Dear Anxiety: But Still I Stand

medicine

I scurried across the campus to the bricks that housed the Department of Psychiatry. Sneaking in the back door, I hurried to the elevator. Fifth floor, the sign read. Sweat coursed down my back as nerves ran up my spine. A conversation with this doctor was going to determine if I would be allocated an additional four to six weeks to study for my step one board examination. This is the board examination one must pass to transition from a second year to third year medical student and begin clinical rotations in the hospital. That is what they tell you. They do not tell you this is the score that almost entirely dictates what type of physician you can become. A lower score on this exam and Ear, Nose and Throat (ENT), Orthopedic, Cardiothoracic, and Plastic surgery are subspecialties you can surely kiss goodbye because these residency programs will likely never see your application.

In the corner of the waiting room, I hid behind one of the partitions set up to enhance patient confidentiality. The psychiatrist greeted me prior to ushering me into his office. A dimly lit room, a couch and two chairs welcomed me. This felt more like an audition than an appointment. My heart was not beating, it was throbbing.

Globally, approximately 1/3 of medical students are being treated for anxiety or have been diagnosed with anxiety by a clinical practitioner. For me, I had never experienced anything like this before; sleepless nights, a lack of appetite resulting in substantial weight loss, an inability to focus, tears streaming down my cheek for no apparent reason and an unending catastrophic feeling surrounding my studies and upcoming exam. At the time I felt alone. Many years later I have come to know there are many who share this story.

At the conclusion of our visit I thanked him for his time and left down the elevator and out into the cold Midwestern evening. Staring into the distance the Ohio Stadium stood proud, a gladiator’s coliseum, while a shell of myself stood frozen in the night. He would either agree these symptoms were inhibiting my studying or he would not. The fate of my future was in his hands—this man I had only met only 60 minutes prior.

The next morning my cell phone rang.

“…We are granting you four additional weeks for your studies…”

In his report, the psychiatrist had noted the anxiety levels I was experiencing dramatically hampered my ability to adequately study.

A sigh of relief set in.

The throbbing within my chest had now decreased to a dull roar that would allow me to finally sleep for the first time in weeks. I made my way to the couch and as I began falling asleep, my mind started retracing my steps to medical school.

Abruptly, I woke up to my cell phone ringing. This time it was the pharmacy—my new prescription for anti-anxiety medications was now available for pick-up.

The journey to medicine is unique to each individual who embarks on it. One commonality is that it indirectly teaches success through repeated adverse conditions and failures—it teaches perseverance. Many of the leading educators and clinicians I have met in this sphere maintain an intrinsic motivation that far outweighs their innate level of knowledge. This intrinsic motivation increases their aspirations, knowledge and purpose; aspiring to serve as a physician, understanding that knowledge precedes healing, and a purpose dedicated to caring for others.

In essence, these men and women are the ordinary ones. They are you and me. They were once pre-medical students with a dream who became medical students embarking on a journey, then resident physicians gaining the skills and knowledge to become attending physicians. Ultimately, these attending physicians continuing to turn dreams into reality for anxious pre-medical students.

This is the journey.

The Importance of Five Minutes

anesthesiology, medicine

Originally published in July 2019 edition, ASA Monitor (citation below)

‘Unexpected death of a colleague,’ I read in the subject line.

As I combed through the remainder of the email, I came to learn that a second-year resident had died in a car accident near his hometown. It was his name that gave me pause.

Just a few weeks prior, I entered one of the campus cafeterias for a meal. There, I noticed a young man sitting alone wearing a navy-blue jacket. A University of Pennsylvania Perelman School of Medicine crest was stitched on his chest.

“Hey, man – I happened to notice your jacket. Did you attend UPenn?”

“Yeah, I did. I’m Joe! Nice to meet you.”

“It’s nice to meet you, too. A few of my closest friends also graduated from there!” I replied.

A conversation started, just pleasant banter that danced around the east coast versus west coast biases, shared colleagues and friends, Portland’s city designation with its small-town charm, and our respective medical specialties. The dialogue was short but delightful and lasted approximately five minutes in total. Before I left his table, I suggested we take a photo together to send to our mutual friends.

Our smiles are in my phone now.

In the five minutes when we spoke, a connection was formed, a foundation of trust laid. Unlikely as it seemed at the time, this simple exchange was similar to the swiftly created bond that forms when an anesthesiologist talks to their patient prior to surgery.

When I was a fourth-year medical student, I told my family and friends that I had applied to an anesthesiology residency program. Their responses varied. Most were happy but they had questions too, specifically concerns that my communication skills would be “wasted.” Knowing how much joy interacting with people brings me, they were disappointed that I would spend most of my medical practice with unconscious patients. My answer: there is a unique responsibility born in that five-minute interaction prior to surgery. In those five minutes, I may have the ability to connect to a patient, gain trust and portray a sense of safety to a complete stranger in a way someone else may not. My communication skills could be the difference between someone entering the operating room with wild fear or measured ease.

When I was a fourth-year medical student, I told my family and friends that I had applied to an anesthesiology residency program. Their responses varied. Most were happy but they had questions too, specifically concerns that my communication skills would be ‘wasted.’

I am not alone in feeling this way. “I have five minutes to convince someone I can take care of their life,” Dr. Marshall Lee – Oregon Health & Science University (OHSU) attending physician – stressed during residency orientation. This time restraint is a challenge that should be decorated for anesthesiology rather than seen as a reason to choose another specialty. A patient waiting in the preoperative area is possibly in one of the most vulnerable states of their lives. Patients may find themselves anxiety-stricken for the surgery itself, fearful regarding the aftermath, pained by the financial burden of the surgery and concerned for the risk of death. Most encounters we have with our patients are brief and delicate. A patient in this highly vulnerable state – concomitant with a short window of time – clings to every word from our lips. After a postoperative call to verify the patient is recovering appropriately, it is probable you will never see nor hear from them again. This does not detract from the memory of how you made them feel – one they may carry with them for a lifetime.1 

When recalling my conversation with Joe, I can no longer remember the nuances nor the minute details, yet I felt more connection and delight upon walking away from the table that day than after many hour-long discussions with others. As anesthesiologists, we only have a few minutes to gain the trust of the patient and family member, positively frame one’s outlook prior to their surgery, and provide the sense of comfort and reassurance they are seeking. During this brief encounter, we must gather information, set expectations and address concerns a patient may have – several factors underlying high-quality patient-physician encounters.2 One underestimated key is non-verbal communication – a grounding component of a therapeutic patient-physician relationship.1 And one example of this is evidenced in a study which demonstrates that sitting over standing is highly favored by patients as it creates a less dominant environment and more empathetic space.3 

As I embark on my anesthesiology journey, I will recall my feelings after I left Joe and the impact of a high-quality conversation – regardless of its brevity. It is a remarkable challenge that is requested of an anesthesiologist. At OHSU, attending physician Dr. Miko Enomoto is known for her saying, “the safest anxiolytic one can administer to a patient is their time, their attention and their care.” Let us never forget that in five minutes we have limitless influence on a patient and their family during one of the most vulnerable phases of their life. They may not remember the details of the conversation, but they will most certainly remember how we made them feel.

References:

  • Ha JF, Longnecker N . Doctor-patient communication: a review. Oshcner J. 2010;10(1):38-43.
  • Simpson M, Buckman R, Stewart M, et al. Doctor-patient communication: the Toronto consensus statement. BMJ. 2010; 303(6814), 1385–1387.[Article]
  • Strasser F, Palmer JL, Willy J, et al. Impact of physician sitting versus standing during inpatient oncology consultations: patients’ preference and perception of compassion and duration. A randomized controlled trial. J Pain Symptom Manage. 2005; 29(5):489-497.[Article][PubMed]

Jason L. Campbell; The Importance of Five Minutes. ASA Monitor2019;83(7):44-45.