PookieMD's Blog: Where Physicians Learn About the Business of Medicine

The King Tut  exhibit is here in Denver, and I can hardly wait to go. I love Egyptology, and perhaps should have been an archaeologist! So for fun, (hey it’s a holiday weekend soon!) I thought I would share with you the Edwin Smith Papyrus.

The so called Edwin Smith Papyrus, a 16th century B.C. manuscript, written in ancient Egypt script,  describes the treatment of 48 traumatic injuries, like those suffered in battle and pyramid building.  Edwin Smith, an American living in Egypt, bought the manuscript in 1862, and it eventually made its way to the New York Academy of Medicine.  It details the physical exam, treatment and prognosis of various traumatic injuries.  It is logically organized, working from the head down.  (We can’t read past the torso, as the papyrus breaks off.)

Among the recommendations:

• honey and moldy bread to cure infection (?early penicillin?)
• raw meat to stop bleeding
• immobilization of head and neck injuries
• use of sutures to close wounds
• use of papyrus to document illnesses (early charting system!)
• how to set a broken jaw.

As to prognosis, the author of the papyrus categorizes  ailments into one of three  prognosis: “An ailment I will handle,”  “An ailment I will fight with” and “An ailment for which nothing can be done.”  The latter must have applied to case 31–a description of paraplegia, in which a patient is “unaware of his arms and legs” and a loss of bladder control is noted.  The papyrus notes that this is secondary to a spinal cord injury.

The papyrus is logical and organized, but if all else fails, there is an magical incantation to be used, noted in case 9.  For a look at the papyrus, and it’s translation as well as explanations and more facts, visit the National Library of Medicine.  You can actually “unroll the scroll” from start to finish, and read along.  Have fun!

I just finished Drive-the surprising truth about what motivates us, by Daniel Pink. A good read, and helpful when looking at why we do what we do.  Recently, I blogged on burnout, and the very next day our “lunch’n'learn” was about physician burnout.  A lot of physicians I know are burned out, and it crosses specialties and matters little whether a physician is clinic or hospital based.

Pink states that we are motivated to do our best when we have autonomy, mastery and purpose. 

Relating to the physician job, lots of us became physicians because we want to be the captain of our own ship.  We like to run the show, and enjoy the stress and mind candy that comes along with doing just that. However, over the past several decades, physician autonomy has shrunk.  We feel controlled by insurance companies, coding requirements, “best practices”, and patient demands. Control of our times feels as if it has gone the way of  tie dye and mood rings.  The very way we do our daily tasks has changed–now we must deal with an EMR that may force us into a new way of thinking that is not our own.  One hospital where I work forces physicians to write notes in a APSO format–with the assessment and plan first then the subjective/objective portions.  Physicians had not choice–they were told that this would make the notes easier to read on the computer.

Mastery should have come through our training during  medical school and residency.  Actually this was just the beginning.  We now realize we can hardly keep up with the speed of change and the increasing fragmentation of specialists. We try to maintain our corner of the medical garden.  Motivation comes with the attempt toward mastery–and it’s hard to improve our skills and knowledge base if we are just trying to keep up with patient flow, learning the *&%@! new EMR and filling out the right insurance forms. As students, we loved the human body, now we rarely allow ourselves to think of the majesty of how the body works and the joy we once had it helping a person toward health!

Purpose has gotten lost along with autonomy.  When was the last time we really felt we were healing, caring and improving?Currently, it may feels as if we just prolong the inevitable! I became a physician with single purpose of “helping people”–really, that’s why!  Too many of us have forgotten that very real reason for why we endured the years of training–because there is nothing more amazing than the mysteries of the human body.

So how do we regain our motivation–so dependent on autonomy, mastery and purpose?  The answers given at our lunch and learn were trite, and not to be repeated here.  I will need to think more about this and invite you to send me your thoughts.

Take a breath, have a sip of coffee, and celebrate all that you have accomplished!

The doctors where I work are completely burnt out.  My department, hospital medicine, is chronically understaffed, and the cardiology and pulmonary departments are overwhelmed with the work load and pending changes.  We react to the increasing work loads and demands for more time tfor non-patient care projects like any other human beings: we whine, we complain, we get short with each and nurses, we lose sleep, and we try even harder. As hospitalists we hate to call consultants because we know they will snarl and ask if a consult is really needed.  We get crabby with each other, and send nastygrams to the hapless doctor that does the schedule.  Patients suffer as our less than cheerful attitude enters the rooom like an icey blast.  We dread answering questions and explaining plans to patients and families as we will just get further behind if we take time to actually talk to patients.

Signs and symptoms of burn out include an increasing cynical attitude, change in sleep patterns, feeling fatigued and drained most of the time, taking out your frustrations on others, loss of motivation and feeling helpless and trapped.

Looking at my department, we all are exhibiting some of these signs and symptoms.

What to do beyond hiring more doctors?

Here are some tips gathered from the internet and tested by me:

• Start the day with a relaxing ritual.  Lately I’ve been doing a “lovingkindness” meditation.  It seems to help when I do it in the morning before heading out to work.
• Eat better food, exercise more and get rest.  The get rest part is key.  I have been forcing the family to go to bed earlier, realizing that 5 hours of sleep is not enough for me.  I finally realized that I should just go to the guest room and sleep if the hubby insists on watching Leno in bed. Arguing about TV turn off time never worked, so I finally decided just to move to a different room when I was ready for bed. I’m also trying to break my cookie habbit, but this is proving to be much more difficult!
• Take a break from technology.  There is no sweeter moment than when I get to turn off the pager and disengage.  Remember: turn the dang thing off!
• Get creative.  I haven’t really had time to do my old hobbies like gardening, scrapbooking and decorating, but this will come.  I did drag out a needle point project and sure enjoyed it!
• Learn how to manage stress.  I have been reading like a fiend on happiness and stress management.  I’ll do a book chat, but don’t be writing in telling me I’m too “woo-woo”!

How do you manage stress and burnout?

I’m reading a cute book–the Happiness Project.  The author has a really fun part–her “12 commandants of adult living”  (or something like that.)  I got to thinking about my 10 commandments of physicianhood–in other words, rules to doctor by.

1. Patients die.
2. Doctors can’t save everyone–refer to rule number 1.  (Surprisingly a rule that I have struggled with as it seems as if this should be something I can do–what else did I train for?)
3. Ask questions, even if you think you will look stupid.  Don’t be afraid that others know more than you–they do, but you know more on other subjects!
4. Read as much as you can.  I have been trying to outline articles on index cards and filing them. No, I don’t think I will ever refer to them, but the act of writing stuff down helps me learn.
5. Have good friends that will watch your back.  We all need someone to bounce stuff off of, and to complain to, who will tell us that we are good doctors even when the chips are down.
6. Stay calm outwardly if possible.
7. Use this ridiculous stuff we experience to write a memoir.  (Someday I will tell you about the white supremacist, the acupuncture incident and the paralyzed guy who walked to his appointments.
8. Resign yourself to spending some long days, no matter how hard you try.
9. Experience is a good teacher.
10. No one but other doctors appreciate sick doctor humor, especially at the dinner table.

Full disclosure: rules 1 and 2 came from M*A*S*H–my most favorite TV show of all time!

I admit that I am a bit of an Egyptophile (is this a word?). It was great fun to read “Ancestry and Pathology in King  Tutankhamun’s Family”, in JAMA’s February 17 issue.  King Tut, made famous by the Steve Martin song of the same name, was portrayed in tomb art (statues/reliefs/sculptures) as androgynous and having a “bizarre form of gynecomastia.” 

The authors of the article examined several mummies thought to be related to Tutankhamun via radiological and genetic studies.  They developed a family tree, and surprise, surprise, the Tutankhamun family intermarried.  Turns out the boy king was the product of a brother sister relationship, and he in turn, likely married his sister.  Tut’s apparent grandpappy, Amenhotep had a club foot,which he passed on to Tut.  In addition, Tut’s father, the beleaguered Akhenaten, had a cleft palate, which Tut had too.  Scoliosus ran rampant as well.

In addition, King Tut had evidence of Plasmodium falciparuminfection, as well as juvenile aseptic bone necrosis, and had may have had to use a cane for much of his life.  Images of Tutankhamun frequently show him sitting during activities in which one would usually stand, like hunting. When Tut’s tomb was opened over 130 canes were found, showing signs of wear.

As for the bizarre body type seen it statuary and artistic renderings of the period? The authors found no evidence of  inherited syndromes that would cause androgynous features and “bizarre” gynecomastia.  The authors conclude that the artistic representations of Akenaten and Tutankhamun were likely stylized and idealized according to the wishes of the king.

The great thing is, the boy king is not likely to sue if the authors are wrong!

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I love that expression–fall down 7 times, get up 8. It sums up what life is like, and how to react. Lately I seemed to be mired in miscues, miscommunications, mistakes and more. What the heck, maybe writing about it will help me get up from the latest fall!

First the “toos”:

Too busy–I have been too busy working to take care of myself. Yesterday I finally got my hair down after they had to photoshop the roots out at work  when they took my picture!

Too tired–I have still been going to the gym, but have just been going through the motions. I zone out on the bike, reading gossip mags to figure out what Brad and Angelina are up to now. I feel better after a good work out, but it has seemed like so much effort.

Too stressed–our census at both hospitals where I work has been in the “red zone”, but that doesn’t mean that you don’t have to take care of patients! I have been harried by the long days, the complexities and dealing with the other doctors that are just as stressed by the high volumes. Hubby’s lack of work adds to the story too! 

Too negative–the root of much of my problem. I am trying desperately to shed this cloak of negativity I have been wearing since Hubby lost his job, but it’s been tough. For those who don’t know about the cloak of negativity, it’s like Harry Potter’s cloak of invisibility, with out the fun factor and much harder to take off.

And the most damaging –the “lacks”

The biggest: lack of faith in myself. I have constantly questioned everything I do, filling my head with “I should haves” and “why didn’t I?” which of course allows that inner voice of criticism to get louder. “You’re not smart enough/a good enough doctor/communicator/wife/human (etc.!)”

Argh.

It all seems so grim. But this time in my life, I realize, is not a permanent reality. I can’t take everything personally and let it become pervasive. So I will dust myself off, and get up again.  Thanks for listening.

It’s early here in Colorado, my most favorite time of day.  There is fresh snow on the ground, and a home made cappuccino at my elbow.  The snow is just slightly pink from the rising sun. Hubby, Tweenager Daughter, and Doggie are all sleeping.

All is well.  

May you all be blessed with peace on this day and those to follow, as we pause to remember a night long ago when a miracle happened.  May your day be filled with miracles, and if you are the one that drew the short straw at work, may you find unexpected joy, and know how much your work is appreciated!

God Bless us all!

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