For Better or for Worse, We'll Be There.

I'm not the first to talk about this, but I'm certainly feeling the most emotional reaction to it after reading hundreds of responses to my simple question for healthcare providers: "What's the most ridiculous personal scenario in which you have still shown up to work?" 

Not only was the quantity of responses alarming, but also the range and severity of situations. From family emergencies, death of a close loved one, natural disasters, and most frequently, severe/debilitating illness, healthcare providers are frequently putting themselves at both physical and emotional risk by coming to work. We candidly speak about the affects that certain health conditions can have on "absenteeism," or missed days of work due to illness, but perhaps in the case of healthcare we should be speaking about "presenteeism."  How does showing up to work under dangerous and extraordinary circumstances affect our caretakers and our patients? And why does it happen in the first place?  Over the next few stories that were so kindly shared with me (kept anonymous and some with paraphrasing) , I hope to unravel the "why" and put out a plea for solutions. 

1. "I'm a physician assistant in the Emergency Department and went to work 5 shifts in a row with flu symptoms.  I felt terrible but we have such a hard time covering night shifts as it is; I couldn't let people down. I wore a mask and kept Tylenol in my system the whole time. We just do what we need (or think we need) to do."

Just a little infographic from a wonderful study that really highlights a major problem.

Just a little infographic from a wonderful study that really highlights a major problem.

I received a rendition of this story several times, many of them with a similar sentiment-- the desire to not let people down or put others in an "unfair" position.  We feel such a strong commitment to our team that we try to be the hero, even if it's self-detrimental.

2. "When I was pregnant with my daughter I was diagnosed with a subchorionic hematoma and told I would most likely miscarry. I was sent home to rest with plans for repeat ultrasound later that week. This was very scary, but I BEGGED to go back to work. I work as a nurse practitioner in a 'high needs' area where people have very little access to healthcare. While I was worried about my baby I felt like I HAD to be at work. I returned, and went into preterm labor multiple times and had many days where I would lay on my office floor with my feet up in between patients." 

To the non-medical personnel, this one might seem absolutely ludicrous. But this is a perfect testament to what so many of us feel-- an intense and unrelenting responsibility for our patients.  I imagine a million thoughts running through her head regarding the wellbeing for those she cares for, and how her "situation" may be letting them down.  [For follow up, just wanted to let you know that this NP and her baby are both healthy and doing fine! But, that's besides the point. It sucks she ever felt that way.]

3. "I'm an RN.  I have gone to work multiple times running a fever, or with a nasty cold/cough, because our policy is no more than 3 call offs in 6 months. Any more than that requires discipline.  I have accrued loads of days for paid time off, but am afraid to use it in the event of a "true emergency."

This one hurts too.  Aside from a commitment to our team and our patients, there is sometimes fear for discipline if we use the small amount of dedicated 'sick days' allotted. There is a nagging threat of your job being at risk, despite the possibility of factors outside your control.  As another person who messaged me so eloquently said, "no one should have to worry about facing disciplinary action if they make the responsible decision to protect their patients from infectious disease." In another beautifully written email that outlined an unfortunate series of health events, one nurse had to put her entire wellbeing on the line for the sake of keeping her job, almost all of it seemingly preventable had there been a more compassionate method of management and work organization.

4. "I took an exam in med school 1 week after giving birth. Hard chairs and long exams are no fun postpartum!"

Well, are exams ever really fun? Let alone, 1 week post-partum! Even our earliest medical students feel a pressure to show up, regardless.  I recognize this isn't unique to careers in healthcare when it comes to education, but in a field that requires so much compassion- maybe it ought to be. Medical students and residents are in a particularly challenging scenario because of a pressured timeline; residency programs start July 1st. End of story. Even the smallest delay in training can set you back an entire YEAR. 

5. "Found out I failed step 1 [US medical school board exam] at the beginning of clinic and had to stay and work through the rest of the day.  Took a call with one of the school Deans in between patients crying on a bench outside the hospital.  Then I wiped my tears and went back to clinic.  My attending asked if I was in 'trouble" and I laughed and went to see my next patient."

This feeling of commitment isn't just limited to practicing clinicians, but it perpetuates early on that there's never a good enough excuse to grieve or react.  For context, failing Step I could be considered one of the most devastating situations in a medical student's education with severe effects on someone's career outlooks. For the protection of this person's mental health, having an environment where it's appropriate to step away (especially when you're still a student and not technically essential to patient care) could really make a difference in how we nurture and support new generations of providers. 

6. "As an intern I worked a 12-hour ICU shift with the flu. I was having active chills and my nose was running to the extent that my mask was getting wet.  Instead of being told to go home by the ICU attendings and fellows I was told to change my mask.   At the end of my shift I went to Walgreens to get my prescription for Tamiflu (called in by a 3rd year resident who could see how sick I was) and a thermometer. My temperature was 102.3 on Advil."

An intern, the "bottom of the totem pole," is just expected to grin and bear it.  Sometimes we're able to hide our illness, and thus it's a self-infliction to work while sick. But I received so many of these stories too-- evidence of severe (and obviously contagious) illness being observed by peoples' bosses and superiors, yet being told to suck it up. Another resident physician wrote saying, "We have this book we get as interns that have phone numbers, key codes, etc., and a nice little note that says 'Never Call in Sick Unless You're Dying.'"  To me, this is abuse. Not only to the interns, but the potential risk to all of the patients exposed. Higher-ups, we HAVE to do better. End of story.

7. "Last year when I was an intern [at a hospital in Florida] I was working during the worst hurricane of the year. Half of us were on an evacuation team and the other half were on lockdown at the hospital.  I was on the evacuation team and I was evacuated to Tampa around 10pm. They called the "all clear" around 2am and I got a text saying I had to be back at work at 7am as usual. So I had to turn around at 2am and drive back across the state in a tropical storm."

Many reached out about the impossible scenarios surrounding natural disasters. This one's a tough one for me to swallow-- on the one hand I feel for anyone who is putting their own life at risk for the sake of their job. On the other hand, who else can care for the sick and injured in a time of crisis? We signed up for an incredibly demanding career, and on occasion it's going to be impossible to evade situations like this. The best I can hope for is that the hospital or employer does everything in their power to ensure the safety and care of its providers.

8. "I went to work while my sister was dying of cancer in the ICU. I am a hematology/oncology fellow. I live that day everyday."

And this is one that just broke me. The simplicity, sincerity, and pain that could be palpated through this message was just too much. And unfortunately it's not an uncommon story- I received a few other stories similar to this one. We are so used to seeing suffering, that we feel able to work through the most devastating personal tragedies. On a personal note,  I remember thinking how strangely fortunate it was that my beloved step-mom died during my vacation week. It meant that I could fully be there with my family. I knew that if I were working, there's no way I could have made arrangements to be gone for more than a day or two, maximum.  My heart aches for anyone without the appropriate time to grieve.

9. "I went to work as a physical therapist 4 days after having knee surgery. *Shakes my head.* "

It's like that old saying about the plummer with leaky pipes in their home.  I feel like we're particularly the worst at caring for the area we know the best! Maybe it's the feeling of being comfortable with what happens when we push the limits.  Along those lines, the number of people writing in saying they worked through entire shifts with broken limbs was quite astonishing. Either way, we can do better at this whole self-care thing. 

10. "A few months ago I left my 16-month old at home with a terrible upper respiratory tract infection and conjunctivitis which I obviously caught too.  But I was on call with no back up resident, so I came in for in-house 24-hour call generally feeling awful.  I was a walking germ! But the self-guilt and expectations are deeply seated."

I picked up on this theme across all professions-- nursing, nursing assistants, doctors etc., that there is a lack of back-up.  In a field so dependent on a workforce for life or death care, why are so many people left feeling like they're the only one available? That in the event that they are putting their patients at risk, they have no choice but to accept it and work it? Another common theme I got from this message and many others, was the inability to be there for our families due to work's extenuating circumstances.  A wife being unable to get to her husband whose truck got stranded up in the mountains. So many parents having to leave their very ill children in the care of others. And many having to leave their sick parents in some far away hospital while they continued caring for strangers.

When I first asked this question, I expected the majority of rationale in showing up to be self-inflicted, meaning that the individual felt such a strong sense of pride to "bear through it" and be the hero.  While this was definitely a common underlying motive, I was more alarmed by the other factors: fear of discipline and lack of compassion from bosses, fear of gossip regarding laziness or lying about their circumstances, and by far the worst-- fearing that in their absence, patients' lives may be put at risk due to not enough staffing or coverage.  Don't get me wrong, I also want to make it clear that for every absurd scenario that people showed up, there's probably so many of other moments in which people felt supported by their coworkers and in a position to take time off. But more often that what's acceptable, that simply isn't the case.

In a vicious circle, as a consequence of health problems caused by burnout, workers may not reach the desirable performance at work, which in turn may lead to increasing levels of emotional exhaustion. The worker’s weakened health along with his/her diminished functional capacity may lead to absenteeism, a great cause of concern for the worker and the organizations that has both social and economic consequences.
— Salvagioni et. al., Physical, psychological and occupational consequences of job burnout: A systematic review of prospective studies. PLos One. 2017

People outside of healthcare might have a simple question: "If it's so tough and unforgiving, why don't you quit? No one is forcing you to be there."  See, the problem with this question is it's truth; for hundreds of reasons, more clinical providers are opting for non-clinical roles in hopes for improved quality of life. But the more we allow for a culmination of toxic environment that lacks the support for self-care and backup, the deeper we'll dig into the hole of the problem.  More people quitting = less healthcare providers = a vicious cycle of creating an unsupportive environment.  There's a remarkable paper published last year on all factors contributing to burnout, and it's one of the first meta-analyses to really touch upon this concept of "presenteeism" (see quote, and click here for full source.)

Instead of quitting, we need to advocate for our caretakers.  And that advocacy starts with every single one of us right here right now, reflecting on our attitudes toward this issue. Really sit and think about how you'd feel about calling in sick if you developed a violent stomach flu tonight.  What factors are supporting you or holding you back from taking a day off to heal and protect your patients?  Now, sit and think about the other scenario: a busy schedule or jam-packed unit and a co-worker calls out sick. What's your immediate reaction? Is it a feeling of understanding, and a desire to reach out and support them? Or do you feel personally offended and angry at how this will affect your own work day? Do you join in on the sighs and groans with other co-workers when you hear the news?

We can't change management or policies overnight, but we can certainly halt any underlying micro-aggressions running rampant within yourself and your work environment. If you're reading this and you ARE a clinic/unit manager, an attending, or anyone else in a position of power, I want to first say I know your job is incredibly demanding and that the healthcare system has not done you any favors. But you are in control of your reactions and responses to others' extenuating circumstances. Let's aim to make them all supportive-- everyone here works too damn hard for anything less than that.

In summary: healthcare is tough for everyone.  Be kind to others, go out of your way to provide support, be in tune to your self care needs.. and if you have the flu, stay the hell at home. Doctor's orders ;-)


Shanny DO





But(t) Why Gastroenterology?

But(t) Why Gastroenterology?

Ever since that glorious and emotional Fellowship Match day back in December, the title of this blog post has been one of my most frequently asked questions. It's funny because to me, it doesn't even seem like a question (doesn't everyone want to do GI?) but when I take a step back and really think about what this specialty entails I start to laugh because I get it. 

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Doctors without Donuts

I'm not writing this to villainize donuts or to get in some debate about processed foods or GMOs or eating organic.  Donuts aren't the problem.  Fast food isn't even the problem. But you know what is? Believing that discussing the health implications of donuts at all, or any other facet of nutrition, is a taboo topic in the healthcare field.

You know what I think? I'm so glad you asked :-) I think the only doctors who don't need to feel comfortable talking to patients about nutrition, are the doctors who don't see patients.  Psychiatrists should be comfortable with the idea of gut-brain axis, exploring dietary habits as a cause/effect of certain mental illnesses.  Rheumatologists should be proficient in explaining how diet can contribute to chronic low grade inflammation that exacerbates autoimmune conditions.  Same with dermatologists, opthalmologists, general surgeons, pediatric oncologists. Each specialist should be an expert in how diet affects the specific disease for which they are so well-trained in treating.  The burden of discussing nutrition should not solely fall back on the primary care provider. 

It's similar to what we know about smoking cessation-- the more involved and consistent that all physicians are in encouraging patients to quit, the higher the success rate in quitting (source.)  I'd have to say that we (as in, we as doctors across most specialties) have gotten pretty good at this; we aren't afraid to speak gently to patients about smoking cessation, and we're quick to offer all support in how to quit.  We are taught in medical school all the steps in counseling patients on tobacco use (ask, assess, advise, assist, arrange follow up!)  I think this is absolutely wonderful; as a result, tobacco use has significant declined over the past several decades.  So why aren't we doing the same about an issue that is quite possibly creating a bigger epidemic than cigarettes? We can easily apply the same principles: ask the patient for readiness to make dietary changes, assess their actual readiness, advise on an individaul approach, assist their journey to better nutrition habits by providing appropriate resources, and arrange for follow up to talk about it. So I'll ask it again: Why aren't we all talking about food?? 

For starters, we're beginning to recognize the pathetic amount of training we get in a topic that is so intrinsic to health maintenance and healing.  There's a wonderful paper written in Academic Medicine by Eisenberg et. al (read it here) highlighting the fact that U.S. medical schools offer 19.6 hours of nutrition-related education across four years school (that's less than 1% of estimated total lecture hours!!) But I was more bothered by the other statistics shared: Cardiologists during their fellowship training must complete 10 cardioversions and 100 cardiac catheterizations, but have zero requirements in nutrition. ZERO. A heart doctor who treats disease that is so closely tied to diet, does not need to know about diet. WHY NOT?! WHY. NOT?!

Now that's more like it.. but we've got a long ways to go.(  Eisenberg et al., Academic Medicine July 2015.)

Now that's more like it.. but we've got a long ways to go.( Eisenberg et al., Academic Medicine July 2015.)

On top of basically non-existent structured training, nutrition is far more complicated than simply advising patients to quit a habit like smoking (which is completely malignant and has no actual benefit to someone's life.) See, nutrition is tricky.  It requires trial and error, and individualization.  You can't just tell someone to "quit eating" as you can with cigarettes or illicit drugs.  And as with almost every heartbreaking burden of the modern doctor, it all comes back to the lack of time.  We have been backed up into a corner of increasing demands for productivity and "patient outcomes" that we're too busy clicking boxes and documenting appropriately that we miss out on valuable time to speak to our patients about this time-intensive topic (but one that is fundamental to overhauling the current state of health in most westernized countries.) 

Don't get me wrong, I am so excited to see medical students and younger doctors who seem to "get it," and feel a passion for incorporating lifestyle medicine into their everyday practice.  I don't know if I've just attracted like-minded people who agree that nutrition will change the healthcare world, but needless to say I am pleased to know that slowly but surely, the topic is shifting from "non-issue" to "ummm we're really missing the point if this isn't at the forefront of our treatment plans."  I'm thrilled to see healthcare providers truly living by example and bringing their passion for preventive medicine to their work environment.  But that doesn't excuse the stories I hear so frequently of physicians scoffing at the idea that lifestyle interventions can be just as affective as a renowned advanced therapy.  Recently a friend told me about their oncologist, when asked for recommendations on how they should be eating while undergoing treatment, stated something along the lines of, "Just eat all the junk you can get your hands on." Um, WHAT?! And this is just one of several stories I hear about the polarization between "medical therapy" and "complementary and alternative medicine."  Can I be the first to say that nutrition as medicine is neither complementary, nor alternative? Rather, it is FUNDAMENTAL to both prevention and augmenting the advantages of advanced medical technology.  

For the most part, nutrition by itself is not magic. It doesn't prevent polio, or fix a broken leg, or perform appendectomies.  Western medicine is absolutely brilliant at treating and managing acute illnesses. But without the utilization of nutrition as a foundation of health maintenance, we will continue to be horrible at treating/preventing chronic disease.  I don't need to provide statistics on obesity, diabetes, heart attacks, strokes; we all know that we're in trouble.  What I can write about, however, is small bits of advice for the patient and doctor to better communicate in how nutrition can aid someone in living their best life. 

If you're a patient and you bring up how your diet may be affecting your health, and your doctor disagrees, please RUN.  Even without the formal education in medical school, we as doctors should be continuously reading literature and with the explosion of data on nutrition in the past coupe decades, it's hard to not feel the heaviness of its importance.  If you're a patient and your doctor gives you ultimatum, generic diet advice, slowly jog out of the room.  I've said it before and I'll say it again: Nutrition is NOT one size fits all.  If you're in a doctors appointment and he/she listens to your dietary concerns, has an open mind of possibilities to improve, and even provides a referral to a trusted dietitian [edit: can I just highlight that dietitians are greatly underutilized for their expertise?! Request a referral if it’s not offered to you!] (because let's be real, the clock is ticking during that office visit and we can't save the world) then stay. Listen and be heard.  Work on dietary changes that are safe and healthy based on your current medical conditions.  Come back for a follow up. Make it a foundation of your wellness.

On the doctor side, we have to work on finding the balance between "nutrition is bullsh*t" and "my way of eating is the best way and everyone else should do it because it worked for me."  You have some doctors stuck in an old-school mentality, as if caring about nutrition is a waste of time and too hippie in the age of advanced medical technology.   But I also see the latter far too often, especially on social media.  Doctors and other healthcare providers promote a very specific way of eating as if its the *only* way to live healthy, and that's just not fair.  But what about the cost and cultural implications of certain eating styles that may truly affect a patient's emotional or financial wellbeing? Plant based veganism, keto, paleo, blah blah blah- there is so much more to consider than just the food.   It becomes dogmatic and that can be incredibly counterproductive for those just starting out on a journey to better nutrition.  The best we can do is live by example, but keeping an open mind to how our method is not THE method.  We have a long way to go, but just the willingness to care is the first step. 

And maybe, just maybe, opting to bring a fruit tray for the office instead of donuts? Just a suggestion :-) 


Shanny DO