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.

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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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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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Are doctors on television just hams?

I recently came across a blogpost entitled “Everyone is Taking to the Camera- Pass the HAM please.” In it, the writer (a published author) says:

I have never seen more Doctors, Lawyers, Judges and ex-politicians on television than I have in the last few years….

Dr. Phil and Dr. Oz certainly must have been good Doctors, but think how much more they have learned on air with a staff and producers that can access any fact in minutes. Working for a producer doing new shows every day is much more demanding than working for patients. These Docs are quite camera friendly and seem to adapt well to the nuances of live TV; including pauses for commercials. Their message is popular and it seems that they here to stay.

….

What conclusions have I drawn from this diverse group of professionals that strayed into the small screen from other high paying professions? I believe deep down we are all HAMS looking for a modicum of fame.

I felt compelled to leave a response and, as you can see, it turned out to be a mini-blogpost. So I share part of it with you here and welcome your own thoughts and opinions.

I think I would have agreed with you on the “ham”-factor a few years ago. I guess I still do to some extent. Any person living in the public eye (including the one online) is likely to be craving an audience, after all. But, as a general practitioner earnestly interested in how accurately the media relays health information, I am less concerned these days about how people (doctors) got onto television and more concerned about the messages they are relaying.

A doctor might find himself deemed camera-worthy by producers after a stint on a matchmaking reality show. Or after being interviewed by Oprah. But what these professionals do with their position is ultimately what counts because their influence is huge. I cannot say whether working for patients or working for producers is more demanding, as I am in full-time clinical practice and have not done the latter. But to me, a big challenge is the fact that ratings (and not responsibility) drive content on television and that medicine discussed on television shows may be anything but “real” for the sake of viewership.

Luckily, more and more doctors are using social media to try to correct misinformation or relay more relevant medical issues without the sensationalism characteristic of television. These physicians might even use video to spread the word. We need good quality information, especially heath information, on television and it ultimately does not matter to me whether this comes from a HAM.

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Social Media Adoption by Physicians. It’s A Little Like Quitting Smoking

Today, Mark Britton, CEO of Avvo (a physician rating site that also provides answers to health questions), gave a presentation to our clinic regarding the role of social media in healthcare. He gave an excellent background on the evolution of social media, as well as general principles to consider when embarking on this path.

 “If you don’t have a meaningful web presence, you don’t exist.”

This quote, from Britton, is poignant and true – true, at least, to the many doctors already utilizing social media. But many doctors feel the opposite is true. They might say, “When I take care of patients, make phone calls, am physically present and working tirelessly in clinic or the operating room… that is when I exist. Social media is a fad for kids and I really don’t have the time for it.” This is the oft-referenced head-in-sand approach – never a good one. Others might feel that social media in healthcare is ALL about marketing and self-promotion. (By the way, the vast majority of physicians do the latter poorly, quite frankly. This is usually due to a fear of the impression it would make on others. In fact, for years, I deliberately did not reveal my profession to many non-healthcare acquaintances I encountered unless specifically asked. ) Some doctors feel their years of experience and employer reputation – rather than fancy web pages – should be enough to convince patient that they are good doctors.

All of these are valid concerns and points. As I have now been blogging, tweeting, and using LinkedIn and Facebook since November of 2010, I almost forgot that I was a nay-sayer once, too. It occurred to me today, as I observed the faces in the room during this social media talk, that educating physicians about social media adoption is akin to smoking cessation counseling for patients. That is to say, one will encounter differing levels of interest depending on which doctors you meet.

PRECONTEMPLATIVE STAGE

Typical response involves using the word Twitter with a sneer or not even recognizing it.  “I don’t do Facebook. I don’t do Twitter.” Doctors in this stage might also wonder, “Why would I change the way I practice now? I have plenty of patients. I don’t have time for this.”

CONTEMPLATIVE STAGE

An individual in this stage might be someone who already uses Facebook for personal reasons (keeping up with family, using Facebook as a photo album,  etc). He may be curious about how social media can work for him. Some doctors in this stage might want to get involved but are afraid of the time commitment. After all, EHR adoption and meaningful use requirements are eating up more of the limited time that is not spent in direct patient care.

PREPARATION

In this stage, the doctors are ready and researching tools. They might be observing the behavior of other social-media-savvy doctors. They might get inspiration or ideas from some of the physician bloggers/tweeps that I follow most frequently: SeattleMamaDoc, 33 charts, Dr. Wes, John MD , KevinMD, Clinical Cases and Images: Casesblog and – ahem- my own blog.

ACTION

Here, doctors are committed and are actively embarking on the social media path.

MAINTENANCE

This is tricky because social media CAN be consuming and it is easy to get frustrated (especially if you are only looking to increase revenue quickly).  It is doable, however,  and takes a little discipline – doctors are good at that, right? – to get just the right balance so that you don’t lose steam. It helps if you receive input on topics that you find interesting and relevant.

****

I was thrilled to see the number of physicians from my clinic attend the presentation. I underestimated the level of interest in the topic. Ultimately, no one should feel pressured into social media for the sake of social media itself or for the sake of generating quick revenue. One thing is true with social media; motives are more apparent than we would like to think.

If a doctor is passionate about his/her work in the healthcare industry, the realm of social media is one that cannot be ignored. To expand on Mark Britton’s words, not only do you not exist if you don’t have a meaningful web presence, you might even have an inaccurate and less than favorable existence, a web portrait painted by reviews on Yelp or Angie’s List or Healthgrades and generated from very limited interactions or experience. This might come as a shock to even the most experienced and well-meaning doctor.

Furthermore – and most important, in my opinion – patients get their information from the internet. If more reputable and qualified physicians are not there to direct them, someone else – even a celebrity without any medical training– will be more than happy to “educate” them.

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The Evolution of My White Coat

The significance and use of the white coat has been a topic of late. Most recently (and eerily coincidental to my drafting this post) there was a piece on Get Better Health about it. Thus, my post can be seen, perhaps, as an extension of those recent commentaries as I present some opinions from the “crowd” compiled by informally polling Twitter and Facebook regarding the question: Should doctors wear white coats?

Results on Facebook (total number of responses = 15):

Yes – 27%

No – 33%

It depends – 40% (unfortunately, those who responded with this answer did not provide further explanation, which would have been interesting)

Results on Twitter (instead of their Twitter handles, the parentheses indicate their background for reference):

(psychiatrist) Id say most psychiatrists typically avoid #whitecoats in the hospital setting as well, need to balance inherent power dynamic

(pediatrician) #whitecoats less about power more about pockets to hold stuff…and the things are dang dirty too like ties
More than docs wear white coats– often one in white coat is NOT a doc:)

(other) not at #hopkins. we have a 25-yr + tradition of white coats for many reasons, not least is de-stigmatizing psych. yes based on healer’s status assoc. w/ successful psychotherapy outcomes (Frank’s Persuasion & Healing) & white coats with status

(chiropractic magazine) It’s nice to see doctors wear #whitecoats or scrubs – some professional garment, to preserve

(a consultant to healthcare industry) All about 1st impressions & ppl r different. I don’t like cuz separates me from Doc. Many seniors do cuz they expect separation.

(a med student) Yes, I think it shows professionalism, not to mention there are pockets for holding things. 🙂
Yes, some patients only know it is a Dr they are talking to based on the coat. And some docs are bad with intros.

(unknown) IMO, #whitecoats show #professionalism which is sorely lacking these days.

(an RN) no but found the hospital experience to be daunting without identity….vulnerable time for those involved.

The white coat has its detractors. Apparently a Twitter conversation was devoted to the characterization of those who wear it as as egotistical or snobbish. There could be some – albeit rare, in my opinion – truth to that. An unfortunate example of this would be one medical student I knew who proclaimed that he loved being in medical school because he was surrounded by doctors in white coats, “like gods.” I kid you not. I was disgusted by that remark and it was evident he was not in medicine for the “right” reasons. But that is not the norm. Furthermore, the use of the white coat is not restricted to physicians. It has also been a uniform for lab techs, aestheticians, barbers, dentists, and Clinique salespeople at the department store counter.

Another reason that the white coat has been losing its appeal is for the same reason physician neck ties have been scrutinized in recent years – potential transmission of bacteria. This issue is referenced in a recent post by Dr. Westby Fisher and presents a quandary.

As for me, the white coat has had different meanings over time:

In medical school – It was a short coat, which looked a little silly, really. But it held a  library (before smartphones) and some tools. It was my identifier that said to patients “I am not a doctor, but I am not a random stranger. I am here to learn.”

In residency – it was a longer coat. It was my identifier that said, “Though I look young and I am a woman, I am a doctor.  And ,yes, I am the one writing your orders. No, I will not get a doctor. I am the doctor and I am practicing in real-time to be an attending. It is very important for me to get this role down.” It also kept me warm and held snacks and notes and patient checklists, and more tools. I had to wash it on my own – frequently. It got pretty tattered by the end. It was a frequent cause of neck pain.

Currently – My white coat holds my pen, stethoscope, cellphone, and some business cards. It seems to be 10 pounds lighter than it used to be. It keeps my clothes clean during potentially messy procedures. In a funny way, I feel it holds me accountable to every patient I see. Hopefully it relays experience, professionalism, and provides some reassurance to new patients that he/she is in well-trained hands even though I don’t have a head of grey hair yet.

Now, I have tried going without the white coat, but, invariably, I forget my stethoscope or need my cell phone. Or someone says, “You look too young to be a doctor” – is that the glaucoma talking? – at which point, I want to run to get it and say, “See? I am not too young. I spent many years training. You can trust me.”

In sum, I think the most notable features of the white coat are that it provides efficiency and protection and a reminder of my role as physician to educate and treat my patients as best as I can and to be as professional as I can. One particularly inspiring view can be found in a transcript of a speech given by Mary L. Brandt, MD during a “white coat ceremony.” She says to the bright-eyed medical students “You are putting [on] a coat of candor, of sincerity, of openness, of kindness and of self-care.” Physicians should read it whenever they need a reminder of what that white coat represents.

But, the white coat as a status symbol? Perhaps, but only for those patients and doctors who perceive it as such. But this is not the case for me. I am only too happy to take it off before I leave the clinic.