Like many other doctors, Anju was stressed with the pace of work, the burden of too many patients, and she felt drained at the end of each day. But a simple change in attitude transformed her practice. This is her story.
Dr Anju Yogakumar is a primary care physician (GP) in Otara, a very poor and disadvantaged community in the southern suburbs of Auckland, the biggest city in New Zealand. Her practice at East Tamaki Healthcare provides subsidised care to poor patients with a very high burden of chronic disease. In her nineteen years at Otara, Anju has witnessed a dramatic increase in workload.
“I came to New Zealand when I was fifteen as a refugee and did my university bursary examinations here and went to Auckland Medical School. I have always wanted to be a doctor to serve the people in need and whoever could not afford care. I wanted to serve them, that was my passion from when I was small and I found that Otara was the area where I could do my passion.”
But over the years, the high workload caused a lot of stress. “About our practice, it’s a no-appointments system, and I work nine-to-three, that’s six hours and sometimes I can see up to sixty or seventy patients. A lot of patients used to wait for two to three hours to see me.”
“I was trying to be my best to the patients and last year it got to a peak where I was constantly thinking, now how do I give that time without getting really stressed. Because I started off with lots of Pacific Island and Maori patients and with increasing time a lot of immigrant patients came from Sri Lanka and India and because of the culture and language, I could speak the same, they started seeing me too so the number of patients increased. I was getting quite stressed inside myself with having young family and looking after my home and work. At the end of the day I felt drained.”
But that’s not how Anju describes her practice these days. The transformation began the day she heard Dr Robin Youngson, the Cofounder of Hearts in Healthcare, speak at a conference.
“So I was listening to that talk, and that was the day it all changed for me, from that time onwards, I learnt how can I still enjoy the high flow of patients. Since listening to Dr Youngson, I’m truly, truly, really blessed and I’m thinking why didn’t I listen to this talk when I was a medical school student, it could really have made a big difference! I practiced for twenty years without knowing this, how can I manage the time, and still care, without getting stressed.”
Anju says it’s quite amazing how the clinic staff have commented, “Anju you are always smiling and you’re so happy, your waiting room is full of people but you don’t seem stressed out!”
Anju explains her new insight with a story:
“I had a 22-year-old Maori girl, she came in with lots of pain due to haemorrhoids and piles and she’s seen three different doctors in the same practice. And when she came to me as the fourth doctor, the first ten minutes she was swearing at me! She was really, really, saying all the bad words, she was full of anger, full of emotion. It gave me time to sit and think, I didn’t say anything, the ten minutes I allowed her to talk. In that ten minutes, it’s amazing how much time I had to analyse the patient and also analyse myself. I had the time in the ten minutes to do all of that. I thought, why is this patient swearing? And I started looking at the notes that the other doctors had written. They had given the right treatment, right everything for the hemorrhoid problems, and written good notes. Obviously this patient is in pain, her problem is not sorted out.”
The patient said, “You, bloody hell, you’d better do something and the others haven’t done anything!” and she was very demanding.
“Then after analyzing the patient I had to think how am I going to help this patient? So many thoughts going inside me, I didn’t say anything. And it was quite interesting after ten minutes of swearing she stopped.”
“So then I just said, I’ve been looking at the notes and I can see you are in a lot of pain. I can see the other doctors have given you the right treatment but if you are in so much of pain I think you need to go to hospital. I’m not going to do anything [that can] make you better but I can see you are in lots and lots of pain.”
“Then she started crying. She started crying and said, ‘Please, please, please, they said you are a wonderful doctor, can you please examine me?’”
“So I said, if that’s what you want to, I’d love to do that. I put her in the bed and examined, and as I finished, she got off the bed she came and she hugged me and started crying. And she said, ‘I’m so sorry, I’m so sorry’”.
“The other thing I was doing, not only self-analysing but I was praying inside me. I was praying for God to give her the strength and that was all I was doing. And she came and hugged me back and I thought, thank you Lord, thank you for giving her that strength to cope with that pain.”
“And it was amazing in that fifteen or twenty minutes how different emotions played out. And she was happy, I didn’t give any other treatment and she didn’t go to hospital. She came back the next day and said the pain was gone and she was happy.”
“So from the patient’s point of view that’s the fourth consultation. So finally I think, the patients, all they want is the compassion and for somebody to listen to them.”
“The next time she comes in I don’t think we’ll need to spend the twenty minutes, it’ll go down to fifteen minutes or ten minutes.”
“Before listening to Dr Youngson, all that time I was trying to change the system around me and asking my boss and everyone to please bring the appointments system or do something, the flow is too many patients, I can’t handle it!”
“But instead of trying to find the resolution outside, I actually looked inside me and I thought how, in a small level, in my own way, how can I actually change it, so that I can provide better care for the patients and for myself, not to get stressed?”
“Dr Youngson gave me the answer, just take one-by-one and spend a little bit more time with one or two patients each day. So I went and did that.”
“So I chose one or two patients, in that day I see sixty patients, and I’m really going to get to know them very well, to give them the extra time.”
“When I’m with that patient sometimes the patient will get stressed out – there are too many people waiting – but I just tell them, I am here for you, so don’t worry. So I’m much more relaxed and I think because I am relaxed, they are relaxed and they feel I am giving more time, I’m there, and they’re open. Sometimes it has gone up to 45 minutes, the first one or two visits, but I don’t even feel the time going, I don’t feel drained.”
“The other day one patient came in and I said, what’s the matter, and she didn’t even talk about the matter she came with, she just said, ‘I’m seeing the bright light around you doctor!’ And we were talking only about that light for the first five minutes.”
“What I’m finding is that they don’t talk about the physical problem any more, it’s more and more general issues, just like a happy family kind-of-thing, and then they walk out of the room, and [the problem] is just a little nuisance and it will go away and they’re confident. Whereas before I was talking more about the diagnosis and the problem, the prognosis, all of those things but now its much more of a friendship relationship with my patients, I find.”
“The feeling that I have to fix something for them, I don’t have that feeling any more now.”
“They trust me. Before, the longer they wait the more angry they are with me when they come inside the room. Nobody likes waiting. But now, even if they wait for two or three hours they’re prepared before they come and so they’re quite relaxed, they say, ‘Its just the fact that I know I can come and just sit and talk with you and I’m happy.’”
“Then I give (my attention to) the person who is right in front of me and I say, “I’m here for you, I want you to be happy. Whatever it is, you tell me!”
“Once I have opened up like that, it’s quite interesting, they’re really caring for you as well. And it takes less time. When you are not open and you sit there as a rigid person the problems increase, the number of problems they keep on coming increases, but once you open your heart for some odd reason their problems go down.”
“The person who comes with ten problems is not telling ten problems any more. When they know there is someone prepared to listen, it’s a magic feeling that they don’t have that problem.” (laughs)
“Even the diabetic patients, so many millions of dollars are spent on diabetes management in New Zealand. To be honest I have actually found their high HbA1c level and brought it down to fifty-four, fifty-five, just purely with compassion and love. I’m feeling so amazed that in just twenty minutes of talking, so many people have started on insulin this year, because they really trust me. And every week they come, just for three or four minutes and I’m looking at their log book and it’s coming down, they’re happy, I’m happy.”
“But before, when you are just telling [diabetic patients] what you have to do, it doesn’t work.“
“Reading that book (TIME TO CARE, by Dr Youngson) was almost like giving me the confidence in believing what was right. I always wanted to be compassionate and provide the health care but I didn’t know how to go about, or how to express my feeling.”
“Because I find that the medical school and the hospital system here does not reinforce that thinking, so for the first time when I read that book, for me the biggest thing is that self-confidence. Yes! There is another person feeling like that too, it’s an OK feeling, a right feeling! I’m more confident about talking to the patients, yes, I can do that now because another doctor is feeling that way too.”
Anju has advice for her fellow doctors:
“Number one thing I think is just self-analyse yourself, to spend a little bit of time, what is stressing you really? Is it the patients who are stressing you really or is it you who is giving stress?“
“Because usually the patients do not stress us, it’s just our response to what they are saying, that is what is stressing. With the same complaint, when you are in a good mood you deal with it in two minutes but if you are in a very bad mood that day the same problem it will take twenty minutes and you still come to the same solution. Then you need to think, what is that difference? Because it’s the same you! So if you work on yourself….”
“In terms of not getting enough money and the workload and things like that, don’t worry about that, it will all flow into place. Once you spend the time, you’ll be with the patient and you’ll see, you earn the same money in a better way!” (laughs).
“The number of consultations will go down but the number of patients will increase and indirectly, your income will be good anyway so you don’t need to worry about that. And in the long term I think you’ll have lots of happy people out there.”
“So I think the government should be spending more money on training doctors how to lovingly care, to get things out of their patients, rather than teaching instructions.”