Two years in review (one in stealth): a career transition

I had intended to post this around New Year’s day along with others who were sharing their reflections of the year past. And while an unexpected event delayed this posting to the point that it no longer seemed relevant, it has become clear to me that some of my readers have not been kept abreast of my career transition. I’d like to share the details of a whirlwind 2 years but it would be the length of a short novel, so here I take a brief look back and share a key point related to being a doctor in a startup in healthcare. 

At the end of 2017, there was little I could say about what I was up to. A year prior to that point in time, I had fully transitioned from practicing full-time primary care to eating, drinking and breathing start-up life. It was a crash course in product development and machine learning at a company that was in stealth mode. My family and peers had know idea what I was working on, but they were curious about the transition.

The first question people ask when I say I closed my practice to work at a startup is “Are you glad you’re working less hours?”

Let’s rewind. I was a young female Internal Medicine doctor working full-time in a large multi-specialty physician-owned Seattle practice, on call for my own patients every night except for weekends, when call was rotated. (I became more and more aware of this being a rarity when the jaws of those I relayed this to – primary care doctors themselves – would gape in shock.) I had good access, a fairly streamlined flow, and a great group of office staff (every doctor knows how critical and valuable this is). My physician-owned multi-specialty group gave the top floor of a beautiful new building in Seattle to the Internal Medicine Department. We Internists felt valued.

No doubt, the work was hard. The paperwork and messages were never-ending. I worked at least an hour and a half almost every night. But I knew what else was out there and how doctors in other health systems worked. I also explored concierge practice and felt the model didn’t align with my values or primary goals at the time. Direct Primary Care (DPC) was a strong consideration. Still, despite moments here and there of wondering what else was out there, I felt I truly had a pretty good thing going and appreciated the organization for which I worked.

It was, thus, serendipity that I came across a job description for a primary care doctor needed for a Seattle startup early in 2016, when I was neither burnt out nor actively searching for something else.

No, it was not about the hours.

 

 

 

Making the leap

Being observant of technology that came out of Silicon Valley, and mostly disenchanted with the leadership in the area at the time and the apparent values – I had been following the Theranos story closely –  I was skeptical but curious. Would a healthcare startup based in Seattle have a better culture? Would it last? 

In residency, one of my attendings had said that it took about 15 years of practice for doctors to really feel they’ve got it down, hit their stride. 15 years. Imagine hearing that now. By the time I answered this unusual start-up job description, I was already at 10.5 years of full-time work (and roughly twice the experience of colleagues working 0.5 FTE). Taking this new job was a risky move. Yet, I was always drawn to the tech side of things, particularly how it relates to usability in multiple areas. I had been dismayed by the way product after product was being developed in ways that kept missing the mark on being actually useful in the healthcare ecosystem or being short-sighted to the point that primary care doctors have to pick up the pieces.

So, after multiple talks with the CEO of the startup and verifying that both of us had an aligned vision, I went from running codes in the hospital to running code….or so I like to say fully tongue-in-cheek ever since a couple of our engineers showed me how to do a little of that.

 

Not breaking things

I learned firsthand what “moving fast” really looked and felt like, and more importantly, when to quickly hit the brakes on a plan and what to anticipate. Moving fast thoughtfully without breaking things is paramount to changing any system that touches people so intimately. This absolutely applies to healthcare, but not solely healthcare.

Failure is the best option….for learning

Though we are careful not to “break things” as a company, one of the most valuable parts of my experience thus far is learning how to fail. It turns out, trying not to fail 100% of the time is time and resource-intensive and unproductively aspirational, particularly when the path to doing something new has not been paved yet. I was forced to keep the risk-averse side (ubiquitous among doctors) in check. There are many articles and books that emphasize the importance of failure. Nowhere has the learning curve around this been as steep for me as in a startup. 

Looking forward

We’ve made big strides since we were a small company of 17. I am looking forward to what lies ahead in 2019 and beyond. No doubt it will include some uncertainty and some failures, but it will be mission-driven and exciting all the way.

Social Media Encourages Initiators in Medicine

Funny how the blogosphere echoes some of the thoughts that have been incubating in my own mind… A few posts have caught my eye recently. One that I have been meaning to comment on was Dr. Vartabedian’s piece “Do You Initiate or Respond?” which characterizes physicians, in general, as trained responders rather than initiators [give it a look, it’s a quick read].

I had myself been concurrently pondering the same idea (though classifying it as reactive versus proactive in my own mind, but we mean the same thing). As Dr. V points out, doctors are reflexive and very much good at it.  We are nimble thinkers on our feet when faced with problems, calculating a large number of variables to try solve problems in -let’s face it- a very short period of time, all the while doing our best to navigate through a myriad of emotions along the way. The importance of this notwithstanding, I wonder if immense talent is being untapped when leadership (aside from hospital/clinic administrative roles) and innovation is not instilled, honed, or even valued from the start of medical education to the end of one’s career.

After all, how much can one learn about leadership when working essentially in isolation (particularly in the outpatient setting) and with a compensation system that rewards “doers” more than “thinkers”? Sure, doctors can work effectively with their medical team and with patients. But the creative energy and solutions that can come from putting some of the brightest minds – ones who work on the frontlines of medicine – together to really tend to the larger problems in healthcare has been sorely missing.

Physicians who blog or create content online are Initiators, and their passion for innovation can awaken the creative part of the mind that has been quieted by the noise of daily clinical work. (If you tell me that part of your mind does not exist, you really have not gotten your head out of the charts for some time). And this is why I keep coming back to social media despite the growth of my full-time practice and its demands for my time. When used more as a learning tool rather than an advertising tool, social media can do more to teach a doctor about leadership and initiation than can a lifetime of working in a clinic or hospital.

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Difficult Interactions in Medicine: Lessons to be learned from the food service industry?

She sat in her crisp, white coat, probably not much older than I am now, leaning back with all of the assurance of someone who recently completed a cardiology fellowship, newly hired by the academic medical center to which I was applying for residency. One of the first of many interviews for me, the conversation was anything but smooth. She clearly wasn’t sold on me. To remain genuine and avoid canned responses, I never bothered to research popular interview questions. Unfortunately, that also explains why I fumbled a little bit when answering “What three people who are not alive would you like to meet?” 

I had just about given up on getting a good review from my interviewer, especially considering that she had already met some of my brilliant classmates whose parents worked for the same institution. But she had one more question for me. “So,” she said, twisting her chair to the left with her arms crossed, looking at me a little sideways. “What makes you think you would make a good doctor? What have you done in the past that makes you think you would be a good physician?”

My answer was ready…and not because it was rehearsed. It wasn’t the volunteering in nursing homes and Habitat for Humanity. It wasn’t the good grades. It wasn’t even because I was a caregiver at one point or because I had spent countless hours in labs.

 “Waitressing, actually.” I said this without hesitation and with an even tone. “I learned a lot by interacting and talking with customers.” I knew I was taking a chance with this seemingly unsophisticated response, but I didn’t seem to have much to lose at this point.

“You know,” she said, looking surprised, suddenly animated, and mildly… exasperated? She turned to face me square on now. “My best friend keeps telling me the same thing. I don’t get it, but she keeps telling me that it’s true.”

And then the ambience changed.

***

This having been my – paraphrased – experience years ago, I could not ignore a recent article entitled: “Do Starbucks Employees Have More Intelligence than Your Physician?”

The short answer is: Yes… and No, of course.

Articles like this paint a sharp caricature of the emotionally “unintelligent” physician. Here, Dr. Peter Ubel points out that Starbucks employees “undergo rigorous training in how to recognize and respond to customer needs,” and he describes the Starbucks solution for dealing with unpleasant interactions, called the “Latte Method” (listening, acknowledging, taking action, thanking, and explaining).  He contrasts this with the physician whose nose is buried in labs, insensitive to the emotional needs of his patient.

Needless to say, a barista’s work and a physician’s work are not quite the same. A negative interaction within a doctor-patient environment is less like one in a food service industry and probably more similar to one experienced, say, by an airline customer service representative and a customer who finds himself unexpectedly stranded after his flight is cancelled, trying to get home in time for his mother’s funeral. (A free coffee rarely solves this sort of problem.) The intensity of emotions tends to be quite high, the variables are many, and there can be a certain level of uncertainty that is uncomfortable for both parties involved. AND, there are multiple other people waiting in line with other high-intensity needs. There are certainly some doctors who seem oblivious to the emotional state of their patients. But there may be other factors, as well. For example, a burned out physician will find it difficult to empathize, and physicians who are essentially running on hamster wheels may feel too pressed for time to address complaints effectively. That being said, I happen to like the “Latte Method” described in the Forbes piece, as it can be applied to various aspects of our personal lives and across different industries.

A lot more work should be done in early medical training to help future doctors acknowledge and effectively deal with the unpleasant interactions between doctor and patient. Out of training now for some years, I was interested to hear about a group called The Balint Group, which focuses on exploring the doctor-patient relationship. Our clinic, The Polyclinic, has a Balint Group, so I decided to join and explore this subject some more. In this group, the meeting begins with one physician presenting a recent difficult or uncomfortable interaction. The rest of the physicians then discuss it by exploring both sides: what it must be like to be the doctor and what it might be like to be the patient in the case. It is very non-judgmental and not meant to be a problem-solving session. While many times there is no one right answer, the mere act of thinking about and discussing this topic can help improve interactions during the regular workday. I would recommend The Balint Group to any physician with an interest in the doctor-patient interaction.

Perhaps Dr. Ubel is on to something when he suggests that Starbucks employees have more emotional intelligence than physicians. Until these goggles that help detect facial cues become available and universally accepted, doctors will have to rely on their own radars, which may be fine-tuned with some more training. While I am not sure I could survive the Starbucks pace at this point, I did sign up some time ago to be a volunteer server for a local culinary and job training and placement program called FareStart. Who knows? I may come back a better doctor for it. 

A Message Worth Repeating

I thought to myself, “I am not going to post a link to this article. It has been circulated many times already on Twitter over the past week.”

But I read it. Not once. Not twice. THREE times. I shared it on Twitter twice.

And I changed my mind.

When doctors recirculate a blogpost over and over again, especially one about such a thing as death, they are sending us all an important message.

So, I share it here with you, as well:

How Doctors Die. 

After you read the article, if you do not know what a POLST form is, please see this link.

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Scalpel, Forceps…Pen?: The Role of Creative Writing in Medical Education

A recent article in The Wall Street Journal reported a trend on teaching humanities in medical school to comply with a recommendation to teach compassionate care. While clinical acumen is important, empathy is a trait that really enables a physician to connect with his/her patient, thereby improving the healthcare experience of that patient. The argument for teaching courses like “narrative medicine” – where students write about their experiences – along with anatomy and pathology, is that exploring and understanding the human side of medicine will enable these doctors-in-training to grow into compassionate physicians.

Writing about medical training is not a new concept, however. I had a chance to sit down with physician-author Emily R. Transue, MD*, who started Mind, Body, and Pen, a creative writing class for medical students that is offered every winter (an ideal time for self-reflection in the Pacific Northwest). She has been teaching this class voluntarily for eleven years at the University of Washington Medical School. In fact, she has had to cap class enrollment to 15 students due to high interest and to optimize the experience for both herself and her students.

“Writing is about honing and maintaining skills for empathy,” Dr. Transue says. She argues that the vast majority of students who apply to medical schools are actually quite empathetic. However, during the course of traditional medical education, empathy can be “beaten out of them…. There is little opportunity for self-expression, and [medical students and residents] don’t have a sense of permission to be affected by experiences.” Dr. Transue’s class gives them that permission. It allows students to process some of the challenging aspects of becoming a doctor. By writing about the death of a patient or the strain on a young marriage, students have an avenue to help bring emotions and feelings “outside of their heads.” In addition, the medical students, who are notoriously competitive, listen to pieces written and read aloud by their peers and have to resist the urge to “one-up” each other. It encourages focused listening and reflection on another’s emotions.

If medical students are inherently compassionate, at what point are the skills for empathy being squelched? Dr. Transue feels the answer may actually be in the culture of residency. Medical residents are role models for impressionable medical students. Historically, the prevailing culture has been one of proving your worth as a physician. This means being a “gunner” at all costs. Not showing weakness. Being a sort of superman in the face of extraordinary circumstances (life, death, illness, sleep-deprivation, strained relationships, depression). Medical students are learning the ropes – more than just the clinical ones – from these residents and the cycle continues.

Humanities courses can allow medical students to maintain their already empathetic nature. But to continue to preserve it, exercises that allow for reflection of clinical experience in real-time would be valuable in residency, as well. It is during this stage that burnout rates are high and critical decisions are being made regarding specialty choice. One might argue that courses similar to Dr. Transue’s creative writing class could increase the likelihood of residents choosing to practice in primary care fields.

*Emily R. Transue, MD is the author of : On Call: A Doctor’s Days and Nights in Residency and Patient by Patient: Lessons in Love, Loss, Hope, and Healing from a Doctor’s Practice. She practices at The Polyclinic in Seattle, WA.