The Pursuit of Mastery in the Worlds of Medicine and Wine

Medical school becomes a blur after a few years in practice. You forget about all the hours spent in classrooms and then every night after a quick dinner. You somehow block out the “pimping” [There is a nice explanation on what this word means in medical school here] and public humiliation of being questioned about topics not quite under your belt. The worst feeling? The fear of wondering if you will master medicine enough to do no harm.

Medical training is, quite frankly, a brutal process that can make or break a person. Your every fear can come up during this process. It’s not enough to pass tests or to know the Krebs cycle. It takes physical and mental resilience to get through seven-plus years of intense training and learning. Then, imagine being a partner to someone going through this. The partner will always be secondary to the subject of study. And it almost has to be be that way… for a time. Missed birthdays and weddings…. Late nights studying with fellow students or your assigned cadaver…. Fictional television shows about doctors-in-training often focus on casual sexual relationships or budding romances. But in real life, I’ve seen marriages dissolve and people have nervous breakdowns under the stress, as well.

I had forgotten about all these details, anyway, until I recently watched Somm, a documentary about four men trying to pass the Master Sommelier exam. What is a Master Sommelier (MS)? See below (from website):

I was completely engrossed in the personalities of the candidates for the MS exam. While it may seem to have very little to do with medicine, I couldn’t help but see my medical student self (and former classmates) in these young men. If you’ve ever been a medical student or lived, breathed, and ate a specific topic for a specific goal, all the while foregoing sleep and relationships, you might relate to this movie. (Insert artist, musician, scientist, etc. here).  The marathon-like effort rewards a few, though many try. There are currently only 135 Master Sommeliers in North America and 19 of them are women. There have been 214 worldwide who have been given the title of Master Sommelier since the exam’s creation.

After you watch Somm, you realize drinking wine is clearly only one tiny part of becoming an MS. Many people have some knowledge about wine or medicine. But mastering these fields involves intense study to quickly calculate and retrieve applicable and accurate information. It also takes a certain amount of competitiveness, observed one of the MS candidates in the documentary who was formerly a baseball player, to attempt to pass “a test with one of the lowest pass rates in the world.” Even some of the terms they use to describe aspects of a wine’s taste or smell (“a freshly opened can of tennis balls”), while seemingly completely bizarre, are reminiscent of some of the unusual analogies we use to characterize various things in medicine. “Ground glass” on a CAT scan of the lung, for example, is not ground glass, but it is the best way to describe something and recognize it quickly.

If you’re curious about the world of wine, what it takes to be an MS, or the psychology of the pursuit of mastery of a subject, I would recommend watching Somm. Though the documentary is a little drawn out, it is not particularly long and you look forward to the ending to find out if any of them passed the test. 

Interestingly, at a recent dinner I had the opportunity to speak with an MS who was working at the restaurant. Everyone at our table had just seen the movie the previous night and we queried him about his experience studying for and taking the MS exam. He did corroborate that it was an intense period of study to learn all the minutiae and details about wine. He reflected that it was all about “the hunt” (to pass the exam). However, he said that in the end, after you pass, “fifty percent is about people skills.”

True in wine as it is in medicine.

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(*please note that original version of this post stated there were 135 Master Sommeliers. To clarify, there are 135 in North America and just over 200 worldwide.)

Paging Med Student Google

A few days ago, I came across an article entitled “Calling Dr. Google” by Jeff Jarvis. The writer describes his experience “googling” his symptoms and finding that the internet brought him the correct diagnosis. He uses his personal story of appendicitis to point out that physician fear of information on the internet is overblown.

One would hope that the argument that you cannot find any trustworthy information on the web is an old, tired one by now. In just the short time that I have been involved in social media and medicine, internet search results have improved significantly. In fact, nowadays, I often refer patients to specific websites for information after I’ve made a diagnosis.

But diagnostic Google is still evolving; symptom checklist websites, as I have tested them in the recent past for myself, have brought up the most benign to the scariest of things. Jarvis had appendicitis. There is a very good – as good as good can be in the very gray world of clinical medicine – probability that acute right lower abdominal pain in a male with an appendix turns out to be appendicitis. (For women, the probability goes down, since the number of possible diagnoses goes up). The diagnostic accuracy for his scenario may be better than for any other condition. A first year year med student could be ridiculed – at least, in the old tough-love days of medicine – for forgetting to put appendicitis on the list of possibilities immediately.

As I see it, “Dr. Google” is currently medical student Google, still in training. Let’s not graduate him/her…just yet. Medical students in early training come up with great answers for possible diagnoses for a case but haven’t quite yet honed their clinical skills to prioritize these possibilities and to come to an accurate diagnosis efficiently. This involves asking the right questions to tease out the “noise” and red herrings and to find a nugget in the patient’s story that will lead to a speedy clinical diagnosis.

But there is a bigger point embedded in the article. What might be missed by a quick read and acknowledgment of Google’s virtues is a fundamental, more important question: What really made the writer not act sooner on the information given? “But I didn’t listen,” Jarvis writes. Perhaps doctors did persuade him to no longer believe what he finds on the internet, as he asserts in his piece. Or, put another way, what is it about online presentation of information that it is sometimes not convincing enough? If a patient called his primary care doctor complaining of right lower abdominal pain that was new, I would imagine that care would be expedited more quickly. Jarvis certainly wouldn’t be the only one who “didn’t listen.” I have seen patients delay getting care for stroke symptoms despite the fact that that they admitted that their same-day google searches resulted in “stroke – call 911 or go to the ER.”

I really appreciate Jarvis’s candor about his experience with appendicitis. His story provides food for thought on doctor-patient and internet-patient communication. I agree that doctors need to try to avoid automatic dismissal (“pooh poohing”) of health information on the web. Doctors who are skeptical should do some searches from time to time to observe what patients might see when they search the web. It truly is amazing how far the web has come and how far it still has to go to effectively manage our individual healthcare needs sans physicians/healthcare providers (if that is even possible).  But med student Google just might graduate someday. And at its current pace, it could be during my lifetime.

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MDs: Advice for the Next Generation

This past weekend, I had the opportunity to meet with local medical students as part of an American College of Physicians (ACP) mentorship brunch. I sat with a small group of second year medical students ready to impart my “wisdom.” Mostly, I wanted to be available to answer questions the students had for me. But I knew there were certain thoughts (a few of many) I wanted to share:

• You may not recognize the medical field you once knew when you first decided to embark on this path. After all, several years pass between the time you make the decision to become a doctor and when you actually start practicing medicine. When I first went into med school, I knew of wealthy primary care doctors who spent 30 minutes or an hour with each patient. Keeping your mind open and not getting too hung up on expectations of what medicine should look like will serve you well and help curb future burnout.
• Think outside of the box. This has nothing to do with the least likely diagnosis in a case and more to do with the practice of medicine. It’s ok to think creatively. Medical training, at least when I went through it, does little to encourage innovative ideas. If doctors don’t get creative, other interested parties will be eager to impose their ideas on your care of your patient, often with their own self-interests in mind. This can be great (for example, a useful new device or protocol). But it is often done with less knowledge of the unique complexities of the actual practice of medicine. Doctors know what doctors do better than anyone else. As a group, we are incredibly bright, but we can’t make much progress with our heads buried in the texbooks.
• Balance it out. It is easy to fill 24 hours a day (or more) with medicine. If you can learn to balance school with other positive activities you have always enjoyed, you won’t feel overtaken by this life of medicine later. Even if it is just dabbling in that activity now and again when you find some time, it will be worth it.
• Watch your digital footprint now. I was – luckily – never faced with this worry as a student. Following doctors who exhibit professionalism online can give you a better understanding of how to use the web in a productive manner and avoid the pitfalls of a web presence. Sometimes you just need good examples.

What words of wisdom do you have for the next generation of MDs?

The Right Way to Solve a Workplace Conflict

One day, in the first few months of my second year of residency, I was called into the office of one of my superiors in the Graduate Medical Education Department. I didn’t know why I was summoned or whether it was a good thing or bad, but I was not prepared for what I was about to hear.

Paraphrasing (because it was some time ago):

Superior: “Did Dr. So-and-so talk to you?”
Me: “No.”
Superior: “Dr. So-and-so didn’t talk to you about a patient interaction recently?”
Me: “No.”
Superior: “I got a call from Dr. So-and-so and he told me you were rude to a patient. That you said something that upset the patient.”

At this point, my heart was racing and my mind was spinning. I was grasping in the realm of my short-term memory…. Probably turning as pale as a person like me can get, I said,

“I don’t know what you are talking about.”

Superior: “Dr. So-and-so said that you went to a patient’s room and said that the patient got you in trouble.”

Me: “That never happened. I don’t understand what he is talking about.”

Superior: “So, you’re saying this didn’t happen?”

At some point in the conversation he revealed when it happened, and it was on a day that I was not even working. I pointed this out to him and was utterly confused about why I was being accused of something completely out of my character.

Superior: “Well, I don’t need to get in the middle of this then.” (This part is verbatim, unforgettable).

“That’s it? ” I thought. “You tell me about something fictional that damages my reputation and character and then leave it for me to lose sleep over? You are already in the middle of it.”

I was shaking inside as I left that room. I felt completely helpless. All the hard work of proving myself over the past year as a trustworthy, reliable, diligent, consistent and attentive physician who took good care of patients was thrown out the window with an unfounded accusation. Lest you think I was overreacting, let me point out that Dr. So-and-so was very highly regarded in the institution and the head of his particular department, which happened to be a field I was strongly considering for fellowship. That dream was over with this event.

Several days went by and with time there grew a constant, queasy feeling in the pit of my stomach. I started to realize that if Dr. So-and-so believed this about me, word would travel to all the attendings on staff in the hospital. Perhaps some residents could brush something like this off. (I wished I could be just as nonchalant.) Perhaps others could just let it brew. (I was already taking that route). However, my integrity was in question, and neither approach seemed right.

I got more and more uncomfortable with the knowledge that I had to work in this institution for another year-and-a-half and would be interacting with everyone in Dr. So-and-so’s department. I mentioned my situation to a few trusted residents, who were just as aghast. Sympathetic, but solution-less, they were. Even my Superior, whom I felt should have had my best interest in mind, offered me no advice whatsoever.

Once resolved to end this issue once-and-for all, I looked up which section meetings that Dr. So-and-so was expected to attend at the end of the day. I picked one and waited outside the door until it was over. When I approached him and asked if he had a minute to talk privately, I could see he was hesitant. But he agreed.

I am going to be completely honest about my feelings here, as it is crucial to the story. You, the reader, may have been able to accomplish the following with ease. But for me (in my twenties) to approach this well-regarded physician (probably in his 50s) who held significant clout and a stand-offish temperament was a psychological and emotional challenge. Telling patients that they had cancer was an easier task for me. And that is very difficult.

Dr. So-and-so and I went to a private room and I told him my side of the story. (Did I even have a side? I wasn’t there!). I am sure my voice was feeble. I am sure I looked meek. Together, this probably made me look guilty. The expression on his face showed that he was disengaged. My heart sank and I started to believe this approach was useless.

Dr. So-and-so didn’t interrupt, however, as I laid out the facts of the matter and that I really had no idea what the issue was about. He then told me his side of the story. His patient had told a nurse that a female resident with dark hair reprimanded him for something and it upset him. The nurse identified me as one of the residents working with the patient, so she told Dr. So-and-so that I had caused the patient’s distress. I had not been the only one with dark hair working with this patient, I pointed out to Dr. So-and-so. Furthermore, other details of the story just didn’t add up to prove any culpability on my part.

Dr. So-and-so’s expression softened (as much as it could for him) and he acknowledged my point. Maybe he said he was sorry. Maybe he didn’t. I don’t remember. But I was able to complete the rest of my training with some dignity and without defamation of my character.

There are a few lessons here, the personal ones so obvious I won’t write more about them. Firstly,

The decline of face-to-face resolution of conflicts as we develop advanced technological ways to communicate is lamentable. For example, I know an employer who received lengthy e-mails about grievances from an employee even when he was working side-by-side with that person daily, as if the issue didn’t exist except in cyberspace. One might say intimidation is a factor. I can relate to that (see above story).

In fact, I was reminded of this story when I read a recent New York Times article about an unpleasant interaction between a nurse and a doctor. The nurse, who wrote the piece, details this incident and goes on to describe the types of bullying physicians perpetrate towards nurses and potential solutions to stop it. It would have been interesting to learn whether she reported her specific incident, what channels there were for reporting such behavior, and whether her hospital’s administration (which tends to affect the tone of the working environment) did anything to help resolve the issue. In addition, any attempt to address the issue directly with the physician is not mentioned in the article, except for the fact that she says, “As we walked out of the patient’s room I asked the doctor if I could quote him in an article.” An article that was published months later. To correct a wrong, timeliness and directness is most effective.

Secondly, if you are involved in medical education as an attending, program director, assistant program director, or chief resident, do not forget that, in addition to teaching the scientific knowledge of medicine and the nuances of doctor-patient relationship and the importance of work-hour restrictions, etc, you are helping to mold these new physicians. You are important examples and should be mentors for the betterment of their professional and personal development. In some ways, you are family for these residents, who live, eat, sleep, and breathe with you more than they do their own families. In my opinion, the duties of a physician in a teaching institution go beyond getting them to pass the boards. It is to also guide them in being able to handle difficult ethical and moral situations and to advocate for what is right. This will serve them and their patients well in the future.

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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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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.

The Gen Y Physician

photo: Sura Nualpradid, freedigitalphotos.net

Do Gen Y physicians want more by doing less? Are they less dedicated than prior generations? I read an article written by a physician that put this group in a less-than-positive light.

http://www.kevinmd.com/blog/2011/01/millennial-physicians-impact-disease-management.html

I have heard similar observations from a colleague who practices in an academic environment. We often comment on advances in pharmaceuticals, procedures, imaging, and public policy. But there have been cultural shifts in the practice of medicine as well: a move away from paternalism, more collaboration between specialties and teamwork with other physicians, and work-life balance for physicians, for example. While I would agree with some aspects of the aforementioned post, there are a few things to consider.

 The “working to live” trend is not limited to healthcare. This appears to be a common philosophy among the young adults in this country who grew up with parents who labored with one or more jobs or overtime while sacrificing time with family. Perhaps this explains why we see many young, intelligent women choose to stay home rather than work. Or why people work at home rather than in the office.

Other factors have helped to mold the current and up-and-coming generation of healthcare providers who are being criticized in this post. For example, the general public, the media, and the healthcare industry, itself, have minimized the role of the physician. They no longer perceive physicians as “gods” (a title that was unlikely self-described by the members of this profession). When insurance companies that are run by nonmedical administrators dictate the rules of practice and larger physician offices are run by – again – nonmedical administrators that want more productivity, it creates a factory-like environment. Read: hamster on the wheel. Furthermore, the utilization of midlevels (who can earn more per hour than physicians, if you take into account taking call and working on weekends) in the healthcare industry, while quite helpful and valuable, also creates a sense that physicians are potentially dispensable.

There are now more female physicians graduating from medical schools than 10-20 years ago. They typically play many more roles than the role of physician. They often do not have the luxury of staying late at the office  – and, yes, I view it as a luxury – because they may have to pick children up from daycare and make dinner and take care of household duties while husbands stay late at their own jobs. Women have entered into previously male-dominated professions faster than the societal expectations of their roles could practically adjust to take that into account.

Whether we admit it or not, a lack of balance in our lives does translate into our interaction with others. We have often seen or heard of a disgruntled physician interact less than ideally with a patient. As the healthcare industry becomes more customer-service oriented, this would be detrimental. Sometimes finding balance does not align with the Type A expectations of our peers. But I am doubtful that any physician would risk being negligent in order to make it to a soccer game.  

Lastly, I would like to suggest that physicians who are concerned about the work ethic of the next generation of physicians consider being role models or mentors to them, as my friend in academic medicine does. Having a relationships with our peers (regardless of age) is essential for mutual support and can also help younger physicians grow into professionals with excellent work ethics.

The Millennial Physician

photo by jscreationzs. freedigitalphotos.net

There was a post on KevinMD that sparked my interest. It has to do with a perception that Generation Y physicians essentially want more by doing less.  I agree with the observation that there is a cultural shift in how younger physicians view the practice of medicine. What’s missing in the argument are potential reasons why this may have occurred and a lack of recognition that there is also a cultural shift in how medicine is practiced in America and viewed by the public.

http://www.kevinmd.com/blog/2011/01/millennial-physicians-impact-disease-management.html#more-50203

In my next post, I will attempt to fill in some of the blanks.