Kids get it.

Children never cease to amaze me.

During the holidays in our office, we had on our checkout desk a simple white Christmas tree the size of an 8oz paper coffee cup. It lit up and was a small part of our festive décor. As one of my patients checked out after an appointment, her daughter went right up to it, took in an audible and pleasantly surprised-sounding breath, and couldn’t help but exclaim, “Oh. It’s so beautiful!” A medical assistant and I just looked at each other and exchanged touched glances at the purity of the emotion.

Children are surprisingly forgiving, too. One minute they are upset about something a friend did, and the next, they can quickly find a way to look past it and be playful again. They are more resilient than we give them credit for. They want to be happy and they want others not to be sad.

Which is why I was both touched – yet not that surprised – at how some 1^st graders in Minnesota supported the Viking kicker who missed what should have been a winning field goal in the last few seconds of last week’s football game against the Seahawks. I was happy for my Seattle team, but couldn’t help but feel for Brian Walsh. Anyone who’s ever worked in any field (medicine or otherwise) that involves making and executing critical decisions in an instant understands that type of weight. And like medicine, though football is considered a team sport with many players, in the end, it can be one person who ends up shouldering (or feeling responsible) for a bad outcome. Even the understandably upset Vikings coach, who should lead his team as an example of sportsmanship, made an unsupportive, frustrated quip to the media after the game. Since then, he has provided a better perspective to his team’s loss of the game. And, of course, may people used social media as a platform for malicious commentary without consequence.

As someone who lived and breathed Bulls basketball in Chicago years ago, and now is exposed to some of the real tough challenges in peoples’ lives,  I can truly say that, in the end, “it’s only a game.” And we are – each one of us – human.

Those first-graders know that. Kids know how to bounce back. They know how to rally and support. We should all learn from them in this very real and important game of life.

#DearPatient, just thought you should know

#DearPatient

It’s midnight.

I’m still up…

…documenting

and reviewing your chart.

Trying to find out what ails you.

Just thought you should know.

I am not Marcus Welby.

But I am your primary care doctor.

Yours.

……Truly.

It was a quiet year….

Two Thousand Thirteen was a quiet year for my blog. But it was a busy year of doctoring with 10-12 hours in clinic most days, an additional 2-3 at night, plus a few hours on most weekends. [We can analyze why over a drink sometime]. Of many sacrifices a full-time primary care practice necessitates, blogging was one of them. Also falling victim to the work schedule were guitar lessons, dinners with friends, and medical conferences I had planned to attend. Reading? Shopping? All of those seemed like luxuries. I missed writing on this blog, which was a nice way for me to reflect on this complex world of medicine.

However, in 2013, I did continue to work out regularly (for my own sanity, and – yes – I think of this as an achievement considering my schedule) and I wrote regularly for the Seattle Times as a columnist for the On Health section of the paper. I continued my position as a committee member with the Women in Medicine group of the Washington Chapter of American College of Physicians, and we hosted various increasingly successful events during the year. I continued to serve as an advisory board member for an IT company, learning more about the complexities of IT systems, networking, and EHRs. I mostly listened on Twitter, often inspired to write posts, but lacked the time and energy to put my best work into it. However, it was wonderful to keep up with some of writing of some of the colleagues I admire. And the best part of 2013 was that I had the honor of having one of my pieces published in a book (more on that in a future post).

We are fully into 2014 and New Years’ Day already feels like it was long ago. My schedule has not changed, but there is one thing I know for sure – this year won’t be so quiet for my blog.

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. 

Is There Pressure to be Informed?

I recently had the opportunity to speak to employees of King County, WA about finding credible health information online. During the Q&A a few interesting questions were posed (rephrased here):

1. Does my doctor expect me to have looked up my symptoms online?
2. Does it help my doctor get to the diagnosis faster if I look my symptoms up online and come up with diagnoses, as well?

The person who asked question #1 told a story about reviewing some symptoms with his doctor at an appointment and being taken aback when his the doctor asked him, “And what did you find on the internet?” The patient had indeed looked up his symptoms online, and was surprised that his doctor knew. However, he was left wondering if he was actually expected to research his symptoms online before his appointments.

The second question is actally a good question that I had not considered but makes sense when looking at it from a patient’s perspective. Should patients do some “homework” prior to their appointments to help a doctor get to a diagnosis faster?

Regarding question number one, I often ask if there was something my patient thought he/she might have in order to make sure I address some concern that might be otherwise left unspoken during the visit. But I do not have an expectation that patients come in having “researched” their symptoms.

My answer to question #2 is based only on personal experience. It does not necessarily help me get to a diagnosis faster if a patient looks up his/her symptoms online. I have certainly had some patients who were able to come up with diagnoses that were correct. More often than not, though, the scenario in my office is one where a patient is concerned about the worst possible outcome (which, luckily, is not often the actual case). Then there are others who may have figured out their diagnoses but never mentioned it. As I do not have a well-studied answer to this question, I am open to hearing from physicians who might have had a different experience. That being said, I would not discourage a patient from using his own resources to find out more about his symptoms. However, he should keep in mind that after a detailed history (which is the part of the visit where the doctor gathers information from a patient’s story) and exam, the diagnosis could be very different depending on the actual details elicited and findings observed.

These two questions from the audience, however, brings to light our changing roles in healthcare. Certainly, the doctor-patient relationship has undergone yet another evolution with the concept of the e-patient, distant now from its paternalistic beginnings. But, in the midst of (at the end of?) the Information Age and, perhaps, heading into an “Understanding Age,” are there now new expectations placed on patients by others or by themselves?  Is there a certain degree of pressure to be an informed patient on those who may or may not be comfortable synthesizing this type of information? Is there an expectation that one knows everything about his/her own medical condition? Is there more pressure involved in just being a patient today? Sometimes, I think there is.

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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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There Are Side Effects to Attending a TED Event

This past weekend, I attended TEDxRainier 2011 , which was a very full day of inspiring, enlightening, thought-provoking, and humbling talks by speakers from various fields. I cannot speak highly enough about the experience. The interdisciplinary examination of ideas and the unifying themes that were explored brought back fond memories of my favorite course at Boston University: the two-year undergraduate Core Curriculum course. This was my first live TED experience and hopefully the first of many.

Today, I received a letter via e-mail from the curator of the event, Phil Klein. This general letter, sent to all attendees, thanks the attendee and provides links to videos and feedback forms for the event. However, it also goes on to say the following:

“Some people report that the few days after TEDxRainier can seem a little difficult or dull in comparison to the vivid intensity of the prior day. That is common, so don’t worry too much about it. It may help to take some time to relax and reflect, or to engage and connect with others on a project or adventure that inspires you.”

This oddly touching acknowledgment of a phenomenon that I did, in fact, experience sounded like something…well, something a doctor might say. Perhaps a new diagnosis is in order here: the post-TED-return-to-regular-life syndrome….

Except, I suspect that you do not go back whence you first started once you’ve attended a TED or TEDx event.

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The Power of the Story (or The Inadequacy of Stats and Data)

Here is a very common patient interaction I come across at least once every summer (truncated generic version):

A patient (usually a healthy woman somewhere between 30 and 50 years old) comes in with concern of swollen ankles for a few days. I make sure to assess for significant issues, such as heart failure, blood clots, etc. But her story is notable for eating more tortilla chips and salsa lately – it is summer, after all – and  vacationing (traveling via airplane) and eating out more. She has been walking more than she normally does in locations where temperatures reach 90+ degrees Fahrenheit in the summer.

I explain to the patient some of the causes of swollen ankles particular to her case: traveling, gravity, salt intake, heat, etc. The patient has skeptical look on face and says something that expresses doubt about my assessment. I explain more about the physiology of swelling in the legs. The patient continues to look quizzical. So I say, “This happens to me from time to time.”

What happens next? Bingo.

Quizzical look disappears. Patient: “OK. So what can  I do?”

–

When I first started practicing, I was very “professional” (or so I thought). What I mean is, I was “all business” during the office visits, focusing only patients’ issues and interests and chit-chatting very little about my own. After all, they were not there to hear about me, right? Futhermore, talking about myself seemed to waste time that was already precious in a primary care physician’s workday. Over time, however, I realized I was wrong and that many of my patients did want to know more about me as a person, and it felt surprisingly nice, especially when it happened organically.

I recently realized that I divulge some of my own personal healthcare experiences now, things I normally wouldn’t reveal in regular conversation with friends. It seems that I have come to do this somewhat subconsciously not so that patients can get to know me, but rather to “validate” my recommendations (see above story). Now, as a – knock-on-wood – relatively healthy, young-ish doctor, I can only draw upon a very limited number of experiences. I am a bit too honest to make up stories. And though I’ve heard countless recommendations by patients that doctors should experience this procedure or that disease – and I completely understand this point –  exactly how many diseases does a doctor have to have for his patients to trust his recommendations?

The better question is: What is it about our stories that make them so much more impactful or appealing than medical knowledge or scientific data? This seems to be irrespective of demographic, as I observe in my practice. Male/female. Educated/uneducated. White/non-white. Younger/older. This effect has been demonstrated in all of these groups.

We see the power of stories in advertisements for fad diets or exercise gimmicks. We see it with new mothers who follow their own mothers’ “tried-and-true” wisdom even though it might be contrary to a doctor’s recommendations. We see it when people share naturopathic – or prescription, for that matter – medications with each other. “Try this, it worked for me.”

It can be mind-boggling and frustrating from a data-driven perspective. All this effort towards public and individual education for the empowerment and engagement of patients seemingly gets thwarted by simple, yet impactful, stories by people who have never even taken a biology class. Stories that may not even have any recognizable medical sense to them. This is not to invalidate The Story. (I feel there is a real place and an important role and a certain beauty to it. Stories in fitness magazines inspired me to become healthier years ago.) On the contrary, I am fascinated by the truth of the power of it…and the inadequacies of statistics and data in everyday clinical situations.

Data and statistics are most effective when gathered and used by objective individuals. They seem to lose relevance when we become the subject. When we are the ones with something even as simple as a sore throat, objectivity might fly out the window. And when we are the ones with illness, sometimes the underlying emotional/psychological aspects of our decision-making become amplified. For example, if we tend toward positivity, we might hear the success rates or the benefits more than we comprehend the risks. If we tend towards pessimism, we might lean towards the gloomier side of the medical equation, even if the chance is 50/50. If our nature is to overreact or always imagine the worst, we might dwell on the rarest side effect/outcome of a medication/disease. And, interestingly, sometimes the seemingly objective patient is one who is in denial.

This reflexive loss of objectivity when faced with a personal dilemma is such a human trait that it even applies to the very people who are trained to be medically objective – doctors. For example, a physician friend of mine was ill for a few days and asked my opinion on whether she needed antibiotics. Based on her reported symptoms – and without offering specific recommendations, as I did not examine her – I simply asked her if she might be reaching for antibiotics a little prematurely. She agreed that maybe she was. She needed a reminder to take a step back and reconsider her symptoms a little more objectively. I myself don’t feel I’m immune to this tendency though I am writing this post. Even though I might be able to treat myself for various things, I see my own primary care doctor for her assessment. I make sure to voice any worry that I might have about an issue, but I trust that she will remain objective, at least more so than I would be at that moment.

Statistics and data can be unglamorous. We can articulate them with various vocal inflections, but they are – (close your ears, statisticians) – still numbers, which do not have the same significance for everyone. But we do know that stories can last forever. They play over and over again in our minds. The story of the apple falling on Newton’s head was never true, but we as a society have held on to that image. It fulfills something within us. Religions “know” this. Cautionary fables, present in many cultures, reflect this. Modern medicine doesn’t. How do we make the data and statistics and the objectivity of our field more influential? Do we even need to? How do we as physicians “convince” patients to follow our recommendations? What do you think, fellow doctors? Patients, what was the most helpful thing your doctor did when you were faced with a difficult decision? I’d love to hear your thoughts.

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How Low Can We Go? A Ten-Year-Old Models in French Vogue

I appreciate fashion – not in the sense that I buy the latest designer clothes. Rather, I enjoy the aesthetics of it. It is creative and can be glamorous, silly, subdued, over-the-top, surprising, and even emotional (as is the case with wedding dresses for some people). Watching designs come to life on a show like Project Runway is entertaining and inspiring. Runway modeling, in particular, can be mesmerizing; the models’ bodies serve as moving canvases for art. However, needless to say, I was quite disappointed with the extremely unhealthy, waif-thin days of modeling. As personified by Kate Moss during that time, in the world of fashion, limits are always being pushed.

In fact, the newest controversy in the fashion world  surrounds a provocative photo shoot of a 10-year-old posing in French Vogue. Here we have a child (younger than a teenager) photographed in adult poses and dressed up as a grown woman with sexy make-up, stilettos, stare, and all. Thylane Blondeau is without a doubt a gorgeous and striking girl (emphasis on “girl”). She clearly has the genetics for a modeling career now and in the future. If I were her mother, perhaps even I might suggest a short stint in modeling at some point. But at the age of ten, are these images pushing limits?

Some feel quite strongly about protecting all children from the modeling world. I don’t take as extreme as a stance, but I do take issue with the way some magazines portray children. Vogue is a fashion/lifestyle magazine. What lifestyle is being sold here? And to whom? If we think that only adults and teens will be reading these magazines, we would be sorely mistaken. The children of women who read these magazines have access to them, circulate the ideas, and sometimes even imitate these images at school.

See, you can’t really understand the issue here until you have heard stories of healthy seven- and eight-year-old girls asking if they are fat or if their thighs are too big, putting themselves quietly on an unforced diet. It is practically a given that a woman in Western culture will spend most of her life unhappy with her body. But we need to take note that, today, our society’s young children – so full of potential and who have been on this earth for not even a mere decade – are obsessing about their weight. Really, it has gone quite too far.

This is my own opinion, of course, and not a professional one, except for the fact that body image issues do not just lead to anorexia. There are issues and struggles related to poor self-image that can be lifelong: making food excessively complicated, giving up easily on healthy eating, and looking at health as unattainable because it is associated with certain celebrity body types. Of course, there are those who say critics should “lighten up” about Blondeau’s Vogue pictures. But they are just ignoring the glaring reality that body image issues are starting younger and younger.

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**photo by BlackHawkTraffic (Flickr Creative Commons)