Do you think about depressing patient cases even after your shift

[Stacker]

If there were a patient that you were taking care of who had a terminal illness (or any other painful disorder), would you still contemplate about that patient during your free time and does it somewhat hamper your social life knowing that you are having fun while that patient is suffering? In other words is there any form of unwarranted guilt?

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[Buzz Me]

Sometimes it's hard not to take your work home with you, so to speak. You learn to compartmentalize, to a certain degree (otherwise you'd go insane).

 

[QofQuimica]

If there were a patient that you were taking care of who had a terminal illness (or any other painful disorder), would you still contemplate about that patient during your free time and does it somewhat hamper your social life knowing that you are having fun while that patient is suffering? In other words is there any form of unwarranted guilt?

I would say that I'm on the touchier-feelier side compared to many of my residency classmates, and my answer to your questions is no. It wouldn't be very helpful to your patients to think about them 24-7 even if you wanted to, because you'd burn out. I think that most physicians learn to compartmentalize, and that's what I do, too: when I'm at work, I worry about patients, and sometimes I focus on helping them over taking care of my own needs (meals, bathroom, etc.). But when I've signed them out to my colleagues and left the hospital, I worry about the same things that you worry about: doing my laundry, making dinner, taking a nap, going to the gym, hanging out with friends, etc. It's not like you really have a choice if you want to be a functioning human being, because you don't suddenly become superhuman when you are handed your diploma.

 

[gutonc]

If there were a patient that you were taking care of who had a terminal illness (or any other painful disorder), would you still contemplate about that patient during your free time and does it somewhat hamper your social life knowing that you are having fun while that patient is suffering? In other words is there any form of unwarranted guilt?

Do I think about those people? Yes...I'm an oncologist...they're pretty much my entire practice.

After my shift? That's so cute.

Does it interfere with my social life? I'm married with a kid...I'm not really sure I have a social life.

But yes, I sometimes discuss patients (in a very general sense) with my (mercifully not a medical professional) wife in order to decompress...just as she discusses the stressful parts of her job with me for the same reason. Then we let the babysitter in, say goodbye to our daughter and go see a movie/concert/performance and life (for me at least) goes back to normal-ish.

It's all about compartmentalization. You figure out how to deal with it or you put a bullet in your head...it really is that simple.

 

[Gasworks]

Do I think about those people? Yes...I'm an oncologist...they're pretty much my entire practice.

On a related note.. case from earlier today - young pt, pancreatic ca, wife, babies, the whole 9. Opened him up for a whipple, found and unresectable mass and evidence of spread. Surgeons did a couple of "palliative" procedures, inserted a port and closed him up. I left the hospital with the pt snoring away in the pacu and the surgeon still talking to the family. This guy was talking about 5 and 10 years survival with the surgeon preop and now he probably has weeks - months of pure misery left. Gotta appreciate the things we have in life, all this death and disease we see every day and you never know when you are going to be the one getting the bad news.

 

[gutonc]

On a related note.. case from earlier today - young pt, pancreatic ca, wife, babies, the whole 9. Opened him up for a whipple, found and unresectable mass and evidence of spread. Surgeons did a couple of "palliative" procedures, inserted a port and closed him up. I left the hospital with the pt snoring away in the pacu and the surgeon still talking to the family. This guy was talking about 5 and 10 years survival with the surgeon preop and now he probably has weeks - months of pure misery left. Gotta appreciate the things we have in life, all this death and disease we see every day and you never know when you are going to be the one getting the bad news.

He had a crappy surgeon, plain and simple.

Median survival for completely resected, NED pancreatic cancer is <2 years. Any surgeon who told him that when he woke up from surgery he'd be free and clear is a liar. This is one of the reasons I'm happy to work in an academic multidisciplinary system. We have a couple of extremely aggressive pancreatic surgical oncologists who are nevertheless quite honest with their patients up front.

And just because he has pancreatic cancer doesn't mean that every minute of his remaining days will be pure misery. We're pretty good at what we do these days and even though we can't cure these folks, we can make a positive impact on their survival and their quality of life.

</cranky soapbox...it is obvious it was a clinic day today?>

 

[penguinophile]

I'm a radiology resident and I still sometimes feels pangs of guilt/sadness about patients I had intern year. There were times that I would be at home checking labs overnight just to make sure I made the right call and didn't leave the on-call intern a disaster. You are human, and suffering will affect you. As a physician, you literally hold peoples' lives in your hands, so you should care. Should it impact your social life? Hopefully not. However medicine cannot ever be a job that you can just leave at work.

 

[dragonfly99]

Yes, I do think about my patients at home. Yes, it sometimes does depress me, and can make it difficult to enjoy some other aspects of life. I think that mentally/psychologically it is better if you can "compartmentalize" and in order to exist you have to be able to learn that at least somewhat. However, I think if you are the patient then the doc who sometimes takes the work home with him/her is probably the one you want...but you may not want to be "that doc" if you know what's good for you.

 

[45408]

Yes, sometimes. I don't think it negatively affects my time at home, but I wouldn't want to be so detached that I never thought about the people I was caring for.

 

[Dwindlin]

If there were a patient that you were taking care of who had a terminal illness (or any other painful disorder), would you still contemplate about that patient during your free time and does it somewhat hamper your social life knowing that you are having fun while that patient is suffering? In other words is there any form of unwarranted guilt?

Not even a little.

 

[Janedoedoctor]

It's all about compartmentalization. You figure out how to deal with it or you put a bullet in your head...it really is that simple.

Very true. In order to be a good doc to your patients, you need to be able to go home, have a good meal with your family, enjoy the company of your friends, walk the dog,... without taking the hospital home with you.
In every class, there are some med students who don't manage that. They all burn out long before their time.

Working with young people who become very sick very suddenly has given me an appreciation of life and its frailty that I do take home with me. But that is a positive thing. I'm a worrier by nature, but I can let go of many petty everyday concerns and appreciate what I do have, because I realise how fragile it all is.

Apart from that, I leave my work at the door when I walk out of the hospital.

 

[jace's mom]

I don't think about patients outside of work often, although of course I've had a some thoughts about those who have died that day...a few moments of sadness in my evening. However, I currently have a case that is the most terrible experience of my (admittedly early) career, and I have been grieving for my patient and the family. It's been hard to put this one aside, though I'm working on it, but I think I would be worried about myself if I could put it aside easily.

 

[Winged Scapula]

Like gutonc, in a heavy oncologic practice, I do think about my patients when I get home ( or "my shift ends"...LOL).

Today I saw a 40 yo 30 week pregnant woman with her 4th recurrence of breast cancer, two 30 yos with metastatic disease, a 75 yo with widespread mets (she refused adjuvant treatment despite an 8 cm tumor and 31 positive nodes) and chest wall recurrence, and two "super elderly" (i.e., > 90) with fungating masses. These are only the "interesting" ones (e.g, doesn't include the run of the mill malignancies I saw).

But I don't take them home and ruminate. Rather I reflect on how lucky I am to be happy and healthy.

 

[dpmd]

I tend to feel things a little more openly than others (have cried with more than a few families after things ended with a death), but I can let things go afterward. If not I wouldn't be able to function. Right now I have a few patients who are dying at home. When one of them was in the ER (his elderly mom who may have a little bit of dementia called 911 even though he is hospice) I saw him, asked if there was anything I could do, mourned the fact that despite his young age we weren't able to help him, took a minute then continued with my day. Unless I made a huge mistake because I was hungover, or wanted to get home early, I wouldn't feel guilt about things. It isn't like I gave them cancer, put them in the vehicle that crashed, perforated their bowel, or did whatever bad thing to them that resulted in their condition. So if I am not able to fix them I don't feel like that is my fault either. Doesn't mean I don't feel bad for a while though.

 

[Law2Doc]

... You learn to compartmentalize, to a certain degree (otherwise you'd go insane).

partly that, partly the sheer volume of people you are going to see crash and burn over time makes each catastrophe a bit less personal. You become desensitized. You start taking a gallows humor, Daniel Tosh type view of the world. It's like all those old MASH episodes where Hawkeye talks about why he makes light of bad situations to not go mad. I think this is why they stress teaching "empathy" in med school, because a lot of folks learn to be very good at detaching themselves from personal connections with their patients to not go insane, so you at least need to at least have some skills to cover up how detached you are letting yourself get. At the end of the day you probably beat yourself up a bit for any potential things you did or didn't do that may have caused a detriment to a patients situation but you probably don't let yourself get too shaken up by the patients underlying condition. It's not like you meet a small handful of terminal patients over the years. It's an every hour occurrence.

 

[Valadi]

For the life of me I can't remember my patients at all. Except for one, Mr. K. He came in like a train wreck with widespread malignancy. I remember the day before he died I asked if I could do anything do help? And he smiled and asked for prayer. The next morning he was death rattling, and when he passed I called his brother to let him know. It was the first time I'd been around a patient who passed, or called family. I don't think I'll ever forget him.. which is strange, because once my white coat comes off, I usually have no recollection about who my patients are at all. I still think of him sometimes, when I meet someone I know I should treat with the love mittens.

 

[Winged Scapula]

I still think of him sometimes, when I meet someone I know I should treat with the love mittens.

I find that phrase odd yet wildly amusing, for some reason.

 

[peppy]

I am a psychiatry resident so right now I am not seeing many people who have tragic physical illnesses (although Psych people can go into Palliative Care fellowships - I'll get into that more below). However, general psych work is sad in a different way.
In psychiatry, you routinely have patients who are talking to you about things like terrible physical/emotional/sexual abuse, loneliness, homelessness, poverty, devastating personal losses (a few times on the inpatient unit we had parents who came in suicidal because their child had died and they just couldn't make peace with their overwhelming grief...those cases always were especially poignant to me). Then there are the psychotic patients who stay out in the cold weather and get frostbite or have suffered other maladies because they couldn't take care of themselves. It is heartbreaking if you really dwell on it.
There are a lot of times when at the end of the day, I do have a passing feeling of, "Whoa, what a day" because I had a couple of different patients with very intense, sad stories. Sometimes I do think about patients when I'm off from work because something will remind me of them. But when I'm off, it's normally just a passing thought and not something that haunts me. For my sanity, I need a break from it.

I do agree with the view that you deal with so many sad and tragic cases that you really can't take every one of them personally. Back during med school and internship, I would read the obituaries regularly. After every inpatient internal medicine rotation, it was inevitable that I'd see a LOT of familiar names in the obituaries for months after the rotation. A huge portion of IM inpatients are sick elderly people who are not long for this world.

Some patients do stick with me. I remember that it affected me more than I thought it would the first time that *I* was the one who told a patient that she had cancer (lung cancer that had already spread - and the patient had no suspicion of anything that serious).
Now, I wouldn't say I felt guilty or responsible in any way for the poor woman's situation. It's just a feeling of sadness and empathy, realizing that *you* are going to change someone's life with terrible news.

On the other hand, I actually did a palliative care rotation once, and contrary to what you might think it really wasn't a depressing experience. It was pretty amazing seeing how the palliative care doctor would go into these tragic situations trying to put the patient/family at ease and focusing on what we could do to make a terrible situation more peaceful, dignified, and humane. I absolutely think that palliative care is under-utilized in a lot of these sad scenarios.

 

[Valadi]

I find that phrase odd yet wildly amusing, for some reason.

Haha. I am to please, WS.

 

[Buzz Me]

partly that, partly the sheer volume of people you are going to see crash and burn over time makes each catastrophe a bit less personal.

Agreed.

Over the years, I've probably coded close to 200 patients...probably filled out around 80 death packets. This doesn't include the traumatic arrests we get in the Trauma Bay. Or the DNRs.

 

[dragonfly99]

Agree w/some of the above comments that once I'd seen "x" number of people die and/or suffer severely, it kind of doesn't have the same effect on me. It use to bother me a great deal when I was a med student, but it doesn't bother me as much now...in a way that's sad, but it's a necessary defense mechanism I think. Some people are more sensitive than others...you could say it's more empathetic, versus just not as good at keeping boundaries...probably some of both. I don't think we do enough of teaching medical students how to deal with this type of stuff...interns also...because the latter are in a different situation where they may feel more responsible for the death (even if there were not lapses in care). Sometimes we don't care for the caregivers enough...

 

[Arcan57]

Tragedies happen. The more you identify with the patient/family, the harder it is to compartmentalize. The "came in dead, stayed dead" patient is pretty easy to put behind you. The 32yo patient with the loving family who just found out his new-onset vertigo is caused by a GBM is a little harder. The dead kids hurt a lot. Regardless, there's always a new patient to see and I find things don't usually bother me for more than a day or 2 for something truly horrific.

 

[dragonfly99]

I wonder if the death stuff is easier for ER docs, as opposed to people who see the patients repetitively (in clinic or wards, etc.). In the latter cases we get to know the family and patient a bit better.

 

[45408]

Tragedies happen. The more you identify with the patient/family, the harder it is to compartmentalize. The "came in dead, stayed dead" patient is pretty easy to put behind you. The 32yo patient with the loving family who just found out his new-onset vertigo is caused by a GBM is a little harder. The dead kids hurt a lot. Regardless, there's always a new patient to see and I find things don't usually bother me for more than a day or 2 for something truly horrific.

We just had a mom+neonate traumatic death combo recently. That one stings.

The trauma that came in brain dead and stayed brain dead...yeah, didn't bother me.

 

[Samoa]

Usually I can leave it all at the hospital. But when there's a bad outcome, I will often review events in my head and try to figure out if there was anything that could have been done differently. A sort of private M&M. As for the emotional aspect of my patients' illnesses, I feel empathy in the moment, but I leave it there.

 

[Groove]

I try not to take home my work. The ones that I dwell on are cases where I'm analyzing what I could have done differently and whether that would have made any sort of impact or ultimate difference in outcome. Most of the times, it just wouldn't have, but it's difficult to sell that to yourself sometimes even though it's usually correct.

Mistakes will happen though. I probably have dwelled on procedural mistakes more than anything else where there wasn't even a major adverse outcome vs the coding pt who dies. For instance, doing an IJ one time and caused a very small PTX. You do enough procedures, long enough and you'll make a mistake, hopefully a minor one but that one ate me up. I work in the ED. I rounded on the pt for the next 2-3 days and wrote a brief note, just to check on her. She did fine. The surgery team was shocked to see an EM note in the chart every day, lol... Luckily, there haven't been too many mistakes but they will happen.

Lesson learned in that one: You really...never need the long needle in the CVL kit for an IJ and even though it's shallow and you can technically do it with the long needle...just don't. No reason to and makes it easy to hit the apex of the lung in a small young female. Also, I don't care how many non UTZ IJ's you've done, and how much confidence you might have, there really is no reason not to use UTZ for an IJ, so just use it. No, don't cheat and use the probe to visualize and then do it with a non UTZ guided approach, do the whole thing UTZ guided.

 

[Buzz Me]

For instance, doing an IJ one time and caused a very small PTX. You do enough procedures, long enough and you'll make a mistake, hopefully a minor one but that one ate me up.

Did the patient even need a chest tube?

I've caused a big pneumo before. Patient needed a chest tube. But then again, I've also caused other complications as well - just part of the nature of the training, unfortunately.

 

[Groove]

Did the patient even need a chest tube?

I've caused a big pneumo before. Patient needed a chest tube. But then again, I've also caused other complications as well - just part of the nature of the training, unfortunately.

Nah, it was a small PTX. It just ate me up though because I pride myself on my procedural competency and am usually very meticulous and try not to make mistakes, but....hey, it happened in this case. Like I said, you do enough of them and you'll have an adverse outcome at some point. Nobody is perfect.

Always a lesson to be learned though which is the most important part.

 

[Buzz Me]

Nah, it was a small PTX. It just ate me up though because I pride myself on my procedural competency and am usually very meticulous and try not to make mistakes, but....hey, it happened in this case. Like I said, you do enough of them and you'll have an adverse outcome at some point. Nobody is perfect.

If you haven't caused a pneumo from a central line, you haven't done enough.

I've done over 260 subclavians, have one pneumo so far. It will happen (even with perfect technique)...you just have to be prepared to act accordingly. Always ask yourself - what would I do if the patient suddenly started to desaturate during this central line attempt?