This Week’s Highlights from @drmlb

Twitter has become a wonderful way for me to send out a variety of ideas and links that I think are helpful (and/or interesting).  Here are this week’s highlights!  If you are new to Twitter RT means Retweet (just “forwarding” it as is) and MT means Modified Tweet (“forwarding” it with a comment).

  • “This is definitely a 15 minute video every medical student should see.” The art of the physical exam bit.ly/nnmaTN @drmlb
  • Comments one makes to colleagues: as important as the interview. Professionalism = doing the right thing when no one’s watching. RT @MedPedsDoctor
  • Beginner’s mind in medicine. How to keep what we do exciting! MT@KevinMD bit.ly/qle7SJ
  • One flight of stairs = 16 calories burned. One day on call = ?10 flights ?20 ?30)..it adds up! @drmlb
  • Epidemiologist with humor?!? This is a great talk about drug development. bit.ly/ovkPyS @drmlb
  • “…small things often adds up to produce a far greater impact than any of us realize.” Surgery through different eyes bit.ly/q5XUkh  @drmlb
  • “..those of us who spend our emotions at work are not the kind to view our work as “just a job.” MT@Kevin MD bit.ly/pRAbmm  @drmlb

The Physical Examination

Abraham Verghese is a personal hero for his thoughtful passion about medicine, his dedication to teaching and for his amazing ability as an author.  If you haven’t read his books, I recommend them all.  His novel Cutting for Stone is a truly remarkable work that, while telling a fabulous story, captures the wonderful moments (and trials) of being a physician..  Anyone will appreciate this novel; physicans will be enthralled.

Photo from a great NY Times article about Dr. Verghese

Dr. Verghese recently gave a TED talk about the physical exam that I believe everyone in medicine should see – especially medical students. From Sherlock Holmes, to the discovery of percussion, to how touching the patient is a ritual of healing … this is a remarkable lecture.  Take the time to watch it.  It will make you remember why what we do is such a blessing.

verghese-ted

Link to Dr. Verghese’s TED talk

Starting Medical School: Rules of the Road

In the next few weeks 17,000 college graduates will start the process of becoming lifelong students of medicine.   Medical school is a wonderful, but at times difficult experience.  Here are five “rules” that I hope will help with this exciting transition.

 

1. You can drink from a fire hydrant, but you’ll need to learn how.

The amount of information you are going to be exposed to in medical school is logarithmically more than you had to learn in college.  At Baylor (where I teach) we calculate that the first year of medical school is the undergraduate equivalent of 22 hours of course work per semester.  It really is like being asked to drink from a fire hydrant.   You are going to have to study more, study better and actually use the time in class to learn.  The first year or two of medical school may, at times, seem like an obstacle course you have to “get through” to get to the “real stuff”.  But these first two years are important; You are learning a new vocabulary… a new language.  If you don’t learn the breadth and depth of this new language, when it comes time to apply it to patient care you won’t be “fluent”.   By the way, sometime during the first month or two of medical school you will think that a) everyone here is smarter than I am, b) the admissions committee must have made a mistake and I’m not really supposed to be here and c) there is absolutely no way to read all of this material.  But, like everyone who has done this before you, will discover that a) you are just as smart as everyone else (sometimes in different ways, but equally effective) b) nobody made a mistake – you really are supposed to be here and c) you have to change the way you study, but you really can learn this much material.

 

2. Make your bed.

You wanted to become a doctor for a myriad of reasons, but one of them was surely because service to others is important for you.   Therefore, you are already primed to sacrifice a lot of your needs for other people.  Sacrifice is part of the culture of medicine.  But, it’s like a Starling curve… a little sacrifice makes you better, but too much makes you ineffective.  “Make your bed” is a simple rule (and action) which helps you remember that you need to take care of your environment, your fitness, your nutrition and your spiritual wellbeing as you are learning how to become a physician.

 

3. Act like a doctor – starting now.

We (all practicing physicians) see you as a doctor already.  I know this is a really hard concept for first year medical students, but it’s absolutely true.  You have started your apprenticeship and, unless you are one of the very, very few who change their mind, you will have an MD after your name in 4 years.  With all of the joys and privileges that come with this role, there are a few responsibilities to start thinking about as well.  Start thinking about your decisions, words and actions and how they might be interpreted by patients or colleagues.  It’s no longer acceptable to put anything you want on YouTube, Facebook, Twitter or other social media.  How you dress and act when you are in professional settings will be important.  You’ll learn more specific details about professional behavior from your professors and colleagues as your training progresses, but the core values of medical professionalism start when you enter the profession, which is now.

 

4. Kindness matters.

It is remarkable how our paths in medicine cross over and over again.  The person sitting next to you on the first day of medical school may be someone who will be an intern with you in 4 years or who will refer you patients 10 years from now.  You and your classmates will be going through classes together (like you did in college), but this is different.  You are starting your professional life together as well.  The camaraderie that results is a gift and is also very important personally and professionally.  Don’t blow off the class events.  Don’t stay home to study instead of going to class.  Go out of your way to meet everyone in your class and really get to know them.  Cultivate and nurture these important friendships.

 

5. Enjoy the journey

You are about to embark on a life changing (and fulfilling) journey.  This journey is a privilege and it is very, very special.  Take a few minutes everyday to write down the events of the day.  The first time you hear a murmur in a heart will be just that – the first time.  Take a minute to record what that was like.  You are going to have a lot to process as you start studying anatomy – more than just the names of the structure.  “Talking” about it in a journal is a great way to make the transition we all make in the anatomy lab.   There are also going to be some hilarious stories and events that you’ll forget if you don’t write them down.  When you look at them later, you’ll be glad you recorded them with words, photos, or drawings.

 

“Our study is man, as the subject of accidents or disease. Were he always, inside and outside, cast in the same mould, instead of differing from his fellow man as much in constitution and in his reaction to stimulus as in feature, we should ere this have reached some settled principles in our art.”

William Osler, from Teacher and Student, in Aequanimitas.

 

 

 

Advice for New Interns

The summer is the time that the roughly 16,000 new doctors in the United States start their residency training. For all new interns, even though it doesn’t feel like it, you are ready!  The first year of medical school gave you the “vocabulary” you needed for this new language. The second year gave you the “grammar.” Your rotations in the clinics taught you the “language”.  Now you get to actually use it every day!

This year will be one of the most profound transitions you will ever make…. and it will also be a year of intense and fabulous memories. Take some time to write down the stories, or take some photos (but not of patients unless you have their permission!). These notes and images will be precious memories in the future.

In talking to other physicians and thinking about my own experiences, here are a few words of advice for you as you start your internship:

Learn from every patient.

As an intern, you will need to know a lot of detailed information on your patients. You’ll need to use a system to keep track of all this information so that when you are asked, you know the last potassium level, which antibiotics were ordered and what the ID consultant said. If you have a system you developed as a 4th year medical student, great! If not, start with 3×5 cards. Keep one card per patient, clipped together or held together with a metal ring. In the era of the EMR, much of the information you need can be easily accessed… but not really organized the way you need it. If you have developed a good system that doesn’t require physical cards, please send me a message so I can see it!

That covers the information, but not the learning. Learning is something that should be actively integrated into your day, not something you do at night when you are falling asleep. Work on a system that lets you record what you are learning during your daily tasks in a way you can review later. 3×5 cards are a simple, cheap and very effective system for studying medicine, which I’ve described in a previous post. Make a separate card (or use the back of your rounding card) to list something (anything) you learned from every patient you see. p.s. Don’t lose your cards!!!! (HIPAA violation)

Don’t confuse gathering information with studying information. Taking notes is a critical part of learning. Don’t just store chapters and articles in your Google drive… summarize them to review later by taking notes.

Be the doctor for your patients.

This may sound obvious, but in the everyday world of the hospital, it is really easy as an intern to get lost in the details of patient care… and forget about caring for the patient. Stop every once in a while and remember that you really are their doctor. Take a few deep breaths and put yourself in their shoes for a minute to ask something about their family, hold their hand, or just sit with them for a minute.

It’s very easy to get swept away by the velocity of the work most interns experience and lose the “big picture”. When you are confronted with something you haven’t seen before, push yourself to make a plan before you call your upper level resident or the attending. What if you were really the only doctor around? What would you do? Spend 2 minutes on UpToDate if you have to, but don’t just be a clerical worker – be their doctor.

Part of being a good doctor to your patients is to recognize your own limitations. You should never feel bad about calling someone with more experience, no matter how “dumb” you think the question is.  It’s the right thing to do for the patient.

Be deliberate about learning your field.

From day one, commit to an organized plan of study to cover everything you need to learn in your field. Make a plan to read (and then study to learn) a textbook every year. Make notes that are easy to review, so you don’t have to go back to the textbook to review the material.   Whatever system you use, make it easy to integrate the notes you are making in the hospital (e.g. the 3×5 card on each patient) with your organized study system. Adding articles into the mix is fine – but only after you have mastered the basics. Don’t let reading the latest finding take the place of really learning the material in the textbook.

Be kind and be part of the team.

Hard work is made easier when it’s done with your friends. You will all be tired, you will all be stressed, but be kind to each other. Staying 5 minutes more to help out a fellow intern is an investment that will help both of you. Look for ways to apply the golden rule of internship:  “Help others the way you would liked to be helped”.

Make your bed.

Do this simple act every morning to remind yourself to take care of yourself. Find time to consciously take care of your emotional, physical and spiritual health. Take good food to the hospital for your nights on call. Find ways to get stress reducing exercise into your weekly schedule, or at least find ways to increase your activity while you are at work. Watch your weight – if you are losing or gaining, it’s a sign that you need to focus on your own well-being by improving your nutrition and working on your fitness. Nurture your relationships – make your family and friends a priority. Take care of your spiritual needs in whatever way is best for you, but don’t ignore this important aspect of self-care.

Smile!

You have the enormous privilege of caring for other people and learning the art of medicine. Take a little time every day to notice the moments of joy in this work and, if you can, write them down to look at on the days you are tired.

Congratulations to you for all you’ve accomplished thus far!  Enjoy this incredible journey!

Can Facebook Hurt Your Career?

There have been a lot of recent posts on the web about social media use by physicians.  It’s very, very important to think about the ethics and the risk of using Facebook, Twitter, etc if you are a physician or a physician in training. The internet lives forever… things you post now may come back years from now when you are applying for a job.   I’ve posted previously about using Facebook and other social media, but there are other, more comprehensive summaries on the web.  Take a minute and read about some of the horror stories – it may protect you!

Link on shockmd.com to a video and pdf from the Austrailian AMA

Guidelines on using social media from the American Medical Association

Starting Clinical Rotations: Practical Advice

Don’t sit in the back of the plane.

The basic sciences are important to learn the vocabulary and grammar of medicine.  Clinical rotations are different – it’s where you actually learn to be a physician.   If you use the analogy of learning to fly, in basic sciences you are studying the book on how to fly the plane.  In your clinical rotations you are in the plane, watching and learning from the pilot.  Which means you have to be in the cockpit.  You cannot learn to fly a plane by sitting in the back.

In every situation you encounter in the hospital, imagine that you are “flying the plane.”  When the resident starts to write the admission orders say “Do you mind if I write them and you show me how?”  On your surgery rotation, be in the holding area early and ask the anesthesia resident if he/she will explain how to intubate, show you how to intubate, or even let you try.  When you are writing an admission H&P on a baby in the ER, imagine you are the only doctor who will be seeing that patient.  Let the adrenaline of that thought guide you to the computer to look up more about the condition, how to treat it and what you would do if you were the only person making the decisions.

Yes, you need to be pushy and, yes, sometimes it will backfire.  Be reasonable, but stay engaged. If it’s not an appropriate time to be assertive, stay in the game mentally by asking yourself what they will do next, what you would do if you were making the decisions, or what complication might occur from the decisions being made.  Write down questions you will ask after the smoke clears if it’s not appropriate to ask during a stressful situation.

Know what you are expected to learn before you start.

I am not a fan of “learning objectives”.  If they are done well, they are very helpful, but most people don’t take the time to do them well (or don’t know how to do them).  For the rest of your professional life, you are going to have to define your own learning objectives.  So, in a way, learning how to do it early – during your core rotations – is also part of the skill set you need to know.  (Word of advice, though – even if they are very poorly written, you need to read any objectives you are given and make sure you accomplish them.)

Start with a basic textbook.  You will NOT be responsible for learning all the details in the textbook!  Textbooks are written for residents and practicing physicians.  But – a good textbook will give you an overview of the topics.

The strategy:

1.     Make a list of the topics covered in a general textbook.  There are usually 2-3 good textbooks for every specialty.  Ask other students or residents which one(s) they recommend.  You will probably rotate on sub-specialty services during your core rotation, but don’t get bogged down in looking in sub-specialty textbooks.  Stay with the general textbook.

2.     Plan to skim and make notes on every major topic.  These should be “big picture” notes, not every detail.  If there are 60 chapters in the book and your rotation is 2 months long, you should be shooting for one chapter a day.  Keep track and make sure you get them all covered during the rotation (not after).  When you are done with the rotation, these notes should be all you will need to review for the shelf exam.

3.     Don’t read the chapters in order – read them as you see patients (see below). But, make sure that all the chapters are covered since it’s unlikely you will see patients with every disease in the book.

Practice being professional.

It’s really important to be professional and to be seen as professional in all your interactions.  First of all, it’s the right thing to do.  Secondly, a bad interaction with a nurse on the floor can lead to a poor evaluation by your attending.  Make learning how to behave as a professional one of your learning objectives.  Learn from those around you.  Which residents and attendings are the most professional?  Why?  When you see bad behavior (and you will), think about it – what would you have done differently?

Learn from every single patient you see.

Use every patient to learn about their specific disease.  Even if it’s the 30th patient with appendicitis you’ve seen you’ll still learn something new.  (or use it to learn about their hypertension instead)

The strategy:

1.     Keep a notebook with an entry for every patient you see.  You can use 3×5 cards or an electronic equivlaent, if you prefer.  In fact, many hospitals have 3×5 cards with the patient info available in the patient’s chart for docs to take. (Remember HIPAA – it is better to do this without any protected information!)

2.     Make yourself read something about every patient you see.  If you haven’t read the textbook chapter on the subject, that’s where you start.  If you have read the textbook, review your notes and read something new (UpToDate or PubMed for example)

3.     Make yourself write down a minimum of 3 things you learned from the patient in your notebook (or on your 3×5 card).

Be the doctor for patients that are assigned to you.

You will be assigned patients to follow during your rotations.  When this happens, make up your mind that you are going to “wear the white coat”.   What if you were the only doctor taking care of Mr. Smith after his surgery?  In addition to reading (see above), ask the residents to help you write all the orders.  Write a daily note and make sure your notes are at the level of the residents (ask them to review and critique your notes).  When a drug is prescribed, know the dose you are giving, the effects of the drug and the potential side effects.  When a x-ray is ordered, be the first person to actually see the image and know the result (and make sure you call the resident as soon as you do!).  Don’t get any information second hand – make sure you see the results and the images yourself.  At any point in time, if the attending asks, you should be able to present your patient as though you are his/her only doctor, which means how they presented, their past history, social issues, test results, procedures performed and how they are doing now.

Prepare for conferences.

Every service has at least one or two weekly teaching conferences.  In most cases, the topic (or cases) are known before the conference.  Ask your residents or attendings the day before the conference for the topics and/or cases that are going to be discussed.  Use the strategy outlined above to prepare e.g. consider these “vicarious” patients and learn from them as if they were a patient assigned to you.

Come early, stay late and keep moving.

Taking care of patients in the hospital is a team sport.  The best medical students become part of the team early and are appreciated and – therefore – taught more.  It’s just human nature and it’s just the way it works.  Don’t brown nose, don’t show off…. just show up.   If there are labs to look up before morning rounds, be there 10 minutes early and look them up for the residents. If you don’t know the answer to a question the best response is “I don’t know, but I’ll find out!” If there is scut work to be done that you can help with, volunteer to help before you go home. Anytime you can, make the residents look good. It’s particularly important not to try to one-up the residents.  You will have more time to read than the residents, so you may actually know more than they do about a specific topic.  But, if the attending asks a question and the resident gets it wrong, don’t correct them in front of the attending.  (Unless it’s a critical issue and you think the patient might suffer in which case you have to speak up!)  Whenever you can, set up the resident to succeed.  “A rising tide floats all boats” – if you help them look good, you will look good and the team will look good. Don’t ever sit in the lounge waiting for someone to come tell you what to do.  There are patients to see, conferences to attend, rounds to do, labs to look up… the hospital never sleeps!

Practice having a balanced life.

Compassion fatigue is a constant threat to practicing physicians.  Taking care of yourself, staying connected to family, friends and the outside work are all critical components of preventing compassion fatigue.  This, too, is a skill you need to learn during your rotations so you can carry it with you into your residency and your practice.

Enjoy!  You are finally a “real” doctor!’’

Your experiences on your clinical rotations will be among the most special of your life. Buy a new journal and take time to jot down the funny and not-so funny occurrences of daily life in the hospital.  You will see some extraordinarily beautiful moments of human life.. and some horrendous examples of what people can do to other people. We all learn to deal with these extremes by telling stories. Write down these stories when you can.  It’s also special to record your “firsts”… the first time you set a fracture or hear a murmur of aortic stenosis will be the only “first time” you have.  It’s a special world you are entering.   You’ll want to remember it by taking notes, recording stories and with pictures of your team and unique sights around the hospital. (No patients, though – remember HIPPA!)

Congratulations! You are well on your way to the privilege and joy of practicing medicine.

Starting Clinical Rotations: Wear the White Coat

Every year, I end up counseling a student who, from day one, was absolutely certain they wanted to go into surgery.  They scheduled their rotations to put surgery last, so they would get really good evaluations.  They cruised through pediatrics, medicine, ob-gyn, etc as observers, rather than real participants, because they were so sure they were going to be a surgeon.  Finally, the big day arrives – they start their surgery rotation.  Within a few weeks they begin to realize….. they hate surgery.  Now they are really stuck.  What kind of doctor should they be?

There is an easy way to prevent this from happening.

Wear the white coat.

When you start your pediatrics rotation, be a pediatrician. When the residents and attendings ask what you are interested in, tell them you think pediatrics is really interesting.  It will be true, if you are “trying on the white coat”.  (It will also inevitably lead to better evaluations, by the way, but that is secondary gain.)  When you are on medicine, be an internist.  When you are on surgery, be a surgeon.  You get the idea.  Really immerse yourself in the field, imagine it will be your future.  It’s necessary, but not sufficient to learn what you need to know for the shelf exam.  If you are going to wear the white coat, you have to go beyond what you learn from patients and about patient care.  How does an internist think?  What makes a particular case in surgery more challenging than another?  How does an obstetrician deal with a difficulty delivery at 2am?  What defines the culture of pediatrics?  Does the “coat” of a neurologist fit you?

Over 80% of students change their mind about what specialty they want to pursue as they go through their rotations. Choosing your specialty is not hard, but you have to genuinely keep an open mind as you “try on” all the specialties.  One of them will fit better than others, but it’s probably not the one you expected!

“Failure”

Dear Dr. Brandt,

I enjoy your blog very much. As a second year medical student, I know that my peers and I all struggle with what we view as ‘failure’ at some point or another. I imagine this problem doesn’t stop (…ever), especially since medicine seems to attract people who hold themselves to extremely high, if not impossible, standards. If you’re looking for topics, I wonder if you might have some insight to offer on how to deal with the downfalls along the way.
 

Dear colleague,

It is part of our profession that we will never stop trying to be perfect and – just as true – that we will always fall short. As a student, it tends to be about the tests you are taking and the feeling that you will never study enough. As a resident, it’s the feeling that you don’t know enough to make the decisions you are being asked to make. As a practicing physician, you will at times stay awake at night worrying about your decisions, even when you know you did the best you could. All of this sounds like a huge downside to the profession we’ve chosen, but it’s actually a blessing.  One of the core personality traits of physicians is that they care. In a way, all of the stress about not doing well enough happens only because you have empathy and compassion for your patients.

Although it’s hard to believe at the beginning, with time you will realize that the feeling of having “failed” is actually a gift.  You’ll discover that “mistakes” and, more importantly, “near misses” become your most valuable teachers.  What’s important is that you grasp the opportunity to learn from falling short, rather than beating yourself up.  “Failing” at a task (or test) is different than being a “failure.”  When you have moments you feel you could have done better, use it as motivation to study a little more, go back to the textbook, look up one more article, or review all the facts again.   William Osler, in his famous book to medical students (Osler’s Aequanimitas) talked about keeping a journal of mistakes:   “Begin early to make a threefold category – clear cases, doubtful cases, mistakes.  And learn to play the game fair, no self-deception, no shrinking from the truth… It is only by getting your cases grouped in this way that you can make any real progress in your post-collegiate education; only in this way can you gain wisdom with experience. “

So, to answer your question about how to deal with the downfalls along the way –  Start by revisiting your motivation. Remember why you started down this path in the first place. If you are trying your best to do the right thing, and are humble about the fact that you are human (and will therefore fall short) you can end every day with satisfaction and a sense of accomplishment. That being said, make sure that you work with focus – that when you study or work it is with dedication to the patients and families who are trusting you with some of the most precious decisions of their life. When you fall short, use it as motivation to learn. But, in this process, make sure you are taking care of yourself. The worst thing you can do when you feel inadequate is to just work more and more. This leads inevitably to compassion fatigue which makes you less effective (and will make you suffer). Compassion fatigue is a common diagnosis for care-givers; it happens to every medical student, resident or physician at some point in time. Just like any other diagnosis, the next step is treatment. In a nutshell, the treatment is self-care. Start with a great walk somewhere beautiful, and as you walk ask yourself how you can best care for your body, your mind, and your soul. Be as kind to yourself as you would be to a good friend as you recover. And just like you would tell that friend… Eat good food, sleep enough, get some exercise, get outside, and look for joy and wonder everywhere you can!

The Perils of Perfectionism

Last week I attended a wonderful lecture in Baylor’s Medicine and the Art of Compassion lecture series entitled  “The Perils of Perfectionism”.  It was presented by Dr. Glen Gabbard, who is a psychiatrist and author with great expertise in physician wellness.   I can’t do justice to the entire lecture, but there were a few key points that I wanted to share:

Compulsion is one of our our greatest assets as physicians, but it can become one of our greatest liabilities.

One of the key personality traits that physicians need to have (and/or develop) is to be compulsive.  In fact, many of us choose medicine because it’s a good fit for our basically compulsive personalities.  Unfortunately, as Dr. Gabbard pointed out, unbridled compulsiveness can lead to “excessive devotion to work and productivity to the exclusion of leisure activities and friendships.”   How do you tell if a good thing (caring about patients, being compulsive) has become an unhealthy behavior?   Here’s some warning signs that he pointed out in his lecture:

  • A reluctance to delegate tasks or work with others unless they submit to exactly the way you want it done
  • Rigidity and stubborness
  • Perfectionism that interferes with completion of the task (checking the reflexes 10 times on rounds instead of once or twice)
  • Self-doubt
  • Guilt
  • An exaggerated sense of responsibility
  • Failure to take vacation
  • Cynicism
  • Chronic fatigue
  • Emotional outbursts
  • Headaches
  • Increased alcohol consumption
  • Marital “deadness” or discord

It’s dangerous to look at the issue of physician stress with an “us-them” mentality

It’s easy to think that discussions of physician stress and impairment apply only to “other doctors” (or “other” medical students).  Unfortunately, the stress that comes with out of control perfectionism can lead to suffering for any physician.  In extreme cases, it can lead to physician impairment, destruction of relationships, burnout and physical illness.  As Dr. Gabbard pointed out in his lecture “impairment is the endpoint on a continuum.”  Every physician, when exposed to the right combination of stressors, can become impaired.  The key is to realize that all physicians are susceptible, that it’s important to watch for warning signs, and that’s it’s even more important to seek help when its needed.

“The desire to excel must be differentiated from the desire to be perfect.”

I thought this was a wonderful rule for physicians to remember.  We all want to do our best, and we all want our patients to do well.  We want to excel, but we can’t ever be perfect.  Physicians don’t have control over many outcomes – some patients will develop complications or die despite our best efforts.  And… we are human.  Mistakes will be made.  The goal is to minimize them, learn from them, and forgive yourself.

“A physician that treats himself has a fool for a patient” (William Osler)

Every physician should have a personal physician.  As much as possible, the relationship should be as “normal” as possible i.e. even though you are a doctor, you should be treated just like any other patient.  That’s not as easy as it sounds, but it’s the right approach for both you (as a patient) and the physician treating you.   Why go to the trouble of finding a personal physician?  If you become ill, it’s nice to have an established relationship with the person who will be treating you.  It’s also nice to have someone you can talk to if you are feeling burnt out.  Depression, stress, and impairment can all be treated.  It’s really no different than going to the orthopedic surgeon if you break your arm.  If you need help, talk to your primary care physician or a mental health expert.

Some of our greatest lessons come from dying patients.

Anyone who has had the blessing of caring for a dying patient has learned from them that there are only two important things in life: to live wisely and to love well.  Our family and our friends are our greatest treasures.   Learn to spend time taking care of yourself  and nurturing these important relationships.  It’s easy to fall into the trap of putting off this important work… but don’t.    “The fool with all his other thoughts has this also:  he is always getting ready to live.”  (Epicurus)

White Coat Ceremony

The white coat ceremony represents the beginning of the journey to become a physician.  One of the greatest honors I’ve ever received was being asked to give the faculty address for the Baylor College of Medicine white coat ceremony.  The following is the text of the speech.

Today is an important day.

It’s the day you are going to put on a white coat for the first time as a member of the medical profession.  This is the symbolic beginning of your journey as a physician.

This journey starts with lots of late nights and seemingly endless pages of anatomy, cell biology and, yes, even embryology to memorize.

There will be hours and hours of studying and a lot of tests.

But in this maze of information and examinations….

You are going to learn how to heal.

You will even learn how to save lives.

And when you can’t heal or save a life, you will learn the important art of compassion – how to walk with someone though some of the most difficult, touching and intimate moments a human being can experience.

And it all starts here – with putting on the white coat.

Of course, you’ll have to learn how to actually wear the coat.  There are all kinds of subtle cultural rules that you’ll figure out.  White coats should always have your name on them.  There is room for a lapel pin or two, but some will be acceptable and some won’t.  And then there are the pockets….  When you first start out, your white coat will serve as a mobile and socially acceptable backpack in the clinics.  You will have reflex hammers, stethoscopes, otoscopes, clipboards, flashlights… all within a moment’s grasp in your pockets.  As time goes on, the number of items will decrease.  In fact, it’s generally true that the number of items in a white coat is inversely proportional to the seniority of the person wearing it.

You’ll also have to learn that wearing a white coat can help or hurt relationships with your patients. The image of authority a white coat conveys can be reassuring to some patients, but a white coat can be a barrier, too.   It’s a barrier literally in some ways – everyone on his or her pediatric rotation has experienced a baptism from an undiapered little boy and was saved from having to change his or her shirt because they were wearing a white coat.    In addition to being a physical barrier, a white coat can also be a psychological barrier because of the hierarchy it represents.  It’s not surprising, in this context, that psychiatrists virtually never wear white coats. Learning when not to wear your white coat will ultimately be as important as knowing when to wear it.

The coat you are putting on today is brand new.  It’s clean and perfectly white… but it won’t always look like it looks today.

One of our star students once confided in me that she had really struggled during her surgery rotation.  She also told me that for the first time, she had gone an entire rotation without washing her coat.   Her partner at home was really worried about her.  After long shifts in the Ben Taub emergency room, her exemplary compassion was taking a beating.   She was burnt out.  It took so much energy to cope with what she was seeing and doing that there wasn’t any energy left for kindness.

Her partner at home looked her in the eye and said, “This isn’t who you are.”

And so, together, they washed her white coat.

“The word candor is derived from the Latin candidus which means white.  The most common usage of the word candor is frankness, being forthright, being honest.  The dictionary also defines it as fairness, brilliance, freedom from prejudice or malice, and impartiality.   It also has an obsolete meaning that has particular relevance for us today.  Candor also means kindness.

You are starting a career that will demand devotion and extraordinary effort.  It will, in return, give you access to some of the greatest professional joys a human being can experience.

You will get tired.

You will have times you are so physically and emotionally spent that you have nothing left to give.

You will have times you lose your ability to be kind.

You have to be candid when this happens and realize that what you are experiencing is normal and expected.  It’s no different than the dirt and stains that accumulate on your white coat.   And so, you have to wash your coat.

Get the stains off your white coat with a good washing machine or by taking it to a professional laundry.

Washing your coat of candor requires just that – candor.   Recognize when you have accumulated the emotional and spiritual stains of learning to care for other people and consciously deal with them by taking care of yourself.  Take care of your physical self with good food, exercise and sleep.  Take care of your emotional self with relationships that allow you to tell the stories of your day.  Take care of your spiritual self with quiet time, with contemplation and by seeking out moments of awe.

Today you are putting on your white coat.  You are putting your a coat of candor, of sincerity, of openness, of kindness and of self-care.

Welcome to the healer’s art.  We are so proud of you and we are so glad you are here.

Mary L. Brandt, MD  – August 13, 2010