Last Friday I finished another week "on service" where I am responsible for all the children who are admitted to the inpatient unit of the children's hospital. I am also responsible for supervising all the other medical providers, including the medical students, interns, residents, nurse practitioner, and for working collaboratively with our nurses, therapists, nutritionists, pharmacists and others.
- I love it. I hate it.
- I teach a lot. I learn a lot.
- I lead. I follow.
- I am energized. I am drained.
- I succeed. I fail.
Like a teeter-totter, the ups and downs of the week may be balanced, or not. Some weeks are great, some are horrid, and some are just average. I despise average. Lets look at how the parameters were balanced out for my last week on service.
Definitions of success and failure in healthcare
Some define success as curing disease. I define it according to the relationships I have formed with my patients and their families. And, while most of the families I met last week accepted me as a trusted partner in their child's care, even in situations where it wasn't immediately clear what was causing the problem, I had one outstanding failure in this regard. Of course I cannot tell you the specifics of this failure, but I can tell you that it ended in what is likely an irretrievably broken relationship between myself and the parents of a young boy, who is likely to require additional hospitalizations in the future.
The disease process is one which was clear from the outset, the treatment very standardized and precise, and yet this family and I might have been in different universes. Something happened where we weren't connecting, and I perceived danger to the child because of that, and the fact that the family all but refused to allow appropriate treatment to be delivered.
I have had differences of opinions with parents or guardians before, but never, in my three decades of bedside care, have I felt so unable to help them see the necessity of accepting prescribed treatment that is completely and unequivocally indicated by prevailing evidence to prevent significant worsening of the disease process.
In contrast to this very dissatisfying and total failure, I had a wonderful experience with a family whose child had had several admissions in the past, due to a complex and evolving problem. While this child continued to be perplexing, and answers were not as forthcoming as I would have liked, this child's family informed me that this had been by far their BEST experience in a hospital setting ever. They felt I and my team communicated well with them, we were transparent in our expectations, and we admitted what we didn't know.
I also received an email from the grandfather of another patient, thanking me for giving his daughter hope, and lifting her spirits as she contemplates the ongoing care of an infant with a chronic and complex problem.
Clearly, although not uniformly successful, a week well-spent.
Being energized or drained by one's experience
This is a hard one to quantify.
Generally I become energized and excited when I am able to "be a doctor;" when I wear a white coat instead of a business suit. No matter how tired I am from a night on call, or the stress of taking care of sick children, my spirits lift, and I start to smile when I interact with my little patients. I almost always am able to elicit a smile from every patient. Sometimes it takes all week, but when it happens, it really fills my tank, and I know that I have connected with my patient--whether he is an infant, a toddler or an adolescent.
However, some components of doctoring become really draining. Like dealing with the "failure" situation I described above, where I couldn't improve the situation no matter how hard I tried.
So the great majority of my interactions were the energizing type, but a few really worked to suck the life out of me, and, in the end I was left exhausted by the week. I went home Friday, full of the negative energy that comes from frustration, instead of the positive energy that generally accompanies a good week.
I am a physician leader, of course I should lead more than I follow
Maybe. Maybe not.
To be a good physician leader, you need to listen to others as much or more than having others listen to you. For me, I am leading successfully when I am role modeling our patient and family centered precepts, and truly putting the patient in the center of all we do. Listening to parents, especially of a complex or chronically ill child is one of the most important things we can do. Incorporating the family's goals for their particular child into our medical plan is not only advisable, but it is essential if we are to generate positive outcomes.
Likewise, as a physician leader, one has to incorporate the talents of all the members of the health care team, which is why we "round" with so many different professionals at the bedside. The perspective of the pediatric pharmacist, social worker, nurse, respiratory therapist, nutritionist, child life worker, bedside nurse, physical, occupational or speech therapist and case manager can add a lot to the assessment and therapeutic plan for each patient. So sometimes leading well really means following the recommendations of those who know more than you, and not being afraid to acknowledge that they do.
A well-spent week on service for me means I have followed at least as much as I have led, and this particular week, I feel pretty comfortable with the balance achieved in this area. I received lots of input from all of the health care practitioners and families, and did my best to incorporate all perspectives into the plans.
I learn best when I am teaching, and teach best through learning.
A little schizophrenic? Perhaps.
Teaching, for me, is included in every action I do when I am on service. Whether this is formalized, through didactic lessons or informal through bedside demonstrations or observations, I am almost always being watched by someone who is supposed to be learning.
In reality it is not possible to TEACH anyone anything, but it IS possible to FACILITATE LEARNING.
I learned quite a bit from this week's experience. I learned that I may not be as good a communicator as I thought. I learned about some disease processes that I had limited prior exposure to. I learned that no matter how much you think you have taken care of every conceivable possibility in a patient's plan, something unexpected will always happen.
My core team of residents, medical students and nurse-practitioners learned quite a bit about ethical issues in patient care, interactions with the department of social services, and how far a parent has the right to go in determining their child's medical care options. They learned that families do not always accept some of the foundations of disease treatment that the medical establishment considers standard. They learned how hard it is to organize home health care for children with special needs.
I learned much from the parents of my patients. I learned that I (and most of my colleagues) had for many years made assumptions about how home health care was delivered, and that these assumptions were wrong. I learned that parents often have to rely upon each other to receive the education they need to provide a safe environment for their child in the home, because our home care personnel may not be adequately trained to train the parents about certain procedures. I learned that it is amazing more children don't require re-admission because of these lapses.
Overall, I learned more than I taught; meeting my definition of a well-spent week
The love/hate thing
The overall assessment of my week is mostly an emotional one. The internal sense of success or failure, of energy or fatigue, of leading and following, and of teaching and learning generally leaves me with a sense of overall fulfillment (love) or agitation (hate). Even the hate, however, does not mean I hate medicine, or hate what I do.
Its just a feeling.
In fact, when I think about it, reflect upon it, even those very frustrating weeks continue to support my love of my profession, my love of my child patients and their families. No matter how hard it was, no matter how drained I feel in the short term, my love of facilitating the learning of others, of role modeling (for good or bad), my ability to believe that I have contributed something positive to the life of a patient or their family, makes me know that I am very lucky to have found this calling, that I wouldn't change what I do for anything.
So, in fact, no matter how much I might hate specific pieces of the past week, now that I have reflected upon it, and written it down, I really did love my week, as all the good truly outweighed the bad.
This was, indeed, a week well-spent.