Journal of Palliative Medicine 2014.17:618-619. Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/03/15. For personal use only.
JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 5, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2013.0334
Reflections in the Corridor: Training Doctors To Care at the End of Life Bridget Johnson, BMed FRACP, FAChPM, Debra Scott, Bsci, MBBS, and Roderick Macleod, MB, FRCGP, FAChPM, PhD
W
e have both had the very great privilege of many good teachers throughout our years as junior doctors, but every now and again a great teacher comes along who makes you stop and truly reflect on your patients, your practice, and yourself. The medical system in Australia commands that you conform in the name of efficiency and after 9 years comprising 10 terms as a junior doctor, 12 terms as a registrar, and 6 terms as an advanced trainee, it has been remarkable to encounter a practice as simple, yet so formative and inspirational as corridor reflections. In a term in a suburban hospice in Sydney, a consultant showed us both as advanced trainee and senior resident the art that is medicine by implementing corridor reflections. This practice allowed us to reflect on our patients, their story, their suffering, our reaction, and how the patients and their stories were in fact shaping us as doctors. The process was not rocket science and yet it inspired both of us to be better doctors and to go forth and try to emulate this method with our juniors. On ward rounds we would stop after seeing each patient and reflect on their story, what seemed to matter most to them as humans, and what was driving their suffering. The professor had a gift for asking open questions with precision that cut to the heart of the patient’s worries and heartache and we would reflect on that as a team—consultant, registrar, resident, and nurses—before moving on to the next patient. The professor would stop to question us not about doses of medications, not minutiae of pathophysiology, but in broad brush strokes, where was this story going? And how were we going to travel this journey with our patient? The process also provided a chance to debrief after each patient, giving their story the time and respect it required to digest, and to role model a clinician who clearly wanted us to marry the science of our medicine with the humanity of the whole person in front of us. Working through this process and being mentored and guided impressed upon us the nature of role modeling and mentorship in medicine and training programs. After years of university, years studying for physician exams, and years in an advanced training program, one could be forgiven for thinking that medicine is a game that one must learn how to win as opposed to a profession handed down for centuries. There is something so grounded about rethinking about medicine as an apprenticeship model, which helps to take the
wind out of those physicianly sails and one’s ego. Again, appreciating that medicine is ultimately a profession that gets handed down from one generation to the next, in and out of weeks and over years, and emphasizing that if you want to be a good doctor you need to learn over years and decades like a craftsman. The current curriculum for both physicians’ training and palliative care advanced training is fixated on box ticking such that the outcome of producing a caring, compassionate, passionate, empathetic, holistic clinician can at times get left at the door. What worked in our corridor reflections was that it wasn’t enough to be able to manage a patient’s symptoms well, nor should it be. We have a very human subspecialty—it’s dirty and gritty and sad, but that is a reflection of life itself. As physicians, our default position is to be ‘button and drug pushers;’ it makes us feel better to change drugs and say that the patient feels better (and therefore we feel better) because we did something. Often our capacity to ‘‘do something’’ appeases our feeling of impotence, rather than addressing the elephant in the room, which is that none of us knows how to fix the human suffering that is in every room we enter. These reflections made us think deeply about the patient’s suffering, acknowledge their suffering, be a witness to their suffering, rather than turning away from it and fiddling with the opiate doses. As all team members were involved, it promoted a unified front in trying to sensitively and with integrity help, heal, and respond to the patient’s need and tend to their whole person care. It takes a role model and mentor to place a value on the psychospiritual and to have it translate for trainees. It is more than using the term ‘biopsychospiritual model’ which rolls off the tongue for a lot of clinicians: the reflections in the corridor and in multidisciplinary meetings made us explore the real meaning of that for each patient. Ultimately, palliative care is a journey through uncharted waters at times with no reports back to us to know how we did; this means that peer-led reflection is essential in our day-to-day practice. The other issue that this form of corridor reflections addresses is that of debriefing. Doctors are ‘‘too busy’’ to afford themselves time to debrief and on some level we have an unhealthy culture that implies that only the weak debrief. The value of the corridor reflections was that they allowed us to debrief informally after every patient; it was an expected part
Hammondcare Greenwich Hospital, Greenwich, Sydney, New South Wales, Australia.
618
Journal of Palliative Medicine 2014.17:618-619. Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/03/15. For personal use only.
PERSONAL REFLECTION
of the day, acknowledging the patients’ grief and then reflecting on our own response. This rolling debrief sewn into the ward round facilitated integration of debriefing into the daily routine and helped to prevent compassion fatigue, which is a very real and concerning issue for palliative care clinicians. Practicing corridor reflections is no more time consuming or emotion consuming than standard ward rounds. It allowed us to cut to the core of the patient, their story, and their suffering and in doing so greatly enriched their care. It is a way of conducting a ward round with the emphasis on genuine reflection in and on patient situations, supportively debriefing with all on the team, replenishing compassion stocks, and role modeling that the patients’ humanity must not be erased from the equation. This is a practice that we will both take from this term. Medicine needs role models. Junior
619
doctors need more than service provision and jumping through the hoops of their term requirements; they need to be inspired to stop hiding behind their text books and actually look the patient in the eye, face the patients’ suffering with them, and reflect on how they can walk with their patient on their journey to the end. Address correspondence to: Bridget Johnson, BMed FRACP, FAChPM Greenwich Hospital 97-115 River Road Greenwich, New South Wales 2065 Australia E-mail: [email protected]
JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 5, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2013.0334
Reflections in the Corridor: Training Doctors To Care at the End of Life Bridget Johnson, BMed FRACP, FAChPM, Debra Scott, Bsci, MBBS, and Roderick Macleod, MB, FRCGP, FAChPM, PhD
W
e have both had the very great privilege of many good teachers throughout our years as junior doctors, but every now and again a great teacher comes along who makes you stop and truly reflect on your patients, your practice, and yourself. The medical system in Australia commands that you conform in the name of efficiency and after 9 years comprising 10 terms as a junior doctor, 12 terms as a registrar, and 6 terms as an advanced trainee, it has been remarkable to encounter a practice as simple, yet so formative and inspirational as corridor reflections. In a term in a suburban hospice in Sydney, a consultant showed us both as advanced trainee and senior resident the art that is medicine by implementing corridor reflections. This practice allowed us to reflect on our patients, their story, their suffering, our reaction, and how the patients and their stories were in fact shaping us as doctors. The process was not rocket science and yet it inspired both of us to be better doctors and to go forth and try to emulate this method with our juniors. On ward rounds we would stop after seeing each patient and reflect on their story, what seemed to matter most to them as humans, and what was driving their suffering. The professor had a gift for asking open questions with precision that cut to the heart of the patient’s worries and heartache and we would reflect on that as a team—consultant, registrar, resident, and nurses—before moving on to the next patient. The professor would stop to question us not about doses of medications, not minutiae of pathophysiology, but in broad brush strokes, where was this story going? And how were we going to travel this journey with our patient? The process also provided a chance to debrief after each patient, giving their story the time and respect it required to digest, and to role model a clinician who clearly wanted us to marry the science of our medicine with the humanity of the whole person in front of us. Working through this process and being mentored and guided impressed upon us the nature of role modeling and mentorship in medicine and training programs. After years of university, years studying for physician exams, and years in an advanced training program, one could be forgiven for thinking that medicine is a game that one must learn how to win as opposed to a profession handed down for centuries. There is something so grounded about rethinking about medicine as an apprenticeship model, which helps to take the
wind out of those physicianly sails and one’s ego. Again, appreciating that medicine is ultimately a profession that gets handed down from one generation to the next, in and out of weeks and over years, and emphasizing that if you want to be a good doctor you need to learn over years and decades like a craftsman. The current curriculum for both physicians’ training and palliative care advanced training is fixated on box ticking such that the outcome of producing a caring, compassionate, passionate, empathetic, holistic clinician can at times get left at the door. What worked in our corridor reflections was that it wasn’t enough to be able to manage a patient’s symptoms well, nor should it be. We have a very human subspecialty—it’s dirty and gritty and sad, but that is a reflection of life itself. As physicians, our default position is to be ‘button and drug pushers;’ it makes us feel better to change drugs and say that the patient feels better (and therefore we feel better) because we did something. Often our capacity to ‘‘do something’’ appeases our feeling of impotence, rather than addressing the elephant in the room, which is that none of us knows how to fix the human suffering that is in every room we enter. These reflections made us think deeply about the patient’s suffering, acknowledge their suffering, be a witness to their suffering, rather than turning away from it and fiddling with the opiate doses. As all team members were involved, it promoted a unified front in trying to sensitively and with integrity help, heal, and respond to the patient’s need and tend to their whole person care. It takes a role model and mentor to place a value on the psychospiritual and to have it translate for trainees. It is more than using the term ‘biopsychospiritual model’ which rolls off the tongue for a lot of clinicians: the reflections in the corridor and in multidisciplinary meetings made us explore the real meaning of that for each patient. Ultimately, palliative care is a journey through uncharted waters at times with no reports back to us to know how we did; this means that peer-led reflection is essential in our day-to-day practice. The other issue that this form of corridor reflections addresses is that of debriefing. Doctors are ‘‘too busy’’ to afford themselves time to debrief and on some level we have an unhealthy culture that implies that only the weak debrief. The value of the corridor reflections was that they allowed us to debrief informally after every patient; it was an expected part
Hammondcare Greenwich Hospital, Greenwich, Sydney, New South Wales, Australia.
618
Journal of Palliative Medicine 2014.17:618-619. Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/03/15. For personal use only.
PERSONAL REFLECTION
of the day, acknowledging the patients’ grief and then reflecting on our own response. This rolling debrief sewn into the ward round facilitated integration of debriefing into the daily routine and helped to prevent compassion fatigue, which is a very real and concerning issue for palliative care clinicians. Practicing corridor reflections is no more time consuming or emotion consuming than standard ward rounds. It allowed us to cut to the core of the patient, their story, and their suffering and in doing so greatly enriched their care. It is a way of conducting a ward round with the emphasis on genuine reflection in and on patient situations, supportively debriefing with all on the team, replenishing compassion stocks, and role modeling that the patients’ humanity must not be erased from the equation. This is a practice that we will both take from this term. Medicine needs role models. Junior
619
doctors need more than service provision and jumping through the hoops of their term requirements; they need to be inspired to stop hiding behind their text books and actually look the patient in the eye, face the patients’ suffering with them, and reflect on how they can walk with their patient on their journey to the end. Address correspondence to: Bridget Johnson, BMed FRACP, FAChPM Greenwich Hospital 97-115 River Road Greenwich, New South Wales 2065 Australia E-mail: [email protected]
