Monday, March 17, 2008

Interview: Final Exam Author Pauline Chen, MD

Dr. Pauline Chen, author of Final Exam: A Surgeon's Reflections on Mortality, now available in paperback, took some time to answer a few questions from Christian Sinclair and some Pallimed readers. (Click here for the Pallimed book review.)Sinclair: Self-care is a common concern with palliative care professionals, especially as a valuable tool to prevent burn-out with the large emotional toll we face. As you discuss in your book, surgeons in training now have less time to spend in the hospital with the 80-hour workweek, and therefore are likely to spend a higher percentage of time in the OR instead of at the bedside. With surgical training focused on the operations and with possibly less time at the bedside, how do you see the role for teaching self-care in surgical residencies?

Chen: My sense is that all physicians, not just surgeons in training, are increasingly finding themselves having to choose between self-care and patient care, as if they were two mutually exclusive pursuits. Some of this choice is probably self-inflicted; we are all driven by that professional ethos to do the best by our patients whatever the cost to ourselves. I also think, however, that the overabundance of what we can, but not necessarily should, do also adds to this sense of conflict. There are so many treatment options available now that it’s hard for us – and for our patients – not to feel obliged in some way to spend as much time trying as many of them as possible.

Limiting work hours for residents was truly a radical effort to improve patient care and self care. But unfortunately, I think it has inadvertently created even more of a self-care versus patient care conflict for the youngest in our profession. Yes, trainees now have a better quality of life, but they also have to think about how they are going to use their limited clinical time on a weekly, if not daily, basis. Am I going talk to Mrs. Jones about those intraoperative findings of metastatic pancreatic cancer or go scrub in on a liver resection? Those are difficult decisions for young doctors to have to make, and I think they are made worse by the fact that residents feel they must sacrifice some patient care experience for the sake of their own self-care. In many ways, I feel relieved that I never had to make those kinds of decision as an intern or resident.

I don’t think I have the answer to how we doctors in our day-to-day lives can embrace good self-care and good patient care. But I do believe that we might be able to improve the current situation by talking more with one another about these issues. There’s a kind of solitude in clinical work; much of what we do finally boils down to that one-on-one with patients. Yes, we interact with colleagues, but we don’t often discuss issues that relate to our own self-care. Perhaps if we did, we might be able to bring self-care and patient care together in new ways.

A few months after my book was published, a girlfriend met up with a former colleague of mine, a doctor with whom I had worked fairly closely for four years. This colleague told my friend that the stories in the book were so similar to his own; he had no idea I had had so many of the same feelings and experiences. When I heard about this exchange, a part of me was delighted that the book had resonated with him. But another part of me asked: why had we never talked to one another about it but just soldiered on in our work alone? Here, I thought, was a lost opportunity for us to have practiced good patient care and good self-care.


Sinclair: One of the policy constructs that may impact approach to end-of-life care is surgical and hospital mortality rates. In times when a patient decides to forego further aggressive treatment after a surgery, how do you think mortality statistics affect a surgeons willingness to consider a primary palliative approach? Are there any suggestions to reform mortality statistics so surgeons are not statistically or financially (insurance) penalized for the decisions of patients?

Chen: On some level, I think that all of us are concerned about being penalized because of statistics, but I don’t think that fear is the main reason why some doctors are hesitant to consider palliative care.

In the case of surgeons, I suspect there is something even more profound that causes such hesitation. I think it is a particularly acute sense of failing yourself, your patient, and even your profession. That sense of responsibility is instilled into surgeons from the time they are interns.

As a junior resident, I remember watching a fellow resident learn that lesson from one of our attending surgeons, a gifted and highly respected elder statesman at my training program at the time. The resident was eager to leave the hospital one afternoon, even as one of the patients under his watch became unstable. The attending surgeon stepped in front of the resident, literally blocking his path out of the hospital and pointing back at the patient’s room. “Son,” he said in the sternest voice I had ever heard him use, “once you lay your hands on a patient, that patient is yours.” The resident ended up staying at the hospital late into the night; and I don’t think he, or I, ever forgot that lesson.

One would assume that this highly refined sense of responsibility would fit seamlessly with the goals of palliative care. Instead, it somehow makes it more difficult. While the strong connection with patients can inspire some heroic caregiving on a surgeon’s part, it also makes it easy for surgeons to interpret therapeutic “failure” as a personal and professional one. It is devastating for surgeons when patients are dying because it’s hard not to wonder if the outcome is, in some way, our fault. Moreover, surgery is a particularly solitary specialty and these deaths end up becoming something surgeons face alone…in a healthcare environment that barely gives any of us enough time to get the job done, let alone reflect upon it.

I think the real challenge for all of us is not just reforming our policy but also reforming our professional culture.


Sinclair: I have heard surgeons mention 'feeling betrayed' by patients who do not want to continue aggressive care, especially after a major surgery. A recent Time opinion piece recently covered this issue of changing goals while in the hospital. What is the role of the attending surgeon in mentoring surgeons in training for these difficult conflicts of surgeon-patient trust/autonomy?

Chen: I think the sense of “feeling betrayed” is quite complex; it assumes that we have, in some way, made a pact with one another, a pact which we have subsequently broken.

I suppose we all enter some kind of unspoken agreement when we become someone’s patient or someone’s doctor. But the more dramatic the treatment modality – major surgery, difficult chemotherapy, experimental medical therapy – the more complex and deeply embraced our assumptions will be in that unspoken pact. Unfortunately, doctors and patients rarely have the kind of discussions that are wide-ranging enough, deep enough, to touch upon those assumptions. All of us are under such difficult time constraints. Extrapolating further, it’s easy to see how feeling betrayed could come up more frequently in certain clinical contexts.

I believe that encouraging discussion may decrease the chances that any party will feel betrayed. And mentoring young doctors in this regard is particularly important because talking about deeply personal fears, hopes, and assumptions is not easy. I remember as an intern feeling terribly awkward asking patients even relatively straightforward questions, like how much they drank or whether or not they had unprotected sex. It is invaluable for young doctors to have more experienced healthcare professionals encourage these types of discussions and to model them.


Sinclair: Your writing style is a great demonstration of the ability to share patients personal stories and their medical obstacles. Could you share how you discovered and honed your writing craft as an outlet for your thoughts? And do you ever find yourself dictating in a more narrative tone, or doing creative writing in a more staccato SOAP note style?

Chen: I’ve always been drawn to people’s stories and to writing, but I did not write much in medical school or residency. There was no question in my mind back then that if I had any free time, I was first going to eat or sleep. But after my training was done, I found myself writing stories in notebooks, on my computer, and on loose papers in my white coat pockets. It was as if some pot inside had finally boiled over and I had to scramble to catch the contents that kept spilling out. Most of the pieces I wrote back then were fictional, and nearly all of them had some medical theme.

After a few months of this, I signed up for a writing course at UCLA, where I was an attending surgeon in the Division of Liver Transplantation. I ended up taking two classes. Midway through the second one, the instructor asked to meet with me privately. I was convinced that she was going to ask me to tone down the graphic clinical details of my stories or to repeat the course since I had missed several classes because of transplants. Instead, she said simply, “Pauline, you have to write these stories.” She recognized my short stories as thinly veiled personal narratives; and her comment gave me the kind of permission I needed to write what I really wanted to write about. That is, my experiences with patients.

I began then to write in a more organized fashion, and as I collected the stories, I saw that a fair number of them had to do with grief – grief over patient complications, grief over deaths, and grief over the kind of care I had provided over the years. But some stories were also hopeful; they involved nurses, doctors, or other health care professionals who had pushed me to think or to act a little differently. Unbeknownst to me at the time, those clinicians were teaching me about palliative care.

They were showing me that there was much more we doctors could do for our patients than simply cure.

In retrospect now, I think that writing the stories gave me an opportunity not only to reflect on the past but also to consider ways in which I might improve my work in the future. As I wrote these stories, I was in fact experiencing narrative medicine, a field which uses writing, reading, narratives, and the approaches used in literary criticism as a way to improve ourselves as health care professionals. And what was emerging for me from this experience was a greater understanding of and appreciation for the power of palliative care.

My creative writing has occasionally spilled over to my clinical writing, but only in the most minor of ways. I suppose I use the passive voice a bit less now. But that’s about it. I think it’s like when I am sewing material rather than flesh. Once in awhile, I may use a one-handed knot to end a repair of my kids’ clothes, but I would never think of pulling out a needle driver and the loupes!

Sinclair: Transplant surgeons and palliative care physicians share some of the same patients given the mortality for patients in transplant lists and the cooperation on patients that are potential donors. Are there ways you see transplant teams and palliative care teams working well together? What pitfalls exist if these teams work too closely together?

Chen: I have always been a big proponent of multi-disciplinary patient care. In fact, one of the reasons transplantation and oncology interested me as a surgical resident was that each field placed a lot of importance on incorporating different disciplines in the care of patients.

To be honest, I see very few, if any, pitfalls to these teams working closely together. I think that there are terrific benefits for both disciplines and, of course, for patients. I believe that a key component of quality care is providing meaning-centered care, and a more diverse group of health care professionals is better equipped to offer that kind of care.

As someone trained in transplant surgery, I think that the presence of palliative care experts is a reminder of just how many things we can provide for our patients and how much better we can make their lives, even in the most difficult of circumstances. My guess is that transplantation presents an interesting challenge to palliative care experts. In transplantation, we often talk about how our concerns extend not only to the recipient but also to the donor and to the person on the waiting list who might have died because s/he was passed over. It’s a very unique situation in medicine, one that makes clinical decision-making particularly challenging.


Sinclair: Similar to your background, I am a physician, parent of twins and writer (for Pallimed), and so I sympathize with your time constraints. How do you balance the demands of surgery, family life, and writing? Do you have one or two shortcuts/tips you couldn't live without? And do you have any tips for physician-writers who want to get a book published?

Chen: I’m not sure any of us has the answer, and the constant juggle (chaos actually!) of my life is a humbling reminder of a friend’s wise words: we might try to do it all, but we cannot do all of it at the same time. She, amazingly enough, is a neurosurgeon, wife, mother of three, author, art gallery owner, and political activist….but not all at once.

I think there is always this process of reassessing how you spend your time. It is sort of like internship. As a senior and chief resident, I used to tell the surgical interns to make a list of the most important things in their life. Then I asked them to cross out everything except for the top two or three items because that would be all they would have time for during internship. I think I always have this internal list of priorities in my head that I am constantly reassessing.

In terms of writing and publishing, I tend to believe that people who start their professional lives doing things other than writing – like doctoring or nursing -- actually have an advantage when it comes to becoming published writers. They have the benefit of experience and the confidence that comes with having already successfully become whatever those other jobs required them to be. They can apply those experiences – learning to become a doctor, a nurse, a social worker, etc -- to the process of becoming a writer.

For example, in my surgical training, I learned that only with frequent practice in the operating room could one liberate the art of surgery. As a medical student and surgical resident, you learn to operate by first learning to tie knots and wash your hands. You keep tying knots and washing your hands until you can throw those sutures and scrub up in your sleep.

After that, you begin to cut. And then you start operating. And you practice and practice and practice until one day you find that operating is the most natural of actions.

When that operating becomes natural, you discover something. You suddenly go from being wholly focused on every one of your actions -- how to hold the knife, how to hold the needle driver, where to place the stitch -- to thinking about the larger picture -- how the operation as a whole is preceding, how the patient is or will tolerate certain maneuvers, how even to coordinate the relative strengths and weaknesses of your current operating team such that the operation proceeds most smoothly. You see certain shortcuts, refine ways of moving, cutting, suturing, all of which make your operating look more like a well choreographed ballet than a step-by-step technical procedure.

What you have done, after practicing technique over and over again, is you have liberated the art.

I have approached writing in the same way -- it’s really the way I know best to become proficient at something. Although I don’t think the craft of writing is all that second nature yet, it is certainly less daunting that when I started.

Sinclair: Are you currently in a program that oversees any trainees? If so, what current lessons (formal or informal) do you teach your trainees about interacting with dying patients?

Chen: I am not currently affiliated with a teaching program, though I soon will be. I would like to think, however, that all the work I do -- writing, lecturing, or working in a clinical setting – will in some way help trainees care for patients and themselves. I don’t think it’s easy for students and young doctors to be thrust into the roles our profession requires. There is such a tremendous amount of responsibility right from the start, responsibility that encompasses not only clinical decisions but also human relations.

I am not perfectly accomplished at all of this myself, but I do hope that my attempts to be honest and self critical and thoughtful about my work will help others do the same.


Sinclair: Blogs have been a place for health care professionals to try creative writing as an outlet. Are there any medical blogs that you read?

Chen: I am a fan of your blog! I do read medical blogs when I can and find some of them to be really good reads. I think the best of them have both a sense of immediacy and great honesty. I recently came upon an MD blogger who posted a comic strip of her medical school surgical clerkship. I couldn’t pull myself away from it because her humorous take on the difficult truths of medical school rotations had me laughing so hard.

Sinclair:
Your book underlines a modern movement in medicine to avoid a purely biomedical approach to care to one that is more biocultural (see: Stories Matter: The Role of Narrative in Medical Ethics). How did/does your anthropology background affect your approach to medicine?

Chen: My anthropology background has had a tremendous effect on my approach to medicine. I was fortunate enough as a college student to have worked with two anthropology professors who were not only brilliant teachers but also truly exceptional mentors.

Anthropologists, particularly medical anthropologists, have long understood the interplay between culture, illness, and meaning. Their work has helped to illuminate the ways in which culture influences the experience of illness, the language used to report it, treatment decisions, doctor-patient interactions, the relationship between risk factors and social supports, and even the particular environments that may affect physiological reactions and the gene expression of certain diseases

One of the most important things we do as clinicians is address the suffering of others. That suffering encompasses not only physical discomfort but also a loss of meaning and purpose in life. We need to be able to address that loss in ways that are meaningful for the patient. We need to be empathic witnesses to those we care for. I think anthropology is terrific training for doctors in this regard.


Sinclair: The MELD score has been probably one of the more robust examples of prognostic tools actually used in everyday clinical medicine. Do you see an appreciation for the skill and tools of prognostication in the field of transplant surgery? Or is prognosis underplayed in deference to the complexity and uncertainty of everyday life?

Chen: There is an ever-increasing discrepancy between the numbers of patients on the transplant waiting lists and the number of organ donors. Even with the growing numbers of living donors -- who I think are truly courageous and inspiring individuals – approximately 18 people in this country still die every day waiting for a transplant. And that number keeps increasing. The relative scarcity of organs has made it necessary to predict, as well as we can, which patients will be sick enough or too sick for a transplant.

But I think that anyone who has used a prognostic tool quickly realizes just how inadequate they are, even ones as well researched as MELD. In a strange way, MELD and all the other prognostic tools in clinical medicine only emphasize to many of us just how complex real life is.

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