Category Archives: Medicine

Of Babies and Donuts

Posted on January 6, 2013 | 3 Comments

Some silliness unfolded this morning on Twitter. I think it began with this tweet (apparently sent by a tired pediatrician, early in the morning, after being called to a baby’s delivery):

Let’s play a game: what do babies and donuts have in common? #WhatDoTheyHaveInCommon

Let me explain a bit about Twitter. Somehow I, a fairly non-techy sort of gal have 3 Twitter feeds. Two for work: @KPHealthed and @KPBabydoctor. On these I try to be professionally focused. On my personal feed, @KateLandMD, I relax a bit more. My non-medical, non-tech savvy friends are completely mystified by Twitter let alone why a doctor would be using it. I explain that there can be power and value to the connection found in the space on Twitter. That it is important for doctors to be present for the discussion. That it is important to battle misinformation with truths; important to be accessible. I explain that we learn from each other; we stay current. I tried to explain that we make friends. Well, that last bit drew guffaws from one person recently. “Friends? Really?” she said with a sceptically arched brow.

Well yes, friends. Take this morning for example – we went on for quite some time making ourselves giggle by answering the question about babies and donuts. Here is a bit of the transcript:

You never want to squeeze too hard.

There is a powdered version of each.

Eventually, they both wind up stuck on your hips.

Oh good grief! You all crack me up! #giggleswithmycoffee Now I want a donut.

Now I want a baby and a doughnut.

Coffee is a good accompaniment.” And necessary!I just have to pause and say, I am cracking up over these tweets! #WhatDoTheyHaveInCommon

A dozen is probably too many.

Have U noticed, while we are being silly some folks here are still thinking big thoughts #classclowns

Silly is such an important part of life. I never want to forget how to have fun.

This fun question brought back two memories of babies and donuts that I couldn’t quite squeeze into 140 characters. First, from when I was pregnant with my middle child. I was a resident working way-to-many hours in the neonatal intensive care unit, not my favorite place to be even when not pregnant. The call nights were many and long; it was hard to talk myself through them at times. So, I developed a system: if I could make it through the night I earned a donut, an apple fritter to be specific. I had a lot of fritters. At birth she weighed in at 10 pounds – no surprise there.

The second memory, triggered by the Twitter silliness, was about this same donut-fed baby a bit older. In kindergarten she developed a problem with her blood cells. The diagnosis was at first unclear – she seemed quite ill;  and the treatment was very high dose steroid pills. These made her a bit  nutty and put her appetite off. In our state of worry we gave into the one food she would eat. Yes, donuts. Donuts for breakfast, lunch and dinner. Soon we got the news that her condition was benign and to be short-lived. So, we sat her down at dinner and explained that this was her last donut for a while. Later I found her talking in her sleep:

Pretty donut…pretty donut…

My time spent on Twitter can be hard to explain. Another pediatrician there, Bryan Vartabedian, often does a much better job in his infinitely readable blog 33 Charts. Recently when discussing physician’s roles in social media he said:

There are 50 ways to use something like Twitter to make your world, or the world of those around you, a better place.  YouTube’s potential application in health care is limited only by the imagination.  While no one has to use any of these tools, believing that Twitter is only a place to share what you’re eating for breakfast is to live with your head in the sand.

Ah yes but, while we explore Twitter’s more meaningful side, a bit of banter over breakfast with our friends is awfully good fun.

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Thanks for the fun to these and others: @rychoiMD,  @thegrandefinalle, @jensen_jessica,  @DNich09

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The Rough Shifting of My Brain From “Mom” to “Doctor”

Posted on December 29, 2012 | 5 Comments

DSC_0885My favorite day of the year is December 26th. All work done, house a mess but, who cares – the kids are happy. No dinner to make. There’s enough left-over turkey for the apocalypse. I was sitting by the fire, new book in one hand, glass of Prosecco in the other. I never sit and haven’t read much this year so you’ll forgive me that I did not at first jump at the voice from upstairs.

Mom?

I am reading a good book, The Memoir Project. It is perhaps worth a blog post soon. I was sucked in by the promise of relaxation (fire, Prosecco) and uninterrupted creative thought (book). But then, there was something in the tone of voice that made me ask

Do you need me?

Yes!

Is someone …hurt ?

This last bit uttered as I ran, up the stairs, because by then I already knew.

The big brother sat wide-eyed by the crying, stiff little brother. They had been wrestling as bear-cub brothers will and, it had ended with the little guy crying out. Later, I asked his brother what made him stop the grip he had on his brother’s neck and he said simply that he said “ow.” Must have been a loud “Ow.”

And that is where the point of this story begins. They say that doctors should never practice on their families. There are good reasons and, dire examples. But how, I ask you, is a mother (doctor) supposed to not treat her kids? I don’t do their well checks. I don’t treat their colds. But I am present for their emergencies. At those , there is always a juncture when I have to wrench my mind out of motherhood and disassociate to be … a doctor. Sometimes it works.

This time it worked fine. I was able to calm the little guy, assess his sore neck (muscle spasm) and hug his sorry brother. Whew. But, don’t think that visions of quadriplegics weren’t dancing through my mind as I acted.

Other times it has been harder. I was an exhausted intern, coming home off a 36 hour stretch when I saw the rash. My firstborn (a.k.a. the big brother) was at a friend’s house when I picked him up. She calmly said that he had the strangest rash. I looked. He did. His rash was that I saw in the hospital on kids who died. My mind churned; it twisted – I had to be the doctor again?

Another day, one when I was supposed to be home recuperating from a big leg surgery I again, had to make that shift. The kids had gone kayak camping with their dad. They had paddled into a remote lake and broken camp, gone to bed and the next morning the sister felt ill. All their dad can tell me now a few years later, is that he just “knew”. So, he and her brothers packed it all up, boated everything out and then carried her out. She came home to me and they asked

is she okay?

Well, I will say I tried. I tried to make my mind turn from mommy to doctor. I tried to think clearly but.. it did not happen. Thankfully, her dad was wise and took his little girl with the near-ruptured appendix to the hospital.

I’ve also missed a few broken bones. Correctly pegged headaches as nothing to worry about. Ignored appropriately, several random stomach aches and, imagined cancer at least a half-dozen times.

The New England Journal of Medicine reports the dangers of treating our families. The American Medical Association advises against it. Many hospitals forbid it. I am a fine doctor. I am the best mother my kids have. I should not though, have to play both roles. But, I do at times and during those moments I hold my breath and try to avoid the worst while I summons a brain-shift from mommy to doctor.

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Trying on The Coat

Posted on October 9, 2012 | 1 Comment

I spoke with a patient’s mother this week. She said that she was sure doctors hear this all the time but… “thank you.” She explained that it seemed what we do must become commonplace in our minds. That we could not really grasp the meaning to her as a parent, of the work we do. She thought I could not understand how much it means that her child is alive and I found it hard to answer her. “You are so very welcome” of course came to mind. Beyond that I felt a bit tongue-tied.

A friend of mine lost a beloved family member recently. The tragedy is overwhelming. So overwhelming that when I was talking earlier to a mutual friend he commented that it was bringing up his own past struggles. He said he felt as if he was “wearing her coat” of pain along with her.  Yes. Exactly.

I have at times shouldered that same coat. In random dark moments my mind slips into thinking about my children’s mortality. Just last night as my eldest drove off in the minivan (a hot date car for certain), I called out to him to “please drive safely!” As if that call out could prevent anything. But still, as my mind wandered towards the worst, I tried. Last year a child I knew (out side of work) died in a heart breaking way. It took me months to stop waking up on the occasional  dark, early morning in a cold, silent panic imagining the pain that her family must feel. I imagined the tragedy, the event. I dipped my toe into their shoes. I wore their coat for a bit.

How could simple words tell my patient’s mother how well I understood her thanks? While I have not walked in her shoes, I have tried her coat on at times. Doing so gives me the strength to reach out and help her more fully. And to answer her that “No, what we do is not commonplace at all. I too feel the wonder of a life helped.”

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Physicians, Burnout and Rust

Posted on August 26, 2012 | 2 Comments

When asked last week to write an article about physician burnout I had to laugh. Really, laughter was the only choice. After all, laughter is indeed good medicine. You see, lately I have been feeling an increased affinity for the 38% percent of practicing physicians reported to be burnt out, according to the most recent issue of the Archives of Internal Medicine.

A sad number isn’t it? Burnout is a syndrome described by a triad of emotional exhaustion, detachment or cynicism,  and a low sense of accomplishment. The authors, Shanafelt, et al. used the gold standard Maslach Burnout Inventory to assess burnout in over 7000 American doctors.  Try these numbers on for size:

  • 46% of all physicians reported at least 1 symptom of burnout
  • 37% felt their work schedule did not leave  enough time for personal or family life
  • 38% of US physicians had high emotional exhaustion, 30% had high depersonalization, and 12% had a low sense of personal accomplishment.

All of this brings me back to a conversation I had a few years back. I was out of residency and had been working for Kaiser for some time. Long enough for the penny to seem a bit less shiny. I was enjoying a glass of wine with friends around my old backyard table. One of them, a pilot and I started talking about work. Our careers, which we had long dreamed of having, and for which we had worked incredibly hard, were in ways somehow lacking.  As cool as being a doctor or a pilot sounds when one dreams it up, in the end what you have is a job that has long hours, enormous stress and may not fully pay your bills. Too cynical? Maybe.

As I read about physician burnout for this article, it occurred to me that perhaps we were making too much of ourselves. The Pub Med search entry “physician burnout” yields no less than 1,233 articles. Are we really that much worse off than the rest of the population? Well, yes we are. The Shanafelt study compares our rate of burnout to that of population-matched controls and  suggests that

the experience of burnout among physicians
does not simply mirror larger societal trends.

And, burnout in physicians has disturbing consequences. This study also measured the rates of depression and suicidal ideation amongst doctors, both found at alarming levels. Emotionally detached doctors are less likely to be empathetic and more likely to make errors. They are more likely to leave the profession altogether.

I met with my financial planner yesterday for a regular review. We talked about this issue of burnout for a while. I learned that he has been concerned by the increasing numbers of physicians sitting before him to ask how they can afford to get out of the field. Pauline Chen in this week’s NY Times writes that this trend

has serious repercussions in a system already facing a severe doctor shortage as it attempts to expand coverage to 30 million or more currently uninsured Americans.

So what do we do about this? I read a good dozen articles on burnout. Each offered a similar list of platitudinous suggestions for the suffering colleague. Exercise more. Spend more time with loved ones. Consider a change. Set limits at work. Only this recent article by Shanafelt et al. delves into a discussion about the need for evidenced based recommendations and system-wide change.

Most of the available literature focuses on
individual interventions centered on stress reduction
training rather than organizational interventions designed to address the system factors that result in high burnout rates…Given the evidence that burnout
may adversely affect quality of care and negatively affect physician health, additional research is needed to identify personal, organizational, and societal interventions to address this problem.

As to my own fight against the  burnout triad (loss of enthusiasm for work, cynicism and a low sense of personal accomplishment), I am on most days winning. I do find that the best approach is humor. My patients make me smile. I find enjoying the bond with my patients and their families can get me through even the hardest days. I do not tend to be cynical by nature so when this mood hits me it can truly seem comical – as if I am doing a bad imitation of a cranky doctor. To maintain a sense of pride in my work I try to continue to challenge myself by aggressively reading about any new patient diagnosis or diagnostic dilemma. Outside work, by taking on jobs that challenge me in new ways like writing, bike repair and learning German. I do this to avoid the apparent alternative to burnout presented first by President Millard Fillmore and later, Neil Young: rust.

And, when I have a vacation I work hard to follow the Dalai Lama’s teaching:

In dealing with those who are undergoing great suffering, if you feel “burnout” setting in, if you feel demoralized and exhausted, it is best, for the sake of everyone, to withdraw and restore yourself. The point is to have a long-term perspective.

Vacations do not involve using the electronic medical record, email, Twitter or my cell phone. But these steps are only stop-gap measures while I and nearly half of the physicians in this country await more research and, perhaps more importantly, system-wide changes.

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Fun with Spring Fevers and March Madness

Posted on March 11, 2012 | 2 Comments

Last year I wrote about Why February is Hard for Pediatricians. I think, today it is time for Why March is Fun for Pediatricians. Why? The air is warmer, the flowers are bursting forth, I put my veggie garden in…the fava beans are getting tall. Spring is indeed here. But these aren’t my answers.

In medical school we were all faced with the challenge of choosing our specialty. Some of us knew from the beginning, some struggled with the decision. For me there was never any choice but Pediatrics. My reasons were a mix of meaningful and perhaps less so. Besides finding a field of medicine that is interesting and exciting, to choose well you also have to consider what social issue you are willing to confront. I found it much easier to help people parent than to help the same people confront their smoking and drinking habits.  I would rather be a child advocate than work to repair years of self-inflicted health damage.  The less weighty reasons for choosing Pediatrics? Easy: kids smell better. And, they make me laugh.

So in this month of spring fever and madness it seems that the sillies have come out in my patients! Enjoying their antics has made me very happy with the choice I made!

  • Last Tuesday one of my patients didn’t say much to me, didn’t answer my questions and drooled constantly; she spent our entire time together sucking on her toe.
  • As one little 5 y/o left I said to him “Bye, handsome!” He turned to his dad and said “see Dad, all the girls think I’m handsome!”
  • I had a well child check up with a 6 month old who giggled so incessantly every time I touched him that his parents and I started laughing with him; we laughed so hard we all had tears and I had to sit on my stool and take a break before I could focus on his exam again.
  • Yesterday, one of my patients was too busy to let me examine her. she had taken out my entire herd of plastic dinos and a book on dinos and was matching the plastic ones to the paper ones page by page. It took a while.
  • One father was irritated at his son who refused to let me look in his ears. The blackboard needed erasing…every single tiny bit of chalk needed to go. It was a slow process so, I gave up and got down on the floor to erase with him. When we were done we stayed there to deal with the ears.

What adult medicine doctor has this much fun with their patients? Then, there were some other kids….

  • One girl on Thursday decked me full-fisted in the nose when I tried to look in her ears.
  • Last week when I opened a boy’s diaper to examine him he looked me straight in the eye, smiled and peed full-stream ahead all over me.

Oh well, at least they smelled good?

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Two Patients: Trusting Intuition in Medicine and Life

Posted on October 13, 2011 | 2 Comments

Sick or not sick? This is the snap judgment all physicians make in the second they first view a patient. This is what they ask as they open the exam room door or pull back the curtain around the gurney. “Is this patient in front of me sick (in a way that means I need to act now to save their life) or not sick (ill but, someone I can patch up in some way and send home)?” Much of residency training is aimed at making sure young doctors leave with this skill finely honed. But, is it a skill or an innate talent that is hard to teach?

At the end of a recent clinic day I had just two patients left. I walked into the first room and inwardly groaned. This one was sick. However after hearing the history I started second guessing myself; it all sounded very reassuring. And, as we are also taught in medical school – the history is 90% of the diagnosis. Maybe I could treat and send this one home for the night? However, I had a gut sense, a hunch, that home was the wrong place for this child. That snap decision of sick won me over and I was right. The child was sick.

The next exam room held a child who I immediately felt was fine; not sick. But, the more I listened to their story the more I worried. There was some real potential for hidden danger. Then I was left wondering – how much of a workup should be done on this well-appearing child? Since the history had given me cause for worry, labs and a CT were done to prove that this child was indeed, not sick.

Later I commented to a friend on this sick vs. not sick judgment we make. He pointed out to me that likely this is based less in instinct and more in hard facts that are processed by our minds before we notice the processing. He felt that in a blink of an eye, on a subconscious level, I connected the dots I observed:  reassuring history or not this patient was sick!

Perhaps but, I have met well-trained, intelligent doctors who struggle with this talent of intuition. In medicine the hard facts are obviously of tantamount importance but, our instincts need to complement our intelligence. Malcolm Gladwell wrote in his book Blink: The Power of Thinking Without Thinking:

 The key to good decision making is not knowledge. It is understanding. We are swimming in the former. We are desperately lacking in the latter.

Another friend of mine is in the process of making a life-changing decision. His sister challenged him by asking how he could make such a choice with barely any evidence of it being right? He explained that it felt right, that his gut told him it was right, that to make this choice made him feel like he was returning to home. Gladwell might say to his sister that:

our world requires that decisions be sourced and footnoted, and if we say how we feel, we must also be prepared to elaborate on why we feel that way…We need to respect the fact that it is possible to know without knowing why we know and accept that – sometimes – we’re better off that way.

In his 2005 commencement address at Stanford, Steve Jobs spoke in large part about trusting one’s intuition both in career and in love.

you can’t connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future. You have to trust in something — your gut, destiny, life, karma, whatever.

I wonder what Jobs would make of this concept of the balance of science and intuition that physicians face with every patient?  In our personal lives it is clear he felt trusting our gut was the way to go. He left those Stanford graduates with wise words:

have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.

 

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A Twinkling Metaphor for the Path Towards Health 2.0

Posted on July 28, 2011 | Leave a comment

In my ongoing stream of consciousness about art and medicine a new connection has worked its way to the surface. Medicine it seems, is in a state of flux, a state of change and evolution. The hubbub about this is alive in Twitter feeds and on many physicians’ blog sites. The dialog has been centered on the role of media in healthcare, of the use of the internet in patient care, the grooming of new medical students to be our future leaders. The path forward towards the grand new world of health 2.0 is a shifting one with moments of clarity and moments requiring innovation and faith all discussed hotly in the world of social media.

This flux is nicely brought to life in a work of art I recently enjoyed. The artist Charles Sandison produces digital installations of grand physical and philosophical scale. Moving, flowing, changing and in the case of his “Origin of Species”, evolving. This piece is made of points of light swirling around the walls and corners of a darkened room. The lights coalesce at times, into words and form – two words at a time -  the entire text of Darwin’s manuscript on evolution. As words meet each other they form the next words in an unscripted display that will take two years to be completed.

when the word man meets the word woman, the word child is produced; and when man or woman bumps into the word threat, the word dead replaces them ~ Ken Johnson

This seems a fine metaphor for our collective musings on the path forward for medicine. The lights in our heads form words that meet in the blogosphere to merge and change into the next iteration of ideas. This forward progress may take some time but – won’t it be great to watch? I would love to see what Sandison would come up with to display our collective efforts as we evolve.

Perhaps on the wall of lights that describe healthcare 2.0 in words two by two we would see that:

“social” and “media” will merge into “expected”

“empowered” and “patient” will merge into “reality”

“work” and “balance” will merge into “obvious”

©

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On Turned Exam Tables

Posted on July 18, 2011 | Leave a comment

I was asked recently by work to write an article for a newsletter about physicians’ experiences with illness. My response to this request was to say that I have been trying to write this very article for a few months and through my efforts I have experienced a new “illness”. It is apparently, quite a powerful one and has had me in its grip for some months now. Its name is writer’s block.

Tonight though, relief has come – in the nick of time. I was reading a NY Times article about a minimalist sculptor Carl Andre. It was entitled “Less is Less” which set me thinking. I started a blog site to challenge myself to improve my writing, to practice writing and to observe myself in the role of writer. One observation to date has been about how story ideas come to me – usually by an odd trickling of input from multiple sources coalescing together to form a lit-light bulb moment of “Aha!” and then, out it flows. No different today. After weeks of struggling with what message to write about from my way too many experiences on the other side of the examination table, that title “Less is Less” did it.

Less is less? Huh? What? I thought less was more. Exactly! That’s it! Every time I began to write about my experiences with being on the other side of the exam table over the last few years, I had too much to tell. I, doctor come patient, tried telling all the stories and giving all the advice I could. But that was too daunting. Instead I find myself thinking, when telling a story, sometimes less is more and,  in the world of forming a bond with your patients? Less is definitely less.

Five years ago, I ruptured my appendix while on vacation in Hawaii. When I made it back to the mainland I faced surgery and a week-long hospital stay. Being the patient it turns out, really is hell. And the worst? The worst was that easily 75% of the people involved in my care did not introduce themselves, leaving me to feel lonely and objectified. From the phlebotomists and radiology technicians who worked without verbal identification, to some nurse and doctors. Yes, doctors. After the initial ED doctor took his history, the nurse gave me some blessed pain relief and the CT was done I waited. And, waited. Then, suddenly into my room burst a young resident who abruptly leaned his forearms on my the rails of my gurney (ouch) and said “So! You have an appy!”. I was tired and in pain so forgive me when I tell you that I looked at him and said in my best attending voice, “I am Dr. Land. And, who the heck are you?”.

This spring I managed to tear all of the hamstring tendons off my pelvis. The repair for that gave me the chance for another stay in the hospital. What a difference five years have made in the quality of care! Every single person introduced themselves and explained why they were with me. They spoke in terms anyone would understand. From the nurses and technicians to the people cleaning my room and the doctors. Yes, the doctors.

This is where more was so clearly more. At my first meeting with my surgeon he entered the room with hand held out, eyes on mine and a calm smile. He sat.  He began by asking about me, about my family, about my job. He cared! He went through my chart in careful detail – family history, medical history, medication list cleanup…. all for my hamstring tendons. I was left feeling that if he cared to take the time to hear about my children and my job, if he cared that my mother and father both had lymphoma, that I no longer take Prilosec then – Wow! He must care about me and he must be a very detailed and thorough surgeon. At my first post-op appointment he asked first how I felt. How was I handling the long weeks of braces and crutches and being non-weight bearing? Then he asked how my daughter was recovering from her  appendectomy (that last bit falls under the category of “when it rains it pours”). Only then after these kind moments, did he dive into what he was there to accomplish.

I learned much from these two times on the patient side of the exam table. Overtly stated, when we as physicians begin properly the rest falls into place. Start with a slow, calm, eye-held introduction. Get to know the person you are with. Then, proceed forward in your work as their doctor. From this beginning success will follow.

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Understanding the Family: the power of a careful social history

Posted on July 10, 2011 | 4 Comments

Perhaps it is my week to be inspired by others blog posts. In the post Do You Like Your Pediatrician? Yolanda MD comments on the importance of forming an emotional connection with patients. After the first visit to her baby’s pediatrician she felt ambivalent about the experience because the doctor did not:

ask any personal questions to get a sense of who we were as a family. … I would expect that knowing the social context of a new patient is an important step to building rapport.

Recently a colleague of mine retired. When I joined the practice 11 years ago he took me under his wing. We are both athletes at heart and love to see patients who are athletic themselves.  Sports injuries were fun for both of us; he taught me lots about broken bones, sprains and tears. He was emotionally wise as well. It was him I turned to fess up to a third not-so-well timed pregnancy. I had just been hired and was fearful of being let go after a trial period so I hid in a too-large white lab coat until I was 20 weeks along.  Then one afternoon I screwed up my courage and sat in his office.

I, um, have something to tell you….

Now I can still remember my sense of peace and confidence when he simply smiled and warmly said his congratulations.

When he was close to leaving our office this winter I battled my own sense of loss by asking two things of him. I asked to have him refer those patient-athletes to my practice and I asked for some of that emotional wisdom. Specifically I asked him for his advice for bonding with the difficult to win over parents and patients. How did he handle the hard to convince or the distant families?

It is likely many a young pediatrician is caught up by the same struggle. My friend’s answer was a simple one. Slow down and really get to know the family as a whole. Ask about their lives outside of our office. Be sure you know what they do, where they live, what motivates them.

This was easy advice to follow with parents that I had a natural affinity for, less so for the ones that challenged me. But, by focusing on his wisdom I have learned to not take it personally when a particularly overbearing mother asks for yet another unneeded lab test; I now know that she had a sister die of lymphoma. I understand that one child who returns again and again for very small issues has both parents newly out of work, they are seeking control of something in their lives. One seemingly aloof mother that puzzled me became clearer when I began to understand more about her marital struggles.

Indeed, “knowing the social context of a new patient is an important step to building rapport”. In fact, it is crucial and the gift of better understanding our patient’s families is a gift worth working to receive.

©

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Launguage Matters

Posted on July 2, 2011 | 12 Comments

Language matters. The words we choose can have far-reaching impact on those we interact with. This is arguably more true in medicine than in any field.

Ryan Madanick wrote a recent blog post on the use of descriptor terms used by physicians in patient’s charts. He felt that the use of phrases like “is a very pleasant 52 y/o woman” or “is an unfortunate 16 y/o boy” is inappropriate. I agree. However, in response to this post one reader commented that he felt Dr. Madanick was nit-picking. He isn’t.

When I see such comments in colleagues’ note I wince. I was taught well by attending physicians who appreciated the power of language. I was taught to leave judgements like “pleasant” and “unfortunate” out of my notes. I was even taught not to use the ubiquitous term “complains of “or complaining of” (as in Mrs. Jones is a 43 y/o woman who complains of stomach pain”). When I was a medical student I had a trauma surgery rotation. The attending during that time was a wonderfully dynamic and caring man. One morning he brought his wife to rounds to listen in (this was pre-HIPAA). Afterwards he asked her what she thought of the experience. She was outraged. Outraged by our use of language. The patients who needed us most were “unfortunate”, “demanding” and “complaining”. Those we liked were “pleasant” and “stoic”. Those we did not were “difficult”. She asked how pleasant, fortunate and stoic we would each be if we were stuck in the trauma unit after a  car accident left us unable to walk or, a bullet to the chest left us struggling to breathe pain-free? She volunteered that it was likely we would all be pretty darned demanding and complaining.

These words aren’t only judgmental and fault-finding, they are dangerous. Dangerous in their tendency to narrow our thinking. I had an experience early on that made this point loud and clear to me. Before seeing a patient one night I was handed the chart by a nurse who asked if I knew the child. I did not. She went on to tell me how difficult the parents were and how the kid was a “frequent-flier”. I glanced at the chart before seeing the child and read a few notes all with comments about this “unfortunate” child and her demanding parents. Several days later I learned that after seeing me, and returning to another physician she eventually presented to the ED in extremis. I sat down alone and went back over my visit. The only error I could find in my care was one of perspective. I entered her room biased. Biased by descriptive words used by the nurse and found in her chart that should not have been used. Did I miss her diagnosis because she was in my office too early in the disease process? Or did I miss it because I was viewing her as a complaining frequent-flier with difficult parents?

When we enter into care for a patient we need to approach them as if they are a tree of possibilities. The choices of diagnosis and the decisions around care should be narrowed not by our own bias and judgment but by careful medical thought. To speak of our patient’s with critical descriptors is not only rude but it is medically dangerous; doing so hurts them, and leaves us at risk as well.

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Putting A Name To It

Posted on June 26, 2011 | 3 Comments

Four years ago my brother-in-law suddenly, and to us unexpectedly, committed suicide. It was a violent and selfish act, devastating in a far-reaching way. He hurt those who loved him, and in unforeseeable ways he hurt even those who did not know him. My children had loved him and were stunned. Their classmates in 6th grade, 3rd grade and kindergarten who did not know him, learned the story from our kids. Imagine! The children in my son’s kindergarten had to learn about suicide far too soon; it was impossible to keep the story silent in our relatively small community. And yet, would silence have been desirable? I think not.

To help my children grieve and to have a designated time to remember his life we have begun a tradition. Each year  our local chapter of The National Alliance on Mental Illness (NAMI) holds a sunflower art contest. The contest is held during the same week he died. We talk about ideas for our entries for weeks then, come together and work, creating individual and group entries. Our neighbors have even joined in. It gives us a set time to personally or collectively, openly or silently think about him.

This year after painting some fabulous flowers, our neighbor Delaney felt stumped. The contest entry asked for a name. What a challenge! Delaney agonized. I suggested that leaving it untitled was acceptable and tried to explain that many of the best artists do just this. But untitled felt, I am guessing, unfinished.

Shortly after I had the good fortune to be walking through a fabulous museum soaking up the art there. The titles kept jumping out at me. Certainly many artists do leave their work untitled but, often an artist is asking us to focus our attention in a direction of their choosing. Richard Wentworth’s room filled with books floating suspended above our heads is named “False Ceiling”. Perhaps a gesture pointing us towards the falseness of the notion that books contain all knowledge in unbiased, unlimited form? At first Tony Cragg‘s sculpture in the Istanbul Modern Museum looks like a study in sinuous, sensuous form. But after reading the title, “Ugly Faces” that is all one can see. Gone is the sexy sculpture, leaving behind just faces in profile. Ugly ones.

Which brings this rubber band story back to my brother-in-law’s death, those kindergarteners, and the efforts of NAMI. By naming the thing in front of us we make it hard to ignore like those “Ugly Faces”. “False Ceiling” became a statement that was hard to stop thinking about. By being comfortable with naming depression we cannot ignore it, we make treatment attainable. NAMI strives to help us put a name to what is all too often right in front of us. To name it allows us to help those who suffer. To leave it untitled allows us to make our own personal and perhaps incorrect interpretations. Wentworth said:

I think I shouldn’t give things titles. I sometimes cringe at it. But it’s like naming the cat. There is something about the act of nomination — sometimes I really love it, like launching a ship.

Sometimes we cringe from naming the suffering in front of us. However, doing so might launch a ship or two…ships of hope.

©

Delaney’s painting? It was enthusiastically named “Bust a Bloom” .

A gallery of some of our sunflowers:

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Balanced Lives – with gratitude

Posted on June 22, 2011 | Leave a comment

Two weeks ago I sat in an open air cafe in Istanbul lazily eating mezes or appetizers, drinking dubious Turkish wine and talking with my godmother. What a gift! As we sat and chatted the conversation turned where it usually does between two doctors. Boring anyone around us, we always seem to find a way back to the days of our training, trading war stories from the hospital days.

In this case my paltry stories were truly weak compared to hers. Her training was Herculean. She graduated from the University of Virgina medical school sometime in the early 60s as one of two women in her class, did a residency and fellowship in the South Bronx and has just recently retired from a career as a hematologist. Her hours were brutal (every other night for every year), her education never-ending. If every minute out of the hospital is indeed education lost, she lost little. Except sleep. Among lots of riveting tales of patient care challenges, there was one striking personal story. Late in her residency she was at last granted three days off for Christmas. On Christmas Eve she drove from New York to Virginia but became terribly lost on the familiar drive because of a haze of illness setting in. She arrived on her parents’ doorstep at 2 AM exhausted and feverish only to sleep through most of Christmas and drive back to NY the following day. When she returned to work an attending noticed how ill she was and sent her for labs that ultimately revealed mononucleosis. This was thrilling to her – two weeks of enforced time out of the hospital! Who cares how ill she was – there was freedom and sleep before her!

My experiences as a medical student and resident could not have been more different. Although I trained before there was any attention to national limits on resident work hours, I certainly did not have every other call at all, let alone for years. I managed to insert a pregnancy into medical school, one into residency and much to the chagrin of my now-colleagues, one the first year I graduated. I did not have to become ill to find a balance in my life (although I may have been equally sleep deprived thanks to the 3 kiddos).

I just finished reading a thought-provoking post by Doctor Chris Porter. He wrote of the need to shift our mentality or thinking about hours worked in the hospital. He felt it benefits our profession to be accepting of a balance of hours in the hospital (learning more medicine) with hours out (nurturing our families). How true. I am a product of the shifting tide of thought. I am also made very grateful to those pioneering sorts that went before; listening to my godmother talk made me even more acutely aware of the gifts they gave us today.                               ©

 

 

 

 

 

Addendum: Dr. Porter has another wise post on his blog site: On Surgery, “The Part-Time Doctor”. In it he states “Openly planning to balance work life with family life is mature and admirable”. Hear, Hear!

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Learning to Sit Still on a Spinning World

Posted on June 4, 2011 | 8 Comments

When I was first a mom I was astounded on a daily basis by the experience. Not to mention, exhausted. The now 15 y/o then wanted to nurse constantly.  For hours on end, day and night we would sit together – him happily suckling and me? Well, honestly I was bored. There was a certain low-level trapped feeling; a feeling of being stuck yet again sitting tethered to the little creature. Don’t get me wrong, I loved breast-feeding and we made a great team. It did however, take a while to settle into the experience. That settling came when I learned to enjoy those moments of enforced peace.

There is great beauty to sitting absolutely still and giving into the process of nursing. I had to relax and let the world spin around me – the clothes unwashed, the dinner cold, the business of life unattended to. And in those moments of peace I would often think my clearest thoughts.

Again I find myself forced to sit still on a spinning planet. Forced by an injured leg, to let go of the multitasking productivity the working mother in me prizes. My family laughed at me last night as they scurried around on their good legs and I sat on my hurt bum watching them. They laughed because I mentioned that having my hamstring tendon torn is a lot like breastfeeding. Huh? No one stayed around long enough to hear why; but I kept thinking about this idea. My life is so full of mothering and work. So full of electronic medical records, blogging and Twitter. So filled out by friendship. So full that I lack, almost completely, time for quiet reflection. Now, in a space without the ability to scurry I am left sitting and relaxing. A novel experience? No, but one that is nice to return to.

I am reading Twila Tharp’s book The Creative Habit. She has taught me much about my own developing creative habit. One of the first chapters talks about the squelching effect on creativity of background noise. Noise both literal and figurative. She suggests turning off our computers, our music and skipping the newspaper for a period of time to understand the effect they have on us. That was hard advice to swallow; I have always worked with music playing. I started to drive my 20 min to and from work without the radio. At first the silence was a bit uncomfortable but as the days passed I found that my mind was productively wandering. Bits and pieces of my days were knitting themselves into coherent stories as I drove quietly along.

Breast feeding, healing and silent driving. Less tweeting, less laundry, simpler dinners. Soon I may be positively Zen-like sitting here watching them all run around. Hopefully I will at least, synthesize a few blog ideas while I watch.

©

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Vulnerability, Becoming a Better Doctor and the Beach.

Posted on May 7, 2011 | 2 Comments

I like to keep a separation between my workday and my home life. It is created by a walk to my car and a 20 minute drive home. During this time I think, create and often, ask myself how I can be a better doctor tomorrow. Lately, I have been thinking the answer lies not in reading more books or journals, timely license renewal or peer review. The answer it seems, lies in feeling my own vulnerability.

I had a patient this week who was perhaps, a bit challenging. I was overloaded, behind, late. She was not doing what her parent and I needed her to do. Frustration started to enter the room but, as I sensed its arrival I stepped back (literally) and looked at my patient. Then, it hit me. She wasn’t trying to be non-cooperative (that horrid, judgmental, doctor term); she was feeling vulnerable. Scared, hurting, feeling… at a loss. Being ill or hurt makes it hard to be brave, strong and – cooperative. The more time we physicians have the “opportunity” to feel this vulnerability, the more we become able to feel what our patients and their families feel.

Maybe I should not take vacations. I seem to end up worse for the wear after many of them. Hawaii the first time found me in preterm labor and complete bed rest at 20 weeks. Scary then, but now he is 15 and perfectly fine. Hawaii again led to a ruptured appendix and way too much time in a hospital bed. Most recently, a sparkling San Diego day disintegrated into an explosion of pain as my skate slipped on a patch of poorly placed sand. I was left immobilized for a handful of weeks and am now facing a ridiculously long period of rehab. Each of these beach-side mishaps left me stranded, forced to slow down and experience the world as many of my patients have had to. I felt acutely vulnerable. Pain. Needles. Limp. Weak. Dependent. All of this bringing to mind an often quoted passage:

“Did you ever say yes to a pleasure? Oh my friends, then you also said yes to all pain. All things are linked, entwined, in love with one another.”

“What does not kill me, makes me stronger.”

- Friedrich Nietzsche

Yes to vacation? Then risk yes to… learning. For I have found during each stint with vulnerability my skills as a physician do become stronger. But maybe on my next trip (in June with my mother and Godmother in a faraway seaside city) I can take a holiday… not just from daily life and work but from learning?

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Pink and Purple Circles

Posted on March 10, 2011 | Leave a comment

Promoting arts education is crucially important for our kids. Before I leave the background discussion of why I need to address one last point. Arts education is often taken to mean creating and performing art. Art history is also of value. This involves art criticism, the academic study of art with its stylistic and aesthetic context. It gives us the ability to understand the sublime that is art.

Briefly, three ideas for why the contextual study of art should be included in the standard arts education:

  • Understanding what influences the framework that art hangs on allows a more enjoyable connection with it. This is likely better explained with an example. My kids all went to a wonderful parent cooperative preschool. On my workdays there I loved being at the art table. Over the years I became increasingly impressed with the influence the children had on each other’s artistic styles. There might be three kids at the table painting away. One more would join in and start painting say, concentric pink and purple circles. Soon I would notice lots of use of pink and purple and lots of circles appearing across the table. Over time I worked with the teachers to form a yearly art exhibit where we hung the kids art on the fences in the school yard. It was grouped by period and context. It was a joy to see how the kids had developed together! This ripple effect or evolution of style is seen in our study of major schools of art. Artists influence each other and create an ongoing evolution of artistic style.
  • An understanding of the evolution of tastes in art generates acceptance of diversity. Artists through time have often been scorned when they challenged commonly accepted ideals with new approaches. They take a new approach that eventually becomes the accepted norm (think pink and purple circles). Seeing this progression as it has played out repeatedly through time can teach kids an acceptance of new thinking, new looks, innovative approaches. It can help them be less judgmental of differences in those around them.
  • Understanding the mechanics of creating art is valuable. Artists work hard. Really hard. They practice day in and day out in order to produce what can often appear simple. Have you ever looked at a modern painting and thought “I could do that”? Likely, you could not. Professional artwork requires both innate talent and earned skill. Understanding this can encourage and motivate a child in their own persistent efforts.

Art is more sublime when hung on a framework of understanding. You have more fun when you can see where the story behind the pink and purple circles. Then you might be motivated to go home and try some of your own.

©

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Black and White in Art and Life

Posted on March 6, 2011 | 1 Comment

I am having a bit of a free association sort of rainy Sunday. Funny about our minds isn’t it? The way we can unconsciously shift through the bits and pieces of what we read or hear during the week to come up with a theme of sorts. What follows is the intersection of learning about the great dance choreographer Twyla Tharp, the painter Caravaggio and thinking about a few failed interactions I have had with patients through the years.

The Calling of Saint Matthew (1599-1600) by Caravaggio

Twyla Tharp explains in her book “The Creative Habit” that she prefers to divide people in her world into two distinct categories: acceptable or not, good or evil, “committed or missing in action”. While I find the book well-written and find myself inspired by her advice, I was bothered by these comments. I recognize that for her this commitment to embracing the extremes rather than the grey zones is artistically motivational but for me, it grates against my own approach to people. I prefer to work in a grey zone embracing the nuances of the personalities I find around me.

Michelangelo Merisi da Caravaggio was an Italian Baroque painter in the late 16th century. He is known for dramatic, dark, richly and realistically depicted paintings of an often religious theme. He is also known for having been a murderer. Good (artist), evil (killer) and yet, to view him fully as one of these extremes we would miss the other side to his story and miss the influence these complex components of his persona have on each other. We would make an error of judgment.

As doctors, we give our best care and make our best diagnoses when our minds are open. I remember a professor in medical school telling me to begin my care for every patient by imagining that the patient’s illness was a tree that I stood at the foot of. A tree full of possibilities. As I tried to figure out their diagnosis I was to consider climbing along a branch chosen after a pruning of other possibilities by listening to their history. The physical exam would allow a deeper cut of the choices, lab tests, xrays and time allowing me if fortunate, to end up on the right twig with the right diagnosis.

I read a blog post today about errors made when “hysterical” E.R. patients’ complaints are dismissed.  Someone loudly and dramatically requesting that they want a certain pain medication in a busy E.R. does tend to get ignored or, written off by the doctors and nurses who care for them. These patients are judged rather than treated in the grey zone of acceptance and this judging can lead to medical errors. This brought me back to two times in the past when such bias crept into my patient care. In both cases I was “warned” before entering the exam room that the patient or parent was difficult in some way causing me to walk into the room seeing a tree with already pruned branches. And indeed, I ended up on the wrong twig at the end of the visit.

Twyla Tharp is a supremely talented artist whose approach to slotting people into good or bad fails me both creatively and humanistically. Caravaggio was a troubled man with a gift; art influenced by his turmoil or, a man of grey shades. Patient care is best done with a clear eye towards the complexity of human nature.

©

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Connections and Bonus Questions

Posted on March 1, 2011 | Leave a comment

I just read “18 Stethoscopes, 1 Heart Murmur and Many Missed Connections” a fabulously written article in the New York Times by Madeline Drexler. She tells her story of being a model patient – a person with a medically interesting “finding” who is asked to help teach medical students. These “patients” are examined by small hoards of inexperienced medical students who have little knowledge, little skill and varying degrees of innate bedside manner.

I was fortunate enough to go to a medical school where we began examining patients – real and staged ones – from month one. I still remember many of these people well; more clearly perhaps, than those I cared for in my sleep-deprived haze of residency. As Ms Drexler describes, I am certain that back then, I too was filled with awkwardness and overtaken by my interest in the examination findings at the cost of expressing empathy.

There is one that comes to mind now. He was a model patient for my final exam in a class on physical examination. I think he might have been the bonus “question”. I had studied hard. I was tired. He was in a room behind a door I nervously opened to find the answer to what exactly was different (medically speaking) about him. There in the room, on an exam table sat this young man. He may have been 25 or so. Dark haired, bespectacled and calm. I approached him and began the work of examining his body for a “finding” of sorts. Heart, lungs, abdomen… all depressingly normal. Mouth, neck, ears…getting closer. Then to my joy I found “it” and remember well the thrill when I did. There was a big part of me that wanted to say ” Woo Hoo! I did it”! Ms. Drexler describes this reaction in other students:

“This was a student who is not uncaring or unkind,” Dr. Treadway told the class. “But in that moment she did something all of us do all the time: she was so engaged with the problem that she forgot about the person who had the problem.”

I had a favorite attending doctor in medical school. Everyone else was scared of him. I looked up to him. Sure, he asked the hardest questions and embarrassed me at times. I stood tall with the knowledge he was doing this to make me better. And, when I watched him with patients and parents I saw that all of his sternness evaporated; he became the most caring doctor in the hospital. He asked, as Ms. Drexler reminded us to do, about how it felt to be stuck there as patient or parent. When he was talking with a family it seemed that perhaps, time had stood still. He had no where else to go, nothing else that mattered more than the people in front of him.

I think of this man often. He motivates me still. And, what I know now after all these years, is that I am still learning. Every visit with every patient I strive to become better at listening, interacting, understanding. I reach for the ability to make them feel that time has stood still in that room with them. I am not there yet but – reading Ms Drexler’s words and remembering my attending’s gifts help me feel that I might, just might get there some day.

P.s.: The answer to the bonus question was prosthetic eye.

©

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The Patient’s Worst Fear or, questions that take my hand off the doorknob

Posted on February 19, 2011 | Leave a comment

In medicine physicians often talk about the patient concerns that come up in the moment we are leaving the room. The “oh by the ways”. The comments that come when the doctor has a hand on the doorknob, one foot out the door. Mostly, these are simple, quick requests (work notes, PE excuses and the ilk). But every now and then they are real humdingers.  Yesterday I had one of those moments, and it got me thinking about what I do and how I do it.

Work has been busy lately. The clinic is full of kids with colds, earaches, and influenza; lots and lots of sick kids. The volume of patients is pushing us to be very time efficient, very focused in our approaches to care. Yesterday in the afternoon a teenaged patient came in with several separate non-urgent concerns. We worked through the history, examination and plan for each of these and I needed to move on to the next patient. Make that patients – four were waiting. So when, as I was touching the door handle, their parent asked her if they wanted to tell me about another issue I admit that I inwardly groaned. Outwardly I explained that I had four people waiting and that maybe we could schedule an appointment next week to discuss this concern. But something was bugging me about the atmosphere in the room. Some alarm beeping in my head made me stop, take a deep breath and ask if I could on second thought, hear what was worrying them.

It was one of those moments that highlights how much of medicine is an art. Much of being a good doctor involves having an emotional intelligence that helps us know when to take our hand off of the door. I wish that I had never actually reached the door. I wish that I had responded earlier in that visit to the little alarm in my head.

There is lots to read on the internet now about how a patient can prepare for a visit with their doctor. Ideas about advocating for one’s healthcare. Making lists of questions to ask. All often form good advice. I would add this piece of advice for patient interaction with physicians: state your fears upfront. Tell the doctor what your biggest worry is. Tell them what keeps you up at night. Doing so is important for several reasons. We can often calm your worries better if we know what to approach. You are your child’s expert and have input that is valuable to us. We may though, need to schedule another appointment. And, of course if the doctor manages to get out the door without knowing that last “oh by the way” humdinger we may have failed to treat the one medical symptom that actually would have scared us and kept us up at night.

My teen patient will be fine now but they needed that last moment of my attention. Without it they would be very ill today. The other four patients? They waited and understood that I was late because I had been helping another child. They understood that I not been off doing my nails or reading a novel. That is for today.

©

For more insight into the approach physicians take to office visits read this excellent outline by BrianVartabedian. It absolutely sums up how I also try to structure a patient visit.

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Why February is hard for Pediatricians

Posted on January 31, 2011 | 2 Comments

It has been rough in the office lately. January is always rough for pediatricians…February is worse. Everyone and their sister is sick, the doctors all get sick too, those of us left standing work extra….Oh well. At least the great thing about pediatrics is that the kids are still cute and make us smile.

Part of what makes the days hard is also that many of the parents who come into our offices are exhausted from lack of sleep and worry. They need our help also. But when so much of the time all we have to offer is the dreaded diagnosis of yet another viral  infection  they feel frustrated. Sure, parents come in for reassurance – they want the piece of mind found in knowing their doctor did not hear a pneumonia or see an ear infection. However, much of the time there is often the hope that they will be handed a medicine that will help their child and get the parent some much-needed rest. I know. I’ve been there; I too have kind of secretly hoped there really was an ear infection to be found because I knew that could be “fixed”.

Too often we can’t offer a fix; we can only offer the diagnosis of “viral infection”. Let’s face it – that is read by the parents in our office as having the subtitles: “I’m back on my own with my sick child” “no sleep tonight” “I wasted my money/time”.  And for us as physicians honestly, handing over the diagnosis that clearly deserves an antibiotic is much easier, much more satisfying than saying yet again… it is “just” a virus (of course this concept of a viral infection being a “just” could take up a whole other blog post).

Then there are the even harder visits when we find an ear infection but need to embark on the discussion of “to treat or not”. Claire McCarthy, M.D. recently posted a wonderful article about this very discussion: Shades of gray: Why medicine isn’t always as clear-cut as we’d like. Her words and perspective have stuck with me through the past rough days at work. They have helped to reassure me and to guide me.

The practice of pediatrics is not unlike the practice of parenthood: full of uncertainty, impossible to understand completely and done best when the child is more important than anything else. We’re coming at it from different places, but we’re in this together.

Thank you.

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Lice again? It is nice to know we learn.

Posted on January 22, 2011 | Leave a comment

Last year I wrote an article for patients at work incorporating the American Academy of Pediatric’s recommendations for the treatment of head lice. Their recommendations and my article we aimed at being calming and reassuring. Lice are indeed gross but – they are not harmful so we mothers need to calm down a bit. As I was writing it I remembered a certain mother’s day I had and changed the article to include this introduction and summary:

Picture this: 0630 Mother’s Day 2008 morning …my dear daughter climbs into bed with me to read a book and snuggles up in the crook of my arm. I decide I will have to do without the dream of sleeping in on mother’s day in order to well, enjoy being a mother. I give into the joy of her good morning love and snuggle in with a nuzzle of the top of her sweet head…only to find….Arrrggghhh! Lice nits! Good grief, what a way to start the day, any day let alone Mother’s Day! So, I did what most mothers would do jumped up and entered into panic/action mode and spent the day (btw that was supposed to be my day) washing, picking nits, combing, doing laundry, vacuuming and cleaning. Let me emphasize the laundry; I totally went overboard with the laundry and did dozens of loads!

And that is really where we need to begin here. So, let’s take a few deep cleansing breaths together (lice tend to reduce the most composed mothers to crazed hyperventilating insane people – me included). Now I know and believe much of what I put my self through that day was unnecessary. We as a nation are too afraid of lice. Yes, they are really, really yucky. Yes, we don’t want them on our children’s heads. However – lice do not hurt our kids (deep breath) and they do not live well or long off of a human head so huge cleaning efforts are unnecessary (deep breath). Having lice is common, does not mean you or your house is dirty and, happens to the best of us (breath).

My Mother’s Day 2008 ended up with a very clean house, 3 slightly traumatized children and 1 exhausted mother. Next time we have lice, and there will likely be a next time, I hope to be able to breathe my way through a more rational response!

So, this week when yet again I was reading and snuggling the very same child and looked below to see…could it really be? Nits? I was able to indeed breathe, relax and not go so overboard. She and I both survived relatively unstressed which made me realize that I too learned in the process of interpreting information for my patients. Glad to know that the deep, subconscious part of my brain that reacts in horror to the idea of bugs on my child was soothed by learning the facts. Education is indeed powerful.

It of course also helped that after a good shampooing the white stuff went away – proving the point that even the “professionals” mistake dandruff for lice!

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