Next Generation is a BWH Clinical & Research News (CRN) column penned by students, residents, fellows and postdocs. This month’s column is written by Junaid Nabi, MD, MPH, a senior project manager in the Division of Urology and the Center for Surgery and Public Health, as well as a 2017-2018 Fellow in Bioethics at Harvard Medical School. Respond to him at @JunaidNabiMD.
While the weather outside Brigham and Women’s Hospital is always changing; the climate inside the hospital remains the same. Every morning when I enter the main lobby of the hospital through the 75 Francis St. entrance, I am greeted by a trove of amazing individuals, who, in their capacity – as a nurse, a receptionist, a phlebotomist or a physician – are working tirelessly to improve the health status of a stranger. Every beloved patient at one point is a stranger to the clinical team – it is through the rituals of patient history and physical examinations, and sifting through diagnostic workups together – that two strangers, the patient and the clinician, can overcome a seemingly unsurmountable malady, or ailment.
Patients, rightfully, expect to be taken care of by the doctor – but who will take care of the doctor?
Often, in our pursuit of clinical excellence, we seem to neglect people and pursuits that are necessary for our personal fulfillment. This neglect can have severe implications on our empathy towards patients. I was reminded of this important lesson a few weeks ago, during an academic journal meeting, colloquially called “D’Amico Rounds” in the Division of Urology. Hosted every couple of months by Anthony D’Amico, MD, a pioneer in radiation oncology, these seminars, loosely based on Socratic pedagogy, are discussions on the latest practice-changing oncology research and statistical methods utilized in these experiments – an approach that emphasizes learning by doing.
That same cold December evening, Dr. D’Amico was particularly solemn. Perhaps he was thinking of his patients; perhaps it was the tired and bedraggled appearance of the residents in the room. After teaching us the utility and applicability of systematic reviews and meta-analyses from two recently published prostate cancer studies, he paused to tell us a story.
He narrated his recent encounter with an elderly female patient who was struggling to walk using the handrails in the lobby. What surprised Dr. D’Amico was not the patient’s understandable exertion, it was how people around the patient – many of whom were health care professionals – responded, walking past the patient. Not many people stopped to offer help – unusual at a place like the Brigham, an institute filled with passionate clinicians and researchers. This is not to say that these highly trained professionals do not care about such patients; still, it did make him wonder why they did not notice this patient. He realized that pager pings and mobile documentation had captured their attention to an extent where the importance of being present in the moment had become secondary.
Another peculiarity he noticed was that the patient seemed to be hiding her face, as if to stay obscure. After Dr. D’Amico approached the patient to help her, he noticed she had a lesion on her face – a mark she was trying hard to hide. Perhaps she was embarrassed to reveal her face; perhaps she found it hard to seek help in a crowd; or, perhaps she did not want to seem a burden to people around her. However, Dr. D’Amico’s warm demeanor allowed her to lower her guard, and she told him where she was headed. After escorting her to the nearby elevator, he witnessed her gleaming smile. While he recounted the episode, he asked us: “What do you think was the reason for such neglect?”
After listening to different explanations – most of which related to being stressed and exhausted from the clinical work –Dr. D’Amico focused on something we had not given much thought to: self-care.
As a seasoned clinician, he is acutely aware of the burden of work in the early years of medical training, yet, he chose to focus on something more tangible, something we can control – I found this to be a refreshingly positive deviation, ground in ancient wisdom. He went on: “We cannot observe the beauty around us, or help those in need, if we do not take care of ourselves.”
His words surprised me. Why would a world-renowned physician worry, or advise, about self-care? Weren’t we supposed to accept this toxic phase of our lives to become better clinicians? The more I studied this issue, the more I realized that he had identified a crucial weakness in the medical education system. As trivial as these efforts may seem, exhaustion and burnout can have severe implications for clinical practice, leading to increased medical errors and decreased career satisfaction. Besides, physician well-being also helps in creating a leaner (less wasteful) health system; a Stanford study revealed the high cost of physician burnout: $7.75 million per year. While a JAMA report makes a business argument for supporting physician well-being, there is an ethical argument as well – it is a moral imperative to support self-care, as undermining the health of early-career clinicians directly undermines the health of the communities they fervently serve.
Self-care, an activity that provides comfort or fulfillment for oneself, has its origins in the medical practice, when, in the early twentieth century with limited health care resources, physicians would routinely recommend their patients to engage in activities that would boost their health and prevent exacerbation of their illnesses. Self-care can be accomplished from a variety of activities: utilizing vacations to spend quality time with family (preferably avoiding the lure of non-emergency messages), allocating time in a weekly schedule to exercise, reflecting on the clinical work at the hospital and documenting lessons learned from successes and failures, and, even taking a nice nap after a hard shift.
Personally, I have followed in the footsteps of physician-writers such as William Osler, FRS, FRCP; Oliver Sacks, MD; and Atul Gawande, MD – who marveled at the complexity of the human condition, documented the nuances of health and sickness and made great strides in advancing the study of medicine by learning from the ones who bare their souls in the presence of a white coat. I have found these exercises to be very fulfilling – they offer respite from the fast-paced environs of the hospital; allow me to reflect on conversations I may have had with senior professionals – what I said and why; and, more importantly, a chance to dissect personal and professional decisions I may have made on the basis of instinct.
It is up to us – the next generation, to invest in ourselves and create communities that support each other, and what better place to start than at the Brigham, a place where we learn immensely each day. Self-care will not only improve our capacity to serve, but also uplift the spirits of those around us – one gleaming smile at a time. This new year, there are several things on our minds that need work: dreams, challenges, exams, research projects. Let us commit to including one more item: ourselves.