Plans
(I started writing this on Monday (5/2) night and did continue my daily practice of writing!)
(Here is a Harold about my Monday in the Hospital)
Opening
Ok, back to it. I was still in the hospital today but not on the academic service. I was what they call in the business (actually just at our institution), AT Flex 1. On Wednesday I will, of course, be AT Flex 2. I will spare you the specifics of what the role involves. It is not my favorite role at my job, but I can easily see the benefit it brings to me, to patients, and to all my coworkers also taking care of patients in the hospital. I see less patients, but it is kind of all over the place so there are less coordinated work periods. Its doing some of this, some of the that, and helping to keep our system working as it should. It is difficult to have accurate predictions for what the day will hold. Being able to solve that problem makes you do well at this role. As I currently perform in the role, it is hard for me to get any extra academic work done during the day even though I probably did less actual work than the average day I was on service in the month of April. If only something in my life had prepared me for the uncertainties of the workday, hmmm, what could that be? I guess that will remain a mystery
1st Beats
1A
I suspect that my issue with the role in the hospital, is that it is difficult to predict the day. When I woke up, there was a possibility that I would have to drive 25 minutes to go see patients at another hospital until noon, then go back to my usual hospital that is 10 minutes from my house and help see patients there the rest of the day. Then the patients that I did end up seeing I am just meeting for the first time and many of them just arrived at the hospital, so there is a lot to catch up on. Some of the time this task is very simple, sometimes it is like an onion. It is a role that I do only sparingly, so my predictions for the day are often off the mark. Me being the optimist, my predictions are often times a sunny version of what another might expect, which makes the inevitable chaos even more chaotic.
1B
The sporadic nature of what happens or can happen becomes the challenge of the day for me. How I maintain my focus when I need to finish something will determine how much work builds up at the end of the day. Sometimes, I don’t feel like doing something right at the current moment, but I know I must, otherwise there will be an additional task that could come my way at the next moment. If the tasks stack, then it is catch up for the rest of the day. That is the central obstacle of the day. It becomes the way for me to have a successful day. It reminds me of this quote…
“The mind adapts and converts to its own purposes the obstacle to our acting. The impediment to action advances action. What stands in the way becomes the way.”
It is from one of my favorite books. I read/listen to at the start of every year. I should read it every ten months because I can feel the lessons slipping starting around September
For an expansion of the above quote and in more contemporary language stylings, might I strongly recommend
1C
The uncertainty of the day plays into uncertainty in the rest of my life. Today’s family schedule also included school pick up, violin practice, soccer events for the older two in the evening. Those rides are a whole logistical undertaking in and off themselves. This is in combination with the other areas of my academic work that need to get done. I am trying to get IRB approval to analyze results from another institution based on an intervention that already took place. I have no idea what needs to be filled out, but I do know I have yet to fill it out. I also received an email from the college I attended that the Dean will be in town on Thursday and wants to meet more alumni in Omaha. Well guess what I want to tell the Dean? That is correct, I am now a doctor who performs improv and teaches improv to other healthcare providers, doesn’t that sound interesting Dean? All sorts of future plans for the day, later this week, the near future, and on and on and on
Group Game #1
Throughout all of this, I feel the need to remind myself to take the improv approach to the day. Embrace the uncomfortable aspects of it, focus on the task in front of me, I don’t need to eat right now, etc. When I practice and perform, I am reminded to focus on the here and now. Focus on what is directly in front of me. If I am able to focus on the task at hand, the task will go better, and also the tasks won’t stack up at the end of the day. I should dive into each new experience like I dive onto a stage to support the ensemble in a show. I’ve got your back. Even though that jump into the unknown can be uncomfortable, it is necessary, and the benefits are almost immediately felt. That is a good reminder for my day, I will have to remember that
2nd Beats
2A
My predictions for the day were often off base. I start each day looking at the computer chart that includes things like vital signs, labs, and the notes of other care team members. It forms an understanding of the patient so that when I go see the patient, it limits how much they have to repeat the things they have already said to countless other members of the care team. It does form a picture of what I think is going on and the things that I prioritize need to be done during the day. Many times, I go into the patient’s room and those predictions are upended. Today, I had two patients that were withdrawing from alcohol and kind of made mental pictures of them to understand their similarities and differences. I concluded that they would have similar hospital courses, which was way off. One of them told me that he was at “4631 Drug St.” when I asked him if he knew where we were, the other was calmly eating breakfast and was able to reflect on his journey with recovery. They did indeed have different days; predictions were updated.
2B
The other patient I saw in the morning was admitted for a small bowel obstruction. The notes said that once she was able to eat, she could go home. When I walked in, she was cutting up some pancakes and sausage. The reason she came into the hospital was because she was unable to eat since food was unable to pass through her intestines. Her hospitalization had been marked by doing things to help food and liquid pass through her GI tract successfully. The obstacle became the way. That is how physicians become helpful, by seeing the problem over and over, and then understanding the problem allows us to treat it when it comes up again in the future. Patients present with problems to be solved, we solve enough of the same type of problem, and then we have expertise in that area.
2C
The patient I was called to admit in the afternoon was someone who was not doing well at home related to her metastatic cancer. Her main oncologist had seen her on Friday and recommended palliative care with hospice, but the patient was resistant to the idea. This made me smile thinking of my sister-in-law who passed away this time last year. She was the same way, and I am pretty sure had a similar hospitalization at this exact time last year. She stayed several days and then left by unhooking herself from IV’s, leaving the hospital, and went shopping, buying a few dresses. That story will always bring a smile to my face to accompany the sadness in my heart. Thinking of the medical care she received along with the challenges in the system has pushed me to be a better doctor daily. This patient was so similar, and I was committed to going to show this patient the most empathy, compassion, and support I possibly could. This was the patient encounter I mentally prepared for in all the improv workshops I teach. My training prepared me for this. I started walking to the ER
Group Game #2
Improv requires you to make predictions and adjust in real time. Many times, the errors in prediction become the game of the scene. The first unusual thing in a scene is taught to be the easiest jumping off point to find “the game” in the scene. Sometimes I will have an idea to play the game, and someone beats me to it, or the scene passes me by. There is no time to worry about that, the show rolls on. After the show, I can think about mistakes and fun parts. This process is important to get better, but the specifics of it aren’t that important. What is important is I figure out the broad steps that brought fun and the moves that brought crowd silence. The show’s over. The disappointment is usually only bad because I know how good it can feel after a fun show. The unexplainable joy after a really fun show is only felt so deeply because I know what it’s like to lay an egg on stage. Either way, the next audience won’t care if the last show was pure joy or rotten egg. The show’s over
3rd Beat
I need to go do a drive by on my patient on Drug St to make sure he doesn’t need to return to the care of the ICU because his withdrawal from alcohol isn’t responding to the dramatically increased doses of phenobarbital I prescribed him this morning. I walk to the cancer hospital to go see him and talk with his nurse. He is not doing great, but we think he will do OK at his current level of cares. While checking on the patient I discharged and reading about my new patient in the ER, I check my email and there is a response from the Dean of my college and it looks like we are going to have lunch later this week. That will be fun. I will have my friend who is a professional improvisor, an alumnus of this university as well, and has been helping me develop the improv program come as well. This is exciting. OK, it is time to go to see my patient in the ER. I mentally prepare as I walk to the elevator. I think of my sister-in-law. I think of my brother. I think of my nieces and nephews. I need to let this woman in the ER know that I care for her. She doesn’t want palliative care right now and I need to meet her where she is at. I need to show support to the people that are in her life. I take a certain path from the cancer hospital to the ER because you walk by a sculpture garden with glass artwork from Dale Chihuly and they blast calming New Age music. I exit the elevator, turn right and just before I get to that area, I will walk past the cancer treatment center. I again think of my sister-in-law and how her final hospitalization was exactly this time last year. This patient I will be seeing is the reason for what I do. I will provide empathetic and emotional care in the time when she needs it most. Deep down, after reading the chart and labs, I know that she has limited time left. I think of my sister-in-law again. I am not going to treat her. I need to empty my mind of everything except the patient in front of me. As that mental battle wages on, I walk past the treatment center. There is a big ruckus and the banging of a gong. That gong is reserved for people getting their last dose of chemo, implying they were done with cancer. This was being hit and celebrated with fervor. This person was done with cancer and celebrating with the people that they loved. I kept walking. I was approaching the glass sculpture garden. The new age music could be heard. My eyes welled up. My face smiled. My heart shattered into a million pieces. The show’s over. What an unfathomable world