Opinion
A PIECE OF MY MIND Matthew J. Press, MD, MSc Division of Health Policy and Economics, Department of Healthcare Policy and Research, and Department of Medicine, Weill Cornell Medical College, New York, New York. Timothy J. Judson, MPH Weill Cornell Medical College, New York, New York. Allan S. Detsky, MD, PhD Institute of Health Policy, Management and Evaluation and Department of Medicine, University of Toronto, Toronto, Ontario, Canada, and Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada.
Corresponding Author: Allan S. Detsky, MD, PhD ([email protected] .ca). Section Editor: Roxanne K. Young, Associate Senior Editor.
Filling Buckets Systems awareness and systems design are important for health professionals but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system. Avedis Donabedian1
The idea that love is the “secret of quality” in health care, which might be viewed skeptically were it not proposed by the revered health care quality pioneer Avedis Donabedian, conjures a lesson from a children’s book, entitled Fill A Bucket.2 The book discusses how everyone is born with an “invisible bucket,” which represents a person’s mental and emotional self. People’s buckets are filled by acts of kindness and love and are depleted by negativity and disrespect. Having a full bucket makes us feel happy and helps us fill other people’s buckets. An empty bucket brings a host of negative emotions, which can lead to behavior that empties other people’s buckets. Physicians have buckets too, and the literature often takes a scientific approach to measure how full or empty they are. For instance, a recent Rand report on physician job satisfaction detailed negative aspects of the working environment, such as excessive documentation requirements and clunky electronic medical records.3 Other work has described physician burnout, the resulting exit from the profession, and how having physicians who are engaged improves patient engagement.4 The bucket concept is a simpler, perhaps more meaningful, lens on the issue. In order to be at our best, for ourselves and for our patients, physicians must have full buckets. Or, in Donabedian’s terms, we must have love. This idea led each of us, at different stages in our careers, to reflect on what it is that we love about our careers in medicine. Here is what came from this exercise. A.S.D. (SENIOR FACULTY) A few years ago, while attending on the inpatient general internal medicine service, I admitted a man in his 60s whose chief complaint was peripheral edema and significant fatigue. He had been admitted briefly to two other hospitals in Toronto in the previous six weeks. Each time, he was treated with intravenous furosemide, and his edema subsided; but no diagnosis was made. On the morning after admission, I asked the senior resident, who was starting his vacation the next day, how he wanted to proceed. He answered, “He seems to have responded to furosemide once again and is stable, so let’s discharge him and have the ambulatory group practice sort out his diagnosis.” I replied, “This is his third admission for the same problem in six weeks. We are not going to do what the previous doctors did. We will try harder.”
On reviewing his records from the other hospitals, I made two discoveries: first, his symptoms had been recurrent for ten years, and second, a recent echocardiogram, performed by a cardiologist whose opinion I trusted, was normal. When I entered the room, I found a thin man with significant leg edema, and ear lobes that were rhythmically pulsating. His very anxious daughter was with him. The physical exam was remarkable for a very high jugular venous pressure, Kussmaul’s sign, cardiac knock, and pulsatile liver—all leading me to a diagnosis of constrictive pericarditis. I told both the patient and his daughter that I might know the cause of his problem, and more importantly, if I was right we could make him better. She started to cry. We asked the cardiologist on call to arrange a simultaneous right and left heart catheterization, which was performed the next day, confirming the diagnosis. He underwent pericardial stripping a few days thereafter. Six weeks later, he returned to our ambulatory group practice and reported that his symptoms of fatigue and edema were completely gone. He was able to return to work as a carpenter. He felt that after ten years of suffering, he was “cured.” As he turned to leave, he told the resident something about me that all doctors want to hear. It was so flattering, I cannot even repeat it here. What I love about being a doctor is that occasionally, perhaps even rarely, we use our knowledge, skill and persistence to make a big difference in people’s lives. What other job provides this kind of opportunity? T.J.J. (THIRD-YEAR MEDICAL STUDENT) At the end of my physically and emotionally draining internal medicine clerkship, I met with my peers to collectively reflect on our experiences. Two hours later, I emerged rejuvenated after sharing stories about the patients we met, and in particular, one memorable encounter of mine. Three things stood out when I met Jennifer (not her real name) in the emergency department. She was young; she was crying; and she was yellow. She had a three-week history of weight loss and painless jaundice and had been to two other hospitals, each dismissing her as a mystery case after negative test results. Sure enough, we also came up empty: negative virology, negative autoimmune panel, negative imaging. After being disappointed for failing to diagnose a zebra, we started over by reviewing the details of her history, which included brief use of a COX-2 inhibitor. We uncovered nine case reports in which that drug was believed to be the offending agent in cholestasis, and those cases were eerily similar to Jennifer’s. The patients were young and otherwise healthy and had nearly identical symptoms and trends in lab values. When we told her that she would very likely make a complete recovery without any treatment, she embraced her fiancé, overcome with relief.
jama.com
JAMA May 14, 2014 Volume 311, Number 18
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of California - San Diego User on 06/01/2015
1859
Opinion A Piece of My Mind
During the hours of reflection with my classmates, the hairs on the back of my neck stood up as I was reminded that even we, the most junior members of the team, can help patients. I realized that my assessment of the joys of practicing medicine should be based not on the ingredients (such as the countless calls and documentation), but on the finished product. It may not be that we treat and cure a patient like they do on television. Instead it may be that a patient’s pain is lessened or, as in Jennifer’s case, that she leaves with a better understanding of her illness. That is what keeps my bucket full: the idea that through constant intellectual exploration and by using the tools of intuition and discovery, a physician can have a positive impact in some way on every patient interaction. Each clinical encounter is unique and exciting because patients are not generic objects to be fixed; they are dynamic, damaged pieces of art and physicians are the conservators charged with sending them out equally beautiful, even if different than before. M.J.P. (JUNIOR FACULTY) Tucked aside on the corner of my desk, a little dusty and still in its silver gift bag, is a bottle of wine. Ruffino Chianti, Riserva 2006. I have no idea how it tastes, and never will, because I have no intention of ever opening it. I plan to keep this bottle of wine for as long as I can, as a reminder of one of the most bucket-filling moments of my career so far. When we first met, Mr R (not his real name) had recently been diagnosed with pancreatic cancer and needed me to help manage his general medical problems and coordinate his care. Despite the difficult treatment for his tumor, Mr R was surprisingly upbeat and quickly charmed me with his grandfatherly warmth and easy laugh. I almost never share information about my own life with patients. Yet, at that first visit with Mr R, I shared, and his reaction was exuberant and joyous. Over the next several months, the toll of the disease and treatment worsened. His voice weakened. He lost weight. He was in pain. But his generosity of spirit—his quest to fill my bucket— continued. One time I saw him, his eyes were closed when I walked in the exam room. They opened, and, as we looked at each other, I could see him smile, even though he didn’t have the energy to move his face. At the end of the visit, he insisted that next time he would bring me “a good chianti.” He did—the Riserva 2006—and, not long after, he died. When I look at that bottle of wine now, I feel lucky to have known Mr R and to have received so much of his love and kindness. I’m not sure I deserved it. While I worked with his other doctors to manage Additional Contributions: We thank Abraham Verghese, MD, MACP, and Brendan Reilly, MD, for their comments on an earlier draft. These persons received no compensation for their contributions. Funding/Support: Dr Press is supported by funds provided to him as a Nanette Laitman Clinical Scholar in Public Health at Weill Cornell Medical College and by a Cancer Control Career Development Award for Primary Care Physicians (CCCDA-13-096-01) from the American Cancer Society. Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for the
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treatment side effects and stayed in frequent contact with his wife (parts of the job that also fill my bucket), I probably didn’t do anything that improved the quality or quantity of his life. In fact, in retrospect, underlying his optimism and selflessness was a thread of fear that I could have done more to address. Perhaps we were both in a bit of denial. For Mr R, filling other people’s buckets was what filled his own bucket. My role was just to be there, to connect with him. Human connections like that, especially ones during hard times, were the reason I went into medicine. They are what continue to fill my bucket. Despite being at very different stages in our careers, living in different countries, and spending much of our time in non-clinical activities such as research and education (which can also be bucketfilling), it was our experiences with patients that resonated most when we thought about love in our careers. Each of us identified the core mission of medicine, making a meaningful difference in someone else’s life—healing if possible, alleviating suffering and fear if not, or simply caring—as the ingredient that filled our buckets. We found the very act of participating in this reflective exercise to be beneficial and suggest that readers do the same, either informally or through mindfulness programs sponsored by their employers.5 What fills your bucket? In what ways do you fill the buckets of your patients and coworkers? Current changes in the practice of medicine, while offering important benefits to patients, have the potential to empty physicians’ buckets.6 Pay-for-performance, residency work hour restrictions, electronic medical records, constant hospital renovations causing disruption and slow elevators, all represent change—and change is difficult. Physicians and other leaders must take steps to ensure that these changes are crafted in such a way that our buckets are still filled at work, and in turn we can fill the buckets of our patients and co-workers. Some physicians may dismiss a conversation about love and buckets as self-indulgent or unscientific, and it is probably not necessary, or realistic, to love every aspect of being a physician or even to love some of it all the time. But there is a fundamental truth to Donabedian’s quote, even if a connection between love and quality of care could never be measured. Possessing a core element of love, and being in an environment in which you can regularly tap into it, must be essential to delivering good care. Physicians who work in places that help them keep their buckets filled, despite the forces that empty them, will be committed to improving the health of those who seek their care.
Disclosure of Potential Conflicts of Interest and none were reported. 1. Mullan F. A founder of quality assessment encounters a troubled system firsthand. Health Aff (Millwood). 2001;20(1):137-141. 2. McCloud C, Martin KA. Fill a Bucket: A Guide to Daily Happiness for Young Children. Northville, MI: Ferne Press/Nelson; 2008. 3. Friedberg MW, Chen PG, Van Busum KR, et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa Monica, CA: Rand Corp; 2013. http://www.rand.org/pubs /research_reports/RR439.html.
4. Shanafelt TD. Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care. JAMA. 2009;302(12):1338-1340. 5. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533. 6. Goitein L. Physician well-being: addressing downstream effects, but looking upstream. JAMA Intern Med. 2014;174(4):533-534. doi:10.1001/jamainternmed.2013.13253.
JAMA May 14, 2014 Volume 311, Number 18
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of California - San Diego User on 06/01/2015
jama.com
A PIECE OF MY MIND Matthew J. Press, MD, MSc Division of Health Policy and Economics, Department of Healthcare Policy and Research, and Department of Medicine, Weill Cornell Medical College, New York, New York. Timothy J. Judson, MPH Weill Cornell Medical College, New York, New York. Allan S. Detsky, MD, PhD Institute of Health Policy, Management and Evaluation and Department of Medicine, University of Toronto, Toronto, Ontario, Canada, and Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada.
Corresponding Author: Allan S. Detsky, MD, PhD ([email protected] .ca). Section Editor: Roxanne K. Young, Associate Senior Editor.
Filling Buckets Systems awareness and systems design are important for health professionals but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system. Avedis Donabedian1
The idea that love is the “secret of quality” in health care, which might be viewed skeptically were it not proposed by the revered health care quality pioneer Avedis Donabedian, conjures a lesson from a children’s book, entitled Fill A Bucket.2 The book discusses how everyone is born with an “invisible bucket,” which represents a person’s mental and emotional self. People’s buckets are filled by acts of kindness and love and are depleted by negativity and disrespect. Having a full bucket makes us feel happy and helps us fill other people’s buckets. An empty bucket brings a host of negative emotions, which can lead to behavior that empties other people’s buckets. Physicians have buckets too, and the literature often takes a scientific approach to measure how full or empty they are. For instance, a recent Rand report on physician job satisfaction detailed negative aspects of the working environment, such as excessive documentation requirements and clunky electronic medical records.3 Other work has described physician burnout, the resulting exit from the profession, and how having physicians who are engaged improves patient engagement.4 The bucket concept is a simpler, perhaps more meaningful, lens on the issue. In order to be at our best, for ourselves and for our patients, physicians must have full buckets. Or, in Donabedian’s terms, we must have love. This idea led each of us, at different stages in our careers, to reflect on what it is that we love about our careers in medicine. Here is what came from this exercise. A.S.D. (SENIOR FACULTY) A few years ago, while attending on the inpatient general internal medicine service, I admitted a man in his 60s whose chief complaint was peripheral edema and significant fatigue. He had been admitted briefly to two other hospitals in Toronto in the previous six weeks. Each time, he was treated with intravenous furosemide, and his edema subsided; but no diagnosis was made. On the morning after admission, I asked the senior resident, who was starting his vacation the next day, how he wanted to proceed. He answered, “He seems to have responded to furosemide once again and is stable, so let’s discharge him and have the ambulatory group practice sort out his diagnosis.” I replied, “This is his third admission for the same problem in six weeks. We are not going to do what the previous doctors did. We will try harder.”
On reviewing his records from the other hospitals, I made two discoveries: first, his symptoms had been recurrent for ten years, and second, a recent echocardiogram, performed by a cardiologist whose opinion I trusted, was normal. When I entered the room, I found a thin man with significant leg edema, and ear lobes that were rhythmically pulsating. His very anxious daughter was with him. The physical exam was remarkable for a very high jugular venous pressure, Kussmaul’s sign, cardiac knock, and pulsatile liver—all leading me to a diagnosis of constrictive pericarditis. I told both the patient and his daughter that I might know the cause of his problem, and more importantly, if I was right we could make him better. She started to cry. We asked the cardiologist on call to arrange a simultaneous right and left heart catheterization, which was performed the next day, confirming the diagnosis. He underwent pericardial stripping a few days thereafter. Six weeks later, he returned to our ambulatory group practice and reported that his symptoms of fatigue and edema were completely gone. He was able to return to work as a carpenter. He felt that after ten years of suffering, he was “cured.” As he turned to leave, he told the resident something about me that all doctors want to hear. It was so flattering, I cannot even repeat it here. What I love about being a doctor is that occasionally, perhaps even rarely, we use our knowledge, skill and persistence to make a big difference in people’s lives. What other job provides this kind of opportunity? T.J.J. (THIRD-YEAR MEDICAL STUDENT) At the end of my physically and emotionally draining internal medicine clerkship, I met with my peers to collectively reflect on our experiences. Two hours later, I emerged rejuvenated after sharing stories about the patients we met, and in particular, one memorable encounter of mine. Three things stood out when I met Jennifer (not her real name) in the emergency department. She was young; she was crying; and she was yellow. She had a three-week history of weight loss and painless jaundice and had been to two other hospitals, each dismissing her as a mystery case after negative test results. Sure enough, we also came up empty: negative virology, negative autoimmune panel, negative imaging. After being disappointed for failing to diagnose a zebra, we started over by reviewing the details of her history, which included brief use of a COX-2 inhibitor. We uncovered nine case reports in which that drug was believed to be the offending agent in cholestasis, and those cases were eerily similar to Jennifer’s. The patients were young and otherwise healthy and had nearly identical symptoms and trends in lab values. When we told her that she would very likely make a complete recovery without any treatment, she embraced her fiancé, overcome with relief.
jama.com
JAMA May 14, 2014 Volume 311, Number 18
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of California - San Diego User on 06/01/2015
1859
Opinion A Piece of My Mind
During the hours of reflection with my classmates, the hairs on the back of my neck stood up as I was reminded that even we, the most junior members of the team, can help patients. I realized that my assessment of the joys of practicing medicine should be based not on the ingredients (such as the countless calls and documentation), but on the finished product. It may not be that we treat and cure a patient like they do on television. Instead it may be that a patient’s pain is lessened or, as in Jennifer’s case, that she leaves with a better understanding of her illness. That is what keeps my bucket full: the idea that through constant intellectual exploration and by using the tools of intuition and discovery, a physician can have a positive impact in some way on every patient interaction. Each clinical encounter is unique and exciting because patients are not generic objects to be fixed; they are dynamic, damaged pieces of art and physicians are the conservators charged with sending them out equally beautiful, even if different than before. M.J.P. (JUNIOR FACULTY) Tucked aside on the corner of my desk, a little dusty and still in its silver gift bag, is a bottle of wine. Ruffino Chianti, Riserva 2006. I have no idea how it tastes, and never will, because I have no intention of ever opening it. I plan to keep this bottle of wine for as long as I can, as a reminder of one of the most bucket-filling moments of my career so far. When we first met, Mr R (not his real name) had recently been diagnosed with pancreatic cancer and needed me to help manage his general medical problems and coordinate his care. Despite the difficult treatment for his tumor, Mr R was surprisingly upbeat and quickly charmed me with his grandfatherly warmth and easy laugh. I almost never share information about my own life with patients. Yet, at that first visit with Mr R, I shared, and his reaction was exuberant and joyous. Over the next several months, the toll of the disease and treatment worsened. His voice weakened. He lost weight. He was in pain. But his generosity of spirit—his quest to fill my bucket— continued. One time I saw him, his eyes were closed when I walked in the exam room. They opened, and, as we looked at each other, I could see him smile, even though he didn’t have the energy to move his face. At the end of the visit, he insisted that next time he would bring me “a good chianti.” He did—the Riserva 2006—and, not long after, he died. When I look at that bottle of wine now, I feel lucky to have known Mr R and to have received so much of his love and kindness. I’m not sure I deserved it. While I worked with his other doctors to manage Additional Contributions: We thank Abraham Verghese, MD, MACP, and Brendan Reilly, MD, for their comments on an earlier draft. These persons received no compensation for their contributions. Funding/Support: Dr Press is supported by funds provided to him as a Nanette Laitman Clinical Scholar in Public Health at Weill Cornell Medical College and by a Cancer Control Career Development Award for Primary Care Physicians (CCCDA-13-096-01) from the American Cancer Society. Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for the
1860
treatment side effects and stayed in frequent contact with his wife (parts of the job that also fill my bucket), I probably didn’t do anything that improved the quality or quantity of his life. In fact, in retrospect, underlying his optimism and selflessness was a thread of fear that I could have done more to address. Perhaps we were both in a bit of denial. For Mr R, filling other people’s buckets was what filled his own bucket. My role was just to be there, to connect with him. Human connections like that, especially ones during hard times, were the reason I went into medicine. They are what continue to fill my bucket. Despite being at very different stages in our careers, living in different countries, and spending much of our time in non-clinical activities such as research and education (which can also be bucketfilling), it was our experiences with patients that resonated most when we thought about love in our careers. Each of us identified the core mission of medicine, making a meaningful difference in someone else’s life—healing if possible, alleviating suffering and fear if not, or simply caring—as the ingredient that filled our buckets. We found the very act of participating in this reflective exercise to be beneficial and suggest that readers do the same, either informally or through mindfulness programs sponsored by their employers.5 What fills your bucket? In what ways do you fill the buckets of your patients and coworkers? Current changes in the practice of medicine, while offering important benefits to patients, have the potential to empty physicians’ buckets.6 Pay-for-performance, residency work hour restrictions, electronic medical records, constant hospital renovations causing disruption and slow elevators, all represent change—and change is difficult. Physicians and other leaders must take steps to ensure that these changes are crafted in such a way that our buckets are still filled at work, and in turn we can fill the buckets of our patients and co-workers. Some physicians may dismiss a conversation about love and buckets as self-indulgent or unscientific, and it is probably not necessary, or realistic, to love every aspect of being a physician or even to love some of it all the time. But there is a fundamental truth to Donabedian’s quote, even if a connection between love and quality of care could never be measured. Possessing a core element of love, and being in an environment in which you can regularly tap into it, must be essential to delivering good care. Physicians who work in places that help them keep their buckets filled, despite the forces that empty them, will be committed to improving the health of those who seek their care.
Disclosure of Potential Conflicts of Interest and none were reported. 1. Mullan F. A founder of quality assessment encounters a troubled system firsthand. Health Aff (Millwood). 2001;20(1):137-141. 2. McCloud C, Martin KA. Fill a Bucket: A Guide to Daily Happiness for Young Children. Northville, MI: Ferne Press/Nelson; 2008. 3. Friedberg MW, Chen PG, Van Busum KR, et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa Monica, CA: Rand Corp; 2013. http://www.rand.org/pubs /research_reports/RR439.html.
4. Shanafelt TD. Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care. JAMA. 2009;302(12):1338-1340. 5. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533. 6. Goitein L. Physician well-being: addressing downstream effects, but looking upstream. JAMA Intern Med. 2014;174(4):533-534. doi:10.1001/jamainternmed.2013.13253.
JAMA May 14, 2014 Volume 311, Number 18
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of California - San Diego User on 06/01/2015
jama.com
