The Bubble of Medical Education

This past weekend I hosted a screening of The Vanishing Oath and was fortunate to meet the director, Ryan Flesher, MD. Face-to-face, he was upbeat and passionate about film and music and his current topic of physician burnout, which contrasts with his portrayal in the film. (His documentary tackles a tough topic, so it is no wonder he is less than cheerful in it.)  He was brimming with ideas on how to expose a side of the healthcare story nobody wanted to tell and which most of the public think they don’t want to hear. Dr. Flesher is observant and a good listener, too, which I imagine is essential to documentary-making, as well as doctoring.

The topic of physician disillusionment came up in the Q&A’s after the screenings and also in a conversation I had with Dr. Flesher. For years, doctors-to-be are in an idealistic bubble of medical education. I felt that not only could The Vanishing Oath educate the public regarding some of the interference in the doctor-patient relationship, but that it could also help medical trainees be more realistic about their career path. Dr. Flesher made the point that, in some ways, medical students and residents have to be idealistic. “They have to be.”

Do they have to be? This idea has been mulling around in my brain since then. It seems that the very thing that contributes to physician burnout is the very same thing that makes a well-meaning 17- or 18-year-old with little knowledge of the world decide to become a physician. Idealism or a sort of delusion must be a necessary factor in a doctor-in-training’s ability to endure – in the words of a friend – “the abuses of medical education.” Would anyone in her right mind sacrifice seven+ years of her youth taking endless tests (some 8 hours long), being demeaned at times by attendings, nurses, and some patients (yes, patients, too), and amassing around $200,000 in debt by the time she is just starting residency? A smart, cost-aware person would pass and might choose an easier path with work-life balance and financial success in another field, such as becoming a CRNA.  

However, I suspect that we, as a society, do not actually want the kind of doctors who are “doing the math.” We subconsciously expect our doctors to be selfless in every sense, foregoing relationships (check), social life (check), family life (delayed), money (check – in primary care). We don’t really want the kind of doctor who is thinking in dollars and cents for himself. We would have had a lot more self-serving physicians and an even bigger healthcare crisis if that were the case.  Shortly after I completed my residency, some non-medical business-minded relatives urged me to get my own practice and to buy an MRI machine. Why? So I could run a bunch of unnecessary scans and reap the profit? Needless to say, the dollar signs didn’t sway me from my morals.

Interestingly, I found that medical residents were among those who were the least moved by the description of The Vanishing Oath, which touches on why some doctors are leaving clinical practice. And now I understand. These are individuals about to graduate from residency. They are not only still in the bubble, but they are also moving towards the light at the end of a very long tunnel. Unfortunately, for some individuals, it is more like a mirage in the desert. As physician burnout occurs earlier and earlier in the current U.S. healthcare system, Dr. Flesher’s film could be a great starting point for discussion on how one might deal with it if it happens.

Perhaps, in some ways, it is best that doctors start out in a bubble of idealism, knowing very little about the business and reality of practicing medicine. The bubble has to stay intact in order to survive the process of medical education.

****

P.S.

Dear American politicians,

Please be kind to your idealistic physicians who, without much business sense, decided to stick it out on a grueling path that just doesn’t add up in today’s economy. Be kind for they care for your children, your parents, and you. 

Thank you.

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Why the Show Must Go On

Last night, I attended a concert put on by Robert Plant and The Band of Joy. It was an excellent performance. Of course, to see a legend perform is always amazing. There is something about witnessing someone in his element that is so inspiring. The energy in the theater, particularly towards the end of the performance, was infectious. The crowd, which appeared to span the age range of adolescence into the 60s, was mesmerized and star struck. (And a few were perhaps a little under the influence of something else that my olfactory sense detected).

I have written before about music and medicine and its value for a physician. It is very personal, as well. Music is inextricable with my life. Having started playing the piano at age 5 or 6, then the clarinet in grade school (and then other endeavors best left to be discussed in person), I have learned much about life through musicianship. Three years ago, I took up the guitar and have been hooked since. I was fortunate to find an excellent teacher who possesses equal patience for a busy physician who tries her best to practice and for 4-year-olds with significantly limited attention spans.

Each year, my teacher arranges a “recital.” This is not your average recital. In fact, it is called “The Jam.” You can play solo or have a band backing you up. You can even sing, if you care to share your voice. During the first year of my lessons, I declined to perform. At that time, I hadn’t performed in a few years and felt uncomfortable now that had become a physician. Why would people want to see a doctor strumming a six-string? Would I be held to a higher standard? When I started taking lessons, I was conflicted enough about what it meant to be a doctor and to continue to pursue music that my teacher didn’t know what I did for a living for at least a year. At times, I questioned why I was even taking the lessons. Somewhat of a Type A perfectionist, I would often get frustrated by slower progress than I was expecting, and I have contemplated cancelling my performance in these recitals at the last minute, including a performance coming up next week (!).

Before a public performance (which I simultaneously look forward to and dread) my heart races a bit and my palms get a little sweaty. I know what I should play because I rehearsed it over and over and I can hear it in my head, but it all comes down to this one very short moment in time. I get a little anxious. I don’t know how I will be received. I might even mess up. The faces of the audience may express boredom or perplexity or excitement. Ideally, at the end, I would feel support from the audience. Otherwise, my fears of dismissal or even disapproval will come true.

Does this sound familiar?

So, last night, as I was watching the performance of legendary artist and growing nervous about mine, I was reminded why this hobby has value for me as a physician. What I described above could just as easily have been a patient experience in an office visit. Sure, it’s not a crowd. It’s definitely not a hobby for a patient. But the pathophysiology and emotions involved in facing a doctor during a relatively brief office is similar.

Most people seem to prefer to “perform” in life within a realm of comfort or mastery. But there is something to be said for trying something with which you are not familiar. When we tread uncharted waters, we remind ourselves of our vulnerability. There is nothing like a bit of nervousness or fear to remind you of your humanness.

This is why, despite my nerves, the show must go on.

Wish me luck.

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There is a Plan B (and Sometimes a C,D,and E…)

Let’s say you are a patient and you see your doctor for a rash. He evaluates you and gives you a cream to try. The rash doesn’t go away. What is your next response?

  1. Go to another doctor because that first one didn’t know what he was doing.
  2. Go to another doctor because the first one did not recommend a follow-up appointment.
  3. Use the cream for longer than the recommended period of time
  4. See a naturopath because you would prefer to try natural therapies.
  5. Call the initial doctor’s office for instructions.

 I hope your answer is #5.

 Unfortunately, I see choices #1 and #2 too frequently in real life. Why do I find this unfortunate? These options can lead to fragmented (expensive) healthcare.

Sometimes, a physician does not explicitly detail out all of the thoughts that go along with diagnosing and treating a patient, especially when rushed. They may come up with a diagnosis and treatment plan in minutes, but there is a lot of cerebral processing that occurs within a single patient visit. There are pros and cons to revealing all of this information. Pro: better understanding by a patient of the issue at hand and that there are other possible diagnoses for a single problem. Con: information overload and more confusion.

In the interest of time or of not overwhelming a patient, a physician may focus on the most likely diagnosis and not mention others or talk about them in detail. And, trust me, there are almost always other possibilities. It is rare to see a patient who has only one potential diagnosis when first evaluated. Even a simple cold can have what we call a list of “differential diagnoses” (a list of other causes for the same symptoms).

The inherent problem with only talking about the most likely diagnosis is that a patient walks away with an impression that there is only one potential diagnosis and one treatment plan. If physicians are not clear about follow-up and the treatment fails, patients may feel that perhaps they were “misdiagnosed” and they may look for another opinion.

Physicians should be better at informing patients at least about the next step by addressing what patients should do if their treatment does not work as planned. I try to do this consistently. A common parting statement I make is, “If this is not working as we discussed, [come back or call our office]. If I don’t hear from you I am going to think this issue has completely resolved.” Of course, for more serious issues that I want to monitor, like depression or uncontrolled hypertension, I plan a follow-up appointment. But for relatively minor issues, I don’t want to waste a patient’s time or block my schedule for other patients who need to be seen when an appointment is not necessary.

Doctors, try not to let the patient leave the exam room without a follow-up plan or at least letting her know she can contact your office if a treatment isn’t working.

Patients, keep in mind that – even if unspoken – your doctor has a plan B, and may even have plans C, D, and E in the back of her mind. If you’re tempted to get another opinion for an issue you just had evaluated once by another physician, consider not “giving up” too easily on that initial doctor. It would be wise to see if the doc has an alternative recommendation. I would be surprised if she didn’t.

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Twitter Church

Engaging in Twitter as part of healthcare social media can feel a little like being part of a church. Here’s why:

1. There are preachers and notable figures (those with higher Klout scores) and there are followers.

2. There are prophets (proposing the healthcare of the future).

3. There is a belief in a metaphorical “witchcraft” (poorly supported healthcare information that most doctors engaged in healthcare social media are trying to dispel.)

4. Nonbelievers (skeptics) do not attend.

5. Nonbelievers are being encouraged to convert. (Recruiting other healthcare individuals into social media).

6. Reading your Twitterfeed is like getting your “Daily Bread.”

7. There are a lot of “Amen!”s from the crowd (apparent as comments or retweets)

8. Support and advice are freely given within the group.

9. There is a desire to reach the farthest corners of the earth (with the goal being the safety, health, and well-being of patients.)

10. Oh, and the most obvious similarity? If a regular attendee is missing, people start to worry (“Has anyone seen @insertnamehere?”).

By My Side

EMRs and iPads may come and go, but I can count on one thing. I realized this last week, when I walked into a couple exam rooms without it. I felt suddenly naked and out of sorts when I entered the exam room whitecoatless. Yet it was not the lack of uniform that flustered me, but rather something more important – believe it or not – than a CT or MRI. It assists my judgment and corroborates hypotheses in a few minutes. It makes the difference between life and death at times. It is often used to help confirm time of death, in fact. 

So basic and resilient is this trusty sidekick that I have underappreciated at times, having recently fallen under the spell of such things as healthcare communications and social media, iPads, and other expensive pursuits/gadgets. Perhaps a bit of technology and information overload has led me to suddenly appreciate the most “primitive” aspects of my profession, which have been so taken for granted that I was completely unaware of it’s unavailability in other countries

I speak, of course, of my stethoscope.

I got mine at the start of my focused medical training. Somehow, it was slim pickings at the medical school bookstore at the beginning of the year. I was left with one of a color that was less than appealing to me, thinking I would, perhaps, replace it when I became an attending. It was quite a steep purchase for a student living on loans and Rice-a-Roni. But it has given me MANY returns during our thirteen years together. And I have not swapped it out for another color (though I have contemplated adding some “bling” to it, ultimately scrapping the idea due to a realization that it would be quite a hassle to clean). 

My boring green stethoscope, in fact, has helped me through codes on the hospital wards, alerted me to carotid stenoses, confirmed suspicions of fluid on the lung, gave me evidence of pericarditis, and even doubled as a reflex hammer. In the age of expensive disposability, my stethoscope has only needed to have its earpieces replaced once. And I might have to do it once or twice more in my clinical lifetime. I do not even know if one of these things can actually be broken. It also has not yet been replaced by a flashy fad. Does anyone really need to upgrade their stethoscope?

My stethoscope is my constant companion, even when I am evaluating a rash. (You never know what you run into primary care, after all). It is the workhorse of medicine, undervalued and underappreciated, much like primary care today.

A Question for the Reader: White Coats

One of the easiest Halloween costumes is to put on a white lab coat. You would be instantly recognizable as a doctor.

I am exploring the White Coat further. What does it mean to you as a patient or a physician? What do you think of doctors who choose to wear them or not to wear them? Is it a power trip? Does it give you, as a patient, a sense of confidence in that physician? Would a different color be preferable?

My question is being posed on Twitter (#whitecoats) and on Facebook. Let me know your thoughts there or comment on this blog post.

I promise that a summary post will come of this….