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“It seems as though the looming reality for many of us is that we will have patients who need ventilators, and none will be available. It seems like we might benefit from remembering that we can still succeed in practicing medicine by being present with those suffering before us, even when we know we cannot cure them of disease.
In a more pragmatic sense, maybe in addition to logistical discussions and articles about how ERs and ICUs are going to decide who should get a ventilator, we should also discuss how we are going to communicate with empathy and compassion to the families of the critically ill and dying; there are ways to learn to do this well that alleviates heartache for families and for physicians.”
Elaine M. Colby is a family physician.
She shares her story and discusses her KevinMD article, “When should we start having a discussion about palliative and end of life care?”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Elaine Colby. She’s a family physician, and she wrote the KevinMD article “When should we start having a discussion about palliative and end of life care?” Elaine, welcome to the show.
Elaine M. Colby: Thank you. Glad to be here.
Kevin Pho: So we’ll get into your article in a little bit, but first off, tell me your story and your journey to where you are today.
Elaine M. Colby: So I’m from Birmingham, Alabama, and I went to medical school at UAB. I loved everything, but I would get bored doing the same thing over and over. I couldn’t decide what I wanted to do. But, very cliche, I wanted to make a difference in people’s lives, and I ended up choosing family medicine. I followed my then-husband to Hawaii, where he did his residency in the army, and I did mine at the University of Hawaii in family medicine, and we lived there for five years. Then I worked for Kaiser there, and then we moved to San Antonio, and I worked for the army at Fort Sam Houston at Brooke Army Medical Center, and we were there for five years, or four years, sorry. And then we came back to Birmingham, and I worked for the VA, and now I am in private practice for the first time. Ten years after I finished my training, I went into private practice.
So I’ve been in a variety of different practice environments. When I started in primary care, I really liked the variety and just being able to really treat the patient as a whole, and just a jack of all trades, knowing a little bit about everything. And, you know, it’s been ups and downs, but I’m really glad ultimately that I made that choice. Actually, my niche in primary care has ended up being mental health. So that’s a lot of my practice, and I’ve focused more and more on wellness.
So much in modern medicine today, Western medicine, we’re just throwing pills at people, and excessive care. And through all these different practice environments that I’ve worked in in the past, I’ve learned so many other ways to care for people. And so much of it comes down to just quality of life and prevention and wellness. And in our culture, we don’t appreciate those things.
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Kevin Pho: And how has the pandemic affected you and your practice?
Elaine M. Colby: I think, actually, for our practice, the number one thing is the uncertainty going forward with everything. We have been very fortunate. We have about 35 physicians here, and we’re physician-owned. So we’re large enough that we have lots of resources and could adapt quickly, but not too big that we were just overcome with bureaucracy. So we were in a very good situation to adapt and start virtual visits immediately. We never shut our doors completely. We just converted everybody to virtual visits. So we were very slow for a while.
Now, Alabama has, I mean, pretty much opened back up completely. So we all buckled down for this wave of patients flooding our hallways, and then nothing happened. Nothing. So I think all of us, like the community, people just got so stir-crazy from being holed up. So now we’re seeing rampant positive tests. And now we’re holding our breath for what’s going to happen next week.
Kevin Pho: Now, let’s talk about your KevinMD article, “When should we start having a discussion about palliative and end of life care?” So I was wondering if you could walk us through that article and maybe share the story of why you decided to write it.
Elaine M. Colby: When I trained in residency, it was kind of a hybrid, half-academic, half-community program, but when we were on call as residents, it was a very small community hospital. I think we had 20 beds. The only physicians in the hospital were the ER doctor, the upper-level resident, and the intern. That was it. We did not have an MRI. We had a CT scanner. We had, like, four beds in the ER. We had four ICU beds, and the residents managed the ICU by themselves overnight. So it was an interesting experience, but a very good one.
And for a variety of reasons, with that hospital also being in an underserved area, we saw a lot of suffering. We were very well trained on discussing end-of-life care in that program. And so I had also really just focused on making people comfortable, and I just witnessed all the suffering that can happen with prolonged ventilation.
When this pandemic started, it was so quiet here, so I was reading and watching about everything going on in New York, and I could easily imagine what a horrendous experience it is for the patients, the families, and the providers, being on the ventilator and alone. I could easily just imagine. Also, in medicine, I was hearing all the frustration from these doctors in New York of not having a cure, and how algorithmic our system is these days, where, you know, you could just run a person through a computer and not even, I mean, I guess you could argue that we are doing that with our EHRs. But just the human aspect is not there. And also, when we don’t have an algorithm to follow, it’s so frustrating for so many doctors.
But in my practice, having focused on wellness and mental health for so long, to me, the most important, valuable part of being a physician is being a healer and a caregiver. I know I can’t cure most things, but I can make people’s lives better even if I can’t cure them.
So I think I wrote that article in about 5 minutes. I was driving home from work, and I must have been listening to something on NPR and thinking about everything I had read, and I was just getting really fired up. Like, why aren’t we talking about minimizing suffering, not, you know, ramping up the pressures on the vents when these people are dying right in front of us? We could do it better. We could do it better, but we’re so focused on getting that cure, which of course is important. We were missing a big piece.
Kevin Pho: Sure. Now, from a primary care standpoint, what are some of the obstacles that a lot of clinicians face when it comes to discussing end-of-life care?
Elaine M. Colby: Time, for sure. That’s probably number one. It can be an uncomfortable conversation if you haven’t practiced it. People need to realize that if you’re not comfortable with it, it’s going to be uncomfortable in the beginning. And probably just time and willingness to be able to just listen. It involves a lot of listening and maybe, you know, learning how to ask the right questions and then listen, and not dictate what we think the person needs to do, but find out what is important to that person.
Kevin Pho: Now, from your experience, can you share any advice to your fellow primary care clinicians? Any tips that you can share when it comes to discussing end-of-life care with patients?
Elaine M. Colby: In my practice, particularly with my Medicare patients, we do advance care planning, and I have just come up with the phrase for how I approach it with all of my patients. And so it’s scripted. I would say, “If you were to have a medical emergency and you couldn’t speak for yourself, what kind of things would you want or not want?”
Kevin Pho: So we’re talking to Elaine Colby. She’s a family physician in Alabama, and she wrote the KevinMD article “When should we start having a discussion about palliative and end of life care?” And when it comes to the coronavirus, the diagnostic and therapeutic treatments seem to be changing almost on a daily basis. How do you stay up to date with everything?
Elaine M. Colby: I think everybody wants their day in the spotlight as far as, you know, the breakthrough research, the breakthrough treatment. And so I will go to multiple sources to cross-reference. And I would say that actually, when I was in college, I read the book “And the Band Played On” by Randy Shilts, about the AIDS epidemic. And that was a huge eye-opener that I’ve never forgotten.
Politics and culture and society, you know, we want science to be straightforward and clear-cut, but it’s not, because humans are emotional beings, and everybody has their own slant and opinion about it. In this scenario, when everything is all new and changing and uncertain, a lot of these things that are going on right now don’t necessarily surprise me, because I read that book. And this all happened once before.
Kevin Pho: And my final question, Elaine, what is your take-home message for the KevinMD audience?
Elaine M. Colby: One of the most important things in medicine is to listen to your patients with respect and empathy and bear witness. And that’s one of the most important things that we can do as physicians, ever.
Kevin Pho: Fantastic. Well, thank you so much for sharing your insight, and thank you so much for being on the show.
Elaine M. Colby: Thank you. I appreciate it.
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