Thursday, December 01, 2011

I Worked Damn Hard to Be Called "Doctor"

Whoa. Am I a snob or what?
Here's the deal.
I am finally, after three decades of education, able to practice medicine without being supervised by someone else. I can write all my own orders, sign all my own notes, see all my own patients, submit all my own bills, do all my own rounds independently. I have my own office (well, okay, I share my office with a colleague, but whatever). My name is on the door. I don't have to ingratiate myself to anyone just for a grade. I don't have to pretend to be interested in areas of medicine that totally and utterly bore me.

I'm a doctor.

I have the $200,000 plus in student loans to prove it. And the forehead wrinkles.

I've spent the past 9 years of my life in medical training, and that was after college.

So, when I walk into a room, and I introduce myself as "Doctor Riegel," and, without a blink, someone says, "Oh, hi, Emily," it raises a bristle on my back.
And not just because I think I'm so super cool and that everyone around me should be calling me "Doctor Riegel."
I don't check the "Dr." box on forms that ask for a Title.
I don't get pissy when I'm checking in at a hotel for a conference and they call me "Ms. Riegel."
I don't have "Emily Riegel, MD" atop my personal checks.

In certain settings, though, it's important to me to be recognized as Doctor Riegel.

You see, contrary to what we've been taught as young children, the masses still see a relatively young woman working in a hospital and assume she must be a nurse. Which means they assume she works for a doctor. Which means they assume that what she says may or may not be the final answer or decision. Which means they sit there, waiting, for the doctor to show up and tell them the diagnosis, tell them what medicine to take or what test to have done.

I have had patients tell me, to my face, after I have seen them for an entire week, "It sure would be nice if a doctor would ever come and see me."


Seriously! People!

Imagine this.
I have taken care of a dying man for several days. Adjusted his medications so that he no longer feel excruciating pain, severe shortness of breath, extreme anxiety. I've made countless phone calls about his ongoing care. Spent hours reading his chart, and writing my own notes. And many more hours counseling his family on the dying process and supporting them through their grief.
All the while putting my years of hard work and education toward this man's benefit.
And, when I walk in the room, overhear someone say, "Oh, Emily just walked in."

When I type it that way, it sounds so petty to even blink an eye at such a comment. Perhaps, some would argue, I should take it as a compliment. Take it as if I have established such rapport with them, and gotten to know them so well, that they feel like I'm a part of their family. No longer a *doctor*. Instead, I'm one of them. I'm *Emily*.

Here's my problem: if my first name were David or Jason or Michael, would they be using it?
Because what I have seen is that no matter how young or old, how good or bad, a male physician is, he is always referred to as "Doctor."

What I really care about isn't that I get called by the appropriate moniker. What I care about is being seen as someone just as, if not more, competent as my male counterparts. What I care about is that my work on their behalf be seen as being just as valuable as if it were done by my male counterparts.

What I care about is that my patients and their families believe in me and the care I can provide them.

So, when I am being called by my first name, I start to wonder if they are one of those patients, sitting there everyday thinking "when am I going to see a doctor."
I start to wonder, "Do they realize that I actually know what I'm talking about, or have they stopped listening to me because I'm not the doctor. I'm just a nurse/aide/custodian. Why should they listen to what I have to say about their disease."

And there's no polite way to ask this. Do I say, "You DO realize I'm your doctor, right?" (okay, so I have had to actually ask that at one point). Do I tell them, "I really prefer you to call me Doctor Riegel."

Admittedly, maybe some of this is my fault. I do cringe when people go throwing around the fact that they are Doctor So-and-So to anyone they encounter.  Maybe I do hesitate to clarify my name. When, after introducing myself as Doctor Riegel, someone says, "Now what was your name?" I do frequently say, "Emily Riegel." I get it, that might set a certain precedent.
I have seen my male colleagues do this same thing, that when they state their name as "John Doe," they still go on to be referred to as "Dr. Doe."

Believe me, I'm not trying to belittle the hard work of nurses or other health care professionals who aren't given the title of "Doctor," but, if you are a patient, can you honestly say that you don't view their roles differently? That you don't have a different kind of expectation?

Harder to take, though, (and, all truths revealed, the impetus for this post) are when male colleagues, who may or may not have more professional experience than me, who may or may not outrank me (Senior faculty>junior faculty [me]>fellows>residents>interns), call me or email me or text me and use my first name, while referring to themselves by their professional title.

Can we meet to talk about the patient later today?
Doctor Blowhard

Thank you for sending me the information about patient.
Doctor Toocool

Emily, please call Doctor Smartypants at ext 568

If you're going to call me Emily, then go ahead and call yourself Joe. Or whatever your first name might be. It's that simple.

In an age when there are more female medical students than male medical students, when more and more women are physicians, how can we still be facing this kind of gender gap?

Does anyone out there have some wisdom or advice?
Am I just being hyper-sensitive?
Should I grow a pair and start insisting everyone call me Doctor Riegel?


Monday, August 01, 2011

I have been evicted...

photo credit
We recently had a very dear patient at the Hospice House. One of those old men you look at and still see the charm of his boyhood, twinkling eyes and affection right there on the surface.
He had been an artist, but as he became more ill he was no longer able to hold his pens and lost one of his great joys. In his last month, he wrote this poem:

I Have been Evicted
   Evicted from My House
The House of Life
The House I Loved so much
For so long and forever will.
Lately it has been going down
  The Shell is breaking
The Structure is cracking
   showing its Age!
I Have been Evicted
  From My House of Life!
The landlord sent me Notice
Friendly but Unmistakable
   Time has been set.
Bring Your House in Order.
   You have to Leave.
Take your Memory with you
   And take Solace
It has been a lovely comfortable House
   But time is Up.
See you all at the new Place
  "The Heavenly Chit Chat"

-JB 5/29/2011

By the time I met him, his house was quite decrepit and plans to move out were well underway. He was still there, though, that boyish twinkle. And so very kind and sweet and always trying to lighten the mood and elicit a laugh. He found comfort in having someone just sit with him and hold his hand. Often he would bring the guest's hand to his lips for a gentle kiss.
From what I was able to learn about him from his friends and his medical records, he had every reason not to be sweet and kind. He had reasons to be bitter, angry, dysfunctional. Instead of choosing to rail against the world that had done him wrong, though, he chose to find beauty and joy in it. Even in the small details of flowers on his table, or birds and squirrels in his yard.
The room he was in will always be his room in my mind, the room where the final eviction occurred, and he set off to "The Heavenly Chit Chat."

Monday, June 20, 2011

One lucky man!

Have you ever wondered what it would be like to be married to a physician? Or, more specifically, to a palliative care physician? Okay, so probably not.
For a moment just try and imagine what it would be like to live with someone who deals with end of life and/or death just about every single day.
"Depressing" might be what you first imagine.
"Weird goth-type person" is what you also might imagine.
I like to think I am neither of those.
I am actually quite certain I am not goth. Although, I am pale...
But I digress.
In general, I would say that the palliative care providers that I know are a generally happy lot. Most seem to have a special sort of joie de vive (yes, I'm busting some french here, tres chic) that may come from seeing daily how fragile and short life is, and that we must enjoy it every chance we have; or maybe its because of this outlook on life that palliative care was an attractive field. Which was the chicken and which the egg, I don't feel qualified to say.  So, overall, I don't think living with me is very depressing. For the most part.
Until, while sitting on our front porch, enjoying a late afternoon cocktail while our children nap, I say to you, "So, let's say you were in a horrible wreck and I had to make decisions about what kind of treatment to pursue or not pursue. What are your feelings about what you want form life?"

And the light hearted afternoon comes to a screeching halt.

Why do I feel compelled to break out this line of questioning on a lovely Saturday afternoon, on Father's Day weekend nonetheless? Maybe because over this past year I have seen far too many young people with young families, young spouses experience a tragedy. Either a freak accident or a horrific illness or even if something they brought upon themselves - young people not far in age or life circumstances from myself who ended up hanging by a thread, and with that thread rapidly fraying. I have seen how quickly life can go from perfect to nightmarish. Husbands and wives now making decisions with immense consequences. Left scrambling to figure out what their partner would want.
Honestly, before Saturday, I thought I had a good sense of what my husband would want. Of what kind of quality of life he would find acceptable and what kind he would find intolerable. Of what his values are and what he finds to be worth living for.
Thank goodness we had our talk, though.
While I don't feel compelled to share the details or outcome of this conversation, what I will say is that I am so happy that we had the chance to share our feelings and wishes with each other. Not only do I feel like I would be able to do right by him if her were seriously ill or injured, but I feel like I have a whole new understanding of him and, frankly,  new depth of love for him that I didn't know was possible.
So, hard as it may be, and depressing as it may sound to do, if you are in a relationship and haven't had "the talk," I'd encourage you to do so. Yes, it is so sad to even try and imagine my husband incapacitated and me having to speak for him - but, by having this talk with each other I can truly say that we have enhanced our life together.
And, at the end of the day, that's what matters most.

Monday, February 14, 2011

So Long, Farewell.

Leaving work at the end of the day can be a very strange experience when you work with the dying. You never know if you are saying a casual, friendly "goodbye" or THE "goodbye." The one that means forever. It can put a lot of pressure on what is usually a pretty simple part of daily conversation.
Usually, when there is a chance the patient won't still be alive in the morning,  they aren't in a state to really seem to care if I am in their room at the end of the workday, much less what I say to them as I leave it. If the patient is able to tell me goodbye, chances are, I'll see him in the morning.  Then one day a patient told me goodbye, and I was pretty sure there was a good chance that he actually wouldn't  still be my patient the next day.
I had this feeling because, as I left his room, telling him I hoped his night went better than last night (he'd been anxious and had trouble sleeping and became fairly confused as the night went on by the time of my visit, his thinking was quite clear). He glanced toward me, where I was standing by his door, and stated, plainly, "Oh, I think it will be better. I'm probably going to die tonight, so I doubt I'll see you in the morning."
He didn't say it with drama, or as if he were waiting for some kind of "oh, don't be silly, you're going to be fine" response. He said it as if it were fact. Simple, known, fact.
The sky is blue.
I will die tonight.
You will not see me tomorrow.
It caught me off guard, and made me smile toward this sweet, gently man, who had often said things like, "this isn't living, this is existing" and "I never thought it would end this way for me."
He had become so sad by the fact that he couldn't just will himself to die and that it actually was taking his physical body so long to shut down and release him, that I truly hoped he was right. It was as if this were his last remaining wish, to simply die. To die before he could feel himself growing any weaker, any less vital, less mentally sharp.
The perfect ending to this story would be that I walked into work the next day and was told that the patient had died. That he had fallen asleep peacefully, with his wife at his bedside sleeping on the pull out bed in the room, and that, as they held hands, he had calmly and peacefully taken is last breath.
I'd almost convinced myself that this would be the actual ending.
So when I walked into work the next day, and saw that he was still alive, I felt sad. I wanted the perfect ending, the poetic outcome.
Instead, there were six more days and nights that this man existed through (he definitely wouldn't have liked it to be called "living"). He hardly had the energy to speak, and for his final few days was in a state of being unresponsive to his family. His lovely wife, to whom he had been married for over 50 years, was there with him the whole time. The morning before he died, I walked into his room and she was sitting next to him, holding his hand, crying quietly. His time was clearly drawing close, as was their life together.
Finally, later that afternoon, he did die. His wife and son were there with him. It wasn't the perfect ending he'd wanted, but he was comfortable and peaceful and surrounded by love. And I was happy for him to finally get what he'd wanted.

Wednesday, January 05, 2011

The World Keeps Spinning

The Road // La Carretera
Originally uploaded by Dark Botxy
or, Death doesn't take a holiday.

Nowhere is the fact that there is no holiday from illness or death than within the walls of he hospital. There are no holidays from tragedy. The world keeps spinning, life keeps marching forward and death keeps putting a halt to all those best-laid plans.
I recently started back on the inpatient palliative care service. Our first new consult came in fairly early in the day and my attending and I began to scope out the situation.
At first glance, the situation was ugly. A young man, involved in a car crash the day before, transferred to our hospital after a "prolonged extrication" from the vehicle. The trauma surgery team's note laid out injury after injury. Multiple broken bones - jaw, cheek, arm, pelvis, thigh, ribs. Internal injuries - liver damage, bowel damage, ruptured spleen that had been removed. Most dire, though: massive brain injury. Part of his skull had been removed to allow his brain to swell. The skull now tucked safely away inside his abdominal cavity, awaiting the time when (if) his brain would shrink back down to fit within the skull and the portion of bone could be replaced.
It's unusual for the trauma service to consult our service; much less consulting us within the first 24 hours of a patient's admission. This creates a dynamic in which we're never quite sure where we are going to fit into the plan of care or how extensive of involvement we can expect to have. My attending and I arrived in the surgical intensive care unit and "met" the patient for the first time. He was, of course, unresponsive. Machines breathing for him, tubes entering and exiting his battered body, a leg pinned in weighted traction, his head wrapped in gauze.
Taken in isolation, the situation is bad enough.
Then, the story of this man and how he became our patient, and what his family was experiencing adds layer upon layer of sadness.
He and his fiance and their dogs had packed up their car early in the morning heading out for a 1200 mile drive across the country to visit his family for the holidays. They were about an hour into the two day trip when the wreck occurred. Hit head on when another vehicle crossed the median of the interstate. The vehicle rolled over. The dogs were killed. The fiance suffered major injuries, too. Our patient, though, was the worst injured of the humans from either vehicle.
His family, those thousand miles away, got the phone call we all fear. Themselves out visiting friends, they were three hours from their own home when the phone call came to them. They went immediately to the nearest airport, nothing but the clothes on their backs and their wallets, purses and cell phones with them. As quickly as they could and at any monetary cost, they flew here.
We met this family, first at the patient's bedside, and then sitting down with them along with the surgery attending managing his care. It was the first time they had a chance to meet face to face with a physician to be given the list of injury after injury, and the news that, in terms of his brain, this young man couldn't be much closer to death.
Life, hanging in the balance.
Hanging by a thread.
Holiday or no holiday, a young man, a good young man, lays near death. His family, a good, loving family, has their world crashing down around them.
I met with them again this morning, delivering them no good news. I asked them if they had any questions, and concerns - a question I always feel ridiculous posing, since of course there are concerns, and questions, how do I even begin to know how to answer the question most looming, the question of, "why?" But this lovely, gracious family, through their tears and terror, smiled kindly, and thanked me for my time and support. "We don't even know what questions we ought to ask," his mother said.
Medically, I know how grim things look, and I think they understand, too. Of course, they hold onto hope, "we're still hoping for the best" they say.
With his sister sitting in the room, holding on to hope most tightly of all of them, I cross a line that we rarely get to cross in medicine, but often must in palliative care. I speak from my heart. I tell her we are in a situation when my heart makes me need to say what I'm about to say.
I know this must be horrible, I tell her, looking in her eyes. I know you are holding onto hope, and you have to keep doing that. If he were my brother, and I were in your shoes, I would want someone to tell me that this is the time I need to tell my brother I love him, and anything else that is important for him to know. I'm not asking you to let go of your hope, but he may not have another chance to hear these things form you, or for you to say these things to him.
There are tears in my eyes as I finish my sentence.
There are words I'm leaving unsaid. Things I know aren't fair for me to let her know.
That her brother is the same age as my own brother.
Young, healthy men.
My brother, like her brother, a good young man.
As I'm trying to prompt her to tell her brother she loves him, I begin letting the thoughts come too close to home - he could just as easily, just as randomly, just as tragically BE my brother. A flash of my family in a room, surrounding the bed of my brother enters my mind.
Stop. You can't go to that place. Put the wall back up. Quickly.
patient's family. I leave the room, letting them cry together.
Afterward, I make my mind move away from the place too close to my heart and try and keep it a safe distance the rest of the day.
On my way home from work, though, I called my brother and we exchange a few bits of conversation. I tell him, "It's important for me to let you know that I love you, and am so happy you are my brother." I feel my voice cracking. Knowing this rare and random expression of sisterly love probably has my brother freaked out keeps me from getting more emotional lest I totally rock his world. I tell him I have a very sick patient who is his age, that he has a sister, and that I want to make sure he knows how I feel, now, when he can appreciate it fully.
He says,"Ah. Well, I love you, too."
So, this holiday, amidst the usual holiday traditions and chaos, let's all make time to tell our families we love them. That we are proud of them, are better because of them, or whatever it is you would have them know.
I hope this family has a chance to do this now, not only with the patient, but with one another.