Category Archives: Medicine

Caring for the Butcher, the Baker and the Candlestick maker

I started my current job straight out of residency full of knowledge but short on experience. To bridge that gap I leaned on the experience of my more seasoned colleagues. Day after day I would show up in one of their doorways with a question about  patients I had left waiting in my exam room. The need for this support was humbling and I was glad to find that as time passed largely so did it. Now years later, the cycle has shifted and I enjoy using my built up experience to help our newer physicians.
A few years ago when one of my early mentors was about to retire, I stopped by his office after work to ask one last question.
Before you go is there anything more I need to know?
He was clear:
Get to know your patients and their families. What do they love to do? What are their jobs? What are their struggles? Who are they outside our office?
That one piece of advice has made all the difference for me.
I recently heard of a surgeon who follows this same advice . He pauses before beginning a procedure to tell the OR team about the patient who is lying anesthetized before them on the table:
She is an Iraq veteran, a mother of three, and likes the Bee Gees.
By doing so he humanizes the experience invaluably. If we dig deep to connect with our patients, we form bonds with them that create trust.
This advice has not failed me. I am happier in my work knowing that I am caring for children of firefighters, air traffic controllers, teachers,  a fashion photographer and children of pharmacists, veterinarians,  mothers who love to work at home, and a cookie baker. We become more connected when I learn that, together with their kids, they ski, travel, volunteer, train show dogs and that they sing, model, raise horses and enjoy hip hop. My care benefits from knowing their grandmothers and aunts, and the names of their pets.
So now, as newly hired physicians come to my door to ask me what labs to order, how to reach a specialist or to come to look at a rash with them, I want to add a bit more to my answers. I want to ask them if they know who their patients are, what their patients care about and what makes them smile.
Rub-a-dub-dub,
Three men in a tub,
And who do you think they be?
The butcher, the baker,
The candlestick-maker,
And all of them gone to sea!
Advertisements

S.T.O.P.ing at The Exam Room Door

I was at a work meeting recently. One meant to address physician “wellness”, but held ironically at my kids’ dinner and bedtime. We were given a stack of Post-it notes and asked to write down things that made us happy during our work days. I wrote:

  • laughing 6-month old babies
  • having time to get to know patients’ families
  • choosing stickers with my patients

The doctor next to me wrote:

  • no shows

Well, there is that. What doctor doesn’t dream of the occasional break in the schedule created by a patient not keeping their appointment?

One morning recently, I saw the name on my schedule of a patient that led me to spend the rest of the day hoping for a smile-inducing no show. When the patient arrived, I sighed a deep sigh but, then decided to test out some of the mindfulness-in-the-workplace practices I have spent the past few months learning. As I headed to the room, I thought to myself:

S for stop what you are doing (hand on doorknob, poised to enter into the room and

Take a breath. Stop thinking of the name on the schedule that brings you stress. Put aside the last phone call. Put aside worrying that the dog stuck at home alone might be eating the trash and the kids need rides to practice and that you need to be home on time tonight. Stop and

Observe how you feel. Yes, your jaw is, as usual, tense. Your leg hurts. Loosen those. Let go of the stress. Ask yourself what you can offer this family. What do they need from you? What can you bring to the exam room behind the door; what can you be open to? And then,

Proceed – open the door.

I have known this family that makes me hope for a no-show for many years and through several children. On that day though, somehow, we connected. I asked first how their ill father was feeling. I asked about their financial struggles. I asked how school was. Then I turned to the reason for the visit. It felt softer and easier to work together. We left with smiles and, for the first time in ages, they left without an antibiotic prescription.

I do not find this physician wellness, mindfulness stuff easy. All the deep breathing tends to send me off for a nap. But on that day, giving it a try worked well. I’ll be S.T.O.P.ing again.

 

 

 

 

 

Full Spoons at Medicine X

I heard a few people talking about spoons on Friday morning at Stanford’s Medicine X conference . They were wondering why artist-in-residence Rachel Stork Stoltz, had asked us all to bring a spoon to the conference? After listening in a bit, I leaned over and tried to answer their questions. The spoon theory was created by Christine Miserandino and is a powerful way of explaining to a healthy person what it feels like to live with a chronic illness. You start the day with a finite amount of energy and as you move through the day you use quanta of energy (spoons) with even the smallest tasks of daily living. You count your spoons and may find you do not have enough spoons (energy) left to do what you want or need to that day because of the demands of your illness.

At its best moments Med X was a masterpiece of collaboration. It was a bringing together of patients, physicians, thought leaders and innovators to work together to discuss the future of medicine. Our recursive efforts mirrored and repeated each others’ in a way that built a powerful basis of understanding to move forward with.

Pamela Ressler opened her panel discussion on communicating the experience of illness in the digital age with a stunning quote from Susan Sontag:
Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.
Using an understanding of this commonality allowed us to enter into a dynamic dialog. I left the Med X space with more questions than answers. The questions are in themselves powerful motivators.
  • How will I recognize the daily efforts of patients in the days of their lives not in my office?
  • How will I be as caring as an old-school physician and as vital as a fully connected 2.0 MD.
  • How will I allow a space of communication about patient’s emotional challenges (as well as those physical)?
  • How will I shape my efforts to motivate health change through social media?
We did bring spoons to Med X and used them to create a sparkly, swirling tower of energy. We were each asked to think of what saps our energy and what refills our spoon count. I paused between lectures on Saturday and stood in the sunny afternoon decorating my spoon with wire and beads and copper. I tried to think as I worked not only of my own energy but of the more carefully counted energy of patients with chronic illness and hoped that they too felt a renewed spoon count from the connections forged at Med X.
Photo (3)
Rachel Stork Stoltz and our spoons

MedX Day One – Going The Extra Mile

After this, the first day of Stanford’s  Medicine X conference, my mind is blown and my heart is full.

This word cloud of tweets today from @tmlfox Symplur.com analytics sums it all up well. BwyU7q0CYAAhFoo (1)“Patients” are at the center and are surrounded by “empathy”, “team”, “livestream” and “care. We see “relationships”, “mind” and “stories.” All are the spirit of MedX. All represent why I attend this amazing conference. There is the pure fun of the technology: tweeting, scanning our neighbor’s barcodes and using an app to request blanket deliveries. There are the people – each more inspiring than the next. The food is great and, have you met @therealzoechu?

At the end of the day though, none of that is really to the point. Instead, what matters is that I am left here pausing, quietly asking myself how I can be as caring a doctor as medical historian Barron Lerner’s physician father. He was a doctor of another generation. A generation of men faulted now for practicing paternalistic protection of their patients but praised for giving all to their work. They took call 24/7, they took every opportunity to reach out when needed, they went the extra mile.

In this era of technological involvement and focus, in this time of schedules and hurry, how do I go that extra mile? How do I pause and turn towards the person in front of me  take the opportunity to reach out and care?

Thanks @MedX.

 

 

 

Frozen

I have learned a new trick. On a busy day of seeing patients it is easy to run from exam room to office desk and off to the next exam room at a frenzied pace. The charts, the orders even the patients can blur a bit. It is not a way to move through my day.

Now before entering the next exam room, I put my hand on the doorknob and pause. I take a moment to notice how I feel, take a deep breath and let it go. I let go of what ever might be distracting me from what is behind the door. Then I turn the handle and focus more fully on the person inside waiting to see me.

One day last week when I opened the door there was some fun waiting for me. A boy had a wart that needed freezing with liquid nitrogen. It is a simple procedure that he had done before and he and I settled in to chat while I worked. Also in the room was his much younger sister – maybe five years old. This girl was wearing a dress and holding a rose. She was smiling and excitedly hopping from foot to foot but – not saying a word obviously trying hard to be polite and wait for me to finish up.

Now, this clinic day was as busy a day as could be.  But when my wart treatment was done and the bouncy little sister finally got her turn to talk, I listened. She said:

Please freeze it.

And smash it!

And so we did. I dipped her rose in the liquid nitrogen and handed it to her. With great joyful enthusiasm she smashed that rose into tiny fragrant icy pieces!

Then with wide smiles we said goodbye. She and her brother got their stickers. I went on, placed my hand on the next door knob and fully focused, went to the next patient.

The e-patient Paradigm Shift

A few years back, I hurt my leg. Badly. So badly, I wasn’t walking well at all, was predicted to never run, ski, swim competitively or, do what had injured me – skate. The injury was dramatically sudden, painful and scary in ways I had never experienced. My first doctor was unsure exactly what I had done. The next ordered the right test but told me there was no repair. The next consultant agreed.

Then a friend stepped in to help. He lives in Switzerland but even from that distance, managed to turn the tide for me. How? By going online and searching for doctors and surgeries related to my injury and by finding a support group of people who also had my unusual injury. He emailed me the link to the support group and I responded:

Thanks but, I’m not that kind of patient.

Don’t be silly, he told me. So I clicked the link and found a world of education and support. In that moment of clicking, I became an “e-patient”

This new term, “e-patient”, is meant to describe a patient who is involved in their healthcare as an equal partner to their physicians. e-patients use electronic tools. They are empowered, educated and engaged. They see the importance in being equipped with the tools to help make decisions about their care. These tools can give e-patients access to medical records, education about their condition, or the support of groups of patients like them. e-patients are producing a culture shift in medicine.

This culture shift is especially visible in the area of breast cancer care. It is perhaps best illustrated with the story of one specific support group. Two friends who are breast cancer survivors teamed up with a breast surgeon from L.A. to start the support group #BCSM. It is held every Monday night as an hour-long “tweetchat” on Twitter. These three women explain:

While other physicians and academics debated how health care could even be discussed in social media and patients were warned to “be careful with research on the Internet”, two important facts didn’t budge. The Internet was not going anywhere. Neither was cancer. This year, some 290,000 women in the US alone will be told they have breast cancer. The need for #BCSM was clear. The project was on.

The mission of this impressive group is to support, educate and empower patients diagnosed with breast cancer. Patients meet and discuss their situation online to come out of the isolation that cancer diagnosis and treatment can create. Last Monday, 156 people actively participated and through their discussion, sent 2,724,048 impressions to their Twitter followers. Every week, expert physicians are invited to add “perspective and clarity” by discussing evidence-based recommendations and research with the group. The #BCSM support group’s mission has been accomplished through this inspiring model of weekly collaboration between physicians and patients. Both benefit.

This shifting paradigm is one we physicians may respond to with trepidation. We can feel irritated and challenged by patient involvement. And our patients do not respond well to our irritation. We are highly trained and this expertise gives us the ability to make informed decisions. However, our patients, especially those with chronic or unusual conditions, are also experts. They know about their own unique experience and through research can often know more about their specific diagnosis than their generalist physicians do. Patients can have an expertise to contribute to our decisions.

While I did not face the sort of life-threatening illness that catapults many into their role of e-patient, my experience taught me much. I see clearly that a well-educated patient has much to offer us. Seeking, supporting and trusting that input will serve us all well.

Fall and the Flu Vaccine: Believe.

I am tired. And, I’m not the only Pediatrician who is tired. It is fall, the traditional calm before the storm of sick patients that hits our offices every winter so why tired?
Because, visit after visit we hear parents tell us that they “Don’t believe in the flu vaccine.” Really?
  • In 1900 influenza was the leading cause of death.
  • In 1918 Influenza killed between 50-100 million people worldwide.
  • It is estimated by the WHO that in 2009 the H1N1 strain of influenza killed up to 575,400 people. 
So, I ask, what is there to “not believe in?”
The flu vaccine does not give you the flu.
Influenza is not a cold.
It is not the stomach flu
 
In 1918 every mother in town would have been beating down my office door to protect her child against influenza. They believed in its power. I have had influenza twice, once was H1N1 in 2009. I too believe in its power and yes, I get my flu shot and give the nasal vaccine to my three children every year.
As Seattle pediatrician Wendy Sue Swanson said:
In the medical community, we’ll work to undo myths around vaccine safety for the rest of our lives.
We may be tired but, it is a battle worth continuing.

All the Cool Cowboys Eat Yogurt (or, Nutritional Soundbite #3: limit drinks that taste sweet)

Two of my patients came into the office recently with their parent for check ups. I was a bit late coming in to see them so, started of with the all too familiar apology. Then we chatted about the heat and then summer books, movies, camps and camping. I asked what questions they had and, they asked if they needed shots (one did, one did not – always awkward to explain, that one!) All the while I realized I was stalling, dancing around the issue at hand.
Both children have weight problems. Technically speaking, their body mass indexes or, BMIs  are well out of the normal range or, in the range we physicians rather horribly term “obese.” They are both attractive, happy, smart and one is really quite funny. They like each other, they are respectful and fun. How on earth am I to find the words to tell them they are dangerously overweight without wounding their young confidence? Without alienating their parent?
I breathed in and began with the usual questions and followed with a display of their growth charts. It turned out the family had already been discussing change. They were walking each night. They were trying new veggies and thinking about serving sizes. I asked about what they thought I wanted them to drink?
Water!
And, what do you drink?
Juice! Apple and orange!
Ah, there was the change to focus on. I offered the rule of thumb that one 8 oz cup of juice a day has enough calories to cause a 15 lb weight gain over a year. That one usually works. But the parent looked at me and said with an exhale
But, it is just so hard to say no.
I get it. My 17 y/o son has a close friend that I adore. They have know each other since preschool days. I have watched this boy move from sandbox play to stellar sports play,  through cowboy costumes to awkward gangsta-style hats and now to be a rather stunning, clean cut young man. He is at my house often and when he arrives he walks straight through the door, around to the kitchen and opens the refrigerator. Spoon in one hand, he then heads to the boy-den in the garage with his bounty. It makes me happy every time. There is something in my refrigerator that he wanted? Cool.
We get such joy out of feeding our children. I cook well, my kids eat well and usually healthfully. My refrigerator staples are rather boring from a kids perspective. But, every now and then I will head off to the store and come home with some major treats. Watching the glee that comes as the kids root around and find these treats is fun. I feel, oddly as if I have done a good job. But after a bit, I get a bad taste in my mouth (and it is not from the chips 🙂 )
In fact, doing the right thing by our children means being a bit tough. Don’t buy the juice. Definitely skip the soda. Cut up the apples and put them in a central location. Skip the chips. You’ll never know what they learn to like. My friend the cowboy-gangsta-lacrosse star? He devours, container after container, case by case, high-protein, low sugar greek yogurts. And, go figure, all this time I thought I needed to bribe them with junk.

Of Babies and Donuts

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.

box

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

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

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.

Trying on The Coat

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.”

Physicians, Burnout and Rust

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.

Fun with Spring Fevers and March Madness

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?

Two Patients: Trusting Intuition in Medicine and Life

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.

 

A Twinkling Metaphor for the Path Towards Health 2.0

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”

©

On Turned Exam Tables

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.

Understanding the Family: the power of a careful social history

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.

©

Language Matters

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 other 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.

Putting A Name To It

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:

Balanced Lives – with gratitude

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!