There's this point where it all comes together for my small groups. Where the laughs become easier and the acceptance is so implicit that everyone has permission to speak freely and just . . .be freely.
I've never been able to put my finger on exactly when that happens in the small group dynamic. But I've been lucky enough to see it happen over and over again. When it has happened and you're in that sweet spot, you feel it, too. No one has to say anything. You just know.
I felt that last night.
Small Group Gamma, est. 2011
You know what? This is--hands down--my favorite part of the experience of being a medical student advisor. It is also arguably one of the main measures of any small group's success--that "come-together" point where everything just gels.
"So what's the key?" a colleague asked a few of us recently. That day, I wasn't really sure. I tried my best to describe this, the "come-together" point, but it kept coming out wrong. But yesterday evening while breaking bread and laughing out loud with my small group of fourth year student advisees, the light bulb came on. I remembered something I'd heard recently that underscores this perfectly.
Ah hah.
What does it take? It takes the same thing that any important, longitudinal relationship takes to be a success:
Time over time. Yes. That.
Putting in time and giving your time. . . . over time. Being present and checked in during that time. And building upon those moments over and over again until it morphs into something that can't be torn apart. That takes time. And consistency. And repetition. Over time. It does. Popping in for a drive-by moment when there isn't some demonstrable longterm commitment to the relationship or group doesn't work. Just like it isn't a so much of a tragedy to miss one session out of the many when you've been putting in good, rich time over the long haul.
And you know? I would say that this concept relates to how we treat ourselves, too. A person who is exercising regularly and making health-conscious choices on most days won't ruin anything by dropping their guard and having some fun on a vacation cruise. Conversely, the person who goes work out with a trainer for 45 minutes on Saturdays but eats with reckless abandon and doesn't move the rest of the days might as well hold their cash money up to a blowing fan and let it go. The ever present parent or spouse who is invested day after day will see those benefits. That time over time will mask the imperfections even when we feel terrified that they'll ruin everything. But really, isn't that what everything is about? Building lasting foundations for strong towers later? That's what I think.
Time over time.
Yeah. So if I answered that question today, I think I'd say that. Because this is what it takes. And everyone involved benefits when that happens. I know I have.
Time over time.
That's it. That's all.
***
Happy Tuesday. Who is getting your time over time? Who isn't but should? Remember, that deserving person should include you.
Now playing on my mental iPod. . . .how 'bout some Beatles, y'all? You're welcome.
BEEEEEP! BEEEEEEP! BEEEEEEEEEEEP!
That blood-curdling sound pierced through the air and jolted me from what felt like only ten seconds of sleep. I scrambled in the dark to figure out which of the three pagers on my nightstand it was this time. In my frantic state, I knocked two of those beepers onto the floor and, as Murphy's law always has it, one of them was the one I needed to answer.
BEEEEEP! BEEEEEEP! BEEEEEEEEEEEP!
This time it was coming from under the bed. My heart was pounding like it always did when a pager woke me out of much needed but never restful on-call sleep. After a swipe under the wire framed hospital bed, I came up with dust bunnies all over my arm and a pager in my hand. Just as it started to chime again, I silenced it and read the four numbers across the top.
"Ugggh!" I slapped my forehead and let out an exaggerated yawn. I recognized where that call was coming from. How could I not? It was coming from the ward and at this point in my residency I was very familiar with every one of those numbers. I picked up the phone and dialed back the extension. "Hey there. Peds Senior returning a page." My voice was grumbly and undeniably irritated.
"Kim?"
"This is me. What's going on?"
"Are you in the middle of something?"
This was what the second year resident covering the floor team that evening asked me. It was a few moments shy of 4 AM and I'd finally gotten the chance to slip into the call room for a few moments of rest after an exhausting night on call in the PICU (pediatric intensive care unit.)
"What's going on? Just say what it is."
I know that sounds rude but I was tired. Too tired for passive aggressive questions when all of it was leading to something that would surely require me to get out of that bed sooner than I'd intended.
"This baby who's been here for five days is getting treated for sepsis and meningitis. She lost her IV and needs four more days of IV antibiotics. She's a super tough stick, though. I tried twice, my intern, Priscilla our nurse, and even a NICU nurse tried."
"Ummm hmmm."
"Want to give it a shot?"
"Do I want to?"
"I mean, will you?"
I wiped my hand over my face in the most exasperated way ever even though I knew my co-resident couldn't see it. "How old is she?"
"Like not even two months. But a total chunker."
"I'll be at the treatment room in like three minutes. Can you please have every single thing set up?"
"Yes! Definitely!" I could hear the relief in my colleague's voice. He was in his second year and was new at the supervisory role but me? I was almost over-the-hill as a resident by this point. In my fourth year of a combined Internal Medicine/Pediatrics residency, I'd been around long enough and taken enough calls to become savvier than my younger peers with certain procedures. It wasn't unusual to call the most senior Peds resident in the house as a back up on a failed procedure.
"Hey. . . .and no drama, either. I just want to come, do it, and leave."
Yes. That's what I actually said. And he knew exactly what I meant by that.
What did I mean by that? Well. Unfortunately, I meant that I wanted to make sure I didn't get wrapped up into the patient care or the people part. It was my request to be a technician and nothing else, the senior plumber who comes in after the sink is already pulled apart and fixes things with one tinkering then leaves the mess for the apprentice plumbers to clean up.
Yeah. Like that.
Now. I wish I could tell you that this is the part where I tell you that this never happened and that all of that was just to illustrate some kind of point I'm about to make. Nope. That happened. And not just once. It happened often.
What got me thinking about all of this was a conversation I had with one of my Small Group Gamma advisees the other day. He was deeply bothered by the way a resident depersonalized a patient during a procedure he'd been present for on his current clerkship. When he was telling me about it, it nearly brought tears to his eyes.
"How could that resident have been so callous? It was so, so disturbing, Dr. M."
That's what he said with his eyes widening in full anticipation of some really deep words of wisdom assuring him that THAT resident was a far cry from people like US and that WE could never, ever be that way. Never as in not ever.
But the problem is that I couldn't say that. I couldn't.
Residency training was a very demanding time. Although they still are, the hours back then were even longer and harder than anything I could have ever imagined. The learning curve was steep, the stakes were high, and growth took place at the speed of light. As horrible as pre-duty hours reform training was, it offered plenty of opportunities for exposure to experiences. And exposure meant repetition. And repetition is what led to mastery.
Yep.
But here's the problem with repetition: Eventually you get into a groove and your mind and hands operate without your heart. Like the two get in cahoots with one another and the emotion, the moment, the feeling of it all is sacrificed for efficiency and technical competency.
Even when you knew that these were human beings and not plumbing jobs.
It was four o' clock in the morning when I answered that page and I am almost 100% sure that I was back in the PICU reading a journal and talking to the nurses by 4:15 AM. The reason I know that is because, in my head, I wasn't a part of the care team. That IV was all business. Their business, to be exact.
So what happened? Well, I'll tell you. I walked in, washed my hands, and approached the treatment table where the nurses already had the little baby waiting. The intern knew to affix the tourniquet on the leg so that the veins would already be plump and engorged by the time I was finished putting on my gloves. That intern even knew where I wanted it placed because I'd already told the second year covering her to "save me a saphenous" -- as in the vein in the aforementioned location.
At that hour there weren't pleasantries, really. Just business. So after a few swipes with an alcohol pad, all that repetition took over. Hands like that of a robot on an assembly line. The flash of blood that came out of the angiocatheter was as predictable as I'd anticipated. And you know? I quickly flushed the catheter with a bit of saline, put one small piece of tape over it, and literally passed the baby's leg over to the intern to finish up the job.
"What about the blood draw?" the nurse holding the baby asked. The intern and second year looked around the room and rolled their eyes which told me that this was another technical thing they'd attempted and failed due to lack of repetition.
"Do you have a butterfly needle?" My voice was flat. Still all middle-of-the-night senior plumber business. The nurse handed it to me and without saying another word, I'd already reached for another limb on that poor two month old baby and plunged it deep into her wrist. Out came the blood, which I didn't even bother to stand there long enough to collect. Because my job was to get the faucet working. And once it worked, someone else could do the rest.
Yep.
So this? This is what I did more times than I can even count. Going through motions doing things to human beings as if they were faulty garbage disposals or commodes in the middle of the night. But see, they weren't. They weren't.
And let me just say that I cared. I did care for my patients just as much then as I do now. But back then I was burnt out at times and tired. I was able to compartmentalize people into the categories of "my patient" and "not my patient" and the former always got more of me than the latter. Which I now know was wrong. Very, very wrong.
This was modeled for me. I valued the senior residents and fellows who could stealthily walk in, nail a procedure and pop off their gloves less than two minutes later. These were the hospital legends to us, and I wanted nothing more than to be one of them. One of the ones who saves the day with few words and whose actions say "My work is done here" even though it never gets uttered aloud.
And there's nothing wrong with stepping in for parts of patient care. But the key is to know that there is a patient there. A human being. And once we get involved, we are involved.
I met a colleague during my visit to University of Pittsburgh named Bob A. who is a really cool senior faculty member with the kind of wisdom that you hold onto for later. He said to me during a simple chat, "Whenever someone calls the clinic or wherever and is needing help, I make sure I either help find what they are looking for or try to get them specifically to someone who can." And he went on to say that the person on the other end is a person with an issue and that, once he answers the phone, a tiny piece of that issue is now his, too. Which maybe you don't agree with at all, but I got his point. He just isn't a fan of punting things off when it wouldn't take much to be more helpful.
Kind of like it wouldn't take much to acknowledge the human being who needs the IV or the blood draw or the whatever-it-is-they-need.
So I was sad when I heard what my SG advisee said that day. Sad because I could relate to that resident who had become robotic like I had. No matter how hard I try, I can't remember what those middle-of-the-night patients looked like nor can I will myself to hear their cries. And I am certain that that baby was crying for her parents. Even at two months old she was, but her doctor--the plumber standing over her that night--didn't hear a single whimper. So I told that student about my experience as a resident and together we pondered if perhaps that house officer had reached a similar place.
"Eyes without a face," I said. My student raised his eyebrows for clarification. I went on. "We have to fight to make sure we never let the patients get to that point. Where they are eyes without faces. And it's up to the role models, you know? It's up to us to help keep that from happening."
"Hmmm," he responded quietly. I could tell he was trying to let it marinate and was curious about my choice of words.
"Eyes without a face. . . got no human grace. . your eyes without a face. . . . "
His eyebrows went even higher this time. He was confused now.
I groaned loud and laughed. "You don't know any Billy Idol?" His face fell blank. "Dude! Those are song lyrics, man. Apropos ones, too."
"Oh, okay," he laughed.
"Youngsters!" I shook my head and rolled my eyes skyward. "You probably don't even remember life pre-internet."
We both chuckled and after that prepared to leave. His face grew serious again as we walked out of the classroom.
"You made me wonder what my resident had seen from his supervisors. That's given me another perspective."
"In what we do, seeing other perspectives is everything."
"I'm learning that."
"Good," I replied, "It took me a while. I wish I'd realized it sooner. But when you know better you do better, right?"
"Definitely. I guess all you can do is what you know."
"Exactly."
And I could tell that he meant that and would be chewing on it for a while. I would, too.
One of the hardest realizations I've had to accept in being a physician is that, in a way, every patient is our patient. No matter what we think, it's true. And the minute we recognize that, it changes everything.
At least it did for me.
You know what? I just thought of something--another perspective. Perhaps to those patients, I was the one with those terrifying eyes without a face. The one who'd gotten so tired that she'd forgotten the human grace she knew her patients deserved. Especially the ones she saw as belonging to someone else even though they were her patients all long.
Damn.
***
Happy Thursday.
Now playing on my mental iPod for the post-iPod era youngsters and the pre-MTV grown-folks. Mr. Billy Idol with the best scowl in 80's pop. Yes!
Honestly? I write this blog to share the human aspects of medicine + teaching + work/life balance with others and myself -- and to honor the public hospital and her patients--but never at the expense of patient privacy or dignity.
Thanks for stopping by! :)
"One writes out of one thing only--one's own experience. Everything depends of how relentlessly one forces from this experience the last drop, sweet or bitter, it can possibly give."
~ James Baldwin (1924 - 1987)
"Do it for the story." ~ Antoinette Nguyen, MD, MPH
Details, names, time frames, etc. are always changed to protect anonymity. This may or may not be an amalgamation of true,quasi-true, or completely fictional events. But the lessons? They are always real and never, ever fictional. Got that?
