Theory and Practice

At 11am I was close to having an argument with a patient's granddaughter. At that point my registrar deflected the conversation, and I realised just how far I have to go in my communication skills.

Since I started university, for some reason I have considered myself to be an excellent face-to-face communicator. I knew I wasn't as good at writing, or at confrontation, but when it came to day-to-day interactions, it seemed to go more smoothly for me than for others. Now, I'm no charmer. I will never say anything just because it's what someone wants to hear. But by that token, people get to know that when I say something, I mean it. When I was young, I read a book about conflict resolution and active listening*, and so I try really hard to listen and understand people in return. And combined with the fact that I have a nice smile and (I thought) a good attentive manner, and my eagerness to say things in a way people will understand ...

... well, it seems to work. People like me. People smile at me when I smile at them. I have gone up to people and made bald-faced unusual requests, and had them granted out of the goodness of their hearts (in a good cause). And patients and their families love me.

Actually one of the positive thinking slogans I made for myself when I was down, was related to this: "The world smiles at me when I get things done and go out!" I really do have all the luck sometimes. I used that as my screensaver, so that when I got paralysed in front of a computer I might think about moving.

Being a doctor ... well, I certainly had a lot of skills to learn when I started - case presentation, handover, ward rounding, informed consent, explaining things to patients and their families. But it's been two years now, and these days I feel pretty confident, especially with the last one: explanations. I really put some thought into finding a simple way to explain what's happening and why we need to do certain things. But maybe I'm over-confident. It's come to the point where I do interrupt my registrar and at times even my consultant, in order to clarify things for the listener. Maybe I'm backing them up, or maybe I'm getting in the way and being inappropriate. I don't know how to tell.

Anyway, today ... we got a call to say the patient's granddaughter was upset and wanted to speak to us. Now, we hadn't met her before, but we were already having problems dealing with the patient's medical issues - mainly pain and agitation - and her son's distress. So on the way in we caught up with the nurse, who said the granddaughter's main concern was that the family hadn't been informed when the patient was moved into a windowless single room overnight. (Ahh, treatment rooms. Another story for another time.) And that the reason for this was that the patient had been agitated overnight, but now she was quite settled in the new room.

Now, we hadn't been informed either. Actually, we'd come in that morning and gone "where's the patient?" "Oh, she's on [a ward on another floor]". So I was all set up to go in and sympathise - after all, we would have preferred her not to be removed from her familiar environment either. But boy, did that conversation take a turn in the opposite direction.

She started by expressing her severe disappointment with the system, and her wish to speak to someone senior. Fair enough. We talked about the bed move, and the fact that yesterday she had specifically asked that the family be informed about any changes in treatment. Obviously that message and its scope (including 2am phone calls about bed moves) hadn't got through to us. Anyway, she thought her grandmother would have been further agitated by the move, and the language barrier wouldn't have helped, as her grandmother now didn't know where she was. I tried to explain that people had tried to speak to her in two of her native languages last night with no success - because she had been confused. She didn't agree.

But then she took a completely unexpected direction. She was concerned that her grandmother was drowsy, and expressed her opinion that she was on too much medication. At this point, I'm not sure, but I think I did no more than frown, I don't think I said anything. The response: "Don't question me." (I was standing facing her with my registrar between us half-facing her, so he couldn't see my face.) So I said nothing further, and she continued along her line - her grandmother was drowsy and not herself. Obviously this was true even if I didn't agree with her over the cause, and my facial expression at that point was (or should have been) of "concern". Suddenly her tone changed, and she looked like she was going to get angry with me. My registrar sensed it too, and quickly changed the subject slightly.

(As I later did manage to explain to her, we had cut her medications by two-thirds the day before, and she had had hardly any that night.)

Later in the conversation there was another flashpoint, where she had questioned the prescription of a medication a couple of nights before - the nurse had needed to tell the doctor a medication he was about to write had already been given. I tried to point out that the doctor was on the evening shift and wouldn't have known the full situation. She didn't respond well to that - she told me not to defend something that was wrong. (Later we pointed out that he had already asked for advice from a senior doctor before making that decision.) Anyway, I guess I scored myself another aggravation point with that one.

My registrar is a very experienced doctor, who worked in Palliative Care last term, and it's to his credit that he was able to defuse the whole situation. He acted swiftly to protect me from becoming a focus for her anger. Later, he explained that he could see her misinterpreting what I was saying, and he was afraid that she and I would get into a proper argument. Overall, his competence with the situation made me feel I should just keep my mouth shut and learn from the way he dealt with it. He did give me a few tips afterwards - on what parts of a conversation I should actively let go, and how to emphasize just the necessary facts.

It's funny, I always thought I was good with families. Now I realise that there are two categories I've learned to deal with. Anxious and worried people, I'm good at - I can give them enough information, and reassure them that I believe in what I'm doing. People who are just upset for no good reason and don't listen - I learned long ago that they're a lost cause. But there's at least one type that I don't respond to adequately - the angry argumentative person who listens to what I'm saying in the wrong way, and throws it back in my face. I get defensive, just like I tried to defend the intern from the other night. Those sorts of things, I need to learn to actively listen to, acknowledge, and then let go, and wait for the right time to provide correct information. And despite my reading, I've never practiced active listening and it's not in my skillset. More practice needed.

And there are probably myriad other situations I haven't yet come across or learned to deal with ...

Oh, and we did manage to explain everything to her in the end, and she agreed with the plan, and we encouraged her to take some of her concerns to a higher level. Later that afternoon, though, we were told she was planning legal action against the hospital.

*bibliography: I'm almost sure the book I read was We Can Work It Out, but it's way too recently printed... I've been trying to find which book I actually read. Any suggestions?

I've been busy...

getting my life organised. It's taken some effort, but I'm really getting there :) Unfortunately, writing this blog seems to have fallen by the wayside. Probably because I keep procrastinating about what I wanted to write about.

Ahh well. Time to write about something else instead!

This evening I went for a walk around the neighbourhood, and came across a little Japanese supermarket. I wished I'd brought my purse with me (I'd deliberately decided not to) because they sell little tubs of green tea and sesame ice cream! I love Japanese ice-cream flavours.

They're an interesting east-west fusion - while green tea, black sesame, red bean, taro (a kind of purple very starchy turnip), lotus seed and lychee are traditional Asian flavours, dairy is not. Soy milk mixes are a tiny bit more common, but usually you see these flavours on their own - red bean paste or lotus seed paste in buns, red bean sweet soup, black sesame soup dumplings, taro cakes (often more taro, less cake, and no egg), lotus seed cake (ditto), lychee and green tea ice drinks, green tea jelly. But the Japanese have made them into traditional milk-and-egg-base icecreams, and they work really well. Black sesame is the hardest on western palates, but green tea and red bean work really well, and I assume taro would too.

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Oh, and in an odd turn of events, I found out that the thing I was so angry about the other week ... I'd attributed to the wrong person. She had nothing to do with it. In fact, it was a guy, who doesn't know me that well at all. I know for a fact he resents me for something I refused once long ago, and I don't particularly care. So I don' t need to pay any attention! So much for the positive effects of anger. Someone mentioned that it gives you tunnel vision ... here, it seems it did.

Well, actually, maybe there have been positive effects after all. I have done a lot of stuff directly sparked by the thoughts I had that night, and none of them have been negative. I certainly haven't done anything to hurt anyone, or anything that I regret. I didn't go speak to her, or him. I have, on the other hand, started some projects which I'm sure, later on, I'll be really proud of. All because I was forced to get creative.

Okay, enough for now! Time to go have dinner.

Very late last night, I read something that made me very angry.

Anger is an emotion I'm very unfamiliar with, actually. It doesn't come easily and I tend to repress it, or rationalise around it. I have a very high tolerance for misunderstanding; I have a very high tolerance for 'lack of progress' when things aren't urgent; I have a reasonably high tolerance for most aspects of standard human behaviour. So a lot of things that get people irritable or angry don't affect me.

I used to get angry, of course, when I was a young child; I remember several decent rolling-around-on-the-floor temper tantrums, none of which had any good cause. They probably lasted until I was about nine; by then I was starting to realise what I was losing, and to take more care of my dignity. Then, too, anger started turning to sadness and retreat - and eventually I started skipping even that step in favour of analysing the situation and, well, doing something about it. Or learning from it.

Part of it, I guess, is that I have a reasonable self-esteem in a lot of areas, these days. So it takes quite a lot to threaten me. It's not often that I encounter any cause for fear, real or imagined; I have a good life. You can't hurt me by saying I'm ugly, or fat, or stupid, or selfish, or a whiner, or silly, or nerdy, or any manner of other things, because I know what I am. (To wit: I look like your average Chinese, I have a poor appetite, people call me unusually intelligent, I do things predominantly for others, and I complain very little. And I'm silly and nerdy and geeky and indecisive and overly serious. So what?) I'm comfortable in my own skin. I'm even popular in certain circles, and loved by others.

I do place a high value on understanding. But I also appreciate that it's sometimes not easily obtained. If someone has misunderstood something, I know that that doesn't necessarily mean they think ill of me; such things can be resolved. Who knows, I might be mistaken, or I might not have made myself clear. I give people the benefit of the doubt in these situations too; I tend to assume they have good intentions, that they don't set out to malign me, and that nobody has perfect delivery. Some times understanding takes more effort than others.

I'm also used to having patience with and tolerance for people. If the lady at the bank has to sort out paperwork the previous customer left, before she can call me up, so be it. The person who stepped on the back of my shoe didn't actually do it deliberately. The patient who makes unreasonable demands is sick and needs comfort. The people in the queue in front of me have their own agendas and stresses. I don't need to get worked up about it.

When I see people's anger in these situations, I've always seen it as getting in the way of resolution - people alienate each other, make each other nervous, and stop communicating. I'm a communication junkie; I love to know that somebody understood what I meant, or how I feel, and to think that I can empathise with them in some way, and see what they are trying to tell me. Anger, as I see it, is often a barrier. And quite often a waste of time.

Which is not to say that I ignore injustice. I don't know, I must lead a charmed life, injustice seldom happens to me, or at least not in any serious way. And I don't have the sense of self-entitlement that leads some people to imagine injustice, whenever they don't get everything they want. When it does happen to others, I do what I can. I try to help those who need it. There are always options, ways around a situation, ways to cope and things to work on. I'm not motivated by revenge, but fairness appeals to me. And I have an exceedingly strong - overriding, even - sense of doing what is fair. Or trying to.


But anyway, last night, I was angry. Very much so. I even considered getting her back, showing her up by making it clear what I really was.

Of course, that idea quickly dissolved. What angered me was that realistically, there was no way to make things right and still be true to who I am and lead my life. There were options - there always are - I had considered and rejected them many times before- but they involve a lot more time and effort than I have available, or ever will. I am going to have a full-time job to go back to, after all.

So I did the first obvious thing: I vented to a friend. I didn't even have to tell her much, just point out what had happened and let her see the obvious injustice. She sympathised - that was all I needed - and I felt better immediately. After a rambling discussion on health, what she was cooking for dinner and what I had in the fridge, I thought I was ready for bed. It was 4am my time.

What I didn't fully appreciate was the energy that comes with anger. My mind was abuzz for the next two hours. I'm not one to think negatively of people, or to go over perceived misdeeds round and round again; I had already accepted that the injustice was there, and permanent; my previous efforts had come to nought. Where I was mistaken was in thinking that acceptance was the same as resolution. Instead, my mind got creative, and started presenting me with an infinite number of avenues. I could do this and this, and limit the damage... I could help others learn from my situation... I could be true to myself and what I really wanted to do by starting this or that project, and everyone would see. And maybe, yes, there was an easier way of showing her up; it wouldn't even have to be permanent ... no, here were some even better things to do with my time ... on and on.

I know now why they say never to go to bed on a dispute. Bedtime is the worst time to be angry, because you know you need sleep, and yet you can't. And you know that no matter what you think of, it will be best done in the morning; you'll be out of whack if you don't sleep; and yet you can't. The energy is there, whichever way you channel it, constructive or destructive ... it quickens your breathing and your pulse, raises your blood pressure, whooshes through your mind and your limbs. And you need your sleep! Darn it.

It got to six o'clock, normal time for our morning walk, although I knew Smith wouldn't be walking because he'd been up late trying to make something work. I got out of bed for a drink of water, and seriously considered doing the walk anyway, in the rain, by myself, just so I could sleep. I'd already tried progressive relaxation (and found my jaw was tense), and attempts at meditation, trying to block everything out with my mantra, but of course I was too tired for that to really work. Concentration was not available.

And then I dismissed the idea of the walk (I probably would have collapsed) and went back to bed, and Smith turned over and put his arms right around me ... held my head to his chest while he slept... and I was safe.

Only then could I let go, tell my creative mind to take a rest; only then could I slowly, visualising each colour in turn, bring my thoughts back to a normal level (I dunno, it works); and then, focused, take myself back to the reality of warm, soft bed, half-light, bird call outside ... cradled by my husband, I relaxed. Even then it took a while ... but I eventually slept.

And of course the options were all there in the morning, and some of them were more realistic than others. Morning is the best time to be creative, because you have the whole day ahead of you to do what you think best!

*sigh*

I haven't been that angry in a long, long while.