Take ownership of your healing

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The sickness role is a psychological concept that we give to patients to help them recognize the fact that they are NOT to blame for having an illness. Being ill is NOT something to be ashamed of, something to apologize for, and they are certainly not responsible for being sick.

Unfortunately, some people have misunderstood this concept to mean that they have no role in their healing, that “others” should be entirely responsible for their care and recovery, and they avoid taking ownership of the fact that their actions DO matter in how their healing journey will go.

So yes, none of us are responsible for having an illness AND at the same time, we absolutely DO have a responsibility to take ownership of the healing process.

A good example that I often see at the ED are patients who are coming in due to various ailments, none of which are significantly impairing or acute, because they would like a formal diagnosis or a second opinion for their condition. These ailments are often things like chronic pain, tension headaches, mood instability, ongoing relational issues, etc. Many of these conditions have already been looked at by (often multiple times) a specialist/ consultant, diagnosed, and treatments have been offered. Yet, many patients come to the ED looking for another diagnosis, a different “sick role” that they feel would explain their condition better. While it is completely understandable that an individual would want a better understanding of their condition, I am often surprised at how many of these patients believe that their recovery is entirely dependent on receiving the “correct” diagnosis and meeting the “right” specialist.

There is a huge societal role in this as well – we are often bombarded with images of patients coming to the hospital to be “taken care of”, where they are tucked into the bed and nurtured like a child, while taking a completely passive role in their recovery. This cannot be further from the truth. Best care is delivered when the patient takes an active role in and ownership of their own healing journey; when they take steps to best serve their body and mind. I wonder what changes we would see in our society if we start sending this message that patients ARE capable of and SHOULD be taking charge of their own health.

For example, someone with chronically depressed mood that have unfortunately shown poor response to conventional treatments can become angry at the health care system and the doctors for failing them, and this would be completely fair. AND, at the same time, they can take ownership of their healing process, and start actively engaging in psychotherapy, exercise regularly, set up a sleep schedule, explore their spirituality, tap into their social resources, and make a commitment everyday to heal.

One can use this for patients who have terminal illnesses as well. Palliative care is a large part of our training. It is incredible how patients with months left to live can make a commitment to do the best that they can every morning that they are alive. When they could walk, they would take a stroll around their neighborhood daily. When they couldn’t anymore, they got on a wheelchair and sat by the window every morning. When they were too unwell to be on a wheelchair, they listened to audiobooks and enriched their mind.

We can all take responsibility and ownership of our own wellness, and make a commitment. Us health professionals depend on our patients to work as a central piece of the healing journey. Without the patient’s commitment, there is only so much we can do.

As a witch and a spiritual person in general, I deeply believe that we are an active agent of change in our lives and the lives around us. Our will, actions, and energy DO have an impact in our life journey. Just like the spells we cast and the intentions we put forward, our everyday commitment and actions to heal from whatever ailment, physical or non-physical, WILL direct us towards our highest good.

Stay safe, my friends, and be well.

Culture of incompetence

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Culture of incompetence is a phrase that us, as resident doctors, came up to describe certain hospitals that have a culture that encourages a passive form of incompetence by discouraging productive change.

This does not mean that they encourage residents to make mistakes or to be incompetent in a general sense. Rather, it means that we are encouraged, either directly or indirectly, to abide by unspoken rules that are prohibitive of increased efficiency or innovative approaches to patient care. To give an example that I had mentioned in my previous posts, I had once worked in a hospital where working fast to speed up patient care was seen as putting pressure on the team and being a bad learner. Other residents had similar experiences in this hospital, where they were asked to adjust to the team’s pace, even when it was clear that there were areas of improvement needed to make the team more efficient. The hospital had set up an unspoken rule that it was happy with the status quo, despite the fact that it was no longer serving the giant and ever growing population of patients, resulting in months or even year long backlogs of patients to see, and patients waiting in the emergency department for days just waiting for a bed to become available in one of the inpatient units.

How does a culture of incompetence form? I believe that it starts from a seed of “leaders” that believe that what they are doing is near perfect, if not perfect, and that there is no room for improvement. Any attempts at productive change is seen as stirring up trouble or even being a bad learner. This kind of culture in turn produces an environment where those who agree with this worldview are the ones who decide to stay after their mandatory rotation ends, and the saga continues.

This kind of workplace culture can cause traumatic moral injury in young and motivated learners, possibly making them lose that spark that keeps them wanting to innovate and improve. Perhaps the reason why healthcare has seen so few innovative changes in the past many years is because this culture is pervasive in medicine. As residents, we get placed in a lottery system that inevitably lands us at a hospital with such a culture at some point during our training. While I wish I could say that most of us come out of the experience with our eagerness and dreams of a better future intact, it often marks the beginnings of becoming a bitter and burnt out physician.

I noticed this change in myself more recently when I pulled out a garnet bracelet from my jewelry drawer for work today. One of my daily rituals as a witch includes picking out a gemstone to support me at work and to set intentions for the day. Garnet, besides from being a protective stone, also encourages vitality, leadership, and positive growth. Since being burned by this culture of incompetence and many months afterwards, I was afraid to wear this to work in case it would push me to stand out more than a resident “should”, attracting negative attention and criticism. Today, for the first time in almost a year, I took out this bracelet for me to wear to work, feeling finally ready to return to my old self again.

If you feel that a productive and growth-oriented behavior that is appreciated by patients or clients is being met with resistance and even animosity in a new environment, I implore you to take a pause and to evaluate the environment before changing yourself. If you could find a way to hold onto that spark inside of you to ignite torches of positive change, a day will come when you are free to light up the world as you are meant to do.

Stay strong, my friends. Better days are just around the corner.

Good cop vs. Bad cop – Splitting in medicine

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I continue to have this rather unsettling experience with an allied health colleague in my team. While meeting a patient together for the first time, she would interrupt the interview during my segment to tell the patient, either directly or indirectly, that I am interrogating the patient, I am being invalidating, the information I am collecting is not important, etc.

The funny thing is, I happen to know her outside of these interviews and she is quite lovely, which is why it shocks me every time she does this.

This behavior where one tries to intentionally or unintentionally cause the person of interest to see one party of the triangle in an idealized manner (e.g. good cop, usually the one doing the splitting) and the other party as an aggressor/ perpetrator/ incompetent member (e.g. bad cop) is called splitting. Splitting behavior is often associated with patients with borderline personality disorder or other cluster B disorders, and is thought to originate from childhood experiences that made them feel invalidated and devalued, causing the child to develop this particular way of relating to others to regain some sense of control. This behavior is hugely stigmatized in the mental health field and often labelled as the patient being “manipulative”.

I am not saying that this particular colleague has a personality disorder. In fact, I am not sure if she recognizes that what she is doing can negatively impact rapport building with a patient. I had a similar experience with a patient who split the team in half, with those who were put in the idealized role constantly fighting with those who were put in the perpetrator role over medical decisions relating to this patient. Residents are often victims of such splitting behaviors because it can be easy to put them in the role of an incompetent provider/ perpetrator, since they do have less experience and confidence to be able to appropriately defend themselves. I was surprised, however, to find that residents often fall victim to such behaviors performed by other members of the healthcare team as well. Bringing up such issues with supervising physicians can mark the resident as a “bad team player”, putting a permanent scarlet letter on his/her scrubs.

After getting sick of feeling bad for myself, I tried to put an objective lens (more or less) on this matter. Why are certain allied staff members motivated to split the patient against residents or doctors in general? Upon reflecting on how splitting behaviors originate in patients with personality disorders, the answer became clear. Patients are much more familiar with the role of a doctor than the role of say, a social worker, occupational therapist, or a nurse, even though each member forms a critical part of the circle of care for this patient. Patients are also taught from a young age that doctors are authority figures who they should lean on for guidance. Because of this, the patient can, unconsciously or consciously, act in a way that make allied health members feel like they are less valuable or important. After experiencing this on a day to day basis, they may have formed this way of relating to patients to regain a sense of control and value in the workplace.

I spent some time reflecting on this to end this blog on a positive note – how can one navigate this environment in a way that prevents such splitting behaviors from developing in the first place? I feel that this situation has gotten so large that it has become a global issue – demonization of doctors and distrust in the medical system, with serious implications for public health especially during this pandemic. Unfortunately, my conclusion was that there are no easy answers to this. How do we protect residents, allied health professionals, and patients so that they do not perform or fall victim to splitting behaviors?

I look forward to the day when I read this blog and feel grateful that such interactions are a thing of the past. Until then…. ??

I don’t know.

Witness to suffering

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As a doctor, a lot of the care that I provide has nothing to do with prescribing medications or performing procedures. Sure, they form a significant part of my training and my day to day work. However, there are also many times where all I can provide for the patients is my presence, to be a witness to their suffering and to create space for them to grieve and mourn.

This was a huge revelation to me in the earlier stages of training – recognizing that there are many things we can’t just “fix” in medicine, and that care doesn’t end with telling a patient “I am sorry, there is nothing we can do”. I never realized how difficult it is to be truly present to witness someone’s suffering until I had to do it myself. It is so easy to give into the temptation to comfort, or to give false hope or even mislead. At the beginning, I told myself that it is because I care deeply about the patients, and it was difficult for me to watch them suffer. However, the more I did this, the more I realized I was NOT helping these patients by quickly wrapping up their suffering in a neat package to replace it with something prettier – I could see how this made them feel confused and lost. Why then, was it so hard for me to change my behavior?

Problem solving engages the prefrontal cortex of our brain – the part that allows us to reason, filter and regulate our emotions. Being forced to turn away from problem solving therefore leaves us feeling exposed, out of control and yes – vulnerable. However, in turning away from problem solving, we can truly be present and focus entirely on the suffering of the individual in front of us. In psychiatry, this is called “holding space”. Having the space to grieve without feeling pressured to go into problem solving mode can be a deeply therapeutic experience that allows one to just “be” and not be judged.

Think about our daily lives – how often do we simply listen to our friends, family or significant others and be fully present to witness their experiences? As children, how many of us had the luxury of this experience when we tried to share difficult experiences with our parents?

I tried to imagine what it would feel like to have someone fully present to witness my suffering, to have an understanding of how this could help my patients. My mind shifted to when I pray or meditate at my altar. Sometimes, I am looking for answers – but more often than not, what I desire is to have the time to sit in my grief and to let it all out, and to have someone sit WITH me in my grief. The sheer presence of my goddesses and spirit guides had always comforted me in my darkest times, and this is what I could do for my patients when there is nothing else I could offer as a doctor. Simply being present in their suffering was a service I could provide in those dark moments.

Now, when I deliver bad news, I sit with them, quietly, with a tissue box in my hand. I stay present with their grief, and in doing so I hold space for them to process their suffering.

It is true that this is much harder with family and close friends – those who we consider part of ourselves and can make us feel particularly vulnerable when they share their suffering. Practice makes perfect and I am still working on it.

Sitting with your feelings

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I was reading “Maybe you should talk to someone” by the brilliant Lori Gottlieb this morning just before work, my little morning ritual, when one message really struck me: it is horribly difficult to sit with one’s own feelings, even for psychotherapists. I am no psychotherapist, but as a doctor, I always ask patients to reflect on their actions, thoughts, and feelings, and encourage them to do mindfulness exercises where they try to notice their thoughts and body without judgement.

The practice of witchcraft also asks one to recognize their thoughts and feelings, so that they can be used to enhance one’s craft and power. An aware witch is a powerful witch – she who rules herself can rule the world.

Why then, is it SO HARD for me, to sit with my feelings? I spend most of my days reading, watching TV, scanning through Youtube, or scrolling through my phone when I am not working in a desperate effort to distance myself from my emotions. In a way, working is almost an escape, because focusing my attention entirely to my patients shifts me away from thinking about myself.

A common concept discussed in psychodynamic theory and in family therapy is that a child who grows up learning that their feelings are invalid, internalize this and grow up to be adults who cannot tolerate their own emotions. The act of noticing and acknowledging their internal processes become associated with deep shame, rejection, and feelings of being misunderstood such that they learn to cope with this by becoming avoidant, not just of their own emotions but of that of others as well.

The difficult part of this is that our thoughts and emotions influence our judgement and worldview whether we acknowledge them or not. Being able to sit with, notice, and acknowledge our internal processes help us realize why we see ourselves, others, and the world the way we do, and lovingly readjust if there are biases at play.

This of course, doesn’t come easily at all. I realized my own tendency to avoid my feelings when a supervisor pointed out how I tend to get flustered if I don’t know something I think a patient wants of me, and how I would completely shift my behavior without even noticing that I am doing this. My supervisor asked me to sit and slow down, and notice the thoughts that arise in my head when this happens. This was an EXTREMELY difficult exercise – at the end, I identified a DEEP SENSE OF SHAME that arose when I felt that I wasn’t giving the patient what she/he wanted. Because this emotion was so difficult to tolerate, I avoided it completely, not even giving myself a second to think about it – unfortunately, this did not stop shame from influencing my behavior. Once I did notice the thought, also called “hot thought” in cognitive behavioral therapy, which in my case was “I am a failure”, I was able to lovingly tell myself: it’s okay to not know everything, you are doing the best you can. In slowing myself down and lovingly readjusting myself, I was able to be more present and authentic with my patients, which in turn made them happier.

When practicing magick, we ourselves form as much of the spell as the ingredients, incantations, and the spiritual forces that we summon to help us. When dark thoughts reside behind the spells that we cast without our knowledge, these thoughts can cause the spell to be weakened or even backfire. See the parallel here?

I still find sitting with my emotions extremely challenging, but I consider it an important part of my journey as a physician and a witch to become more self aware. I will be sure to keep you updated on that journey – wish me luck!

Embracing the Other

Working in a hospital as a doctor is an interesting experience because while you are working on a team, you are often the only doctor on the floor, especially if it is overnight and you are on call.

The responsibility of being the only doctor feels HUGE the first few nights any resident does call by themselves, and it never really goes away as staff physicians often tell me. Once in awhile, a physician from a different specialty will work on the floor with you as a part of a “buddy system” to be an extra pair of hands on the floor, which is always greatly appreciated. The downside of being that “off specialty” doc is that they are often othered by the team, seen as less competent, and treated as such as well.

I was having yet another overnight shift at the ED where my staff happened to be this off specialty doc. However, he had been working as a ED physician for many years and considered himself (perhaps accurately) a specialist in the area. Unfortunately, the night went very poorly for him. Several resuscitation cases came in that he could not manage on his own – he had to call the help of another ED doc but alas, it was not enough to save the patients. I was not involved in those cases so I did not know of the details of what happened in that resuscitation room.

The rest of the night marched on with a heavy mood. I could hear whispers from all corners of the hospital talking about how these cases did not go as they should have, that another physician would have been able to save them. It was hard to control myself from not thinking what they were thinking. Would the outcomes have been different had it been a different doctor? Someone who was trained in ED from residency?

When it came time to review some of the patients with this physician, I could see the worn and defeated look on his face. As soon as I started presenting, he abruptly cut me off and without giving me a chance to finish, he started to ask basic questions, insinuating that I basically did not know what I was doing. When I showed him my documentation proving that the information was all there, he LOUDLY told me that residents are not to be trusted and that because of this, I must follow a way of presenting as per his preferred style to demonstrate that I “am not making stuff up”. I was dumbfounded by this experience. Immediately my mind went to what I was going to put on this supervisor’s evaluation for treating his residents this way. Then, the goddess whispered in my ear, “no, Embrace the Other”.

He was alone in this entire ED, managing a highly acute floor by himself in a truly difficult night. He was further othered by the staff here due to the failed resuscitation cases. I imagined what I would have felt in his shoes, and my heart immediately broke for him. The thing is many resuscitation cases are not “salvageable” when they come into the hospital. Patients often have the wrong idea of what a resuscitation is like from TV shows – miraculous recovery is extremely rare. Even if a person’s heart is to start beating again, the chance of them regaining much of their baseline level of functioning is even smaller. With his years of experience working at the ED, I am sure he knew this too, and so did the rest of the ED team who were judging him. However, amidst all this background information, his identity as the “other” is what shifted their view into judgement and criticism instead of understanding and empathy. His harsh criticism of my work, increasing his voice so that everyone else could hear, was probably an unconscious effort on his part to re-exert his power and sense of control on this floor. Yes, it came at my expense, but what I had to endure was far less than his suffering.

Gritting my teeth and controlling my breath, I told him “Thank you so much for teaching me this, it is very helpful.” He nodded and sent me on my way to see more patients. At the end of the night, when he was doing my evaluation, he said “I was so glad you were here, it would have been a rotten night without you”. It was in this moment when the teaching of the goddess became apparent. Had I not shown understanding and patience in that moment, I would have pushed him further into the darkness. In choosing to set my ego aside to embrace the Other when nobody would, I accompanied another physician, another human being, in his journey from darkness back to the world of light.