MEdIC Series | The Case of the Backroom Blunder

MEdIC Series | The Case of the Backroom Blunder

2017-01-20T12:30:39+00:00

Are you ready??website cpr image 2 Season 2 of the ALiEM MEdIC series is about to begin! We are so excited to kick off the ‘school year’ with a riveting new case from our Medical Education in Cases series.

Join us now to discuss the case of the Backroom Blunder wherein Trevor, the 3rd year medical student, finds himself reflecting about the use of humor by his colleagues in the resuscitation bay.

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of the Backroom Blunder

by Heather Murray (@HeatherM211)

Trevor, the 3rd year medical student rotating in the Emergency Department, sat down in the staff changing room to gather his thoughts. He had never seen a cardiac arrest before, and this one had been a doozy. An elderly, obese man had come in by EMS after suffering cardiac arrest from a huge lower GI bleed. The ED team had run the arrest for a really long time, transfusing blood, IV fluids and tons of drugs, intubating, bedside ultrasound, everything. The room had been a mess when they finally called it. Trevor had gone with Dr. Elliott, the attending, to break the news to the family. He had been impressed with her gentle compassion as she talked with them.

Trevor was thinking about the code. He was pretty pleased with his CPR – he’d practiced in the sim lab to get the timing and compression depth just right. Dr. Elliott had even complimented him on it. He thought about the smell – melena, rectal bleeding, vomit… it had been really awful. He hoped they could make the room smell better before the family came in. They had been so upset. He thought about the rest of the code. It seemed like Jeff, the senior resident, had struggled with the intubation. There had been quite a scene at the head of the bed. Jeff had needed 3 extra suction catheters to deal with all the airway vomit. Dr. Elliott had even asked if Jeff wanted her to take over. Trevor thought that it should have been a bit smoother.

He got up and left the change room. As he was about to come around the corner, he overhead Dr. Elliott and Jeff talking. He stopped, not wanting to interrupt, but as he listened he realized they were laughing together about the code! He heard them making jokes about the smell and the rectal bleeding, calling the patient a “frequent flyer” and talking about his “red underpants.” They didn’t seem to care at all that he had died, or about how awful it had been. And Jeff had screwed up the airway, Trevor was sure of it. Shouldn’t he be apologizing to Dr. Elliott instead of laughing? Dr. Elliott had seemed so nice and sympathetic to the family… was that all pretend? A fake show of sympathy?! Now Trevor was angry.

After Dr. Elliott and Jeff went back into the ED, Trevor stayed in the back hall, fuming. Sonia, another 3rd year student, arrived for her shift. When Trevor told her about Dr. Elliott and Jeff’s conversation, she pursed her lips and thought for a minute.

“Weird. Dr. Elliott always seems like she cares about people to me. Maybe it upset them, too? Maybe they’re just blowing off steam?”

“No way. A caring doctor would never talk like that. And the slang? That’s just awful. That man was somebody’s dad, and grandpa. I’m thinking of writing a complaint.”

Key Questions

  1. Medicine has a lot of slang – words that are specific to our particular culture, and sometimes derogatory. Is there a role for this language? Should medical educators be held to a higher standard?
  2. Black humour has been used as a coping strategy for stressful or traumatic events. Is this appropriate in a patient-centered care world?
  3. How should physicians cope with stressful or horrifying situations? How can we “blow off steam” effectively, and how can we support our learners?

 

Weekly Wrap Up

As always, we posted the expert responses and a curated commentary derived from the community responses one week after the case was published. This time the two experts were:

  • Dr. Brian Goldman (@NightShiftMD) is a staff ED physician at Mount Sinai Hospital and host of White Coat, Black Art on CBC Radio One.  His new book The Secret Language of Doctors is about hospital slang and what the slang reveals about modern medical culture.
  • Liz Crowe (@LizCrowe2) is an Advanced Clinician Social Worker in the Pediatric Intensive Care Unit at the Mater Children’s Hospital, Brisbane Australia. She also is involved in a large research project on Advance Care Planning with Griffith University. She is doing a doctorate examining staff wellbeing in critical care to inform interventions of support and education. Liz is a passionate and humorous educator and the successful author of ‘The Little Book of Loss and Grief You Can Read While You Cry’. When Liz is not working, studying, or writing, she hangs out with her kids and husband and enjoys walking, cycling, and reading.

On October 3, 2014 we posted the Expert Responses and Curated Community Commentary for the Case of the Backroom Blunder.  After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary which was released on October 3, 2014.  That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Teresa Chan, MD
ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada + Teresa Chan
  • Ok, so someone has to start us off! I must say, more and more now that I’m a staff person I’m paying attention to the terms I use – and steering ppl away from loaded terms like “frequent flyer”.

    There are serious consequences to our choice of words, and I think that this can engender cultural impressions on learners. That said , I’m also struck by the evolution of medical slang and it’s way of parsing big concepts into dense nuggets of information that are quickly explained. But mindfulness of the language is important.

    • Loice Swisher

      It is interesting to me that “frequent flyer” seems to be such a loaded term for some. It isn’t for me. Perhaps much of the message is contained in the tone with which others use the words. For me it means that the person has been at our institution quite often.

      Just like shortness of breath has a wide differential diagnosis so does a “frequent flyer”. I find that it is my job to try to figure out what that is and if there is anything I can do to address those issues. Those that come back routinely quite possibly have not been able to overcome hurdles to have the issues addressed. For me the approach would be different among patients if say it was a 25 year old who had been back 8 times this month for palpitations versus a 50 year old man who is brought in intoxicated every weekend.

      Knowing a person is a “frequent flyer” tells me that I likely will have information available from prior visits as to what has been tested, tried and offered. It may give me a clue that being the 6th doctor to see a patient with unexplained abdominal pain that I might not be able to provide an answer and that I need to help the patient get on a new path out of the ED revolving door. It could mean that there are underlying social or financial issues that might have some assistance available.

      I do find that a patient who has been to the ED 60 times in the last 3 years is different than one who was to the ED only 1 time before. That doesn’t mean that I think less of the patient as a person.

  • rhymes_with_buckett

    Even as a relatively newly-minted resident, I often catch myself using words or phrases that I would have balked at as a medical student. It doesn’t mean I care any less about my patients, and I hope I still project the empathy and concern that I genuinely feel.

    I sometimes think that using off-hand language like ‘frequent flyer’ helps me avoid being seen as a ‘bleeding heart’ resident who is idealistic but not pragmatic, and that’s important when trying to fit into the culture of the emergency department.

    Of course, finding the humour in a grim situation goes a long way in alleviating emotional distress. That’s not just a strategy for medicine – black humour could be called a way of life for me!

    • S Luckett G

      Hrm, who knew I had two disqus accounts? Not me!

    • LizCrowe

      Black humour was first recognised in the World Wars, but has probably existed since the beginning of time! Language and humour sometimes help us gain some distance either for perspective or self protection

  • Michelle Gibson

    Many moons ago I was subjected to personality testing as part of a team-building process. I forget most of it, except that one phrase resonated with me: “You believe that *how* things are said is important,” and that is 100% true. Sometimes the issue relates to the words being used but just as often it’s tone, nuance, body language, and what is not being said.

    What struck me with the scenario above is that this was not just about slang and black humour … both of which can be used without showing disrespect to patients … but that I read the discussion as oozing with a lack of respect for a human being.

    I don’t think that medical educators should be held to a greater standard – I think that all physicians should have the same standard. I get it – we work in a difficult job. We need to decompress. We need to laugh. I love black humour. But we need to be aware of how we use these strategies and our language regardless of our role.

    The use of language and how we communicate in a broader sense usually reflects how we feel about things. The issue is less about the language, to me, as what it represents.

    So what do I do? I try to be explicit. If I laugh about something that involves a patient, I try to explain up front what made me laugh, and I hope that my deep respect for my patients comes through. I am not going to pretend I am not frustrated, annoyed, etc. etc about things patients do – that happens, um, always – but I try to be frustrated by the action, not the person, and I try to understand why the person did/did not do whatever.

    I hope that doesn’t sound preachy because I’m in no position to preach! I’m certainly not perfect, and I’ve said things I’ve regretted (ahem … many things). I do try to explain why I refuse to use certain terms (failure to cope should be banned), and I laugh a lot at the absurdities we encounter daily. I debrief traumatic events, and I laugh during these times too.

    Interestingly, I get feedback about this a lot where med students say they can tell I care about my patients. I wonder – does this mean they do cannot tell that some of their other teachers care?

    Early morning points to ponder. Pre-coffee, so take it all with a grain of salt!

    • Heather Murray

      Interesting points, Michelle. I’m wondering if you can expand on why you think the term “failure to cope” should be banned?

      • Michelle Gibson

        Happily. I will reference Dr. Kate Granger here too – she is talking
        about the even more upsetting term “acopia” but I don’t think that
        Failure to Cope is any better
        http://www.ncbi.nlm.nih.gov/pubmed/24098878 .

        “This term is offensive and lazy, implying fault on the part of the
        patient and allowing the assessing doctor to erroneously label the
        patient as a ‘social admission’ when, in fact, such patients are likely
        to be frail with co-morbidities and have an acute (potentially
        reversible) illness.”

        It’s a good example of what I’m describing. Just listen to it as it would apply to someone you care about if you weren’t in medicine Your uncle/mother/granny/dad is failing (thus, it’s their fault) to cope (and we always define coping skills as being positive things). Thus, one could conclude, the person
        must be deficient in this quality that society values.

        More
        importantly, it is often represents a system failure- failure to
        diagnose underlying conditions, failure to manage these, failure to
        support frail older adults at home with appropriate home care – but the
        patient is labeled as the one who has failed. This series notes that
        almost 30% of patients who were triaged as “acopia” (in this particular
        setting) had sepsis:
        http://ageing.oxfordjournals.org/content/38/1/103.full.pdf … not sure how well I would personally cope with being septic.

        This
        inevitably raises the question about how physicians feel about older
        adults. Yes, many ER docs (including the vast majority that I know!)
        care as much about their frail older patients as any others, but sadly,
        ageism exists in all aspects of health care. Sadly, we see evidence of
        this all the time, still. (Not picking on the ER here – honest. These
        issues exist everywhere.)

        So, back to my point – language
        matters. If learners hear the term failure to cope, even if used by
        people who do not mean to be ageist, can you blame them if they think
        that a) their teachers don’t care about older adults, or b) that the
        patient is at fault?

        I seem to have a lot to say today. I guess I’ll boil it down to this- many/most doctors care a lot. However, not infrequently language reveals how people really feel about patients. It is hard for patients, family members and learners to differentiate between those who do care and those who don’t so it is our responsibility to consider what we say and how we say it.

        (Hazards of being on a train… time to write/think.)

  • Heather Murray

    Thanks for the great comments. I am curious why black humour is felt to be appropriate but slang is not. Aren’t they two sides of the same coin? What makes them different?

  • amcunningham

    Hello Heather,

    A few years ago I wrote a blog post about slang (http://wishfulthinkinginmedicaleducation.blogspot.co.uk/2011/09/social-media-black-humour-and.html). I quoted Delese Wear where she says that medical educators “throughout academic medicine might begin candid discussions of derogatory and cynical humour in their particular cultures in order to become better aware of their participation in it and their responses to it when they overhear it from others”. (http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.2008.03171.x/full).

    What’s worrying is that this medical student has not been given an opportunity to debrief about this traumatic case. And what about the doctors? I am hearing increasing conversations on my side of the Atlantic about a need for supervision for doctors and other healthcare professionals so that we can deal with the stresses of our work.

    • S Luckett G

      Thanks for your comment, Dr. Cunningham. I agree that the lack of debriefing is a frustrating and concerning aspect of this case. As a med student and resident, I have sometimes had to pursue debriefing after a difficult case, or one where my performance was lacking.

      How do you deal with debriefing learners (or yourself!) after a challenging case? Do you think that appropriate debriefing would reduce the use of such gallows humour?

      • amcunningham

        I think we decide it is a priority and we do it. I’m a primary care doctor and had a particularly traumatic case last year. I found discussing it invaluable. I do think we have a duty to model to learners that this is important.

        • S Luckett G

          I would have to agree. It is difficult as a learner to seek out debriefing if we have not had its importance impressed upon us!

  • There are better ways of managing the communication around this event from the get go. First as the fatal outcome may be subject to various levels of investigation in the hospital system, this would be relayed to all of the team members involved in the resuscitation attempt. Second anyone who felt upset, distressed would be offered support. Third, the use of slang although it may occur is not actively promoted as already mentioned by Teresa Chan. My suggestion for addressing this type of culture is that it not be actively promoted by the hospital leadership but instead the opposite is promoted- ie leadership skills, professionalism and sensitivity. After all what some people may think is amusing may not in fact be shared by other healthcare employees.

    • S Luckett G

      Dr. Verran, I agree that this event could have been controlled and managed more expertly. I wonder how often this kind of management is actually executed, especially in the fast-paced world of the emergency department.

      I also agree that humour is often not shared by all. Do you think there is an appropriate forum for the use of humour in debriefing? Are there circumstances where it could be more or less acceptable?

      • It is possible to use humour in debriefing but one has to be mindful that in doing so one does not create a distraction to what needs to be dealt with via the debriefing process. Also context is important with scenarios where there have been significant adverse outcomes, requiring extra consideration.

        Where humour can be more effectively used is in education forums where these types of scenarios may be the subject of an in depth discussion. In order to create audience engagement and also allow everyone to feel that they can actively contribute to such a discussion, humour can be used to facilitate this.

  • Deirdre Bonnycastle

    Congratulations Theresa on the multiple layers in this case: death, communication with families, black humour, role modelling, human body fluids.
    I recently did a session on harassment for residents and we talked quite a bit about humour’s role in bringing people together, in de-stressing situations but the residents said the line was drawn when humour was used to push people out of the group or to dehumanize/objectify another person/group (to make them not us). I wish I had seen this case before the session because I think it perfectly illustrates pushing patients into that dehumanized “red underpants” category, so doctors don’t have to feel the pain of a life lost. This also means they don’t have to think about their own or a loved one’s messy death because they are different.

    I agree with all the people about this being an important discussion that needs to take place. I think there is also an issue with preceptors needing training on Intentional Role Modelling.

    • S Luckett G

      Dr. Bonnycastle, many thanks for your thoughtful comment. You’ve thrown me into an ethical quandary: How can we use humour in such a challenging situation without objectifying the patient? Is there a way that we can avoid thinking about our own or a loved one’s messy death without doing so?

      I find the idea of intentional role modelling intriguing. I sometimes find, as a resident, that my preceptors are not aware of the effect of their modelling (or perhaps even the fact that they are modelling). In fact, just the other day, I reflected back what a preceptor had said in conversation, and that preceptor replied with, ‘I hope I didn’t say it like THAT’. To me, it was an accurate representation of what that teacher had said, and I wonder if it would have been said differently had that mentor realised how closely I was watching and listening for guidance.

    • Heather deserves the credit for this case!

  • Forgive my observational intrusion as a patient into this series, but my reaction is based on both being a heart patient with ongoing cardiac issues (you know, one of those “frequent flyers”) as well as being a longtime employee of the same hospital where I was first admitted six years ago. Perhaps the culture’s different in hospice/palliative care, however, where I can honestly say I’ve never heard any my colleagues there snickering about degrading end-of-life realities of our patients – like “red underpants”.

    In your particular case, it wasn’t so much the common issue of collegial slang that struck me (terms like “circling the drain”, as this month’s expert Dr. Goldman describes the imminently dying in his new book, for example).

    It was the laughing.

    Some may blow this off as merely stress-releasing, as if it were somehow effective, instead of what it actually is: a symptom of depersonalization that is ultimately the slippery slope to career burnout (right alongside its two trademark companion symptoms of emotional exhaustion and reduced sense of accomplishment).

    As a patient, I’m pretty used to experiencing pervasive depersonalization in hospital (being openly referred to as the “MI in Bed 8” or “the 10 a.m. procedure”, for example, or – as Kate Granger’s #HelloMyNameIs campaign can attest – the abject lack of simple common courtesy in introducing one’s name and specific role to patients.

    But to assume that high hilarity over a patient’s rectal bleeding is in any way “normal” behaviour should be as chilling an observation to health care providers as it feels to me.

    (Thanks, by the way, to AnneMarie Cunningham of Cardiff for inviting me to offer my two cents worth here… )

    • S Luckett G

      Carolyn, a breadth of voices add depth to our understanding, and your patient perspective is most welcome here.

      I think your comment draws important attention to an aspect of gallows humour and slang that we haven’t yet addressed here.

      As a junior learner (I’m a first year resident in emergency medicine), I find a limited amount of depersonalisation almost a necessity in doing what I do. Were I to feel every challenging event or loss deeply, I wouldn’t be able to move on to the next patient with the energy to give empathic care. Kind of paradoxical, but nonetheless true from my perspective.

      I wonder how more seasoned physicians feel about your commentary; perhaps my particular perspective is coloured by the high volume of learning I feel pressure to accomplish at this early stage.

      I agree that depersonalisation can be a dangerous thing if taken too far. Do you think there is ever an appropriate amount of depersonalisation, or is it always inappropriate, from a patient perspective?

      • Thank you both for your comments!

        I think one of the issues around using beds as the surrogate for patient identification is that privacy laws make it very difficult to talk to my colleagues without other non-healthcare providers overhearing in the ED.

        As such, we usually use terms like the “cardiac patient in bed 10” because I’m not supposed to say “Patty Smith” and talk outloud about Pts names….

        How do we reconcile patient confidentiality with a personal approach, especially in ED environments where curtains replace walls?

        • S Luckett G

          Another important point! I try, as a learner, to use phrases like ‘our gentleman in bed 10’ or ‘our lady with the chest pain’ or ‘our 10 year old with fever’ as a way to get around that, but it’s definitely clunky and I’m not sure it actually reduces depersonalisation.

      • I agree – depersonalization can often be viewed as a form of practitioner self-protection particularly during catastrophic events – and particularly in the high-turnover reality of Emerg – but how does one know when it’s “dangerous if taken too far?”

        We do see examples of the other extreme – at discharge – when we are sent home. I’ve been discharged home at least twice after hospitalizations by staff who knew absolutely nothing about me or about my home situation, without one single doc, nurse, social worker or janitor asking even the most basic of questions: is there anybody at home to care for you during recuperation? is there anybody at home YOU need to care for? will you be able to take enough time off work to recuperate? will you be returning to a stressful job? can you afford to pay for the $500/month worth of new meds you’ve just been prescribed every day for the rest of your natural life? Small wonder so many of us feel like we’re merely yet another small cog in a very big wheel, and that’s the real danger of depersonalization.

        Please don’t get me wrong: I’m not wanting to make friends and go camping with my care providers. Depersonalization to me just means the opposite of NOT “seeing” me as the obstacle between them and their next break, or as a bed control issue (“You’re taking up a bed. We need that bed.”) I’ve written a bit more about this at http://myheartsisters.org/2009/07/10/open-letter/

        • I’m sorry to hear about your experience. Very important to remind us always to see our patients as people.

          Social history is something that is important and I love that it is being built in as a routine part of Hx/Px in most medical school curriculae – but to truly understand a patient’s experience is the most difficult part sometimes. And to understand when people come to us to ask for help – it isn’t a failure necessarily, it’s a privilege for us to serve.

          But compassion fatigue and it’s more insidious counterpart burnout can result in differences in empathy and ability to walk another’s shoes.

          • S Luckett G

            Social history was deeply embedded in the curriculum at my medical school, and I routinely ask who patients live with at home, whether their houses are on multiple floors, and whether they have coverage for the services we offer them. I suspect that most other beginning residents are in the same boat academically as me and also ask the same questions. I certainly hope that’s the case!

  • Guest

    I’m more of a pragmatist than anything else and I’m sure my comments will neither be wholly popular or politically correct. For anyone who hasn’t listened to Liz Crowe’s talk from SMACC, follow this link and check it out. She says it better than I ever could.

    I don’t like to use certain slang like “frequent-flyer” but not because it dehumanizes but rather because it leads to premature diagnostic closure without even starting any diagnostic process. “Mr(s). X is a chronic alcoholic and frequent flyer . . . ” makes you immediately think, “Great. Mr(s) X is back because (s)he’s drunk and has no where else to go.” Thinking or saying this makes it far more likely that you miss the critical illness when it pops up. The so-called “frequent-flyers” (alcoholics in particular) were created to screw with Emergency Physicians. As soon as you start to blow them off, they’ll have life-threatening issues.

    All of this being said, black humor is important in all fields of medicine and particularly in EM. We see the worst that society has to offer on a regular basis. We see terrible things happen to good (and bad) people every day. I think depersonalization is critical for us to keep our sanity. If I became personally connected with every person I saw in the ED, I’d have a very short career.

    None of this means that we can be empathic and show empathy towards patients. It does, however, mean that we need to separate that empathy from our core.

    As far as our roles as medical educators, this is tougher. I don’t think that medical students and even early on trainees should be exposed to all of our black-humor. We don’t want them be callous. I often talk to students and trainees when they start working with me about this. I let them know that from time to time, we say things that seem insensitive and that it’s likely to be our defense mechanism against the onslaught of horrible things we see. However, any good physician knows how to differentiate the two. It’s our job in medical education to teach or trainees to be professional but also to be able to cope with the job.

  • Guest

    I’m more of a pragmatist than anything else and I’m sure my comments will neither be wholly popular or politically correct. For anyone who hasn’t listened to Liz Crowe’s talk from SMACC, follow this link (http://lifeinthefastlane.com/swearing-way-crisis/) and check it out. She says it better than I ever could.

    I don’t like to use certain slang like “frequent-flyer” but not because it dehumanizes but rather because it leads to premature diagnostic closure without even starting any diagnostic process. “Mr(s). X is a chronic alcoholic and frequent flyer . . . ” makes you immediately think, “Great. Mr(s) X is back because (s)he’s drunk and has no where else to go.” Thinking or saying this makes it far more likely that you miss the critical illness when it pops up. The so-called “frequent-flyers” (alcoholics in particular) were created to screw with Emergency Physicians. As soon as you start to blow them off, they’ll have life-threatening issues.

    All of this being said, black humor is important in all fields of medicine and particularly in EM. We see the worst that society has to offer on a regular basis. We see terrible things happen to good (and bad) people every day. I think depersonalization is critical for us to keep our sanity. If I became personally connected with every person I saw in the ED, I’d have a very short career.

    None of this means that we can be empathic and show empathy towards patients. It does, however, mean that we need to separate that empathy from our core.

    As far as our roles as medical educators, this is tougher. I don’t think that medical students and even early on trainees should be exposed to all of our black-humor. We don’t want them be callous. I often talk to students and trainees when they start working with me about this. I let them know that from time to time, we say things that seem insensitive and that it’s likely to be our defense mechanism against the onslaught of horrible things we see. However, any good physician knows how to differentiate the two. It’s our job in medical education to teach or trainees to be professional but also to be able to cope with the job.

    • Heather Murray

      Thanks for this – Liz Crowe is one of our expert commentators and we will be posting her written response to this case next week.

    • Anand Swaminathan

      Sorry, posted as anonymous. Above (post starting with “I’m more of a pragmatist” is from me.

    • S Luckett G

      Dr. Swaminathan, I don’t think I have ever encountered a preceptor who has had an upfront discussion with me about the use of black humour by staff. I feel that I understand why and where it is used, but I also feel that I need to participate so that I don’t seem too green and naive, or not pragmatic enough.

      You’ve intimated that students and trainees might not always benefit from hearing all the black humour staff has got to offer, so what strategies should we be using as our own defence mechanism?

      • Stella Yiu

        Great conversation so far.

        I agree with Swami that we gradually built our armour of coping/defense mechanisms for our hectic daily work. I would even go further and suggest that sometimes when the situations are dire, we “need” to depersonalize so we can focus on tasks and decision-making objectively rather than being swept up in emotions. I think that mechanism of separating illness from the person works well (for say, a pediatric code, a disaster etc.) that we started using it for other patients as well. It might be such a gradual process and not so explicit to ourselves (not everyone is as introspective as Swami) that we never see it as such and therefore do not explain it to our learners. We have all thought about patients and cases long after the shift has ended when the full impact of “who” they are hit us – and the learners clearly do not see this (or do not have this explained to them later).

        On the point of calling patient by name versus not, I have now adopted calling the patient by their initial (if it is a public place – therefore “Mrs. P”) since I think that 1) knowing patient’s name is respectful and 2) I have more than one patient with the same complaint so I need to be clear. I expect my learners to at least strive for that for practical reasons.

        Thanks for listening.

        • S Luckett G

          Thanks, Dr. Yiu. At the very least, it’s comforting to hear that others more senior than I consider depersonalisation a normal and sometimes necessary part of providing health care. I wonder if being more mindful is the solution to indiscriminately applying that strategy.

          I like your solution to patient naming. Personal but protective of patient confidentiality and a facilitator of good health care.

          Do you ever have a dialogue with your learners about black humour and depersonalisation, Dr. Yiu?

          • Stella Yiu

            Interestingly, not explicitly. As staff physicians often talk about this struggle among ourselves.

            It has come up with learners that this is about cognitive emotional bias – negative like how it was mentioned before, and even with patients we bonded with or know since it is sister of a friend/nurse I worked with 3 yrs ago etc, our judgment is not always objective. So we end up doing less invasive exams or more tests.

            To get back to your reply, Dr. Luckett, I think being more mindful is helpful. But our daily work hones that skill extremely well, to the point that we often do it automatically. This ‘separating what is the clinical problem’ becomes as good as the ‘what is the deadly differential’.

            It is interesting that I wrote something about this coping mechanism when I was a trainee:

            http://www.cfp.ca/content/49/10/1275.full.pdf+html

            Thoughts welcome.

          • amcunningham

            Stella,
            Thank you so much for sharing this. Two things struck me from your piece- first that you left the medical student alone, and second that you yourself seemed so alone in making your way through this. (I am sure you had a lot of positive feedback at the time but the nature of publishing in 2003 was that they are not visible for those who find your piece later) Isn’t it wonderful that we now have this forum where we can all discuss this together and learn that there are not right or wrong answers but that we shouldn’t feel alone?

          • I’m really glad that this case is resonating with people – and creating a good forum for discussion around topics that one might encounter is our aim – but sometimes it’s also a chance for those who have HAD experiences to reflect back and/or share with us about other points to consider.

            I think that this IS the reason for MEdIC – creating a layered community of practice that can use fictional cases to prompt honest and great discussion.

            Thanks for both taking the opportunity to share and discuss with us. We really sincerely appreciate it.

          • Stella Yiu

            Reply to both above,

            It was an interesting range of responses at the time, and certainly I did not have the forum to discuss it further. I think it exposes our vulnerability (as humans) and some don’t examine or contemplate it further. This forum is a wonderful space for it now.

            I did (and still don’t really) have the correct language to describe the whole ‘depersonalization as coping’ process. Also am learning to master the switch between the empathetic and logical (Kirk and Spock?) personnae.

  • Heather Murray

    One of the things no one has commented on is that the conversation which upset Trevor is one that he was not meant to be part of. He has overheard a snippet of a conversation and drawn his conclusions based on that. In medicine, as in life, context is everything. Some twitter commenters have mentioned that we should remember that we are always being observed by learners, and this case is a good reminder of that.
    But what if the overheard conversation had looked like this?

    Dr. Elliott took Jeff to the back room – he looked awful.
    She sat him down.
    “That was a really challenging case, Jeff. What do you think
    about it?”
    Jeff sighed. “I feel awful. I just couldn’t get that stupid tube
    in. If I’d intubated him sooner…” His voice trailed off.
    “Jeff.” Dr. Elliott looked at him. “You did what you had to
    do – you used lots of suction and stayed calm.”
    Jeff looked up. “I just… I feel responsible for the outcome.”
    Dr. Elliot sighed. “Jeff – he was sick, with lots of other
    problems. He’s been a frequent flyer for years, and has been at death’s door
    many times before he showed up today with red underpants. This is not your
    fault! Besides, no one can intubate through a bucket of vomit.”
    Dr. Elliott laughed and Jeff laughed with her. “It was pretty
    gruesome. One for the record books.”

    • Heather Murray

      This is just one possibility – the case doesn’t give you the actual conversation. But would the language and humour have been more palatable to readers if this had been the scenario? Or is it never acceptable? Interested in people’s thoughts!

      • Loice Swisher

        I think what Trevor is reacting to is that most EM docs become very good at being emotional shapeshifter. We are trained to rapidly change for one situation to another while making every attempt to have our demeanor match the need. I can go from telling a family that their loved on has died to a hysterical mom who cut a fingertip while cutting an infant’s nails to a screaming naked man on PCP in a matter of minutes.

        When one observes this shifting to find where the other person is, well, it can be confusing and seem deceiving. One needs to remember that the duty to care is not only for the patient but also for the resident. In addition, the approach for one trainee might not be right for another.

        In addition, to get to the heart of the matter one might use terms with one person that would not be used with another. Here is a much different example from when I was very new in EM. The triage nurse asked me to come in to talk to a 15 year old boy with a urethral drip to figure out if we needed parental consent to treat (one doesn’t for STDs here). I asked the young man if he was sexually active. He said no. I looked to the nurse who leaned in and said “Do you f**k?” He enthusiastically said “Oh yeah all the time!” Taught me that you need to use words and approach to reach the other- even when sometimes it just sound off.

    • amcunningham

      It becomes more interesting. So we are witnessing a debrief. The junior expresses emotion about the death and his part in it and the senior responds with slang to depersonalise the patient so that the junior feels better (and can get on with his work for the rest of the shift?) This may be very necessary but we should acknowledge the processes that are going on.

      • LizCrowe

        HI All
        Sorry to be late to such a wonderful and thought provoking conversation- it is school holidays here in Australia!!.
        My primary place of work is paediatrics and we just had a horrendous case last week where the range of emotions following the unexpected death of a child have been both confronting and surprising. As the social worker in the Paediatric Intensive Care Unit I usually hear the slang, depersonalisation, humour and judgements in the lunch room, ward rounds and around the hospital, sometimes I am whole heartedly involved and sometimes just a listening participant. What I also know to be true is often those who laugh the loudest, make the crudest remarks or are the most dismissive are those who cry the hardest, attribute the strongest personal guilt or suffer the most behind closed doors…. I would love it if we could all be more real, more compassionate and greater educators. I would love it if we could find an ideal solution to assist people to be more present, aware and respectful however there is no one size fits all solution to this. Sometimes our most skilled surgeons, physicians, nurses or allied health have the worst bedside manner – as I often say one person rarely ‘gets it all’.
        However to be deeply human and honest for many often leads to huge vulnerability. In this deeply distressing and unexpected death last week, we debriefed very quickly as everyone had to run back to clinics, waiting rooms full of patients, a PICU with 14 ventilated patients and a baby on ECMO and then the rest of us stayed with the devastated parents and did memory making. There was no time available in that moment to do anything more. If everyone had allowed themselves in that moment to weep and fall to the floor, which I know many – me included (which is exceptionally rare for me) I just could not have gotten on with the job. How do we balance a need to attend with our emotions in the moment when we have so many other critical things to do over the course of another sometimes 10 hours of work?? We can not go back and tell patients and their families that there needs, sometimes critical medical needs will have to be put on hold while we reflect and compose ourselves, while we try to make meaning of something that unfolded in front of us without warning.
        We did run a two hour debriefing five days later which all of the nurses could attend but only one of seven physicians who did CPR on the child could attend due to work schedules… An alarming but challenging reality of the work. What happens to these poor doctors?
        There is no easy solution but perhaps having insight into the human psyche and being curious about what really is happening for the clinician that appears so disrespectful is a start. If something shocks me I find usually just saying “I find it very hard to believe you don’t care”, OR “I certainly feel really differently to you, I feel completely distressed” is often met with silence or a wave of emotion.
        Some individuals are better at managing emotions then others. Many are terrified of the depth of emotions they feel and wonder if it is a warning sign that they are ‘not cut out’ for critical care medicine or medicine in general.
        I am doing my PhD in staff support particularly looking at what would help clinicians- debriefing, education, individual counselling etc. I have just started collecting data and have 150 responses to date and already I can tell you that there looks to be little consistency across the board as to:
        a. what distresses people at work
        b. what would consistently help.
        I believe every patient we see deserves every skill and talent that we can bring to that situation. Every patient while we are there in front of them deserves our respect, their dignity, our time, our honesty, our connection and humanity. What people then do hopefully behind closed doors to unpack their day and put it somewhere safe I have more flexibility about. I sometimes tease my loved ones around a whole range of things – I am not disrespecting them – I am teasing them and sometimes I think depersonalising something with humour is more like teasing or distancing then a general disregard for another human being.
        On Monday I went to a one day workshop on Resilience which was run by Dr Glenn Schiraldi from the University of Maryland. He is suggesting that we run simulations that incorporate learning about distressing feelings and emotions so that when these arise for clinicians or soldiers they can recognise them as normal and not build unhealthy responses to them. I LOVE this idea and will be working it into my studies….
        I also believe we need to have more forums like this so we can hear and be challenged and confronted by how others view our behaviour. This will force us to rethink and make sure that we don’t become self righteous in our responses

        • “… suggesting that we run simulations that incorporate learning about distressing feelings and emotions … ” an increasingly important educational intervention to stop bullying and burnout …

          • LizCrowe

            I think we need to simulate, discuss and work through every component of clinical care. Including our emotions, reactions and how we reflect. Even reflection is a learnt skill that needs practice

          • Yes Liz, reflection is a learnt skill. We teach our midwifery students how to reflect. The undertake reflections in a structured way and submit their reflections for assessment. We have a clear process and they are taught the process from year 1. The students don’t like it in first year, tolerate it in second year and really see the value in third year. By the time they graduate, the process is embodied and ‘natural’.

          • amcunningham

            Carolyn,
            I don’t want to distract this thread but could you send me the materials you use to support students in this process?
            Many thanks
            AM

          • Happy to do that – can you please email me your email address? My email address is Carolyn dot Hastie at scu.edu.au

          • LizCrowe

            I think nursing and allied health have far more opportunities to learn skills around reflection. Many allied health disciplines also have access to regular supervision to talk through cases that they are concerned about. I think it is wonderful that midwifery students have this opportunity.

        • Great post and yes I share your concerns re: those who exhibit the most bravado at the time may perhaps be at the greatest risk in the medium to long term. This is an important topic and it will be good to see more emphasis being given to how healthcare workers can learn to cope with these types of scenarios. How this is best incorporated into training and education programs is one question that requires further consideration as you have mentioned.

    • Loice Swisher

      This scenario rings completely plausible to me. I work nights in an urban community hospital where for several hours it is usually only me and a 2nd or 3rd year EM resident. The time it takes for a code and a discussion with the family is usually long enough to really back up the place causing other patients delay in their care. I can think of very few scenarios where I would feel compelled to talk to a resident in a back room (likely the most private place I could find). One of those is if it looks like the resident’s head is not in the game. This skill is critical for EM docs- regardless of the outcomes – regardless of mistakes.

      At that moment, I need to be able to find a way to reach that resident so they can finish the shift competently- rapidly since people are waiting to be seen. Perhaps it is important to remember the duty to be able to give the deserved focus and care to others in the emergency department as well. I find some way to compartmentalize in the moment can be essential.

      For longer, deeper discussions I always believe that I can make the opportunity to discuss cases one on one outside of clinical hours.

  • Jordan Grumet

    Many years ago I stood in front of my cadaver while a group of classmates pulled up the covers and made disparaging remarks about the size of the man’s genitalia. They all laughed and smirked as I cowered in the corner ashamed. Later that day, i pushed everybody out of the way and dissected the facial structures by myself. I wouldn’t let the rest do such a delicate and intimate job after what had occurred earlier.

    As the years passed, I have learned that dissociation, the building of walls, ultimately is necessary to deal with the pain and difficult decisions involved in being a physician. Often gallows humor and slang are used among medical professions to fortify these walls. The novice, the medical student, has no experience to understand the depth of the wounds inflicted by making decisions that alter people’s lives. The experienced physician, years removed from his training, often forgets the softness and purity that propelled him into this profession in the first place.

    Ultimately, I found that gallows humor and slang were immature coping mechanisms, Becoming cruel and callous would neither shield me from the pain or save me from my own failings. Instead I have become a believer of intention. Intention is my true north. And it leaves very little room for demeaning those who i have taken a covenant to protect.

    We currently face a most difficult period in medicine. Burn out is at an all time high, and physician suicide is the topic gracing the pages of our most prominent periodicals. Our coping mechanisms are not working.

    We must stop making our patients the butt of our grisly humor. I think we need to learn how to forgive ourselves for the difficult truth that medicine is not what we dreamed when we entered this noble apprenticeship,

    and personal perfection is an unattainable goal.

    • LizCrowe

      Cruel and inappropriate humour may not always be immature coping mechanisms. However they are often only first line of defence coping mechanisms that allow individuals to continue with several hours of difficult and busy shifts that lay ahead. However, for many they will then need to unpack their emotions, review their intentions and work through their emotions and experience of the event. We are all really different.
      I also am interested in the burnout literature. Burnout is real and a challenge for modern medicine but as the positive psychology movement raises profile we are finding for every burnout study we can often equally find positive traumatic growth and or meaning making in the workforce.
      Also often what is burning individuals out is often not death or trauma in the workforce it is actually bureaucracy, bullying, areas of understaffing or the demands of life and how to attain a good work/life balance.

    • S Luckett G

      Medicine is definitely what I thought it would be, though perhaps I didn’t come in with dreams of it as a noble apprenticeship, but rather an understanding that it was a job, and a difficult one at that! I think we all arrive from different perspectives, and that’s part of what makes this discussion so rich.

      I consider myself a mature, self-aware, and reflective individual, yet I still find a place for gallows humour and slang. Further, I don’t think that either has made me cruel or callous – I doubt I would be participating in this discussion did I not care deeply for patients and colleagues.

      I’d like to know more of what you mean by intention being your true north!

  • Eve Purdy

    Great case! I’ll join the conversation here as a medical student.

    I can relate to Trevor. I’ve been there, not exactly there but close, and it is desperately uncomfortable when you see superiors making light of a situation that has really shook you. It slams any door shut to debriefing. A task, that in my experience, is usually left in the student’s court to initiate. For early medical learners, many situations are a ‘first’ and may not seem worthy of debrief by those further along but I feel I need to talk about and could use some perspective on. I simply won’t start the discussion if it doesn’t seem like a safe, respectful supportive environment. As a medical student I have often spent much more time with my patients than my seniors, I know the names of their grandkids and where they met their spouse. When they die and I feel like I need to talk about it but I overhear my senior laughing with a colleague saying, “well at least our list is one shorter,” it bothers me. It really bothers me, and it always should. I go home not having talked about the situation with anyone.

    Do residents and physicians get training in how to debrief? Maybe we don’t do it often enough because we don’t know how?

    I’m not opposed to black humour in the right time, in the right place (just ask a few of my close friends at #qmed) but when it isolates team members it is a big problem. Specifically with this case, the medical student is not a regular part of the team in the ED. He may not have worked with the resident and physician before. He may not know that the resident and physician do in fact care a great deal for their patients. He is left with this superficial impression because he is not really a part of the team. He may be switching rotations the next day and not get to know any better. He may begin to think that this is okay. If everybody involved in the conversation is not coming from the same place there is a lot of room for black humour to do damage.

    • S Luckett G

      Hi Eve! While I certainly can’t speak for everyone, I have not had debrief training (yet) as a resident. In fact, there has been at least once instance where I needed to debrief, and I initiated that with my supervising attending. The attending was more than open to the debrief when I made the approach, but I don’t think it would have happened without my insistence.

      • LizCrowe

        I am interested to see people talking about the need for debriefing, a culture of debriefing and who leads debriefing. We established a very clear pathway for debriefing in our hospital that is activated whenever there is a need identified by staff – usually following a death, a code, when there is a difficult ethical case that is causing unease in the Unit or when we have challenging personalities. It is always led by a Consultant, a senior nurse and the Social Worker. We follow a strict procedure around the debrief to ensure that all aspects of the incident or case are addressed. Anyone who needs further individual support is then either seen by the most appropriate profession or referred for counselling. I feel very strongly that Health need to adopt a culture of debriefing similar to the Armed Forces and the majority of Emergency Services – in Australia this is common place, however health still do not do it routinely and I am not sure what our hesitation is?

      • Loice Swisher

        Hmmm…. I think you can speak for the great majority in medicine. I find it is a vey few that have actually had training during their medical education in debriefing leadership. As evidence, a recent article on pedi EM fellows showed that 88% did not have formal training in debriefing but more than 90% would like such training. http://www.ncbi.nlm.nih.gov/pubmed/25198763

        On the other hand, attending are expected to do these jobs- and do them well- yet we do not truly prepare our leaders for these roles. In examples such as this, I see it as an unexpected peek behind the curtain to truly see the Wizard. To paraphrase the Wizard of Oz- I am only a person…. perhaps a very good person but only a person. Sometimes those peeks behind the curtain reveal our human failings. Sometimes those partial peeks do not reveal the entire extent of the conversation- quotes out of context- and not the whole story. Sometimes those peeks are shocking.

        Over the decades I have have seen some movement to incorporating the development of these skills into curriculum; however, most are just really an introduction and hardly could be conceived to confer competence. In addition, the pressures within running an ED with length of stay and patient, documentation and even patient satisfaction seem to limit further the ability to see real time debriefing as a high priority- unless it is brought by someone as a specific concern.

        In the short snippet of the case I can’t say what truly was happening between the resident and the attending. However, it does seem that Trevor peeked behind the curtain and was shocked not to see the Wizard he was expecting and then didn’t have a path to figure this out. Perhaps sometimes a back room is needed just to decompress to be able to do better when one is in the front of the house. Even then it takes experience and dedication to personally meet the highest standards and confront those that do not strive to them.

  • As an oncology patient I’ve been nudged in here by Anne Marie Cunningham, and although I think ED has really different pressures than oncology, I have a quick thought which I hope it’s OK to share. The thing is, patients also use pretty black humour about their illness and treatment, especially when we’re together. Sometimes it’s the only way to live with a challenging diagnosis. I’ve noticed that it can mean we’re more comfortable being frank about the physical state we’re in than the people who are treating us, who are held to standards of professional courtesy. This is something illness sociologist Art Frank wrote about in his cancer memoir: nurses and doctors who even went out of their way not to say “cancer” in his presence.

    I’ve been so grateful for staff who are wiling to be frank about the state of things with me, in ordinary human language–including humour. So what strikes me in this case study is the difference between black humour used to make a human connection to the patient, who already knows exactly what’s messy and undignified about their condition; and its use in their absence in a way that does seem a bit dehumanising to me.

    • Always welcome patient perspectives!! That’s why we use fictional cases, so we can all get involved and discuss.

      Thank you so much for sharing your thoughts.

      I think it is a great point to distinguish between humour we use WITH our patients vs. humour we use to discuss our patients elsewhere… without their knowledge.

      In a case as in the above, however, does that mean we can never utilize humour to discuss a patient death or situation around their death? They, unforunately, will never be party to the conversation in those situations…

      • I think it’s realistic to joke about these things. Patients joke about their own death, lets face it. But I think at its best, humour takes us deep into the heart of what troubles us and helps us think it through without being overwhelmed. Sometimes there are things only humour can let into the room, and maybe we need them too.

      • amcunningham

        In this case the question could be ‘would this humour be used with the relatives?’ I don’t *think* it would at this time at least. It is about the staff distancing themselves to allow them to cope. But how do we make sure that all parties are able to move past this ‘first pass’ coping strategy?

        • Loice Swisher

          As I reflected on this I believe there is a difference between patient discussion and situation discussions. These discussions take place with different people and thus it isn’t unexpected that the words and emotions might be different and the setting for discussion should be different. Think about talking about sex. The talk would be different with a 5 year old, a 15 year old and a 25 year old. We have the same issue in the ED- nurses who have done many codes might not see the same need as a 3rd year student who just experienced the first code. This resident might have needed a different “talk” and was able to make the needs known to get that. Unfortunately, Trevor was struggling for his “talk”.

          Trevor moved from Quadrant 1 to 2/3 rapidly and unexpectly.
          http://iteachem.net/2014/05/interplay-emotions-learning/
          Now the thing is to figure out how to get back to Quadrant 4

      • JonMendel

        One question is how confident doctors and students can be that these discussions take place without patient/relative knowledge. The paper @amcunningham posted (http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.2008.03171.x/full) says that derogatory humour took place in locations including “hallways outside patient rooms during rounds”. Clearly, there’s a low risk of dead patients overhearing, but is there a risk of living patients or relatives overhearing?

    • Heather Murray

      Hello Kate – thank you for your comments. It is really great to hear the patient perspective on this issue. You are suggesting that patients themselves would be open to, and perhaps even grateful for, inclusion in the humour that may arise from their situations. I think that the differences in personalities and coping mechanisms between people is one of the interesting themes that has come out in this conversation. It is very hard to know what people will find amusing and what people will be shocked and/or hurt about, even in regular life. Those tendencies may be magnified in the heath care setting. I suspect that there would need to be a fairly strong pre-existing relationship between a care provider and a patient before that level of “risk” would be taken in a health care setting – there are just so many ways it could go wrong. Certainly I would be very reluctant to make jokes with a patient unless they were initiated by that patient.

      • Yes, that’s entirely understandable, and not easy to get around. From my experience and discussion with other patients, we also hide the humour a bit around staff. There’s a kind of illness professionalism in patients too, weirdly. There isn’t an answer to this; I’m just suggesting that maybe there’s some black humour being used to cope on both sides, that mutual professional courtesy keeps apart. Thanks for the welcome, by the way. It’s so interesting to read all as a patient.

        • LizCrowe

          I love that Kate has mentioned how inappropriate patients may be about their illness and symptoms also as a means of coping, creating distance and normalising. Very similar to not only what health professionals do but also very common in the defence forces and emergency services. I use very different humour, language and levels of crassness at work then I ever would in my personal life…Why? Because others just won’t get it. Because what I have to see and cope with at work cannot be compared to in my personal life. I have seen many a family use black humour during a crisis and even following a death.

          • amcunningham

            Liz, could you expand on what you mean by ‘inappropriate’ in this case? Inappropriate by society norms? Inappropriate by health professional norms? Inappropriate by class norms?

            It’s a very rich discussion and I don’t envy you having to summarise!

          • Luckily Liz already wrote her expert response. It’s poor Dr. Heather Murray that has to summarize this month (I’ll be helping obv. :D)

          • amcunningham

            oh- well I think that in will actually be a pleasure for you. This has been such a deep conversation 🙂

          • LizCrowe

            I guess I meant inappropriate by the standards of others. What cancer patients or cardiac patients or burns patients or anyone may joke about their illness or appearance may be confronting and shocking to others but for those individuals it is a way of coping. In Australia several years ago we had a fantastic comedian called ‘Steady Eddie’ who had quite severe cerebral palsy and he used very dark and confronting humour to make people confront their prejudice about disability. Some found him very “inappropriate”. I thought he was a revolutionary. I think there are several dangers when using black humour to cope with a work context – like our case study someone will hear part of the conversation and be really offended without understanding what may have happened before or after. That people only use humour without using any other forms of coping – which we know can be a risk. There is a study that shows Police who only use humour and drinking are more likely to die from cardiovascular disease and obesity….we do not want to encourage that. I think for anyone, in the moment humour is often a fantastic first line of defence but we need space and time to unpack distressing or confronting events.

          • Thanks Liz. I was also wondering about this question of what’s “appropriate”. One of the most confronting aspects of any illness or condition that changes physical appearance in a serious way is the felt pressure to mask this appropriately out of concern for the social standards of others. Audre Lorde wrote at length in her cancer journals about the pressure to wear a prosthesis, and she includes an incident in which she was rebuked by a nurse for coming to an appointment without one because this was “bad for the morale of the office.” Truly.

            Being a patient is a constant negotiation with the expectations and preferences of people who are not ill, including the staff who treat us. Sometimes I think this keeping-up-appearances aspect is precisely what generates the secret humour shared among patients.

            This is not to say–not at all–that we should fail to reflect on why all this is the way it is. But I’m not sure that for me “inappropriate” is a label that encourages this reflection.

          • LizCrowe

            Dear Kate
            Apologies I was using ‘appropriate’ or ‘non-appropriate’ in the general standards. My personal degree of what is or isn’t appropriate or what is or isn’t normal varies from most people’s standards. I believe people who have an illness or injury should have the right to laugh and label about themselves, to cry or not to cry at will. I do not believe in ‘normal grief’ or ‘normal reactions’ – as long as you are not at risk to yourself or others than I think any strategy that can be engaged is powerful. I made a joke about stripping for my brother when he was going to deposit sperm before the first round of chemo – clearly I have a sick sense of humour – but the health professional I said it in front of clearly wanted to report us! He could not identify that we were devastated and frightened so the first thing I did was to use very confronting humour to keep us grounded in the moment. This is why I am also very slow to judge health professionals who in the moment and hopefully in a very confidential and safe space sometimes use humour also to cope. I have never found this humour disrespectful particularly as it usually follows a very intimate and confronting experience. It is just a way to quickly step back and reset so they can get on with their day.
            I hope you are laughing and pushing boundaries as a patient Kate, it will teach us and your fellow patients wonderful creative ways to cope and hopefully give us all a laugh on the way!!
            Take care

          • As in all things, consider the source. Insider humour is present in all areas of life – including among patients. We get to do this among and for ourselves – but not ABOUT others. Among heart patients, we can joke “Welcome to the Zipper Club!” to each other, but if a nurse/doc in CCU said exactly the same words to a recovering post-CABG patient, it would just be tacky.

          • LizCrowe

            Yes what we can say about ourselves, our family, our illness, our profession is very different from what we will allow others to say. Most people have very strong double standards on this!

      • John Cosgrove

        This thread would seem to provide plenty of evidence that many are themselves uncomfortable with hearing black humour and associated derogatory language and believe it to be immature and indicative of lack of caring.
        Interestingly, in this fictional case, the approach to patients of the doctor whose language is criticised suggests she is in actuality very caring.
        Is there any good quality evidence that doctors who use black humour and derogatory language in private care differently for their patients than those who don’t?

        • Heather Murray

          Thanks for the comment. I don’t know about evidence – certainly my personal observation has been that there can be a dramatic disconnect between observed behaviour and actual feelings. I trained with a gruff senior doctor who was known for his black humour and somewhat disrespectful language – he would refer to patients, for example, as “that old geezer in the corner.” One of my good friends had a devastating miscarriage and saw him and to my surprise she told me that he was by far the kindest doctor she met during her hospital stay. He even went up after his shift to find her postoperatively to see how she was doing. When I told one of the nurses that story, she told me that he had a reputation among the nursing staff for above and beyond kindness to patients. This kindness was hidden from his trainees, which is too bad. I think we all would have benefitted from seeing that, and modelling that kindness. I wonder now, though, if his ED personality was a key piece of his coping mechanism?

  • John Cosgrove

    This thread would seem to provide plenty of evidence that many are themselves uncomfortable with hearing black humour and associated derogatory language and believe it to be immature and indicative of lack of caring.
    Interestingly, in this fictional case, the approach to patients of the doctor whose language is criticised suggests she is in actuality very caring.
    Is there any good quality evidence that doctors who use black humour and derogatory language in private care differently for their patients than those who don’t?

    • amcunningham

      I don’t know what good quality evidence would look like! As Liz points out below there are unlikely to be any simple correlations in either direction.

      • John Cosgrove

        Can I quote you on that, Anne-Marie?! 😉
        I suppose, for example, one could compare the use of gallows humour by clinicians with their patients’ satisfaction and measures of quality clinical practice.

        • amcunningham

          Or how about we looks at correlations between use of gallows humour and burnout? We know there is little correlation between burnout and patient satisfaction, so this may be at least as much about maintaining healthy health professionals as it is about hard (or soft) outcomes for patients.

          • John Cosgrove

            If gallows humour is a marker of doctors (and others, presumably) at risk of depression, then we should certainly support them. Could that support not include allowing them to continue to use a coping strategy that they find helpful?

          • amcunningham

            We don’t know that the relationship exists but might be worth investigating. Next, I think there is a danger in shifting the conversation away from discussion of cultures that don’t support health professionals, to one about individual doctors and their coping strategies. Yes, the two aspects are related but let’s not lose sight of the bigger picture.

      • John Cosgrove

        We should certainly seek to encourage healthy ways of coping. Is the use of black humour necessarily less good or less healthy than other strategies, why and for whom?

      • “Can they be given time and space for better ways of coping? That seems to be the challenge.”

        Not when our performance is judged on the number of patient’s we see, number of RVU’s we generate, and length of stay’s in the department. I’d love to debrief after a code, even with my nurses just to talk about what went well, and what didn’t, but because of this 45 min code, there are now 3 patients waiting to be seen, and 8 I need to follow up on. There’s just not time to do this on shift. We as EP’s get very good at putting things in mental boxes and closing the lid on them when done. Maybe that’s not a good idea long term, but there’s just not time to do it any other way. Unlike many of our colleagues, we don’t get breakfast and lunch rounds to sit around and talk about “great cases”. It’s go go go for 12 hours. I’m not complaining one bit, I love it, but it is what it is.

  • JonMendel

    I think power relations are important here – for medical students to joke about patients seems more worrying than, say, jokes about consultants would be. I’m a (non-medical) lecturer and have taught hundreds of students; I presume that at least some of them will have made jokes about me, and if students want to let of steam by doing this then I’m pretty relaxed about it. I’d worry a *lot* though if, say, students were making jokes about vulnerable research participants (to the best of my knowledge, they don’t, and of course I aim to teach students to respect research participants).

    Another question is how practitioners would feel if the situation were reversed. What types of humour will you be happy for medical professionals to use to discuss you when you’re ill, dying or dead?

    • amcunningham

      My guess is that if health professionals see this kind of humour as a legitimate coping strategy then they will know/guess that it is happening around their care too. But as this thread started by Kate shows, sharing humour between and health professional and any patient needs a lot of discretion. https://www.aliem.com/medic-series-case-backroom-blunder/#comment-1609068559

      • JonMendel

        You’re much more familiar with this culture than I, but I wonder if – assuming professionals know/guess certain types of humour is happening around their care – they would be happy for potentially-derogatory terms like ‘frequent flyer’ to be attached?

  • Heather Murray

    There have been many mentions of debriefing, and the importance it plays in helping traumatized professionals recover from stressful events. I’m not sure that there is a widespread institutional culture promoting this practice. Any “debriefs” I have ever attended have actually been adverse event debriefs, with the focus on individual and systems error prevention. There is some attention paid to staff wellness, but they are generally too far removed in time from the actual event to serve this purpose effectively. When I think of my own recent forays into black humour, they occur as a type of debrief – sometimes in the forms of “inappropriate” jokes and conversations occurring in private, in the company of a trusted colleague and friend.

    I know that some of the things I have said, and laughed at, would be upsetting to the patients involved, and would send a very negative message about me to learners or even some colleagues who overheard me accidentally. But yet, I consider myself to be a compassionate and caring physician. Are these two positions incompatible? Furthermore, these opportunities to laugh debrief me enough that I can pull myself up, and go on to the next case.

    It’s exhausting to try to simultaneously provide good medical care, be kind and supportive to patients and staff, guide learners at several levels and maintain a calm and professional demeanour. Those stolen moments of laughter feel like a guilty pleasure. Are they inherently wrong? I’m struggling with this a bit.

    • amcunningham

      I think that is a really good summary of where I have got to in my understanding of all the comments here. These jokey conversations are a form of debrief with the aim of distancing those involved from the trauma so that they can move on to the next patient. Does anything more need to happen after that? Is this ‘first pass’ debrief all that is needed. I suppose we could think about what the next stage might look like. A Schwarz round? http://www.theschwartzcenter.org/ViewPage.aspx?pageId=20

      • Shannon McNamara

        What a fruitful discussion! I’m commenting on Q3.

        I agree with Heather and Annemarie above, that the use of black humor is often a distancing tool to cope with a stressful event and move on.

        As Emergency Physicians, we frequently witness patients suffering and dying. How do we move on to the next patient? How do we go home? How to we do that on a regular basis and retain our empathy and humanity? It’s hard!

        We know that a significant portion of Emergency Medicine residents suffer from PTSD symptoms related to residency training: http://www.ncbi.nlm.nih.gov/pubmed/15656996

        What can prevent that? My thoughts:

        1. Personal stress management – time for sleeping and eating, family and friends, exercise, hobbies, meditation, mindfulness training, counseling, vacation, safe space to talk about work stress. We all need to figure out what works for us and make time for it, and make sure residents and learners have time for it. We can’t be good doctors if we don’t take care of ourselves, yet sometimes medical culture praises workaholic behavior over finding balance.

        2. Community stress management – creating a culture where these issues can be and should be discussed – Schwartz rounds are a great example, as is this post!

        Philadelphia has an annual city-wide wellness day that addressed common issues for EM residents, like sleep hygiene, post-residency realities, grief, personal finances, and preventing substance abuse. This was a great way to establish an institutional culture of wellness.

        Immediate team debriefing after a very stressful clinical encounter can be useful – a cumulative acknowledgement of the emotional stress – but a formal delayed debrief after especially awful cases is also important. Those types of debriefs need to be led by professionals – we don’t want to accidentally open the pandora’s box of psychological trauma without knowing how to handle it.

        Creating a culture of wellness is a huge challenge, but essential for keeping us sane in this wonderful but intense profession.

  • Loice Swisher

    I have been a practicing emergency medicine attending for more than 20 years in an urban community hospital with EM residents as well as occasional students. The issue I find most disheartening is the option this theoretical student considered the best way to approach the situation. Instead of approaching the either of the parties directly, he wanted to give this to someone else to take care of. I rarely find creating a triangle with a third essentially uninvolved person solves much- rarely changes behavior or understanding.

    There are all kinds of words that can be depersonalizing, demeaning and disrespectful that happen with various frequencies in the ED. Seeker is one. One of my sayings is “sometimes people are seeing pain medication because they have pain!” If you haven’t heard terms such as dirtbag, troll or chiseler come out of some healthcare providers mouth then you probably haven’t worked in the ED long or have a exceptional professional development program.

    The way we can effectively support our learners is to teach them to directly discuss the situations which concern them. I can see this as the best way to eventually have attendings that create a safe environment for discussion- or confrontation if needed.

    • S Luckett G

      Thanks for your comment, Dr. Swisher. I’m glad you brought up the term ‘seeker’ here; that is one that I have struggled with as a medical student and resident. I found, early in my education, that the term ‘drug seeker’ blocked me from thinking about real sources of pain in these patients; a thoughtful attending set me right on that one. Once already during residency (I am in first year), I have found myself educating a medical student about use of that term and have said precisely what you have said about – we have to treat pain, even if the person is a ‘seeker’!

  • Jonathon Tomlinson

    Thanks for this excellent discussion. I’ve been a doctor for about 20 years and am researching moral development in clinical practice and medical education.

    Among the reasons doctors are so stressed is that with the public scrutiny of social media and a salacious traditional media combined with the active soliciting of patient feedback (in a commercial, rather than genuinely patient-centred way) – we feel under more pressure than ever before to demonstrate our kind, compassionate, respectful, empathic character traits. It is not enough for us to do that in the intimacy of a consultation, but these personal values and behaviours are now the subject of a rapidly growing literature, conferences and public discussion. One way people react to being told (excessively) to behave one way, is to do precisely the opposite. A “fuck you” response. It’s particularly pertinent when there is an actual or perceived power differential as John Mendel suggests. A good example is on AnnMarie’s blog about this same subject in which an anonymous doctor wrote, Stasi PC bigots like Cunningham who avoid patients by becoming “academics” and start telling people (who do the real work) what to do make me sick.

    As Liz Crowe and others have emphasised, the visceral trauma and sleeplessness of medical work is not the only cause of stress; an update to Menzies Lyth’s work in the 1950s about social defences in the face of the emotional labour of care concludes by saying that Unless we develop ways of containing these anxieties without denying them or viewing them as indicators of weakness and failure, health workers will continue to be confronted with impossible and damaging demands. Including the demands to be compassionate and empathic at all times.

    Behaviour is contagious: from Hafferty’s work on the hidden curriculum to Cruess’ and others work on role-modelling as a means of teaching professionalism in clinical practice and medical education, the importance of role modelling is probably beyond dispute. We learn ways of coping from our peers, gallows humour is one of several ways we cope, but it is a problem if it is the predominant or only way of coping because it is very unlikely to be suitable or sufficient for all the members of a team.

    I’ve worked with very compassionate, popular, committed fastidious doctors with extremely dark senses of humour and doctors who are the opposite. I know whose company I prefer. But I’ve also worked with callous, unprofessional idiots and gentle fools.

    Instead of telling doctors and students how they behave we should advocate for humane working conditions and make time for all healthcare professionals to discuss their work and in ways that gives us other ways to cope.

    • amcunningham

      Jonny,

      I don’t want to hijack this thread with a discussion of my own blog post but I feel I should reply. I am so very glad that this discussion feels so much more productive that the comments (like the one you have alluded to http://wishfulthinkinginmedicaleducation.blogspot.co.uk/2011/09/social-media-black-humour-and.html#comment-1005664761). In fact the response was so vitriolic that I have rarely felt able to comment about it publicly since.

      When I was a medical student I was a patient on a gynae ward. I remember being wheeled down to theatre slightly sedated and noting that the president of the medical student association was attached to the ward. I hoped inside that someone would have the wit to protect my privacy and keep him out of theatre when I was there. But I didn’t say anything. You don’t feel like you have very much power when you are a student as patient on a gynae ward.

      So maybe I wasn’t able to put enough distance between my own experiences and my reaction as a ‘medical educator’ when I came across those tweets. I didn’t feel as if I wrote the blog post from a position of power. I felt vulnerable. That’s why I mentioned near the end that at least my blog felt like a space I had control of. But of course we live in networked publics and it wasn’t long before my blog was posted over to Facebook (https://www.facebook.com/medicalreg/posts/234199529961529 )and I was described as ‘humourless old trout’ amongst many more misogynistic remarks. That is the context within which I read the comment you linked to. It didn’t feel as if I was in a powerful position and was being rebuked for telling doctors “to (excessively) behave one way”. It felt more that I was getting the same treatment as many other women who spoke up about what they saw comments that could be perceived as misogyny on the internet.

      So this was a very particular case. I wish very much I had been able to explore more about why so many doctors felt the language I picked up on was OK, and what could be done to support doctors working in these environments. I wish I could have been that person. But instead I was scared.
      Looking back I should not have written the blog post when it was all still so very fresh for me. This is why I am so very, very pleased to be able to contribute to this much more productive discussion.

    • bennetson

      Having worked extremely long hours in multidisciplinary teams under highly emotional, physical backbreaking and mentally stressful circumstances where HCPs and other social work and social care staff wouldn’t dream of using the kind of patient-hating terminology that is routinely bandied about by doctors, I don’t think it is quite so simple to say that this kind of behaviour arises simply from stressful working conditions and that it would all go away with a few extra tea breaks and a nice chat about work with one’s peers. I would argue that the routine derogation of patients has more to do with the longstanding culture of patient-denigration in your profession.

      The routine ridiculing of patients has been an enduring feature of medical practice. It used to take the form of abusive comments in the paper notes, or derogatory comments in letters that wouldn’t be seen by patients. Nowadays it’s all out in the open on social media, Twitter, Facebook and the endless deluge of denigrating columns about patients that you find in GP mags which are the cultural artefacts of your profession.

      I think the use of denigrating language like “frequent-flyer”, “heartsink”, “acopia” and “bedblocker” not simply “gallows humour” but rather an attempt by doctors to Other patients and to place themselves in a superior, “special” position thereby reifying the power-differential that already exists between patients and doctors. If you select doctors solely based on their ability to rote-learn and regurgitate factual material and their willingness to jump through a tickbox list of extracurricular activities, how can you really know that the people you’re recruiting are in fact compassionate, kind or caring? Supervision would be a start, but I’m not convinced many of your peers would be receptive.

      What’s shocking to me is that this kind of patient-denigrating language is seen as so professionally acceptable by doctors that it routinely appears in their publications and medical magazines. AnneMarie is the only GP I’ve seen on social media who would seem like someone I’d actually want to consult with. She sticks up for humane treatment of patients, even when it may lead to personally damaging attacks from her emotionally stunted peers. She shows a much higher degree of integrity than the norm.

      • S Luckett G

        I find that a harsh judgment of a profession that I have found, on the whole, to be caring, compassionate, and respectful in our treatment of patients. Unfortunately, we all struggle with both providing excellent care and emotional self-protection, which can often be at odds with one another. I’m a junior trainee, and while it may be that my credibility is non-existent with many who would characterise my peers and me as a rote-learning, fact regurgitating, box-ticking patient-haters (which I feel is unfair, as I am certainly none of those things), my experience has been that my peers and mentors strive to maintain a sense of humanity and humility in circumstances that are inherently challenging.

        I think you draw our attention to an important aspect of this discussion that others have also noted, namely that we have to be mindful not only of what our near-peers and mentors hear from us, but also how others perceive us. Perhaps context is the most important element that is often missing from these discussions. We are not simply talking about gallows humour and its effect on us as providers, but also its effect on those outside our immediate circle, which includes patients, families, and other team members.

        • bennetson

          Read the UK GP mags – they routinely use patient-denigrating language…. “frequent-flyer”, “heartsink”.. The columns about mental health are often stigmatising. The comments from doctors are little better. Perhaps it’s different in other countries. This wasn’t a comment on you personally, it was a comment about the professional culture of medicine in the UK and how it’s culturally acceptable to use patient-denigrating terminology.

          PS. UK doctors are recruited first and foremost for their A level scores which are mainly focussed on rote learning and regurgitation of facts. Medicine is not a postgrad degree in the UK.

          • Anecdotally, I have seen all members of the health care team (doctors, nurses, social work, porters) become very frustrated with the limitations of the system, and at times, I think this brings out certain language around usage. I’ll be honest, I’ve never heard some of the terms you highlighted until now (“heartsink”, “acopia” and “bedblocker”), although I have seen similar terms.

            Bedblock is such a daily occurrence in Canada… But our literature is wrought with discussions about the systems level discussions around how we might do better by our patient.

            The UK GP mags are very far outside of the scope of this blog – it is, after all, focused at academic emergency physicians (largely in America/Canada), but I appreciate being made aware of the issues on your side of the pond.

            It is our hope that is creating opportunities for transnational discussion we might actually be able to foster a supportive community of practice that is better able to deal with and be aware of issues around language.

            I am both glad that you like AnneMarie so much to say this: “AnneMarie is the only GP I’ve seen on social media who would seem like someone I’d actually want to consult with.”

            But my dream is that by improving and adding to the educational experience via activities like this, you will see that there is a vast network of physicians AROUND THE WORLD that you know are working hard to raise awareness and teach around these issues.

            Personally, the last time someone used “Failure to Cope” as a diagnosis, we had an extensive discussion about the causes of said ‘failure’. After taking a far more extensive history (yes… occasionally, we do that in the emergency department), he was able to identify at least 5 reasons why our system had failed the patient, and why the patient and her family were so frustrated. I think via this encounter, the resident was able to better empathize with the patient and her family, and he has come back to me recently to explain that this has changed his view on how he approaches the problem – and he has changed his approach to patients in acute distress with social issues.

            My friends, it is not so easy to teach these issues, but if we can do a little bit every day, I think we can create the next generation of physicians in Anne Marie’s image – willing to set up discussions online or in person, willing to acknowledge power differentials, willing to listen to patient perspectives, and most importantly, willing to listen to change our minds.

            Thank you for sharing your thoughts and observation. I aspire in my career to make your concerns about our field less of an issue.

      • Jonathon Tomlinson

        ‘A nice chat with one’s peers’ is not really what I had in mind by peer support – which is why I mentioned Schwartz round and I had in mind John Launer’s narrative-based supervision and Greenhalgh’s educating for complexity – challenging, ethical discussions in small groups these are the most effective ways of educating for professionalism.

        Jill Maben’s work on nurses and burnout showed that the working environment was morally corrupting. Idealism present in nursing students was compromised or crushed by their working conditions.

        But it’s not just about conditions as you say.

        Role modelling perhaps explains why teams in very similar working conditions differ in their use of derogatory or black humour. A lack of good role models is a problem, in one study 34% of medical students identified a lack of role models to be a barrier to learning about empathy: http://goo.gl/3uejsI Bad role models can be morally corrupting, making the unacceptable (derogatory humour) acceptable. Medical students very frequently witness doctors behaving arrogantly and insensitively towards patients and each-other, but feel powerless to challenge it: it http://goo.gl/SXmPpn.

        Humour may not necessarily be indicative of the doctor’s attitude to the patient, BUT studies of medical professionals’ attitudes to overweight patients e.g. http://goo.gl/RB25LN and http://goo.gl/HGURcW showed that moral judgements, for example that overweight people are lazy, greedy, irrational and lacking in self-control, are as common as they are in the wider population.

        Medical professionals should be held to higher standards than the rest of the population but to reach these standards will require a mix of education and support with career-long peer supervision, patient-feedback, humane working conditions, and open and honest discussions like this. I’m unconvinced that at the time students enter medical school they are mature or experienced enough for us to judge their future attitudes.

        Finally, I was inspired to start writing my blog about the relationships between doctors and patients because I wanted to counter the disparaging comments in the GP journals. What I hope I succeed in showing there, is that being a compassionate professional is a constant struggle: abetternhs.wordpress.com

        • S Luckett G

          Dr. Tomlinson, thank you so much for your comment, and for bringing some helpful evidence to the table.

          I’m struck by your comment that it is difficult to judge future attitudes at the time students enter medical school. I have only just begun residency, and I think I’ve changed plenty between the day I was accepted to medical school and now. I think this is an important comment because it suggests that we still are quite malleable upon starting medical school, meaning that our attitudes, attributions, and practices are still changeable. Perhaps it would make sense for the peer supervision and support you suggest to start on entering medical school, while we are still so fluid in our personal characteristics.

        • Great comments. Agree about getting the culture right and yes this requires role models (ie leadership)

    • Dr. Amy Price

      Yes excellent points however medical professionals are the adults 🙂 It is part of the job…We might not all be naturally kind, compassionate, respectful, empathic etc or be able to show it at the same level as others and that may be an artificial standard like “good wife” but we can all choose to speak with kindness, it is a choice, it does take practice and it is not easy but it is doable.

  • gourmetpenguin

    So, I’m going to take this slightly off tangent and look at the wider implications of using this kind of terminology from my personal experience. I work in paediatrics, and staff will not uncommonly refer to patients with mental health problems in derogatory terms. The ones that stick with me are the terms used to describe patients with eating disorders (manipulative time-wasters would summarise these). On the one hand, we’re all terrified of mental illness & well outside our comfort zone when patients arrive on the ward. So, I think it stems from a depersonalisation coping mechanism.
    But on the other hand, I’ve struggled with eating disorder for over a decade of my working life. I’ve had periods of self-harm & depression too. I *know* I’m a manipulative time-waster without that being reinforced by other professionals. The language we use can reinforce myths & stereotypes, becoming accepted unless they’re challenged. It can translate into poor physical care for our patients (e.g. not doing a full biochemical profile, because “as long as the potassium is fine that’s all that matters”), and it makes it much harder for patients to seek medical attention.
    So yes, it matters.

    • amcunningham

      Thank you for sharing this. Maybe power really does come from exposing our vulnerability:)

      • gourmetpenguin

        The only (partially) successful way I’ve found of challenging it is to “come clean” at work. Which seems a bit drastic but maybe we need drastic!

        • amcunningham

          I’m watching and learning:)

    • Dr. Amy Price

      Yes I think being labelled as a manipulative time waster or hearing someone with a similar issue labelled as such would be a barrier openness and is kind of a self fulfilling prophecy. I can’t imagine it opening doors to compliance

  • Dr. Amy Price

    Physicians would benefit from grief management and communication re-framing strategies from the beginning 1st year. Most go into medicine because they want to multiply life or quality of life and that is not always possible. Dark humor does not help long-term and it short circuits ways of coping and re-framing and real support through the dark times when we give our all and the effort is death or destruction. If the person survived there would be celebration and joy, it is like war where only the victory is acknowledged but the fight and the price are greater for the loss for which there is no peer to peer comfort. Death is messy and provokes the most brutal of self examination, in that kind of setting there will be errors. Also sometimes relatives overhear or pick up that harshness when it is really someone just trying to cope with the horror. I think the concept of failure is this arena is like blame, it solves nothing and names targets, everyone does their best and sometimes even that is not enough and that is OK

    • S Luckett G

      Thank you for your comment, Dr. Price. I agree that most go into medicine with the aim of making their patients’ lives longer, better, or both. I wonder if part of the problem we face comes from a combination of this objective with the high-achieving personality of the medical student and medical professional. Are we especially vulnerable because we are unable to accept that sometimes ‘everyone does their best and sometimes even that is not enough’?

      • Dr. Amy Price

        I think this is a perceptive concept. I know I feel harsher when I feel the winds of failure nipping at my heels and that is when I need to exercise the mos discretion so yes even knowing we do our best sometimes does not seem enough, a lot of tragedy in relationship comes from unrealistic expectations

    • LizCrowe

      I wonder if the issue behind all of this is that we teach people medicine or nursing or other specific disciplines but we do not teach humanity, compassion, healthy ways to cope and reflect, how to build teams, how to lead. These essential qualities we expect people to magically acquire along the way…and it’s not possible. Particularly when people are trying to study, work long hours, go from shift work to day shifts back to on call. Sometimes I believe what we are asking from our Doctors is unrealistic. Just because you are incredibly academically smart does not mean you naturally come with good emotional intelligence.

      • I would say that my experience has been very different from those mentioned here.

        I am surrounded by emotionally aware colleagues in my generation… Who (by and large) are insightful, reflective, and aware.

        As noted in Dr. Goldman’s book however, the older doctors and nurses do seem to use terms like “turf” or whatever. And usually role models insidiously do have an impact on culture – and newbies will often adopt “lingo” to fit in…

        The new generation of learners that I often teach, however, do seem somewhat better at communicating and being aware of language usage or personal perceptions – since we are now building more reflection and discussion around social sciences and humanities in medical school.

        Ironically, I think it is often the younger docs/nurses that shed light on our culture’s flaws – the veritable children

        • So, I’m excited to see if we can make individuals within our system to be more aware of language….

          • Dr. Amy Price

            If we could see it as building or destroying, perhaps. I know my words and then my actions were more compassionate when I knew the patients would hear them and then I thought what if they hear through other means like body language, the good words could provide boundaries for dignity and compassion, kindness costs only extra thought and it can become a way of life

        • Jonathon Tomlinson

          Here are some papers about the idealism of younger doctors (in my experience they all start of with great attitudes)

          The desirable qualities of future doctors–a study of medical student perceptions http://goo.gl/VPGdC3

          Attitudes and Habits of Highly Humanistic Physicians http://goo.gl/wpUQCK

          Formation of medical student professional identity: categorizing lapses of professionalism, and the learning environment
          http://goo.gl/t5Rwf1

          And a recent discussion about what happens to it: Medical Students’ empathy gap: http://goo.gl/IcAGBm

          • Dr. Amy Price

            Jonathan did you come across this one as well which appears to deal with a bully culture and territory rather than a slip from idealism. Black humor can be a slippery slope Possibly it is a toxic climate that most prefer not to inhabit but at times attitudes mixed with exhaustion and unresolved grief can make us less aware to these things happening around us and the roles we can play to problem solve in toxic climates http://aeon.co/magazine/health/why-rude-doctors-make-bad-doctors/

      • Dr. Amy Price

        I agree that emotional empathy can get crowded out due to the sheer strain during learning and practice, however we can be trained sometimes by a single well timed example to be aware and in a climate where empathy is celebrated opportunities to see the awareness in practice will be plentiful. Positive language is helpful for this process.

  • Jonathon Tomlinson

    I’d caution against the idea that we can reliably select the right types of students at the beginning of med school. e.g. see http://www.ncbi.nlm.nih.gov/pubmed/17518822. I was (like most of my peers) immature and inexperienced when I started med school and I’m not sure I would have got in on a character assessment. I remember at a careers fair being urged to avoid the caring professions and do something creative but solitary. I’ve written blogs about teaching/ nurturing kindness http://goo.gl/p6m2CT and empathy http://goo.gl/mMTdW9 making the point in each, that kindness and empathy don’t come naturally to me, but there are things we (I) can do.

    The influence of the hidden-curriculum and role models (see for example http://goo.gl/JufcFh and http://goo.gl/8DjSkr and http://goo.gl/q9xlxS ) can be positive or negative, and for most students is a mixture. I’ve not read anything that convinces me that we can guarantee the good role models outweigh the bad.

    Launer’s recent paper about the use of work-placed discussion groups shows that these are effective ways to foster professionalism http://goo.gl/xGx2Dx .Huddle has a nice paper about teaching professionalism as medical morality: http://goo.gl/109mBn He makes the point nicely that we cannot become moral by learning ethics any more than we can become French by learning the language, we need to share the culture, a point also made in a paper about educating for virtue http://goo.gl/w3ln7t A brief synopsis of evidence in teaching children about moral behaviour concluded that what they witness is more influential than anything they are told http://goo.gl/xaGDw1

    Cultural change requires taking on board the lesson that medicine is a moral practice and not an amoral practice to which we can bolt our moral competencies. Managing the complexity needs frequent discourse (peer supervision) within a just culture in which power and unprofessional behaviour can be safely challenged http://goo.gl/5B9GUu

    • amcunningham

      I think essentially this case is about how ER teams can handle trauma. The team-based professionalism idea is very interesting, though I wonder if those working in ER settings feel there is time for this kind of work.

      • I think that team-based debriefing after critical events would be welcomed (and I try to do it, though I know i’m an anomaly so people don’t know what to do about it when I try).

        That said, I think next day or soon-thereafter debriefs offline when people have had more time is useful. But often learners are not party to those (they are often for the staff nurses and doctors).

        I’m glad we’ve raised these points and all these resources for people to read… Looking forward to making a compilation of things that will be useful to read.