The Doctor Child

I sat in the exam room with a pleasant elderly 80 year old woman.  She listened carefully as her diagnosis of myelodysplastic syndrome was explained.   She listened even more closely as the treatment plan was outlined.  It was then that she asked me for my opinion.  But this woman is not another patient.  This woman is my mother and I feel the internal struggle between my physician persona and my mother’s daughter begin.

This was not something that I ever spent much time thinking about.  Maybe subconsciously I assumed that my being a physician would keep my loved ones from ever dealing with any serious health issue.  Logically I know my mom is not going to be with me forever, but this was the first time that I have had to face the reality that my mom will die and probably within 10 years.

As Family Physicians, we face grief regularly.   Over time we learn to deal with loss, frustration and grief.   We have to learn to be comfortable with end of life issues so that when our patients are faced with death, we can help guide them and their families through  the stages of death and dying.  When our patients die, we have learned to set grief aside.  We have to be able to leave grief on the sideline.  But are we really able to do that or are we fooling ourselves and those around us?

What is grief?  On the surface grief is a natural reaction to a loss of any kind.  We usually define this loss as the death of a loved one.  But we can experience grief with a diagnosis of a terminal illness, loss of a job, the end of a relationship or the loss of anything that is important to us.

 Grief can be described as a punch to the gut and it is painful, both mentally and physically.   When we do not acknowledge and deal with grief it begins to take an emotional and physical toll that can cause us to be less effective physicians.  We can become cynical and less empathetic.  We can start to pay less attention to our patients and mistakes become more likely.

It is important that we face our own feelings of grief.    We need to look to others (our loved ones or our colleagues) for support but it is not easy for us to admit that we need help.   We are the strong ones that others look to.  But being ‘strong’ eventually exacts a toll as evidenced by fatigue, decreasing energy reserves, onset of depression and physical illness.

I know that I am not the only physician son or daughter to deal with a parent’s illness or death.  I have watched several colleagues deal with these very issues.  But I am struck by my own tendency to fall back into my white coat persona which makes it easier to put up a barrier to the grief I know I will face.

 I hear my doctor voice as I explain what is happening with my mom to my brothers and sisters.  I start to feel that slight detachment that I have felt when I talk with the family of a patient that is nearing the end of their life.   This is how we as physicians have learned to deal with death.

I feel conflicted, but it is somehow easier to deal with the facts and statistics of my mother’s illness than the emotions of the situation.  I suspect this is how many of us deal with the deaths of our own loved ones.  Maybe it’s time to start a new conversation and develop new skills to get through this very human emotion.

Chris Jeffrey, MD,FAAFP

The Power of Family Medicine

As Family Physicians, we have an amazing power.

Tonight I’m not talking about political power, although over the last few years we have made huge political strides.  Tonight the power I refer to is the power that we have to influence the lives of our patients and by extension their families.  We have the ability to influence them in good and bad ways.

Over the last few years as we have made political gains I would argue that payment reform and healthcare reform have shifted focus toward financial gains, metrics and other quantifiable measures and away from what we as family doctors do best: take care of our patients.

So I would like to try to refocus for a minute.  We are facing a time of identity crisis and this is leading to problems with frustration, anger, and disillusionment that are contributing to unparalled levels of burnout.  We cannot be all things to all payers, employers and the government without losing ourselves and then failing at the one reason that all of us pursued a career in Family Medicine – taking care of our patients.

The power that we have been given to help our patients is a gift that has not been afforded other specialties and that is what sets us apart from specialists.

Through many of the so called advances in healthcare over the last decades we have seen our scope of practice shrink.  We have become billing staff, coders, data entry clerks and transcriptionists. In the eyes of many we are not doctors but are now referred to providers.  We see fewer patients but work longer hours.  We spend more time with the EHR than we do with our patients and if we are not careful our patient will forget our faces and as they stare at the backs of our heads in the exam rooms.

It is easy to forget that we are doctors, but our patients can’t afford that and neither can we.

But I almost forgot that this week.

I woke up Monday morning already exhausted, thinking about the fact that I am behind on charts, forms and letters.  I was dreading dealing with the newest EHR upgrade that somehow knows my workflow better than I do.  And then I remembered that I needed to stop at the hospital.

I saw my first patient rather quickly and then typed my note.  I walked down the hall to head to the ICU to see Pat and her family.

I’ve known Pat since I joined Physicians Clinic in 1999.  We are the same age, both have two children and both had been recently divorced.  These commonalities were the foundation of our relationship and we went on to develop a very strong patient/physician relationship.  Over the years we traded stories about our families.  She eventually remarried and added two teenage stepchildren.

She saw me at least once a year for her annual exams.  Things were going well for her and her family.  Five years ago she came in for her annual exam and mammogram and looked to be the picture of health.  But this time her mammogram came back positive and the lump turned out to be an aggressive form of breast cancer.  I referred her to the surgeon and then to oncology.  After that her visits were not as regular as she was focused on her cancer treatments.

Her cancer progressed and spread to her brain and lungs.  She developed pulmonary emboli, effusions and nodules in her liver.  She lost her appetite and began to lose weight.  Her activity was being limited by her shortness of breath.  In December she had to have the malignant pleural effusions drained multiple times and I began to wonder how much longer she would be with us.  I gingerly brought up the topic of end of life, but she was not ready yet.

One week ago I admitted her to the hospital for shortness of breath.  She had pneumonia and her condition worsened rapidly.  After talking to her family, we decided to put her on the ventilator to support her lungs and body while the antibiotics got to work.  But this time they didn’t work.  We all prayed for an Easter miracle, but it didn’t come.

As I walked to the ICU Monday morning, I knew in my heart that would be the last time I would spend time with her.

I entered the room and her entire family was present – her husband, sons and daughters and her sister had gotten in from Denver.   We sat in an empty patient room to discuss the next step.  I talked to them about her cancer that was spreading in spite of the chemotherapy, her weakness and weight loss.  I talked about the lengthy recovery she faced if she was able to get better.  We talked about what quality of life meant to her.

We decided to withdraw care.

Tears were shed and I hugged every member of the family before I returned to Pat’s room to say my final goodbye.  I left Pat and her family to spend their final moments together.

As family doctors we are in a unique position to guide our patients and their families through difficult decisions while always keeping their best interests in mind.  This is something no metric can measure.  There is no box to check to satisfy a meaningful use criteria.  There is no templated note to record this interaction.

I realized that out of all the sadness I received a most valuable gift from Pat.  She reminded me what it means to be a family doctor.  She reminded me why I chose the specialty of Family Medicine.

I went to the office with a renewed understanding of what is important.  It’s not the EHR, the metrics or any other measure.  With the focus being put on payment reform, data collection and other issues it is easy to forget what it the most important.

What we bring to our patients cannot be quantified.  Our relationships with our patients are priceless.

We are more than providers.  We are Family doctors and we become part of the extended family of those we care for.  This is something we cannot afford to forget.

Our patients are counting on us.

-Chris Jeffrey, MD, FAAFP