quality of your own care and that of your partners.

Keep a sense of perspective, and try to stay positive. When the job is really getting you down, take a break, go out to the ambulance bay, take a few deep breaths and try to remember the big picture. We have a great job. It’s a privilege and an honor to be allowed to care for patients. We can sometimes make a huge difference in people’s lives. We have respect and status in society, and are quite well paid for it. Many people would give their right arm to be where you are. Yes, seeing the 10th drug seeker of your shift is a drag, but damn, it’s still better than sitting at a desk and moving numbers from column A to column B.

Sublimation is a defense technique that is particularly valuable in the ER. It is a form of displacement where the negative feelings are transformed into something positive, or at least more-or-less acceptable. The most common form it takes is “gallows humor.” Tragedy and comedy are deeply linked, and a morbid witticism can provide a lot of relief of the emotional tension that builds up in a clinical setting. Others may channel these feelings into art or literature. To each their own. If this is not your thing, find an outlet. I practice karate, and there’s nothing like pounding the hell out of the heavy bag — or a white belt —after a bad day.

Finally, and possibly most importantly, when you know you screwed up, when you know there was an error that harmed or may have harmed a patient: forgive yourself. You are human, as are we all, and we make mistakes. Take the time to understand it, do your best to learn from it, and forgive yourself. Let go of it, file it away, and move on. If you don’t or can’t, self-doubt and self-hate will paralyze you and in the end it will sink you.

One last thing: if you are really having trouble, get professional help. If you’re self-medicating, or if you are bringing work home to the point it’s affecting your family, be humble and realize that doctors can benefit as much as (or more than) any other patient from psychological counseling and support. Many hospitals have a confidential Physician Assistance Program, staffed by professional counselors trained to deal with the issues doctors struggle with. I’ve seen doctors torpedo their careers with behavior and substance issues, and I’ve seen programs like these successfully rehabilitate physicians who were in a downward spiral. Check with your medical staff office and use the resources that they offer.

HOW ON EARTH I AM IN THE MIDST OF BABIES?

I, being a person who enjoys making fun about my own self, I rarely have any embarrassing moments as such that can really entertain my readers. Yeah, I had two such moments where I had to be embarrassed because I could not hold back my bursting bladder but let loose on a crowded street in my trouser once and in a cab another time. The first incident I had already shared in the comment section of Pradita’s article “Looking for the Loo” and the second one was quite similar to the first one, so I don’t want repeat it again.

Let me share something today which might be quite different than what others have shared or will be sharing.

It was in 2001, February 20th, when I had my second heart surgery. The surgery was over but I was in complete darkness and haze because of the effects of anaesthesia till the next morning. When a nurse woke me up in the morning the very next day, I heard cries of babies all around my bed in the Intensive Care Unit of Manipal Heart Foundation, Bangalore. I saw the morning shift nurses were looking at me with a confusing expressions reflecting on their faces while taking over the duty from the night shift nurses. I thought maybe the young nurses were fascinated by my handsome persona and that’s why they were discussing about me with each other… But I was in such a pain, that I was not so mindful of what they were thinking or discussing. Remember, I just had an open heart surgery a day ago and I was in a state where I only could thank my God for granting me another life.

Minutes later, I realised what they were discussing about me when I overheard a nurse asking a senior nurse in charge of me, “how come this patient of 25 years old was brought in to this Paediatric ICU?” The senior nurse smiled and walked close to me saying, “This is my 25 years old baby who was kept here because there might be a shortage of beds in the adult wards”. And all of them giggled looking at me though not in a bad intention yet I felt embarrassed wondering, why on earth I was between all the babies around me. I forced a smile looking at my nurse but was really mortified to know where I was at that moment as I tried to look around painfully tilting my neck, to see only babies and their cutie nurses all around their respective beds. Soon, to my utter dismay, I realised I was bare completely under the sheets like a new born baby while there were young nurses all around me. When one of them did the whole body sponging and her fingers caressed through my bare skin, at those uncomfortable areas of me, it made me feel embarrassed all the more.  Although I knew there’s no alternative to it and she was just doing what she was supposed to do. Probably, I would have enjoyed the bath if I would have been in a different scenario but not at least in the condition I was in that time. :p

Later that evening when my surgeon came to see me, my first question to him was, “Doc, why am I in a Paediatric ICU?” And it was a new revelation for me as well as the nurses around me when he addressed my question… “Chiradeep, you are a congenital heart patient. Your heart and lungs didn’t develop as of a normal adult and thus a Paediatric Cardiologist can only understand the movements taking place in your body much better than anyone else. That is the reason why you are in this particular ICU.”

After two days, I was shifted to a normal adult ward to my relief and did all my routines on my own that were supposed to be done privately.

Now, years later when I visit my specialist, I wait for my doctor in the OPD sitting along with the babies all around. When I go to the counter to register, they ask, “Where’s the patient, where’s the baby?” And I answer them politely with a smile, “I am the one, I am the patient… I have congenital heart problem and I am supposed to be shown to the Paediatric Cardiologist”.

It has become a habit for me now to get a surprise look from people about me as there are very few like me who must be moving around in the crowd. But I would say, my embarrassment 18 years back was not because of my silly mistakes or oops moments but it was because of a lifestyle that was in the process of being set for me inimitably by God over which I didn’t have any control at all. When I recall all, which have happened in my life in the past or still happening now, I get marvelled and gather them as precious lessons for my life and for the life of others to embrace them, to learn from them and to live.

Stay Blessed!

(Picture Credit: Google Inc.)

BE SAD, NOT DEPRESSED

Sadness is a normal human emotion. Had there been no moments of sadness in our lives, perhaps we would not have cherished the happy moments that life bestows on us. In fact, psychologists of old have identified ‘sadness’ as one of the six major emotions that human beings across all cultures all over the world experience.

Having said that sadness is normal, I would like to draw a line for it. How sad can we be and how long can we be sad?

Events in our lives that affect us directly or indirectly ought to make us sad. If a girl doesn’t feel sad when her parents don’t permit her to marry the guy she loves, perhaps I would question the genuinity of her love. If a boy doesn’t feel sad after flunking in the exams, perhaps he is too casual about his academics. If a father doesn’t feel sad on losing his child, perhaps he is too thick-skinned a person. All such events in our lives provide reasons for us to be sad.

However, if this sadness penetrates too deep that we are not able to come out of it, if it lingers on for months together thereby affecting our thoughts, words and actions, we are likely to sink into depression.

Let’s not confuse depression with sadness. Sadness is normal, whereas depression is not. Sadness can be overcome after a span of time. Depression is a clinical disorder and requires prayerful psychiatric treatment. 

A remorseless person is a likely to have a robotic personality. Let’s not be remorseless. We need to be sad when the situation so demands. But, let us not allow sadness take such a grip on our lives that we sink into bouts of depression.

TURBULENT TIMES AND THE SPARK OF SUCCESS

“Sweet are the uses of adversity

Which, like a toad ugly and venomous,

Wears yet a precious jewel in its head;”

William Shakespeare, through the mouth of Duke Senior, in his famous play, As You likes It, Act 2 Scene 1.

Yes, you are right!……the same old words. Your eyes and ears must have passed these words several times in your career, although William Shakespeare wrote them way back in 1599, and not until 1623 did it make its public debut. Some of us have even read it as part of our English curriculum in School. Two days back, when the very same words, crossed my eyes, for the umpteenth time though, in a newspaper column, it forced me to rethink its meaning in new light. Turbulent times, if endured are definitely the gateway to success.

World renowned American Author and Motivational Speaker, Og Mandino, once said, “Obstacles are necessary for success because in selling, as in all careers of importance, victory comes after many struggles and countless defeats.” There was a phase in my surgical career, wherein every Suprapubic Prostatectomy, i.e. Surgery to remove enlarged Prostate Gland , that I did was ending up with bleeding and eventually getting re-opened. It was just not happening for me. I wasn’t sure whether it was wrong technique that was causing this or poor assisting by my surgical assistants or a combination of both. Slowly a sense of fear crept in and it forced me to avoid doing Prostatectomies anymore. 

I could not sleep at night because doubts about ability and technique crept in pretty quickly. I called my Boss, to watch over me while I operate in order to catch any wrong steps, but alas! None existed. It led us to go back to our books and resources on the net and after exhaustive reading we made some procedural changes. Its been 4 years since that epochal day and not a single Prostatectomy patient has bled. Those procedural changes have become very popular among many surgery specialists. Had my patients not bled a better procedure would never have evolved.

The other day watching an interview of World famous, Skier and Olympic Gold Medalist, Jean-Claude Kelly nailed the idea completely. While skiing, some of the most treacherous runs on Earth, something remarkable happened with him. Out of the razor’s edge, where he felt his greatest discomfort wherein his limiting beliefs started to scream through his brains and tell him that he would never make it down, it was at that opportune moment that he felt the most alive.

He said, “The fear you move through when you go to the edge of your limits actually causes your limits to expand.” This is true not only of Skiing but life as well. That expansion leads to not only better work but greater performance. As Nietzsche said:  “What doesn’t kill you makes you stronger.” 

Most people hide in their shells when the going gets rough. They retreat into their bunkers. They push away anything that’s pulls them the least bit out of their comfort zone. And sadly, in so doing, they push away their chances for growth, mastery and lasting achievements. The brave don’t run. The brave eat their fear before their fear eats them.

If that’s not enough, deep change is a purifier of sorts. Yes, it can tear down the very foundations on which your thinking and way of operating have been built. But just maybe those old foundations need to come down to create space for even better ones to be installed. And during the transition process that lies between the old structures coming down and the new ones being put up in place, it’s a real stress filled, uncertain time. But just maybe it’s like the transition of the Caterpillar morphing into the Butterfly. It looks like a mess but something beautiful is being created. As Novelist Richard Bach, once famously said, “What the Caterpillar calls the end of the World, the Master calls the Butterfly.”

Author’s Bio: Dr. Anupam Dey is a General Surgeon in a Mission Hospital at BISSAMCUTTACK, ODISHA. He is a thinker and a thought provoking writer.

WHAT WILL HAPPEN TO ME AFTER MY DEATH? WHERE WILL I GO?

woman-441415_1280“What?” “I have only one week in my hand?” “Are you sure doctor?” I was shocked and confused as to what words to choose to express my emotions. The doctor calmly replied patting his hand on my shoulder, “Yes…maximum 7 days.”

I couldn’t sleep that night. But after struggling for a few hours I didn’t remember when I fell asleep and started to dream.

I saw… I am standing in a solitary place and there’s light around me. Suddenly I see a medical scientist walking towards me. The thought of death was in my subconscious so I asked him quickly, “Sir, I am dying… Do you know what will happen to me after death?” He looked at me, smiled and said politely, “Sir, I don’t know… according to medical science there are no such proofs of life after death. Death is the dead end for an individual.” And he walked away leaving me in tears.     

Then as I was weeping I saw a Pandit coming towards me. I asked the same question to him in tears and he took out his book and started explaining what Hindu Shastra (Scripture) talks about life after death…

BrahmasoulsHe said… “Most of the Hindus believe in the cycle of birth, death and rebirth, which is called ‘Samsara’.

‘Samsara’ or the doctrine of rebirth is also known as the theory of reincarnation or of transmigration of the soul. This doctrine is considered to be a basic tenet of Hinduism. According to doctrine of rebirth, differences between individuals, even at the time of their birth are due to their past karma i.e. actions done in the past birth. For example if one child is born healthy while another is handicapped or blind, the differences are attributed to their deeds in their previous lives. Those who believe in this theory reason that since all actions may not bear fruit in this life, there has to be another life for facing or reaping the consequences of one’s actions.

It is mentioned in the Bhagvad Gita –

“As a person puts on new garments, giving up old ones, the soul similarly accepts new material bodies, giving up the old and useless.”
(Bhagvad Gita 2:22)

The Doctrine of Re-birth is also described in Brihadaranyaka Upanishad:

“As a Caterpillar which has wriggled to the top of a blade of grass draws itself over to a new blade, so does the soul, after it has put aside its body draws itself over to a new existence. 
(Brihadaranyaka Upanishad 4:4:3)

After he finished reading and explaining he went away.

Then after sometime I saw a Maulvi coming towards me. I greeted him and trapped him too with my question.

He too smiled and started describing calmly. He said…

Jahannam“It is mentioned in the Qur’an

How can ye reject the faith in Allah?
Seeing that ye were without life,
And He gave you life; Then will He cause you to die,
and will He again bring you to life; And again to Him will ye return.
(Al Qur’an 2:28)

Islam states that a human being comes into this world only once, and after he dies, he is again resurrected on the day of judgement. Depending on his deeds he will either dwell in heaven i.e. Paradise or he will dwell in hell.”

(Source: http://www.islamandhinduism.com/ih/life%20after%20death.html#link2)

He too went away his ways.

Two different explanation made me think for little more. I waited and waited for somebody else to come and explain it to me little more. Suddenly I saw a Pastor coming towards me. I ran towards him to meet him and asked him the same question.

We both sat down on a rock and he started explaining what he knows about after life.

RaptureHe said, “What exactly does the Bible say happens after death? …the Bible tells us that after death believers’ souls/spirits are taken to heaven, because their sins are forgiven by having received Christ as Savior (John 3:161836). For believers, death is to be “away from the body and at home with the Lord” (2 Corinthians 5:6-8Philippians 1:23). However, passages such as 1 Corinthians 15:50-54 and 1 Thessalonians 4:13-17 describe believers being resurrected and given glorified bodies. If believers go to be with Christ immediately after death, what is the purpose of this resurrection? It seems that while the souls/spirits of believers go to be with Christ immediately after death, the physical body remains in the grave “sleeping.” At the resurrection of believers, the physical body is resurrected, glorified, and then reunited with the soul/spirit. This reunited and glorified body-soul-spirit will be the possession of believers for eternity in the new heavens and new earth (Revelation21-22)

(Source: http://www.gotquestions.org/what-happens-death.html)

After explaining the Pastor got up, said good bye and went away leaving me alone there confused.

My dream ended when the nurse woke me up for the medicine. I opened my eyes and saw sun rays streaming inside my room. It was morning already and I didn’t realize it.

The dream was in my mind. There were questions popping up and troubling me. I have to decide and believe in somebody as everybody said differently.

I keep thinking and praying: “Oh True God, the Creator of heaven & earth and the whole universe, reveal yourself to me. Let me see and know who you are so that I can believe you and you only. Oh Almighty, reveal the mystery of life after death and let me know what will happen to me after my death? Where will I go eternally?”

 Author’s Bio: Chiradeep Patra is a finance man who works in a NGO at Kolkata. He is a writer, motivator & counselor.