When I was an intern, one of my attendings told me that I was “too nice.” He said it to mean that I needed to toughen up to “make it” as an emergency medicine (EM) physician, and that the alternative might be fatal. To give some context, this attending was of the direct, overly sarcastic, wry sense of humor variety. In the end, I left that shift alarmed, with a diminished sense of my ability to become a successful EM physician. Had I made the wrong decision in choosing EM as a specialty? Did I have what it took? I feared that maybe I wasn’t cut out for this after all.
Thankfully, those words were not premonitory, and I did become an EM physician. I graduated residency, completed fellowship, and joined faculty in a rigorous academic department. I also garnered some accolades along the way for being “nice” including some of the top Press Ganey scores, and other recognitions for clinical excellence and compassionate care. One colleague comically poked that I must be “feed(ing) those patients some secret sauce.” Well, not exactly, but there may be a hint of truth to this amusing comment.
Though I may be inclined towards an optimistic and generally friendly disposition, it can be challenging to be “nice” working in the high-stress, fast-paced and often thankless setting of the Emergency Department (ED). While I love my job, I have also had my fair share of frustrating experiences, and said or done several not so “nice” things. In my continued growth as a physician, I have made it a point to learn how to be a better provider, which includes being “nice.” These are some lessons that I’ve picked up.
The landmark study by Swayden et al. found that patients who had their provider sit down with them perceived time spent during the encounter to have been longer when compared to a control group that had not. Providers that sat down were also rated more favorably. Similarly, an article by Merel et al. showed that perceptions of quality of a physician’s communication was higher in those that sat down with their patient. In my experience, there is lots to gain from sitting down with a patient. Sitting lends to a more organic discussion. It stops you in your tracks (figuratively, and in actuality). It centers and focuses you. Additionally, patients, already inherently in a vulnerable state have cited time and again the awkwardness of having someone, physically, “talk down” to them. Naturally, there’s the obvious limitation of access to furniture. But I can promise that I’ve never had a patient show displeasure with me sitting on the edge of their bed! Get at eye level and help to restore some compassion and dignity to your patients.
Listen, and really mean it
Active listening, especially in the ED, can be a tall order. There is a constant flow of sick patients, nurses asking for orders, EKGs needing attention, and other equally important events often happening concurrently. But as most that read Paul Kalanithi’s sobering autobiography, “When breath becomes air,” it challenged me to take pause. And listen. Like him and others who have written about being on the receiving end of care, my own experience with a parent’s critical illness gave me newfound respect for this. Of all the things that I remember most during the harrowing experience, was the surgeon sitting down to explain what had happened, listening and answering our plethora of questions, despite having just emerged from a 10-hour surgery. So strive to be a better listener, force yourself not to interrupt, repeat back what is said. Do it again. To this end, I really loved the article about distraction management strategies by Ratwani et al. with one of the recommended techniques being to “delay or reject interruptions when appropriate … ask the interrupter for a moment to complete work or at the very least reach a good stopping point.” In sum, attempt to protect this time as much as is possible.
Don’t take things personally
While working in the ED, one has a very short time frame to build rapport, “pitch” an idea (diagnosis and management plan), gain buy-in and close off a relationship — all with a complete stranger. And do this 20 to 40 times a shift, if not more. No easy feat. At times, a patient might reject this “pitch,” become displeased or disagree with a plan, request (or even demand) an alternative, become angry, or ask for a second opinion, and it’s difficult not to take this personally! The Four Agreements by Don Miguel Ruiz provides some sage advice on creating boundaries and not allowing circumstances to dictate your response: “Whatever happens around you, don’t take it personally … Nothing other people do is because of you. It is because of themselves … You are never responsible for the actions of others; you are only responsible for you.” Naturally, this can be easier said than done, but look forward to inculcating this mantra. It will not only help you, but every other patient, staff member and trainee that will be looking to you the rest of that shift, and beyond. Finally, a focus on shared decision-making, empowering and educating the patient to be able to make an informed decision has proved time and again to be an effective tool in difficult situations where a patient encounter may not have come to a resolution, and the evidence supports patient interest in greater involvement in their care.
“Get your lovin’ at home!”
In 2019 statistics, EM ranked among the top 5 highest specialties to experience burnout. The toils of the job are real. With that said, one of the best ways to avert burnout, and continue in a field that we still remain so passionate to serve in, is to invest time in activities that renew your energy outside of the workplace. One of my greatest rejuvenators is going to the gym. As much as is possible, I commit to spending 1.5 to 2 hours there on most days of the week. I actually schedule it in, guarding this time with tooth and nail. The book, Power of Habit, refers to exercise as a “keystone habit” given that it drives many other successful habits and routines. Some of the results of regular exercise cited include improved sleep, improved diet, and better energy overall for other daily activities. There are plenty of other opportunities for wellness, and most academic societies and private organizations have taken this up as a priority. Look around you for low-hanging fruit, such as those within easy access to your home/ job, that a group of friends already engage in, or those that are free/ affordable, so that you won’t be easily deterred and may have some accountability to get you started. Either way, find something and do it regularly!
In sum, we can all be “nice” doctors, though it may take some effort and reflection to get better at it. And we can all do better. For ourselves. For our patients. I hope that I’m not being too nice to think this could be possible.
Christine Ngaruiya is an emergency medicine physician.
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