As I turned the last page of my text book “Your brain at work” by David Rock, I settled into my litany of thoughts of how my daily work at a hospital impacts my decisions. The book discusses how we can efficiently train our pre-frontal cortex in the brain to achieve maximum efficiency at work. I asked myself “How different would my career choices have been if I were not working in a hospital system like OHSU?” OHSU is academic health care system which has a hospital, a dedicated children’s hospital, research institutes, medical school, nursing school and dentistry school and a joint public health school (with Portland State University). It is a complex system which embodies different disciplines of health care.
Listicles are often berated as lazy, short, psuedo-pop articles not worth the time it takes to spell check listicle. Short? Yes. Pop? Sure. Lazy? But effective. I am, by nature, a list maker. As this is my fifth fall at OHSU, and fall is my favorite season, I have naturally been reflecting back on my time here as a Ph.D. student. For all the hard times in graduate school, for all the times the world was ending, or inspiration was gone, or hope had faded, there are some times to which I will always return with fondness, and some memories I shall always cherish. Here is a list of those memories, those little joys.
Things I love about graduate school:
There is something wonderful when you truly see a person for the first time. I’m not talking about “Hey, we ran into each other and now we’re friends,” but rather I mean the moment when you thought you knew someone or you had an idea about them and you realize you never really knew them at all.
Over the last six months in my Population Health course and while working at the Maybelle Center, this has been my daily experience in Old Town, a community in Portland’s historic Chinatown that is mainly filled with individuals who are marginally housed or living outside. The stark contrast between hospital and home is odd. Getting to know a patient, or even a colleague on an inpatient acute care unit, compared to getting to know them in the community is incredibly polarizing. In the community there is a type of vulnerability and unabashed honesty in seeing the lives of those we care for in the place that is their home.
During the first year and a half of my nursing education the majority of the work has been preparation. Prep the drug list for your patient tomorrow, prep the discharge planning, prep a care plan, prep what you think the priorities of care are (which you are usually wrong), read their notes from three years back in Epic (that probably no one has looked at for quite some time), prep your hand off, prep on the disease process, prep, prep, prep. Is this important? Definitely. Does this fully prepare you to see the patient in front of you and give them the care that they need? Not even close.
Last spring term, my partner and I were placed at the Maybelle Center for Community to care for and learn from individuals who were considered marginally housed. We sat in the community room after being introduced to our first client and exchanged maybe twenty words total, feeling as if we were probably the last people in the world he wanted to be drinking his coffee with.
I recently marked my four-year anniversary of starting graduate school. When I reflect on the years that I’ve spent here, embedded in the practice of science like a mosquito in amber, I’m reminded of a line from that Bob Dylan song: “Then you better start swimmin’ / Or you’ll sink like a stone / For the times they are a-changin’.”
The times are a-changin’ indeed. The biggest thing I’ve learned from my experience here is that science is everything. Science offers us students—most of us overeager, street-dumb twenty-somethings—an unparalleled opportunity to peek behind the curtain of existence. Science allows us to dive deeply into truth-with-a-capital-T and retrieve information to help save the lives of those around us. It’s amazing…and it’s why I entered graduate school in the first place.
But science isn’t exclusively good. Science, the exhausting, elbow-greasy practice of it, is also a blackened altar onto which we sacrifice so much of our lives and our freedom. Science is a jealous god, one who hears the cries of its greatest worshippers and sometimes, more often than we’d like to admit, capriciously holds back its favor and love. We become a wandering people looking to the sky for manna and seeing only thunderclouds forming on the horizon.
StudentSpeak is pleased to feature this excerpt from Caitlin Harrington Brown, MS4. Caitlin’s original post appeared on the web site for Women in Thoracic Surgery.
Surgeons are like professional athletes. They commit years to rigorous training, and spend hours preparing for a specific case, and then before they know it, it’s game day. All that pre-game prep is all well and good, but it’s what happens on game day that actually counts. Every patient and case is different. Surgeons are prepared for the unknown in a very high stakes environment because they are trained to be problem solvers and be clutch in a crisis. They use their knowledge and their technical skill to fix complications, even if it’s the first time they’ve seen that particular problem. Their ability to operate when facing the unknown does not mean they are comfortable – it means they are competent and confident.
As medical students on a surgery rotation, we have been told that a large part of our attendings’ and residents’ analysis of us is their assessment of our decisiveness. We are seeing things for the very first time, and they are looking for us to apply our knowledge to an unknown situation and confidently make an educated choice. When you first experienced this, it felt uncomfortable, right? Maybe it still does, and there is a reason for that! Making an educated guess feels like we are unprepared, probably because we spend the first two years being told exactly what to study for on an exam, and then suddenly find ourselves on clerkships where any question is fair game at any time. It’s hard to prepare for this, and if we don’t know the answer, it feels awful. But like with all things in surgery, there is a reason why our teachers put us in this position.
When I got accepted to OHSU’s PA program, my husband and I made the decision to keep our home base in Bend and have me return from Portland every weekend. I have, to date, driven 349 hours in 51 round trips. The repetition of this endless loop sometimes gets frustrating [Why do slow drivers suddenly speed up at passing lanes?], but overall I like the weekly echo. My mind can wind down after a crazy week, and I have time to think slower, longer thoughts.
On the drive I pass by some small towns and many scattered remote homes. Seeing those, my thoughts pause on the topic of human migration. I am speaking of migration in its purest form, without influence from strife or other external factors. Moving for the sake of newness. Relocating for the sake of adventure. [Does victimless human migration even exist? Probably not, but let’s pretend.]
With this pureness in mind, what makes a person decide that a location is good enough to stop and make a home of? Like, imagine all you know of the land is that an ocean is due west, and you have just crossed an interminable desert to happen upon a lovely green dip by a river. Why pause there? Why not keep going and aim for something better? [Again, imagine you have a choice in where to stop. Again, imagine that there are no losers in this game; no displaced persons pushed out from your desire of a better life.]
The ability to stop on the journey and be ok with that land as your new home takes a calm sort of confidence. A complete ability to trust oneself. To know that you and your family can flourish here. That the horizon is fine being left alone for now. This isn’t a loud, showy confidence that needs an audience nodding approval at your decision, but arises from a core of self-assuredness.
I think we can all relate in the fact that we each know people who seem more adept at storytelling. They build suspense, they hold the punch line until exactly the right moment, they kill it during wedding cocktail hours. They somehow captivate attention, an unofficial prerequisite to succeed in clinical year of PA school. At least, that’s what I’ve experienced. The challenge lies in convincing the most educated person in the room to listen to the least educated: that’s right, yours truly. It’s the inherent nature of being a student and especially evident in a teaching hospital with experts at the top of their field. On morning rounds, we interview our patients looking for salient characteristics of their disease. We work through OPQRST; when was the Onset, what Provokes it, what’s the Quality, et cetera, and present our patient’s case to the attending physician. But what seems to result from 15% eagerness and 85% absolute terror, our once organized information comes out seemingly garbled and out of context as the gaze from five white coats pierces through us. Sufficiently flustered, we smear historical details, lab values, and physical exam eponyms between the patients we are managing. We ask ourselves “how is this happening to me? I took such good notes…”
At times like these, I reflect on advice I received from an emergency physician early in my clinical training: “Just tell me a story, Anthony. Two people may have the same disease, but how they got here will always be different.” After this exchange, I quickly realized how inadequate “OPQRST” is with information gathering. Based simply on pertinent positives and negatives we try to place patients into discrete categories: cardiac vs pulmonary, sick vs not sick, admit vs discharge. But in this binary outlook, I believe we start to lose sight of who our patients really are. As we ask them to change out of their clothes and into hospital gowns, we unintentionally strip away their personality and quirks that make them unique human beings. Out of efficiency, we search for patients by medical record number instead of by name. We refer to them as bed 5 or exam room 1. We orally present a patient’s “case” to our teams as if we’re defending them in trial rather than addressing their health. No wonder it’s easy to mix up the details of their hospital admission. At this point, our patients are no more memorable than the bland textbook pages where we first read about them during our didactic training.
My point is this: put down your moleskine-bound notebook, the proverbial security blanket for health professional students everywhere and speak about your patients from your interactions rather than your notes.
I have been lucky to somehow accomplish a number of milestones in my lifetime: graduate college, enter medical school, build a company, spearhead a premiere medical technology conference, pen a blog with over 10,000 followers and, now, in what seems like the largest stroke of luck, receive an invitation from The White House, under the direction of President Barack Obama’s Office of Science and Technology Policy (OSTP), to assist in the newly launched Precision Medicine Initiative.
Just recently, I traveled to Washington, D.C. to attend The White House OSTP and Stanford Medicine X joint workshop on “Engaging Patients as Partners in Research.” When I first received the invitation a month prior, embellished with the official logo of White House, I had to do a double-take and then verify the legitimacy of the sender. Indeed, everything checked out and I had been officially invited. Mom was the first to know.
After I received my official appointment badge, passed through security and entered the White House campus, a chill ran through me. I was entering arguably the most powerful building in the world, in which decisions are made that have effects and ripples everywhere. The gravity of my involvement was not lost on me. Determined to represent myself and OHSU’s innovative ethos well, I strode past doors that read “National Security Council” and “Office of the Vice President” with a resolve I hoped didn’t betray how giddy I was inside. Once all 50 or so guests assembled inside our conference room, the workshop kicked off.
Norma is part of cohort of nursing students traveling and studying in Thailand. Learn more about OHSU Global Southeast Asia. Read about the recent trip to Thailand in this exchange
Close your eyes…Now imagine yourself in a sauna and you’re profusely sweating. Your pores open, you breathe in, and it’s like breathing in nothing but steam. Now imagine you have stepped out of the sauna and have proceeded into the showers. Your body cools down, you towel off and you have now returned to your air conditioned room. You now feel refreshed, relaxed and energized all at the same time. You think to yourself, “Wow, I feel great!” – This has just described how I felt everyday while in Thailand. Yes, it was very hot and very humid, however, it was a good feeling over all. What made it even better was remembering why I was there in the first place – for an amazing learning experience!
This opportunity offered a basic understanding of the current healthcare system in Thailand. We resided in Bangkok and visited outlying areas that surrounded the city. The visit and presentation at the Ministry of Public Health was a fundamental source of information, that allowed for greater insight into their healthcare system and infrastructure. The healthcare reform goals were shared with us, and one that stood out the most was the integration of Traditional Thai Medicine (TTM).
During shift change you get a hand-off on one of your patients, “a 68 year old Chinese man who was admitted again for fluid over load because he continues to be noncompliant with his medications and diet. His provider prescribed the meds to manage his heart failure related to his chronic unmanaged asthma. Adult protective services recently removed him from his home where he was living with his son, because it was pretty apparent his son was neglecting him. I mean you should read the case file, the guy’s bathroom was covered in feces from a broken toilet, his floor was caked in black mold. Watch out for the son, he keeps causing a scene every time you try to talk to the patient. And the patient wants to move back in with his son, but that is obviously not going to happen because this guy cannot take care of himself and it’s pretty clear his son is not going to take care of him. Get ready this family is difficult. I would stay outta there as much as you can.”*
I have had a hand-off like this, and I am sure you have too. One that makes you automatically develop an image of who you are about to care for, and often put them into a category of “this is what they are going to be like” before you even meet them. Often times the person who is sharing this with you is usually trying to help prepare you, while also decompressing from what was most likely an extremely long 12 hours. The problem here is when we are presented with a patient that is labeled difficult it allows us to detach from them before we even introduce ourselves. And when we detach from the beginning, we miss the opportunity to learn about their truths of how they got here, what they really need from us to leave better than when they arrived and most importantly eliminating our ability to provide truly compassionate care.
I wrote this guided imagery (with editing help from my dear friend Janell Senn) for a group project in response to an experience one of my classmates had with a client like the one in the above hand-off report as part of our presentation. I wanted the rest of my peers to reconnect to the part of them that makes it difficult to shut down and shut off, and for any of you that listen to this – I want that for you too. The next time you meet a person that makes you feel frustrated for the way they live or have a patient you want to call “difficult” or “non-compliant,” you might step back and examine your own compassion switch and be honest if you need to turn it back on.
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