Archive for tag: patients

Lessons from Dr. Gawande, Enabling Well-Being

I am finally reading a book I got for Christmas, Being Mortal by Atul Gawande, a surgeon and a storyteller. The 10 hours of flights to and from Boston for an interview in Vermont are what finally got me to crack this book. It is a remarkable read, especially poignant in these last few weeks of medical school as I prepare to navigate this world as a doctor. It's a little funny to think that I require 18 more days, 432 more hours of life, before I can officially identify as a doctor. I feel like I'm already there. There is nothing like reading about the significance of a few comfortable and happy hours at the end of life to make the 432 hours between me and graduation day seem an insignificant barrier from doctorhood.

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Early morning departure from Billings, headed east

In his book, Gawande writes again and again about the "vital questions" a doctor can ask a patient to understand things: "What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?" He writes that as doctors, "We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being."

Gawande is writing from the perspective of a surgeon and the cases he presents are from his personal life and from his professional life of advising terminally ill patients about their choices for surgery. Those of you reading this are most likely like me, we are not going to be surgeons, we are not going to be radiation oncologists or geriatric doctors (at least not officially, until Medicare recognizes our medicine...), but we are going to be enabling well-being for our patients, every day through primary care.

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A poignant paragraph in "Being Mortal"

In our ideal naturopathic world, all of our patients are willing and able to attend to their basic determinants. They are willing and able to eat healthy foods, sleep through the night, reduce their work stress, leave their toxic relationships, eliminate endocrine-disrupting cleaners and other environmental exposures from their lives, and make time for rest and relaxation. But reality is that most everyone cannot improve all of these things so readily as we would like. We know our natural therapies will work better if the patient will just take care of these things! And we know that we can effectively use very low force interventions if everything else in life is made healthy. But, the majority of patients are just not going to show up to our offices ready, willing, and able to make all the changes necessary to their lives at that very moment.

While observing during an interview day for a residency position, I listened to a 40-something female tell about how in the past 4 months she has found a care facility for her disabled son, has got her troubled daughter into counseling, has changed her diet, has found a job, and has started seeing a counselor herself, but that she still lives at home with an abusive partner. This woman has better mental clarity, her stress is markedly reduced, and she feels good about having purpose in her work, but she knows one major obstacle to cure still remains and it will, for a while still.

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Snowy April day in New England en route to interview

As NDs counseling patients and their families at the end of life, we can certainly ask Dr. Gawande's questions: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?

But, we can also use these questions in caring for our patients who are not yet at the end of life. We can make sure they understand their picture of health and the possible outcome with treatment, or without it. We can ask them about their fears or their hopes in consulting us for our specialty, which is natural medicine. We can discuss the trade-offs they are willing to make for our natural therapies to work well -- are they willing to turn off the TV at night? Change their dinner menu? Make time for exercise in their already busy day? We can ask if the plan we've created serves their understanding of their health picture and their goals. These questions serve to create well-being for the patient, and therefore, they are part of everyday doctoring. It is this style of what I believe is called "Interpretive" doctoring that I hope to remember and use with my patients. This means advising patients of their options and giving your insight into which option you think best fits their needs. The place to start is by asking Dr. Gawande's questions, or at least keeping them very close in mind.

You Should've Seen Me When I First Came Here

Today I listened while two doctors discussed a patient who is also a friend. This patient has alarming findings on MRI of the spine, and spends his entire day in active, physical work I got an excellent refresher on spinal pathology and also a glimpse into what it's like to provide medical care to someone you've come to know well, and really love as a member of your own community.

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Kaila loving the big sky before snowshoeing.

The discussion centered on going back to the reports, reading the radiologist's notes, and stepping away from the emotion of it all. The collaboration between these two docs bounced back and forth from supremely rational to emotionally weighted. They made a concerted effort to remove their worry about their friend from the case analysis. They discussed referral for a second opinion, and reread the reports several times. In the end, they concluded that perhaps things weren't as bad as they thought, and that first things first, they must check in with the patient regarding actual symptoms.

I spoke to my mother, a dermatologist in the Boston area, over the weekend and she told me that four of Friday's patients thanked her for being there. My mom's comment was, "You probably hear that all the time." She's right, I do. It's probably every third patient I see that tells me I should've seen them when they first came in here. They tell me Dr. Beeson has completely turned their life around. Dr. B always smiles, hugs, thanks them for their kindness, and remembers to acknowledge that very little could actually come of her doctoring if the patient wasn't ready and willing to contribute their own effort.

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Off the Beartooth Highway near Red Lodge.

Doctoring is absolutely an art. Yes, I'm learning about when to order which type of ultrasound, but I'm also learning a heck of a lot about the core of just being there so that the patient who needs the ultrasound comes seeking your help in the first place. Last week, my classmate Kaila came to stay with me here in Billings for a residency interview at YNC. It was such a treat to have her company while dancing to live music on Friday night, followed by a trip over to Red Lodge for a spectacular snowshoe hike in the mountains on Saturday. I loved sharing an appreciation for being outside in the sun and snow with all that crisp fresh air all around! And, we got to talk and talk about our respective experiences of applying to residencies and the stress of not knowing what happens next. It was a relief to realize she also has had a lot to mull over concerning the future.

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Where Kaila and I went for a drive after our hike.

I recently took stock of the past few years of my life. It's silly, but I did this partially by looking through my Instagram feed (@zoozzah). What I learned in looking back is that I've really thrived by studying hard. I am enlivened by intellectual conversation and by practicing medicine. I'm so excited to start life as a doctor, and also to have my conversation partner back in my life. Hanzi comes to Montana next week! He will help me wrap things up here, and then we will make the drive back to Chicago for graduation. The day is fast approaching! Just a few more posts from me, and then you'll be hearing from a new blogger -- speaking of which, anyone out there interested?

Music, Art, Hiking, and a Whole Lot of Medicine

It's the end of my first week at Yellowstone Naturopathic Clinic (YNC). I cannot believe it was only a week ago that I was driving through North Dakota en route to Billings - that feels like it was a month ago!

I'm renting a small basement apartment in Dr. Margaret Beeson's house, so this weekend she came down the stairs and invited me to join her and her son Julius at a live show by a local band one night, and for the Artwalk, an event that happens 5 times a year in Billings, the other evening. I followed these two around downtown, stopping in to galleries and watching them greet their people, appreciate local artists, hand out free Bernie stickers, and pass out flyers in support of the local co-op here.

 

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The band Satsang, playing to a full house at the Yellowstone Valley Brewing Co.

At the show, I danced to some groovy reggae-inspired roots music and watched the people of Billings love on this local band (check them out here: reverbnation.com/satsang). I hope I grow into the kind of healer and community member who knows someone everywhere I go and laughs as much with her people as Dr. B does.

As for medical things I've learned this week -- oh, my god -- where do I begin? Like I said in my last post, there's no comparison to learning by watching a doctor work. At YNC, there are 3 associate docs besides Dr. B, and 4 residents. There's also a chiropractor, an acupuncturist, and a massage therapist. There are 2 front desk ladies and about 4 or 5 other employees working in medical records, dispensary, and other management positions. It's a busy place! 

All of the doctors are willing to engage my questions and teach. In this way, I get to understand a little bit about how each one thinks and works differently from the next. I've watched some prolo and PRP injection therapies, listened to a patient's story while he received a vitamin C IV as supportive treatment for cancer, and watched Dr. B doctor and refer a 70-something patient in need of back surgery.

I've learned from one of the associate docs about the difficult experience of having to tell her patients she is leaving the practice to do some volunteer work and ponder her next move. Her advice to me was "If you know where you want to live, go there and start your practice. It is so hard to leave your patients!"

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Sheltering from the wind, taking in the view (this does not do it justice!)

Speaking of knowing where you want to go, now that I'm in the West, I am have a hard time picturing myself anywhere else. It feels really, really good to be here, under this big sky, with ranchers at the table next to me in the restaurant, and patients driving 3 hours from their very rural home to see the naturopathic doctor. It is very different from the big city, and that weight of millions of people has lifted from my shoulders; it feels much more like home.

In other news, I'm starting to hear from residencies and am hoping the communications continue through this next week. I'll try to keep you posted on progress with this, but at the same time not get my hopes up. I'm trying my best to relax into the process and trust that I'll end up wherever is best.

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Strolling the ridge after scrambling up a cold north-facing trail

To take my mind off things, I went out for a little hike at Phipps Park to the west of town. It was brilliantly sunny, the view was expansive, and I found a cave to sit in for a few moments, out of the wind.

Lastly, I can't end this post without mentioning that many of my ND student buddies took boards last week. Congratulations to all of you on making it through that hugely exhausting experience! May the answers you didn't know be the same ones nobody else knew, either!

The Beginning of the End

Welcome back for Spring Tri and my very last one at NUHS! Congratulations to all my fellow 10th tris on making it this far, oh my god! The 10 of us ND 10th tris had a pretty good break working at the clinic. We had a generous number of days off around Christmas and New Year's and got to see plenty of patients, as well as give each other some well-deserved treatments. Two of us finished and sent off our residency applications -- a very exciting and curious process. I am proud to share with you that I finished up my numbers at the end of last trimester (Disclaimer: the way to do this is to never think of your patients as numbers!), and am preparing to head out to Montana for a preceptorship in Billings starting in February. So, get ready for stories from the West! But first, let me fill you in on the latest.

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Made it back East to celebrate Christmas with my family

This first week back I worked at the Salvation Army clinic in the city, where I got to suggest treatment options and watch my fellow DC interns do rehab with their patients. The most striking case was a patient with a history of a self-inflicted gunshot wound to the foot. The patients at the Salvation Army clinic are all residents of a program for recovery from drug and alcohol abuse and/or addiction. They live and work in the same building as the clinic, and come in for supportive care during their stay in the program. The patient population at the Salvation Army clinic helps to put into perspective some of our patients seen in the Lombard clinic. In Lombard, it is easy to get worked up over the evils of gluten and a lack of sleep, but working with patients who have spent the past months to years addicted to cocaine and living on the street sure provides some valuable perspective on the definition of health and disease.

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DC Intern Andrew checking out the view from his office at the Salvation Army Clinic

In preparation for my departure for Montana I've been getting all my ducks in a row. Lately, I've been catching up on some volunteer hours with the very organized Oak Park Food Pantry. This past week has served to remind me of all the different types of people out there in the world that I can help by sharing my medicine and my time. 

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Holiday twinset photo with Dr. Dybala taken by Dr. Coe

At the Lombard clinic I've been tying up all the lose ends, preparing a Grand Rounds presentation for this week, and spending time transitioning my patients to their new interns. It is hard to say bye to my patients! They have taught me so much and I like to think I've really helped them to feel better, too. Thankfully, I know they are in good and capable hands, and will get to learn and heal with the help of different minds than mine. If all goes according to plan, you should be reading one last post from Chicagoland, and the rest will come from Montana! Here goes the beginning of the end!

Good People

My wonderful peers rallied around me when I started coming down with a migraine in clinic last week. I collected 2 more secondaries to help get everything accomplished for my patient's visit. It was a testament to hardworking peers, helpful friends, people who are prepared to drop everything and help you and your patient, and of course, it was a testament to that ever-present need to care for myself.

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Foggy morning on campus; finals are beginning

I slept very little during the week due to waking up early to finish assignments at the last minute. I know better; if I don't sleep enough I can be sure I'll face the consequences in the form of a nasty headache.

I had an amazing team. My clinician used up every ounce of thumb strength pressing on trigger points to keep the nausea at bay while I finished writing up my chart. Some of the greatest gals helped me collect products from the dispensary, and others helped me chart my findings and watched my work while I performed the physical exam. I finished up the entire appointment swiftly and smoothly because of the ready help that came to my rescue.

On a side note, I currently don't have any patients scheduled for Thursday this week and I wondered why until I recalled who I saw this past Thursday and the week before that. All of those patients who had been seen on Thursdays have gotten better! Oh my god! (Not feeling great? Perhaps you should come see me on a Thursday, the odds are looking good...) I saw a chronic condition improve dramatically in 2 weeks. I saw one acute condition improve 80%, and another clear completely with full patient compliance with my treatment choices.

I was given a few beautiful reminders this week, the least of which was the obvious one that our medicine, nature cure, absolutely works (and that I need to use it to care for myself). The other reminders involved giving thanks to friends and coworkers. Thank you to my people for carrying me along during that impending headache situation and letting me draw on all your strengths to bring about a personal success. Thank you also to the kind ones who complimented me this week on my hard work and my easy patient interaction, and who told me it would be fun to work with me in the future.

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Study break -- getting out of our creepy pink house to go for a walk

I am going to miss the people here more than I know when I leave NUHS for the big wide world. I work with some who challenge me every day. And I work with others who seem to exist simply to lift me up; they make me laugh, they give me words of encouragement, they laugh at my absurdities and help me tether my mind-floating-away-with-possibilities.

And I can't leave this last post of the trimester without saying huge, enormous CONGRATULATIONS to all of our 10th trimester interns graduating next week, OH MY GOD! You did it! I am so incredibly proud of you and am grateful for having had the opportunity to work and learn with you! This is the first time I've felt really connected to those who are graduating and my heart is bursting with pride; you're a smart bunch! As us 9th tris would say, go out there into the world and Stimulate the Vis... Doctors!