• Paul Kalanithi - When Breath Becomes Air: With my renewed focus, informed consent - the ritual by which a patient signs a piece of paper, authorizing surgery - became not a juridical exercise in naming all the risks as quickly as possible, like the voiceover in an ad for a new pharmacist, but an opportunity to forge a covenant with a suffering compatriot. Here we are together, and here are the ways through - I promise to guide you as best as I can, to the other side.
• ^ - Openness to human relationality does not mean revealing grand truths from the apse; it means meeting patients where they are, in the narthex or nave, and bringing them as far as you can.
• Lucy Kalanithi: trying to grapple with existential distress with medical knowledge and statistics is like trying to quench a thirst with salty water. you just can't. thinking about the human condition through these other fields - whether it's humanities, literature, philosophy, or certainly you'll all come across bioethics - when youre thinking baout whether to draw life support - youll see that all really quickly: those other disciplines' ability to characterize the human condition and help us understand and cope with what we're doing.

- you can increase your patient satisfaction by 20 points just by asking "so how is this affecting your day to day?"

• Why I chose family medicine

My decision to do family medicine evolved during med school, when a family member became ill. I had time away from studying medicine to contemplate what was important to me, as I suddenly found myself on the receiving end of health care. During that period my time was divided between doctors’ appointments and work at a non-governmental cancer control agency. I came to see the immense value and influence of the family physician not only from a public health standpoint, but also to individual patients and families. Family medicine fit best with my values. The approach is to make recommendations that respect the patient’s own goals and lifestyle. Following patients over time creates a special relationship that makes a physician feel protective of his or her patients and makes it very satisfying to see improvements in their health.

I think being open-minded is important in family medicine. We see patients of all walks of life with varied life philosophies. It is important to recognize that while you as a physician have ideas of what may be best for your patients, family physicians must think of medicine as a means to help patients live their lives in the way that they choose. We educate, encourage healthy choices, and ultimately work with patients to help them achieve their own health goals.

• How does your experience of being a medical student compare to practising as a doctor? And do you think having been a medical student and being a doctor has changed you in any way? (https://tmblr.co/ZS5Lhn2Q7UDYK)

Med school is intense, but it’s very theoretical. It feels like a superpowered version of school. You still have homework, you have lectures, and you have lots of exams. It’s scary, and you’ll spend the entire 4-6 years constantly worrying you’ll fail your exams or get kicked out. When you’re a clinical med student, you are there in the background. People aren’t always sure where you are meant to be, or what you are meant to be doing, and you have to work to make opportunities happen, or learn as much as you can. You get put on the spot a lot, because people want to make sure you are learning. You might see patients (if your seniors think it is appropriate), but you don’t have any *real* responsibilty. It’s very protected in that way.

And then you graduate, and people ask you to make decisions that actually impact people’s lives; that’s a huge responsibility for any new graduate! It’s scary, and you feel out of your depth, because no matter how much theory you learned in med school, it’s nothing like knowing what to do in practise. Fortunately, you have seniors to supervise you and to ask for help. But the higher up you go, the more you become the senior who others ask for help, whilst still being far from all-knowing, yourself! And medicine is vast, and things are difficult, so you can work for a long time and still have so many things you don’t yet know. The most important thing remains that you should always seek help if you need it.

I still feel like the same science-obsessed arty teenager that I was at school. But I think it’s also changed me a lot, in many ways. University makes you more organised and responsible with your studies; you become used to planning your life, juggling lots of responsibilities, and doing things that have to be done, regardless of whether you like to do them or not. Which, if we are brutally honest, is kind of what adulthood is about. Things that just feel really awkward and unpleasant (like calling up an important senior, who is a stranger, to argue for something I know they will give me a hard time about, but I have to advocate for my patient, so I have to do it) become easier and less scary.

I think the fact that we are exposed to life-and-death situations and people’s personal lives also makes you mature quickly. By being exposed to so much illness, suffering and death, you learn a lot of lessons about life and people. Where most of your peers might be spending their early 20s getting drunk or out on the pull, you try to balance having a social life with holding the hands of dying pensioners or comforting people whilst they cry about their life. You still get time to ‘be a young person’, but at the same time you have to balance it with trying to shoulder heavy responsibilities.

Even if you’re introverted, you slowly learn to cope with a world that values extroversion. You talk to so many people in your professional life, and though it’s really intimidating when you start, it gets a lot easier with time. You learn to work with a lot of other students, nurses and doctors, until it becomes second nature to walk into a room full of important people and announce ‘Hi, i’m X and I’m the on-call doctor’, and people actually care that you walked in! It’s so strange. Teenaged me would never have had the guts.

You meet a lot of patients, who absolutely need you to present the image of a doctor. You learn to present yourself as a confident and competent clinician, even though inside you’re still a nervous person working out what you are doing. You learn to fight your corner when it comes to requests and referrals, and know when you have to stand your ground. You slowly learn to look and act like a professional adult, developing a manner and body language that both engenders respect, but also puts people at ease. It’s funny to think of it, but none of us were like this back when we were teenagers, and even when you are out of university it doesn’t exactly come naturally to you.

I know a lot more, obviously, and that’s not a knowledge you can switch off; medicine becomes like a sort of lens through which you view life itself. Evaluating evidence, and thinking critically are also things that you don’t just use in your day job, but something that become part of your life. I do think medicine changes your outlook on life, though perhaps each of us take away slightly different lessons. It might teach you how short life is, and how insignificant most drama is. Perhaps it teaches you that hell is other people, and that we can all help to reduce human suffering. It might teach you to be efficient, hardworking and focused.

Nowadays I’m not fazed by seeing a deceased person, and I can handle really quite scary medical situations without feeling traumatised by it all. I deal with hostility or abuse from the public, and though it’s still draining, it’s less scary than I thought it would be. When you realise most people are really scared and upset and acting out, it makes you see interactions differently. I’d go as far as to say it makes you see a lot of things differently; it really helped me put a lot of people and things into context. And the more you work with people, the better you become at reading them, and knowing just how to act and what to say to make them feel better. And actually, being introverted and insightful can be great when it comes to observing people and learing to understand them.

People think a good bedside manner is innate, but it’s really not! I was a shy, introverted teenager with a nerdish streak, the kind who might not speak up at all during some lessons because the ‘loud students’ were answering all the questions, only to eventually pipe up with something insightful. My teachers (bless them, where would I be without their patience?) would always give me feedback to speak up more in class. “She has lots to say, if only she would speak up”. Every year, in every school report. So I’m not a natural born leader, nor an extrovert, and yet I love the communication aspect of medicine and have always tended towards specialities where you could make people feel, as well as be, better.

Perhaps it’s hard to truly tell how med school and medicine changed me, or any of us, because we all change with time anyway. It’s not really impossible to truly remain as we are. We experience lots of interesting things that make us grow as people, and we mature as we reflect on the things we’ve learned throughout out lives.

------- We learn the skills to be a good doctor. None of us start off with the full set. But over the years, we work hard to become more confident, or better at leading. We learn to work in a team. We learn to understand people, relate to them, and persuade them. We learn our limits, and we learn how to work on our weaknesses. And medicine is a job where you’re expected to think about how you can improve, and you’re expected to work on it. And every year is a step upwards in terms of what people expect. [...] It means that you don’t really get a chance to take a breather, but it also means you don’t stagnate. [...] It’s not a passive process that just comes with time, though experience is very useful. And I think that bleeds into how I see life in general; I feel that we can always work on becoming better, at anything and everything. It’s never too late to try.

• Ways I make a difference that has nothing to do with medical knowledge

- When I go over every medication the patient takes and find out they’re taking something wrong or that we have something wrong in the computer

- When patients thank me just because I took the time to listen

- When I let a patient yell at me and then I validate that it’s okay they feel that way and they immediately soften

- When I explain what is going on to the patient and/or patient’s family

- When we make a new plan or find out something new and I go back to update the patient

- When I make jokes and laugh with a patient

- When I spend too much time with patients and it “ruins” my schedule/ my cred with an attending but I feel like I have a rapport

- When I talk to someone who is refusing discharge and emphasize that we’re not abandoning them or kicking them out and they decided to accept going to rehab/home/etc

- When I take the time to use a translator line for a patient even if they speak some English and we understand each other better

- When I am a kind voice in the night telling someone their loved one has passed

- Etc.

(there are a million things we do that have nothing to do with medical knowledge…and I’m not saying this to make excuses! Keep striving to be the best you can be to offer your patients the most accurate and up-to-date knowledge (I will too!).

• Doing Right: In the new era of scientific medicine, the humanities—among them ethics, great art, and literature—provide crucial balance to a humane universal education7. Becoming a better medical practitioner may be achieved not only by learning the biochemistry of the Krebs cycle or how to recognize geriatric depression but also by reading books such as Miriam Toews’ All My Puny Sorrows 8 or Tolstoy’s Anna Karenina 9 or watching a classic film such as Kurosawa’s Red Beard 10. Exposure to the hu-manities not only enriches the lives of practitioners, making them better, more compassionate, citizens of the world, but also increases the likelihood they will understand and empathize with the worlds of patients and their families 11.