How a mid-career fellowship in palliative medicine refueled and refined a doctor’s love for emergency medicine.
I vividly recall my first taste of emergency medicine (EM) as a medical student. My quiet, “take in my surroundings” disposition was swallowed by the hustle and controlled chaos of the emergency department (ED). I started my first shift as a wallflower, and hours later, I had magically become a valuable part of a skilled multifaceted team that extended beyond the ED. I was exceptionally intrigued by how patients and families, having just met and received heartbreaking news from their emergency physician, placed the utmost trust in the healthcare team to help them make decisions in some of the most vulnerable situations. I loved being a part of their story, both in times of healing and suffering. I knew I had found my place.
Practicing emergency medicine over the years, my niche evolved. I tackled several quality improvement projects, led my hospital’s ethics committee and championed our geriatric ED — all meaningful roles. During that time, I observed the complexity of my patients soar alongside my list of clinical responsibilities. I also began to feel a tremendous weight — call it compassion fatigue or burnout.
We see an incredible amount of suffering every day. Many times, I found myself void of the capacity to address or relieve the suffering that my patients experienced. Sometimes I lacked the confidence that the healthcare system could do it either. Or potentially – the ability is there, but we fall short as our ED patients do not have access due to disparities, resources or other barriers. Human suffering is far from simple, and hospice and palliative medicine training provides a window into this complex patient experience.
I entered a hospice and palliative medicine (HPM) fellowship in 2021. It was a welcomed culture shock to say the least. Open discussion of personal and patient-care-related struggles was a daily experience, offering outlets to collaborate and support others.
Many of my HPM team members regularly sought their behavioral health support and shared about it. Vulnerable communication training sessions were facilitated in an environment of psychological safety. It was a year of daily boot camp tackling complex patient and family interactions. Working with an interdisciplinary team on the palliative medicine consult service, I felt a familiar rush. I was called in times of distress when a patient’s goals were not aligned with medical decisions, when expectations were unattainable, or when a patient was actively dying. The greatest gift I could give many times was simply sitting with patients, lending an empathetic ear, and bearing witness to the magnitude of their suffering.
Many of my EM colleagues raised their eyebrows when I informed them that I would be reentering training stating, “EM and HPM are opposite ends of the spectrum.” On the contrary, I like to think of them as complementary colors. Every bit of EM that weighs me down, HPM provides me lift. The philosophy and skills I developed in HPM training have refueled and refined my love for EM.
True connection and the value of supportive statements
My palliative training emphasized how much psychological suffering (emotional, social, spiritual) can contribute to distress. In the ED, I can often address physical suffering (pain, nausea, dyspnea), but my patients will not feel released until I manage the other domains. My patients expect me to ask about their stories, and understand their symptoms within the context of their lives.
Her shoulder pain is not only 5/10, constant, non-radiating, it’s “bad enough to miss my granddaughter’s track meet.” This isn’t his third COPD exacerbation requiring admission in the last six months, it’s the first one despite adherence to his outpatient care plan. I challenge myself to zoom out and look at the big picture, and I do this by eliciting what worries them the most.
I recently cared for a young man with fever, myalgias, and sore throat. It was his third visit to the ED despite a week of symptoms, and he was worried about HIV. He consented to testing with plan for results the next day, but despite having very few risk factors for HIV, I could tell he was distressed. I watched as my resident compassionately shared, “I’m sorry you are going through this. We are going to support you every step of the way.” The patient was so overwhelmingly relieved with this simple statement, and the tension and angst in the room melted away.
Due to the dynamic environment of the ED, it is often impossible to feel 100% present. Often what worries me about a patient’s presentation is not what concerns them. Building true connection requires intention, shared purpose, and cultural humility, beginning with a glimpse of the world through their eyes.
Illness is a family affair
Most will agree that the presence of family adds an element of complexity to an ED encounter. I often cringe when my triage team tells me “What Aunt Betty in California thinks is going on” or “What cousin Jerry would like to see ordered.” In patients with advanced or life-limiting illnesses, families carry the burdens as caregivers and advocates for those they love. My HPM training has taught me when to capitalize on small opportunities to engage patients and families in meaningful dialogue, even if it is brief.
On week one back in the ED, I met a gentleman with ALS presenting with difficulty clearing secretions. He was calmly asking me to “suck the mucus out” of his throat. I asked him what his neuromuscular specialist had shared about his illness. His son at the bedside immediately interjected, “What does that have to do with why he is here?” Before I could even respond, my patient shared, “I only have about six weeks.” His son was startled and moved by this statement.
My patient then shared, while his physician hadn’t discussed prognosis, “My body is telling me I only have six weeks to live, and I’m OK with that.” What followed was a moving discussion between father and son, his hopes, his worries and that he was already thinking about end-of-life. It was organic and required little to no effort on my part. Facilitating communication between loved ones is one way to influence a patient’s healthcare trajectory.
Uncertainty – finding comfort in the gray zone
I like to think of the ED as the point of greatest uncertainty in a patient’s illness. Much of medicine is managing expectations and grazing on the “what if’s.” In the ED, we encounter patients in moments of crisis, and they often have a wide range of prognostic awareness related to their chronic disease states.
Whether recovery is possible from an acute event or decompensation takes time, often days to weeks. Many EM decisions I make are black and white: to intubate, administer a thrombolytic, and auto-launch critical care transport for time-critical diagnoses. I find that patients and families live more in the gray. Literature tells us that patients and families want a balance of honest communication and hope. This is undoubtedly difficult.
I cared for a patient during fellowship with septic shock requiring a considerable amount of vasopressor support. Her illness was sudden and unexpected, and her husband of 50 years was paralyzed with anticipatory grief. It was beginning to sink in that her time was short.
When asked what support he needed in that time, he told me he needed her physicians to believe that she could get better. This experience has molded how I speak with families in the ED after a catastrophic medical event. I no longer feel the dissonance of sharing both “I hope that she improves” and “I am worried she may not survive this hospitalization” in the same sentence.
What defines a good shift?
After a full year away from EM, coming back was like riding a bike. The incessant alarms and interruptions were shocking at first, but I find myself looking at things through a new lens. “A good shift” is no longer measured by a great catch, a heroic moment, a clean board, or getting out on time, as I have no control of these things.
At the end of each shift, I make it a point to be reflective – recalling meaningful interactions with my patients and their families, and conversations with my fellow ED and consulting colleagues, residents and staff members. “A good shift” is one where I reach true connection with one patient or family member, more broadly as human beings, and become part of their story. When I have these deeper interactions, I give them business card with my name and title. I am not only “the ED doc,” I am Dr. Candace Leigh, the person that cared deeply for them in their time of need. I am exceptionally proud of the care I provide.
During fellowship, I found myself asking patients “What is most important to you?” multiple times a day. It felt natural to feel self-reflective at these times. I love my career in medicine, but several personal values and priorities come before my work. How this translates for me now – I only lead projects that bring me passion. I intentionally take time to encourage my colleagues in their successes. Aside from my clinical work, I’ve taken an interest in mentoring. I dream of how small changes in how we connect with our ED patients could have enormous effects downstream.
Last year, I observed many of my hospice patients courageously and peacefully enter their final days knowing they placed their time with things they truly valued. I want to reflect on the days I’m given, pause and feel the same.
Good article Candace
I am honored to work with the author of this piece daily. She excels in humanity and grace.
This is a wonderful article, Candace.
Inspiring article Dr. Leigh! I’m blessed and privileged to know you. Chaplain Dave