Transitions in Medicine – One Doctor’s Perspective

By Tia Will

Today, I was asked to write about transitions as they occur in medicine by a fellow poster on the thread regarding the reaction to the national election. This request comes at a particularly poignant time for me as I prepare to make my last transition within the group with which I have worked for the last 30 years. But I would like to start by addressing some other issues of transition in medicine.

So that we are all starting on the same page I am going to use the following definition of “transition” :

The process or a period of changing from one state or condition to another.

In the field of medicine, transition can refer to many different processes. For the patient, it may mean change from one state of health to another. It may mean the change from a state of complete independence , full mobility and bright prospects for the future to one of devastating loss up to and including near complete loss of movement and/or speech. It may mean the need to transition to the awareness of a very brief life span when the assumption had been of a long life. These changes may occur in the blink of an eye as in a collision, gunshot wound, or stroke. Or they may be prolonged over a period of months to years.

  For the family it may entail the change from one state of membership to another as in a death or a birth. These changes are likely to have different meanings for different family members. I had been unable convince my 2 ½ year old daughter that the baby in my tummy was a boy. She was insistent that it was a baby sister. She was much less ecstatic than I was when she realized I was right. Smooth sailing for me. A much harder transition for her.  It may involve necessary changes in the roles of some or all family members as one family member may become either more or less capable of self care or the care of others. It may mean that someone who is used to being in control can no longer fulfill this role, which will mean that someone else will need to step up into this capacity. This may lead to growth for one and inevitable loss for another. All points of view are worthy of empathy.

In this country, transition for the patient and their family may also be marked by major economic change. It may mean the loss of the major household income and with it the loss of home and/or lifestyle. It may mean moving from independence and a sense of hope for the future, to loss of home and all prospects for upward mobility. It may mean children who were expecting to be able to pursue an advanced education, may now have to work to help support the family. In one case in which I was involved, a young man who was the sole English speaker in his immigrant family had a stroke plunging his entire family from a functional state in which his parents and sibs were working while learning English with his help, into a state of near complete linguistic isolation overnight.

I have had the privilege and responsibility of witnessing and helping when I could, both individuals and families face their own transitions. I have seen those who accept change with grace, resilience and strength even under the worst conceivable circumstances. And I have seen others who lash out with anger or who are swamped with self-pity and inertia when faced with what I perceive as relatively minor changes. What this has taught me is a respect for each individual pathway through the process of acceptance of change. The problem and the path to resolution is that of the patient and family. It is mine job to observe, attempt to understand and to alleviate pain and suffering when I can, and to accept when I have no ability to help further. It is never my right to judge the reaction of another. To do so is to limit my capacity as a healer. Every time I minimize a complaint, symptom or concern, I limit my own ability to serve as an advocate for my patient in terms of helping them to achieve the best possible outcome. Every time I become angry, or frustrated, or impatient, I become a less effective health care provider.

In medicine, transition is not limited to patients and their families. For health care providers, transitioning is a constant in our world. The rate of accumulation of knowledge, use of different drugs, different surgeries and different treatment modalities is accelerating far faster than it was even at the beginning of my career. This requires providers to be learning on a near daily basis.

The pressure to master any given field of care is bringing many to much a sharper realization of their limitations and with it the need to either self limit the scope of their practice or face the reality that sooner or later they will be forced to do so as they prove unable to transition ( acquire updated skills in all knowledge areas) quickly enough to be considered competent to practice. In addition to this need for constant updating of learning, medicine has an especially formulaic process of transitioning.

Medical school and residency are characterized by a yearly transition in lock step. Every July, ready or not, the trainee is expected to make the transition from a lower, less independent level of care to a higher position with much more responsibility. The stakes are extremely high. Some programs will allow for additional and more intensive training if the individual has not quite mastered all of the expected skills. Some will not and failure to advance may be the end of a career. This is of course necessary in extreme cases for patient safety. But failure to make this arbitrary cut off and transition to full responsibility for the new set of expectations can prove devastating.  The ultimate transitional step in this process, becoming an attending or independent physician can be a very smooth and natural process. Or it can be a terrifying realization that the buck does indeed stop with you even in life and death situations. Some will adapt to this position very gracefully and seemingly almost effortlessly. Some are nearly paralyzed with fear. Most of us are somewhere in between and almost every one makes the transition with adequate and appropriate support. This requires a degree of empathy from all those who have already successfully made this transition. What is helpful is differential support of our juniors including the assurance that those of us supervising will not allow our students to hurt the patient. What is singularly unhelpful is to criticize, belittle their concerns or lack of confidence , or deliberately shame or blame them publically. A timely word of encouragement can make or break someone’s sense of worth when something has gone wrong and there has been a bad outcome regardless of whether or not they were to blame.

In medicine, we are at our best when we recognize that best outcomes for our patients are achieved when we are all working as a team, acknowledging, respecting and honoring each member’s contribution as opposed to belittling someone who has not yet transitioned to the top position of independent attending physician.

Our outcomes in medicine are demonstrably better when we work in an integrated manner with other members of our health care team. It is only though this integrated approach that we can fully recognize the patient’s condition, their style of problem solving, their personal priorities as they transition through various stages of health and wellness. This willingness to set our own egos and preferences aside and to fully appreciate the patient’s possibilities for making the optimal transition for them and their families so as to provide the best possible advice and guidance.

If you ever find that you or a loved one have a serious illness and are struggling with a major health transition, I sincerely hope you will find a physician who is respectful of all of your concerns, who places your well being, as defined by you, as their first priority, and who recognizes that in medicine the patient’s perspective is far more important than the prejudice of the physician no matter how knowledgeable. Even the world’s most skilled physician will not have good outcomes if she insists that she knows best and disregards the difficulties faced by this particular patient during their, not her, transition.

So to move full circle, I have a few thoughts about my own transition from practicing physician to retired physician. My hope for myself is that I will make this particular transition with grace while focusing on making a meaningful contribution to our society in my new, evolving situation. I am still considering my options: teaching at the new medical school in Elk Grove, continuing to participate in public health on the county level, volunteering in community clinics in my area of expertise, attempting to form a new collaborative center with others interested in sharing their time and expertise for time, not money. There is much that I could do. The most difficult part of the transition now is choosing which will be the best fit

I would be very interested in hearing your thoughts about my experiences and about your experiences with transitions in your own lives and professions. I would see this as a very interesting topic for sharing and am thankful to hpierce for the suggestion.