Stuart Swadron MD and Molly Hartrich MD
Take Home Points
- Fostering kinship with patients and colleagues can help preserve compassion.
- Bad behavior is often a symptom of trauma, severe mental illness, substance use and years of living at the margins.
- Hartrich is a senior resident in emergency medicine at LAC+USC in Los Angeles. Toward the end of her PGY2 year, the light at the end of the residency tunnel seemed far away and she was tired. She had worked in clinics for years and developed a bedside manner that was commended. However, her compassion was exhausted. She did not view herself as the smartest or best procedurally in her residency but she was good with compassion.
- Her compassion started to disappear within a few months of her second year of residency. Booth after booth of drunken head whacks, psych boarders, pan-positive review of systems and jail malingerers wore her down. She developed severe anxiety that she was missing something big on every patient and sending people home to die in their beds. She had challenging conversations with consultants and a handful of missed intubations. She was broken down by her own self-loathing, shame at her impatience with her patients, colleagues and self. She had florid imposter syndrome and a feeling of deep loneliness. She tried to get in and out of work as quickly as possible. She lost the desire to connect with people. She was losing a grip on her relationships with family and friends. She was contemplating leaving medicine.
- She often drove home from work crying and despondent. It was not sustainable.
- She was the limiting factor. She needed to change the way she interacted with patients, colleagues and self. She did a lot of things. She talked to a lot of people. She focused on kinship.
- Father Greg Boyle is a Jesuit priest and the founder of Homeboy Industries, which uses social enterprise to provide assistance to at risk youth, gang members and formerly incarcerated individuals. His headquarters is in the same catchment area as LAC+USC. In his book Tattoos on the Heart, he writes, “You stand with the least likely to succeed until success is succeeded by something more valuable; kinship. You stand with the belligerent, the surly and the badly behaved until bad behavior is recognized for the language it is, the vocabulary of the deeply wounded and of those whose burdens are more than they can bear.”
- Facilitating kinship for patients and their families as a manifestation of her role as a doctor was the initial boost she needed to get out of a dark space. She moved on to how she could get her feelings of belonging back, to experience family and teamwork at work. The relationships she is cultivating at work are those she relies on during the awesome and difficult days of residency.
- Opportunities to cultivate kinship are everywhere at work. Kinship is your colleague who feels like family. The ones we confide in about fears, shame, inadequacy, mistakes, joys and accomplishments. Those we comfort when an intubation doesn’t go well or there are problems at home. We form kinship bonds with our clinical team when we are resuscitating a patient or working a tough or fun shift. We seek comfort in our seniors when we are doing something new and terrifying. We stand next to our juniors when they are putting in their first central lines to reassure and guide them. When we stand together, celebrate the triumphs and talk through the failures, we are creating kinship.
- The last element she reclaimed in her quest to find joy and meaning was to cultivate kinship between the patient and her. Kinship is comforting and trust-building for the patient and physician. When she feels her energy being drained by a patient and empathy dwindling, she tells herself a mantra she learned from Boyle. “Bad behavior is the vocabulary of the deeply wounded and of those whose burdens are more than they can bear.” What he calls bad behavior is symptomatology just as Kussmaul breathing points to DKA. The combative, uncooperative, altered, intoxicated patients show the manifestations of trauma, severe mental illness, substance use and years of living at the margins.
- Now interactions with patients are opportunities for kinship. Hartrich seeks infinite empathy. When empathy is no longer conditional, when she chooses to enjoy every conversation with patients, she has better shifts, feels more fulfilled and feels like a better doctor.
- She connected and leaned more on her family, partner, certain seniors and attendings. One senior encouraged her aggressive self-care rather than her aggressive self-loathing and studying. She had a lot of fear that she would appear weak discussing her struggles. She found that what she was experiencing was not unique.
- There is comfort on both sides when you connect with patients, families and one another. We are part of the story. Kinship has given her insight and meaning that each of us belongs here and we belong to one another.