AMA Journal of Ethics. May 2015, Volume 17, Number 5: 465-468.
An Intergenerational Conversation about Frustrations, Lessons, and Hope in Physician Activism
The primary care physician and activist Dr. Gordon Schiff advises those advocating for systemic change to set priorities, work with others, and realize the power of small actions.
Shira Heisler, MD, and Gordon D. Schiff, MD
SH: There is a common narrative among interns and residents. We work crazy hours. We often feel like we’re in over our heads and don’t know what we’re doing. And yet, somehow, we are expected to be taking good care of very sick patients, among the sickest in our cities. While being a first-year intern is well understood to be overwhelming, one of the most significant challenges is rarely discussed and confronted: that our patients, especially in distressed environments, have urgent nonmedical problems that stem from systemic injustices.
Patching patients up in order to “discharge them” (the omnipresent priority of a resident), sending them out to the same environments and situations that led to their admission, often seems even crazier than the hours we are working. Sometimes, no matter how diagnostically astute or compassionate we try to be, it seems that inadequate housing, poverty, substance misuse, and other socioeconomic forces continue to overwhelm our best efforts. For instance, how can we discharge an uninsured patient with end-stage liver disease secondary to hepatitis C into homelessness when he has ascites so severe that he will need repeated therapeutic paracentesis with sterile dressing changes on a regular basis? How do we manage the care of a transgender woman with AIDS who is in and out of the hospital with opportunistic infections requiring a long course of IV antivirals? We can’t keep her in the hospital for the six-week duration of treatment because she is not “acutely” ill enough to meet the criteria for admission. And the one rehabilitation facility that accepts patients with a history of recent drug use makes her feel so alienated and stigmatized about her gender identity that homelessness becomes her most reasonable option.
So, after long hours on the floors, writing endless notes, and talking to social workers until 9 p.m. about discharge planning, I’m left with perpetual questions. How can I help my patients while simultaneously working to create a more equal, just, and truly caring world?
After months of feeling this sense of hopelessness and helplessness, I was fortunate to reach out to Gordon Schiff. He has been a primary care physician and an activist for nearly 40 years, somehow maintaining both his idealism and love for medicine. I was inspired by an essay he had recently published in JAMA about crossing boundaries to care more fully for patients , and I was able to connect with him by phone. During the next hour, Dr. Schiff walked me through some ideas and strategies for surviving my internship year and the years to follow and for most effectively helping my patients.
GS: After first setting some overall priorities for managing feelings of hopelessness as physicians, we can then look at specific approaches to helping patients and ourselves. I would offer the following ideas.
SH: As our conversation progressed, I more deeply understood why we call pushing for transformative change a struggle. It’s because there are no simple or perfect solutions, and the process can be painful. The growing pains I am feeling are a result of the steep learning curve of a resident paired with the complicated reality of working in a place often full of hopelessness and pain. But as with all growing pains, this is where change and transformation take place.
Furthermore, answers to our questions are always raising new questions, and even after nearly four decades of work as a physician, Dr. Schiff is still struggling with these same concerns, dilemmas, and problems that I am. So how do we do it without getting burnt out and forgetting why we chose this profession in the first place? And how can we make the systems we work in more humane and just? Dr. Schiff’s answer is that, first and foremost, we must never lose sight of the power of our smallest actions, because you don’t know which of the seeds you are planting will bear fruit. I think my answer today won’t necessarily be my answer tomorrow. But, today, it is remembering that this a process.
My patients—who tell me painful stories about living on the streets in freezing temperatures, who describe what it is to go through detox countless times, who talk about the ongoing trauma of living in prison for over 20 years—are the people who can teach us what resilience and strength look like. It is this strength and tenacity that reminds me, and all of us, of the power and perseverance of human beings. If we see what one individual can overcome, oftentimes with little or no support structure, imagine what a community of physicians, social workers, nurses, and particularly patients who share similar values and goals can do together. Imagine a world where we can help each other process the painful stories we hear and begin to think of new, creative ways of healing.
Shira Heisler, MD, is an internal medicine and pediatrics resident at the Detroit Medical Center and Wayne State University in Detroit.
Gordon D. Schiff, MD, is a primary care physician who works as a safety and quality improvement researcher at Harvard Medical School’s Center for Primary Care and Brigham and Women’s Center for Patient Safety Research and Practice in Boston. He is a longtime activist and former advocate at Chicago’s John H. Stroger, Jr. Hospital of Cook County.
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