Each month, ACH President Jenni Levy, MD, FACH addresses ACH members through her president's message, sharing updates, goals, and information to keep members engaged and involved in the Academy.
Those of us in the US are recovering from Thanksgiving. We spend the weekend traveling and cooking as we try to create traditions for our kids and either replicate the warm memories of childhood or avoid the conflicts our parents visited on us. I remember sitting at the big table in my grandmother’s house listening to people argue about whether my mother’s contribution was sweet potatoes or yams. While the grownups were arguing, the kids were eating the marshmallows off the top. There are no marshmallows at our Thanksgiving table these days, but there is something called Orange Elephant, which is part of our friend Mark’s family Thanksgiving – and now part of ours.
If you’ve never experienced an American Thanksgiving, you may be wondering why it’s necessary to recover from a holiday. There are lots of answers – too much food, too much alcohol, too little sleep, too much traffic – but I think the connecting thread is “expectation.” We expect Thanksgiving to be picture-perfect. We have an image in our mind and if we don’t meet it, we are disappointed and often angry, even though that image is as unreachable as a mirage in the desert. The gap between expectation and reality creates tremendous distress.
If you spend any time in conversation with US clinicians, you know that expectations are creating distress in medical practice as well. Primary care clinicians feel overwhelmed and pressured by what they often call patient “demands.” Antibiotics for viral illness, work notes, disability forms, MRI scans for minor back pain, and, most of all these days, opioids. I’m sure many of you can add to that list. Our colleagues know they are being rated and often paid based on patient satisfaction and they feel the easiest way to great ratings would be to give patients what they want; they also know that in many instances, that would be terrible medical care. They are torn between surviving their busy days and keeping their jobs and being responsible professionals. Specialists have their own versions of expectation anxiety. Thanksgiving expectations come only once a year; patient expectations show up every fifteen minutes. It’s exhausting and demoralizing. When I ask colleagues what they want to do differently, they have a hard time answering. What they really want is for the patients to be different. We have no control over that. We can’t change other people. If we could, Thanksgiving would be very different.
Are we thus doomed to Thanksgivings of anxiety and disappointment and the sense of dreading our own patients when we go back to work? Nope. The same skills can help us in both situations. We can’t change other people’s expectations, but we can change our own. We can meet people where they are – both our patients and our parents. This requires us to be aware of our own emotions and to set aside our visceral reactions so we can listen with true attention and speak empathically. With patients, we can ask about concerns and expectations to understand what’s driving that infuriating demand.
We can often validate the underlying concern with both family and patients. My great-aunt constantly asked me when I was going to have a baby. That was a sore subject for me and not something I wanted to discuss with the whole family. I dodged her questions and fumed to myself. Now, years later, I wish I’d asked her why she asked. Maybe she couldn’t think of anything else to say to me – she’d never been a medical resident. Maybe she was worried about whether we’d raise our kids Jewish. Maybe she really wanted to tell me stories about the days when she had babies, or when my mother was an infant. I still wouldn’t have answered the question, but she would have appreciated acknowledgment and understanding, and maybe the questions would have stopped.
When the next patient tells you she needs a Zpak for what you know is a viral infection, ask what she’s concerned about. Maybe she can’t take any sick days and is afraid she’ll lose her job. Maybe she has a friend who was hospitalized with pneumonia and she’s afraid of worsening illness. Maybe she got one last time and got better right away. Asking the question will shift the dynamic; she is more likely to feel heard and to appreciate that you want to do the best thing for her.
In order to use these skills effectively, we have to take care of ourselves. Fatigue and perfectionism wear us down. The systems (both family and professional) push us into patterns that are not healthy for us. Our own relationships can be sustaining and nurturing – but creating those is one more thing to cram into a busy life.
We still need to set boundaries with family and we still need to say “no” to patients. If we can do so empathically, we can find a path through the disagreement that doesn’t compromise our principles. Of course this doesn’t work all the time – some patients will still be dissatisfied and some family members will continue to ask intrusive questions. If we adjust our own expectations and explore theirs, we can move more comfortable through difficult encounters, whether those encounters are with the 4:30 add-on patient or intrusive Aunt Dresyl*.
*I did actually have a great-aunt named Dresyl. For real.