medicine Archives - Man, Medicine, and Mike

In the end of my post on burnout, I asked for your input. Based on that I feel compelled to write once more. This is a longer post but please bear with me. I think you will find something of value in it for you.

As a result of the first post on burnout, the vast majority did what I had really hoped you would do.

Recognized the burnout or tendencies toward burnout in yourself. (Everyone has this, by the way.)
Thought about what can or should be done within your life.
Banded together as “brothers” in the battle.

Some of you were deeply concerned for me. This was very nice but made me want to reassure you. I am far less worried about me than I am about my friends and colleagues.

I am the one who has been given a forced sabbatical. I am the one who has had such fatigue from my surgery and treatments that I have been forced to sleep. In fact, I have slept more recently than I have been able to sleep in years. This period on short term disability is the longest period that I have not worked in my entire adolescent or adult life.

I am also the one whose mind has been reopened and regained the ability to think and write. This blog is what happens when you let Mike have a little too much free time! J

What my post did (several thousand views), was to open up and expose a wound.

Like a surgical debridement, it seemed to expose the raw but living tissue under some layers of scar. And like a surgeon, once I cut down and could see the raw granulation tissue it made me happy. There is healthy and living tissue underneath.The pain that you feel and the longing to live a full and rich life is a sign of health. It is the essence of you that remains. Deep down you are there. You are very much alive.

For the non-medical, what does this talk of debridement mean?

Sometimes when someone has a wound, devitalized tissue (scar tissue or dead tissue) can form over the wound. The scar tissue blocks oxygen from the wound. It can make it hard or even impossible for the wound to heal. In those cases, a surgeon has to do a debridement. This is when they use a scalpel and cut into the tissue. They carefully peel back layers of tissue that are no longer alive to get to the tissue that is still vital and alive. The layers the surgeon remove might seem as though they are providing a covering or protection to the wound. But in reality, they are just hurting the healthy tissue and preventing it from healing.

That was my intention of the post. By openly sharing my pain and struggle, I hoped to open up your wounds as well.

And now that the surgeon has opened the wound we must proceed with the next step. We must protect the wound and see if we can truly help it to heal.

This makes me nervous. In terms of burnout, I am better, but I am living not in reality and I do not yet know that I am cured. I do not know if I am yet competent to apply the salve or the sterile dressing that could best help with the healing. I am empowered by dozens of comments and messages. I feel an obligation to attempt the wound dressing because I was part of cutting the wound open again. I also feel an obligation to tabulate or collect the wisdom that was shared with me and reflect it back to you.

Image result for salve on a wound — https://www.wikihow.com/images/thumb/d/df/Treat-Deep-Cuts-Step-7-Version-2.jpg/aid9471077-v4-728px-Treat-Deep-Cuts-Step-7-Version-2.jpg

What are the next steps?

How can everyone go forward with sustainability and joy and balance and without guilt?

Pray for wisdom.That is the very first step. Pray for wisdom to live the life that you ought to live. Do not just live the life that others tell you to live. Live the life that the Lord has intended you to live. What is your role in this life? Do you have a vocation (a calling)? What is your drive and desire? What is your role in this life and how can you do that in a full and rich way?

Passion:Indulge in passion. I have learned over and over again that experiences that you do fully are much better than those that you try to minimize.

As a teen I had the job of driving the forklift forward to catch the cherries off of the cherry shaker (harvester). Honestly, it could be a dull job. Drive forward. Wait. Drive backward. Wait. Repeat. Do that a LOT of times over and over and over and over again.

This job however became much better when I pretended to be the best cherry tank forklift driver ever! Could I get the tank in place as soon as possible? Could I pull in perfectly each time? What would the world’s greatest cherry tank driver do? That I was going to aspire to. And suddenly the job got much better.

For whatever you do, please do not shrink away. Own it and dominate it. Seek passion within yourself and exert that passion. If you have to deal with difficult patients or difficult situations ask yourself, “What would an expert in this situation do? How would the BEST person handle this? Can I become the expert? Can I be the BEST!”

Live:Do not be afraid to live. Do not feel guilty to live. As I have said repeatedly and as was sent back to me in so many different messages and ways – live.

What does this mean? It means feel, taste, smell, see, and hear what you are experiencing right now. Stop at least 5 times a day to just live. Stop yourself and take in the world with all of your senses. Like you might do if you felt it was your last chance to do so. Or do it as if you were allowed to come back from the future to get to relive an experience one more time. Truly experience it.

In this moment I feel the chill in the air. I see the pale light of the one click on the 3-way light and the empty shelves my wife made last night in her work to redecorate for Christmas. (I wrote this in the decorating gap between Thanksgiving and Christmas.) I smell little but the familiar smell of our home. I hear the clock in the background and the sigh of our beagle, Malley. Ok – I don’t taste much – which reminds me that I could go get a cup of coffee! But nonetheless – these past 10 seconds were rich. They made me love this moment. This time at 5:10 am when I am awake and not able to sleep, I now love. As a future time-traveler coming back to this moment I would relish in these familiar 5 sense experiences of my present home. Why then should I not similarly enjoy them now?

Look across the table at your spouse or your children. Look at the beauty in their eyes. Look at their supple skin. Look at the curve of their mouth when they smile. Indulge in it. Smell the food. Savor the taste as you put the food in your mouth. Hear the giggles or the beautiful tone of their voices. Reach out and touch them. Feel their silky hair or the soft skin of their hand. Perhaps the hand is older and wrinkled. Enjoy how you have gained those wrinkles together. Recall the first moments you held hands and when the hand was clammy with nervousness. Smile inside as you richly drink in this full experience.

Decide that you are going to remove the blinders and force yourself to stop at least 5 times a day to just LIVE.

There will never be enough time. Can you be so brave to live in the time that you have?

Seek treatment more than a cure:This is a hard but important lesson. In patients with chronic pain we are taught that if they seek to be pain-free they will never get better. If they seek to be pain free, the psychological focus shifts onto their pain and it begins to dominate their lives even more. Instead, we are to ask them to focus on living their lives.

The focus of treatment is to be able to do more and more. The focus must be to regain functional capacity rather than to be pain free.

So also, must we do with our burnout. The harsh reality is that this world is a fallen and broken world.

The Bible tells us, “Cursed is the ground because of you; through painful toil you will eat food from it all the days of your life. It will produce thorns and thistles for you, and you will eat the plants of the field. By the sweat of your brow, you will eat your food…”^[1]

I don’t mean to not be cheery but whatever job you do, it eventually will become work. Your goal is not to escape toil for it is not possible. Your goal is to seek a better life within it. I cannot fully make your pain go away. I cannot relieve you of work. I cannot at this moment take away the electronic health record (EHR.) I cannot make call nights go away. But I can encourage you to enjoy your life nonetheless. Focus on living better. Accept that some pain and toil are a part of what it means to be human. But please don’t let them dominate your mind or your life. Do not drive yourself crazy by trying to be pain free. Do not seek a perfect life. It does not exist. Seek to live a good life amidst the toil and pain and brokenness. This is indeed possible.

Celebrate:Celebrate the good that you have done. Do not brush away the successes. Relish them. Keep them in front of you as reminders. There are always good things that you have been a part of. Without guilt, indulge in experiencing them. Perhaps it is the patient who you really helped, or the project that was finally completed. Save a memento or some icon that will help you to remember it.^[2]Say to yourself, “This! This is why I do what I do!”

Band of brothers: From the Shakespearean play Henry V:

“We few, we happy few, we band of brothers; For he to-day that sheds his blood with me; Shall be my brother; be he ne’er so vile, This day shall gentle his condition; And gentlemen in England now-a-bed Shall think themselves accursed they were not here, And hold their manhoods cheap whiles any speaks, That fought with us upon Saint Crispin’s day.”^[3]

Image result for henry v st crispin's day speech — https://i.vimeocdn.com/video/634683697_1280x720.jpg

Do NOT – I repeat – Do NOT – do this alone. We can and must band together as a happy band of brothers (and sisters). You must have friends at work. Indulge in their presence. Indulge together in the challenges and thereby the glories in which you work. Think and fight together to make things better. Celebrate the ways that you stand up under the pressure together. Do not seek to run and hide but seek to stand up together under the strain and know that there is glory in that for you and them.

Within our advanced heart failure section, my favorite meeting is the early morning meeting that we have once a month when we meet at a coffee shop. It is generally without an agenda but is mostly a chance for us to gather as a “band of brothers and sister.^[4]” This has power because we are in it all together.

Honestly, Henry V is one of my favorite Shakespearean plays purely because of this scene. Get the movie and watch it or search out the St Crispin’s Day speech on YouTube. Go ahead and do it now. Turn the sound up. Stand up as you listen. The scene gives me chills and inspires me. Even now I feel stronger just thinking of it! Perhaps you should bookmark it on your web browser and then in times of struggle, pull it up with your colleagues and play it before you charge off to work!

Change jobs or retire:This is what some of you have done. Most are not able to do this. I am never one to recommend running away from your problems but for some this is the best solution. Only you can tell if this is the correct path for you. But for those who do not do this – please – do not just wait to retire. Please live your lives today. You cannot get yesterday back. Live today so that you can celebrate the yesterday in which you just lived.

Burnout is an epidemic. There are some things that are a huge part of the cause. I do not mean to lament the burden of charting in an electronic health record but this is one large factor. We must seek to fight to improve this. It will not go away but we must constantly fight against the current state.

And I hope the few suggestions above will provide some benefit to you?

There is one other solution, but I do not recommend it. It has something to do with getting diagnosed with cancer, a laparotomy, radiation and chemo and several weeks off of work. It does work. But I think the ideas from my prior post plus your collective ideas in items 1-7 above are more desirable than that!

To my own band of brothers (and sisters): I miss you! I hope to soon rejoin the battle. Please know that you have my respect and appreciation. You few. You happy few!

^[1]Genesis 3:17-19 (NIV)

^[2]Please see my LinkedIn post, “Nice Shoes”. Those shoes are an important icon to me to remind me to celebrate my career. https://www.linkedin.com/pulse/nice-shoes-michael-dickinson/

^[3]St. Crispin’s Day speech, Henry V, William Shakespeare, 1599

^[4]We love you Milena! We need more sisters like you with us in cardiology and AHF!

My first overnight in the hospital as a patient!

Brenda had an acute appendicitis. She was suddenly very ill and had surgery and ended up in the hospital. I am sure it was no fun. But I envied her.

I was a 3^rdyear medical student and felt very tired and very stressed. It was before the concept of work hour restrictions. Call was truly overnight and all night. There were no medical student call rooms. The post call day was not easier or an early day. It was harder because you had to present and defend your care of the admissions from the prior night. I was learning a lot. But I was tired.

I envied Brenda. She was lying in a bed and reading or watching television. I dreamed of what it might be like to have people bring me food and drink and to just be able to click through the channels on the television.

Oddly this pattern has continued throughout my medical practice. Rounding on the day of the “big game” I wander in and out of patient rooms. The game will be on the television and I am tempted to look but I have just a few too many patients to see. I push on. I listen to the patient. I listen to their heart and lungs. And then I move on.

Sometimes it is the show, “Gunsmoke.” I loved that show as a child. I even wrote to James Arness for an autographed photo. I used to keep it in a certain drawer in my parent’s desk at home. One year I got a full outfit complete with a plastic gun with plastic bullets and holster. I haven’t watched that show for years but one day I saw it on television in a patient’s room. I envied him.

Gunsmoke - The Directors Collection — https://www.amazon.com/Gunsmoke-Directors-Collection-James-Arness/dp/B000H7JCHI

Once again however I pushed ahead. I asked my standard questions of them (enough to at least bill a level 2 rounding note). I looked at their neck veins, listened to their heart and lungs and felt their ankles. And on I went.

Sometimes it is “Fixer-Upper.” I watch this show at home. For those of you who are fans, my wife, daughters, and I have been to Magnolia and to Magnolia Table in Waco! And no, we have not met Chip and Joanna. But when it is on while I am working, it oddly feels like it would be such a luxury to stop during the work day and just watch it.

Image result for Fixer upper magnolia — https://i.ytimg.com/vi/zbebsu3rCoc/maxresdefault.jpg

And then I got sick. And for the first time in my life a bunch of things flipped:

I became a patient rather than the physician.
I was suddenly taking a lot of pills
I was off work with a lot of time available to me.

And so today I write as a voice of someone who has “crossed over” to the other side of being a patient. I do not know that I will be particularly eloquent or poignant, but it is a different perspective. I am hoping to share just a few impressions here. Perhaps others who have experienced the other side will want to add some more in the comments later?

Phase 1: Post-op:

I was very sore. I couldn’t move around without clear intentional action. To get up and out of a chair was something that was planned and then executed. Walks (a lap around my living room) were planned and carefully performed.
I was able to read and watch a lot of television. I watched, “Gunsmoke”. I realized that it is kind of a depressing and sad show! There are a lot of sad things that happened to make the drama for the show. I watched some movies. I watched recommendations from friends and coworkers.
My body was not intended to sit or lay down a lot. My neck and back would get sore. I would get headaches as a result. I tested and used every chair and sofa in my house trying to find the best position to sit or lay. My daughter taught me the joy of a hot shower. (I now understand and have compassion for our LVAD patients who are not yet allowed to shower!)
I walked very slowly. My wife laughs when she tells about my first walk at the hospital. I kept asking her to slow down. I think she felt that if she slowed down any further, we would be walking backwards!
Rolling over in bed was a job. I never imagined this with all the patients that I have managed through surgery. I had to think very intentionally about rolling over and whether that was good or bad.
Electrical jolts. These were a very unwelcome surprise. I have tried to look up the anatomy and realize that nerves are never quite as logical as I think they should be. If I tried to slide toward my left and roll a bit to hug my wife, I would feel a sudden and severe hot knife stab to the left groin. Wow! Ok. So, I guess I had better not do that. The good news is that those have now passed.
“You just wiggled your finger! That’s wonderful!” “I’ve always been a fast healer.” For those that don’t recognize those lines they are classics from the movie, “The Princess Bride.” As I recovered one day Sarah made this pronouncement. We laughed a lot at that one and those lines have become a hallmark of my recovery process.

Phase 2: Radiation and Chemo:

Fatigue more than drowsiness. I may post this as a full blog post later. But I have learned that sometimes sleep is needed more than desired.
Queasy and nausea: My thanks to Karen W for suggestions and advice on how to handle this. My profound thanks to the pharmaceutical industry and the combination of Zofran and Compazine! I think about all of the patients for whom I have prescribed mycophenolate who have then struggled to manage the nausea. Sorry!
Obsession with bowels: Not going to get into much detail here save it to say that I feel like an old man especially when shopping down the bowel regimen aisle at Meijer. It is embarrassing to be jostling for position next to the 80-year olds who are also shopping there!
Oddly – too tired to read – but not too tired to write. I don’t understand this but maybe it is some glitch of my own creative mind being deprived of work? I am sure that it will pass but for an avid reader it is a bizarre part of this phase.
Home blood pressure checks: Seems that it would be easy to just do this regularly right? I bought a home BP cuff but frankly I am pretty bad at doing it. I seem to grab it when I am obsessing about my BP but then mostly ignore it!
Learning to swallow a lot of pills: I had become a bit proud of my ability to swallow an occasional naproxen or Tylenol. Now I marvel at home many pills I take! When I lay them all out, I want to take a picture of them (I have done this!) It just amazes me all the things that I am putting into my body! But I also found that it became harder to swallow so many. Big tablets are the worst. I used applesauce and it started teaching me how to take bigger swallows. I have since been better able to do the same large swallows with water again.
Dry mouth: This was actually with both phases from the pain and nausea meds. It is a really odd thing to feel the need to swallow and to be unable to do so. It is a mild panicky sensation. If I wet my mouth, then I can swallow and then I feel better.
Thankfulness: I really value and appreciate my treatment team. Their kindness and interactions with me are important to me. I enjoy getting to know them and who they are. Their kindness and understanding make things a lot better. The arm that they offer me to help me off of the radiation table is oddly such a real comfort and support. I find myself wanting to give back to them.

So what have I learned?

I don’t envy Brenda anymore. The grass does indeed always seem greener, but it is not. I would prefer to be up and moving around rather than the one in the bed. Appreciate what you have. Be content with what you have and enjoy it in the moment rather than wishing for what others have.
When you get the time to do all the things that you were wanting to do, you might not have the energy or desire to do them. Life can play cruel tricks on you sometimes! Enjoy the good in your day today rather than wishing it away on tomorrow.
I better understand the struggles of my patients for whom I have prescribed a TON of medicines. I am even thinking about setting alarms for myself to remind me to take my pills. I am anxious that a pill box may be in my future! It is not easy coordinating and remembering to take every dose on time. I think I am capable of it but then yesterday morning I went out to breakfast with a friend and realized that I had forgotten to take my pills beforehand. Oops. (I took them an hour or so late instead!) Listen and problem solve with your patients. It is hard for even intelligent and motivated patients to be perfectly adherent. I now completely understand why we have a pharmacist in the advanced heart failure clinic!
I really appreciate the role of direct caregivers. The nurses and aides are so valuable. Health systems – pay attention to this – if you want good patient satisfaction scores – be sure to take care of them and make sure that you have good staff in these roles! Appreciate and value those who directly touch the patients. They are SO important.
A desire to give back: As a patient I want to contribute and show my thanks. Please let me do this. It is hard enough to be in the receiving role. It makes me feel good to ask how you are and to support you. Let your patients give as well as receive.
We were designed to be creative and to work. I think that is part of what is driving my energy for this blog so much. Mimi E I hope you don’t mind me calling out to you from this blog, but you are a great instructor for all of us in this. You were a great teacher as a physician and now you continue to be as a patient. To be human we all feel a need to create something. Mimi does an amazing job with her painting and photography. We were all meant to work. Feel the joy of it. When you are stretched feel it as a good thing, as a growing thing, and as an essential part of being human.

And so, as a conclusion to this posting I will quickly repeat my primary lessons:

Be content with what you have rather than envying others. It really is not that great being in the hospital bed or sitting at home watching, “Gunsmoke.”
Seek out and really enjoy the good that you have in today. Do not squander it wishing for tomorrow.
Partner and problem solve with your patients. This is the key to compliance / adherence.
Value the staff that directly interact with the patients.
Let your patients give back to you.
Enjoy the work that you have today. I know that there may be parts of it that are not fun but as humans we are meant to work. Like a good workout feel the stretch and pull and challenge and enjoy it.

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