S4E7: Changing Perceptions

Harjit: Cold open, like cold brew coffee. No, just kidding. You guys, guess what?

Margaux: Chicken butt.

Harjit: No, Margaux.

Leen: Someone's in pediatrics.

Margaux: True.

Harjit: My guess what is now I am a regular coffee drinker. I have coffee every day.

Leen: I have cut down on caffeine completely, like I barely drink caffeine.

Harjit: Who are you?

Leen: I don't know. Yeah. I don't drink caffeine at all. And so now, when I even have a little bit, I get so wired. It's crazy.

Harjit: How we've changed, how our lives have changed.

Leen: I know. So speaking of changing perceptions, I think that leads really well into our topic of choice today. We came into medical school . . . I think we came in with perceptions that were quickly or maybe not quickly shattered or changed as we have now become the actual medical provider for a lot of our patients. And, again, I think we all have different experiences in the sense we're all doing very different things.

I think the biggest thing for me in terms of shattering perspectives was I moved out to New Jersey and I'm doing residency in Newark, New Jersey, and it's a completely . . . well, I guess it won't be 360 . . . 180 from being a med student in Salt Lake City, Utah. I'm working, you know, low-income, inner city, right outside metropolitan New York area, where everything is different, right? Everyone out there doesn't know anything about Utah besides Zion Park. All I know about the East Coast is New York City. And I think working with the different population and having to take what information I learned from Utah and now applying it to a whole different population, definitely, my perception has dramatically changed in many things.

Harjit: I think for me, like I did not move across the country, right? And I've been able to stay in Utah. But I will agree, Leen, that I think that the way that we saw the world when we were med students is much different than the way we see the world now. And that shift in perspective over the past couple of months has really made me think about how when our role's shift we also start seeing the world different, and I definitely have noticed that as well.

Margaux: Yeah, I agree with both of you. Like you said, Harjit, I think that we are sheltered from certain things, behind-the-scene things as med students, but rightfully so, as a med student, it felt stressful enough what we were given and what we were doing. And then, it's like you advance to the next stage and see a whole new level of responsibility and actions and behind-the-scenes things that go on. And so that was also a big adjustment or changing of perspective. I think I've seen a lot of things in terms of dealing with patients or thinking about how I process clinical information, or even working with med students that has changed as a resident compared to when I was a med student. It gives me a new perspective into the system that we're working about, the good, the bad, and the ugly about it too.

Harjit: Yeah. And Margaux, I want to kind of go off on that. I just feel like things just seem more real now as I keep on progressing both in my life. And I don't know if that comes with experience and wisdom or whatever, but things just seem more real and we just see the reality of things much clearer because we're trying to get rid of those shades. And I think, at least the four of us, we're very . . . one thing that I think tied us all together is that we think of things really deeply and critically. As I get older, I feel like I see the world in a more real way.

Leen: Yeah. I didn't realize how much patient populations would be so different, I think, in terms of medical management and just approaching them when you're in a medical setting from any setting. And so I think our population over in Newark, I would say sometimes it's a very difficult population in terms of medical trust. We live in a predominantly black and African-American area. That's what we serve. There's a huge medical distrust in that community, especially, and I don't blame them. Obviously, there's a history there that is just absolutely awful when it comes to treatments of these populations. And I've had lots of patients who will refuse treatments that I absolutely am like, "Oh, no, you absolutely need this."

For instance, there was a patient who was on a dobutamine drip. That's the only way their heart is going to keep working and they had to be on this drip. And as much as I tried to convince them, they're like, "No, I got to leave. I got to leave. I got to leave." And I think that's something I didn't necessarily experience in Utah, I would say.

I mean, there's difficult patients everywhere. But I think in Utah, there's not historical mistrust that's now become generational in the medical field as there is in these populations that I'm working with. I'll have patients come up to me and say, "You know, I don't want the white doctor. I don't want them to treat me." I'll have patients who just absolutely don't have medical knowledge in any aspect, and when something dangerous is happening, they'll be, like, "Nope. I want to leave."

At first, going into residency or even as a med student, I'm like, "Oh, all you have to do is, you know, you just talk to them and you got to figure out where they're . . ." or the interview question, like, "How do you deal with a difficult patient?" And, like, "Well, I want to see where their perception is coming from and I want to talk about that." That makes sense and that's great if you have the environment to do that. But sometimes I've realized with various . . . and it depends. I've noticed, especially with patients under the influence or some underlying psychological issue, you cannot convince them, to be honest, in my opinion. I think at least in my work, you have to realize there are some other factor playing in here to why they're not responding to you the way you think they would need to respond to a medical emergency.

And so I think learning to deal with patients under the influence and learning to deal with patients in acute psychiatric cases, I think that's something that I didn't really expect as a med student going into residency that would be more difficult than just the interview answer of try to find out what's going on in their background and try to connect with them. Some patients you can't connect with and you have to manage them that way, and you have to be able to give them the best treatment realizing that they're going to probably refuse everything. And I think there just comes a point where sometimes people just don't want treatment and you can't give treatment to someone who doesn't want treatment, and that's something you got to be okay with, I think.

Margaux: I think also it's a perception change and the responsibility change because as a medical student, I think we were often protected or not assigned to the "difficult" patients or families. But now, as a resident, you have no choice but to treat, like you said, every patient regardless of if you have rapport or even the time to ask those questions and try to build rapport and understanding.

In pediatrics, we often . . . I'll just give an example. In the ED, we had a parent who was angry about . . . they don't do appendectomies overnight. And so this parent didn't understand that even though they had been told multiple times, "We don't do appys overnight. Your child will get their appy first thing in the morning." The parent got so angry progressively. And granted they were probably tired, they had been up all night, they're sitting in an ED room which doesn't have a comfortable chair necessarily, so you have to take that perspective into mind.

But I was the one who was having to go in and every time they were belittling the nurse or whoever was walking by, you had to go in and talk to them, and a), balance, like, it's not okay to be rude to staff, but also I understand and try to mitigate that, and that's a responsibility that I don't think I had how much the weight of it bears on you as a med student, and it's difficult to navigate. And it sometimes gives you a better perspective of patients, like, "Oh, I don't want to deal with you," right, because I think that's our internal way of, like, "I don't know what to do and this is uncomfortable. So, therefore, I'm going to reject the situation."

Leen: Which then leads me to also say, on the other end, when you have a VIP patient, have you guys dealt with any VIP patients?

Harjit: Almost did. Whatever. I was going to be fancy. But tell us your story.

Leen: It was really funny because I was very frustrated in taking care of this patient because I was getting so much feedback from many doctors that also knew this patient, and they were telling me, "You should do this for the patient. You should do this for the patient." I'm just the intern and I'm like, "I don't know who to listen to. I only listen to my attending, right?" And I think that got really frustrating.

And it just so happen to be coincidentally that during our conference hour that day, we talked about treating the VIP patient. I thought it was really fascinating to show that research shows that VIP patients tend to get worse outcomes in terms of . . . when it comes to treatments because we tend to go overboard with their treatments. And I thought, okay, that's another scenario in dealing with a difficult patient that, one, my perspective was completely shattered on that aspect. I thought, no, VIP patients will get the best treatment and that might be fair or unfair. I don't know. But now, to hear that they might get worse outcomes because of not everything we do is truly benign, right? And I think that was something that as I was taking care of this patient, the fear of having so many doctors watching over me as I'm putting in orders for this patient just exacerbated that idea, right?

Margaux: Now, that's totally true, Leen, and I think it comes back to now that we have the responsibility as residents, as providers who can actually sign orders of critically checking our own biases and the lens that we're using to evaluate this patient, and what sort of evidence we're using to guide us, right? And I think we've just spent some time in this episode talking about dealing with difficult patients, but in our next episode, we'll touch on evidence-based medicine and how that has changed in our perspective now as residents from medical students.

Leen: That brings up a good point, Margaux, and we'll continue this conversation in part two of "Shattering our Perspectives." Thank you all for listening. Please continue to join us for our conversations at bundleofhers.com. Thanks, Bundlers.

Margaux: Here's a sneak peak of the next episode.

Harjit: I think the bigger thing that we need to get good at is should I use this for my patient? Will it be good for them or will it not be good for them? For my knowledge, I might need to know the exact number, right, because that's what I'm learning and I'm a student, and I should know 46%, 80%. But the bigger question is should I use this on my patient or not?

Leen: As a resident, now that I'm, like, "Oh, but did you guys even look at the patient? Did you look at the patient? I don't think this is going to work for them." Use your clinical basis to figure out the disease rather than saying, "Let's run a test for this patient. I might not do the best thing for them."

Margaux: I have appreciation for protocols, but there's also the other side where all protocols don't fit all patients and you still have to be critical of that. So I'm trying to navigate that balance of utilizing EBM more and being more cognizant about looking up data and statistics, but also recognizing when a particular study or metric might not be applicable to the patient in front of me.