Care Redesign

Twitter Tailwinds — Little Capsules of Gratitude

Article · September 10, 2018

Esther Choo, an emergency medicine physician at Oregon Health Sciences University, was at a mall in Portland, Oregon, waiting for her son to finish at a birthday party, when she fired off a tweet that briefly transformed medical Twitter: “When I first met B, he’d been dead for 20 min. We got him back, inexplicably. He calls me every year on the anniversary. 10 years now. #ShareAStoryInOneTweet” (@choo_ek). Soon, and without further instruction from Choo, my Twitter feed, typically dominated by debates about drug prices and research integrity and insurance design, briefly lit up with stories.

An internist recalls the early days of residency, admitting a patient dying from AIDS-related complications. The patient, whose father hadn’t spoken to him since the diagnosis, dies quickly. The internist writes, “Your father came up to see you only after you passed. I saw him cry and you didn’t” (@DrJohnAquino).

An oncologist recalls telling a 25-year-old she has acute leukemia. “You listened. Wide eyed. Then you said to me: ‘It must have been so hard for you tell me this.’ I wept” (@EAEisenhauer).

An emergency medicine resident and former paramedic recalls a patient who collapsed while working at Home Depot, “dead” when the ambulance arrived. “I got u back,” she writes. “U have no idea who I am.” During her darkest hours in medical school, she says, she visited Home Depot “just to see you.” She concludes: “You saved me back” (@AbbersMD).

On most days, it’s hard to escape the sense that ours is a profession in need of saving. There’s the crisis among us, as we grapple with epidemic levels of burnout and many physicians report depersonalization, emotional exhaustion, and a diminished sense of personal accomplishment.1 And then there’s the crisis around us, for which we are, at least in part, responsible: a health care system that costs more than any other in the world, with quality, we are told, that’s mediocre in comparison with that in many other countries. I often wonder whether one crisis can be solved without addressing the other. To be a shrewd observer of health care today is to declare the system a failure. Yet if you carry this awareness of the many ways the system falls short, can you still experience that sense of tremendous pride that once sustained the profession?

Choo, who typically takes to Twitter to focus on aspects of medical care and health policy that disturb her, readily admits that the social media platform tends to magnify all the grimmest aspects of medicine. “People in medicine can be very down about the profession,” she told me. Though Choo emphasizes the value of having a platform where this relentless dissection of medicine and policy can occur, every once in a while she looks at her Twitter feed and realizes that an entire aspect of her practice — the good that occurs right next to the bad — is underrepresented there. “Maybe what the field needs,” Choo said, “is to be reminded a little more of the good.”

As part of a large physician family, I was surrounded by such reminders during my youth. “Your mother saved my life.” “Your father restored my vision.” “Your grandfather took care of my mother and sister their whole lives. Tell me, how is my dear friend?” Though excessively emphasizing how physicians improve patients’ lives risks self-aggrandizement, what struck me about many of the stories was that they were as much about the ways patients help clinicians as the ways clinicians help patients.

A patient with a tracheotomy being treated in the MICU reaches out and touches the face of a 22-year-old nurse, heartbroken from her recent breakup, and asks her what’s wrong. “I learned to be less selfish that day,” she writes (@TiaX_line). An aging patient with multiple medical problems asks her internist why he looks so tired, and he says something about wishing the day were done. “Don’t wish any away, there are fewer than you think,” she says. He writes, “You changed my outlook on life” (@YoniFreedhoff). Some physicians are transformed by error. Others by injustice. And some by the people in their lives for whom medicine fell short: “I was still a resident when you called to say you were having chest pain,” an ED doctor writes. “I flew home and was with you when you were diagnosed with Stage IV lung cancer. You never got to see me graduate Mom, but you are with me on every shift” (@ElevateMedicine).

Most of us spend years dreaming of the day we will graduate and become doctors. Yet when that moment finally arrives, our sense of good fortune can quickly evaporate. What happens? In describing what they call the “headwinds/tailwinds asymmetry,” the psychologists Davidai and Gilovich liken the challenge of maintaining a sense of gratitude to the ease with which cyclists stop noticing the wind at their backs.2 “As any cyclist or long-distance runner will attest,” they write, “combatting a stiff headwind is a challenge.” When the wind dies down, “there is considerable relief,” but “it’s a relief that’s short-lived. One quickly adapts to the change and soon no longer notices that there’s any tailwind at all.” We are wired to focus on that which holds us back; what can be gained by focusing on all that allows us to soar?

I probably spent 7 minutes with you but I think of you often. You’d had a motor vehicle accident, fracturing your right ankle; in the previous week, it had become necrotic, so you had been admitted for a below-the-knee amputation. Your head was shaved, your gaze a bit disconjugate, your childlike innocence making me wonder whether you’d had a traumatic brain injury that I’d overlooked when I quickly read your chart to get a sense of your perioperative cardiac risks. When you mentioned your father and grandfather, I asked if you had children too, and you said, “No, but I wish I had a couple of ’em.”

Your right ankle was predictably necrotic; the way the spokes from the external fixation device poked the ischemic tissue turned my stomach, but when I looked at your face as I placed my hand on the dead foot, you seemed totally unfazed. I discovered that your left foot was also in a boot, and when I asked you why, you said, “That used to be my bad side.” For a few years you’d had a diabetic neuropathy that caused pain and difficulty in walking. “Now,” you said, “that’s my good side.”

Davidai and Gilovich give several examples of the ways our perceptions can skew toward misfortune, despite the many “boosts” we’ve received. It’s not only that challenges naturally have greater salience because they must be overcome, it’s also, the psychologists note, that “informational disparities often make headwinds more available than tailwinds.” For example, because we spend longer hiking up the trail than cruising down, it actually seems that “the trail itself” has more uphill than downhill segments. Davidai and Gilovich don’t comment on how the asymmetries of our individual perceptions may be amplified at the level of the group, but my own sense is that the headwinds we face as a profession are increasingly writ large. To a certain extent, they should be: we would be remiss if we didn’t constantly and exactingly focus on addressing all of medicine’s shortcomings. But how to balance fixing what’s wrong with holding on to all that’s right?

Stories aren’t for everyone, and surely they can’t solve all our professional woes, be they practical or existential. But one thing we do all share is that, every day, we witness people facing what is often the greatest headwind of their lives: illness. To the extent that stories capture the grace so many people summon when facing these challenges, I suspect they can help us pause, if only briefly, to feel the wind at our backs.

As I walked out of your room, you called after me, “Doc, do you think I’ll be able to walk again?” The problem was, I really didn’t know, and I didn’t want to lie. But you answered for me: “That’s what I’ll do,” you said. “I’ll learn to walk again.” And I said something like, “Yes, that’s what people do.”


SOURCE INFORMATION

Dr. Rosenbaum is a national correspondent for the Journal.

1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc 2015;90:1600-1613. CrossRef | Medline | Google Scholar
2. Davidai S, Gilovich, T. The headwinds/tailwinds asymmetry: an availability bias in assessments of barriers and blessings. J Pers Soc Psychol 2016;111:835-851. CrossRef | Medline | Google Scholar

This Perspective article originally appeared in The New England Journal of Medicine.

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