Where Do You See Yourself in Eleven Years?

A recent Harvard Business Review article entitled “Career Plans Are Dangerous” suggests that the where-do-you-see-yourself-in-five-years question is essentially irrelevant in the modern world.

“…increasingly, the world is not this predictable. And it is in settings of high uncertainty where traditional career planning is both a waste of time and potentially dangerous. A career plan can lead you into a false sense of confidence, where you fail to see opportunities as they arise and miss taking smart steps you otherwise hadn’t planned for.”

The authors assert that this does not apply to certain professions, like nursing. Well, yes and no. The answer to where one sees oneself in 5 years is partially dependent on what the field looks like by that time, and the changes in medicine in the past decade have approached top-speed, and this not even accounting for any advances in pharmaceuticals, medical devices, or screening technology. If one looks simply at the changes in one-to-one provision of healthcare and the doctor-patient interaction (including EMR adoption, shorter appointments, patient portals, concept of e-patients, generational changes in expectations, creation of midlevel providers, rise in urgent care facilities, and healthcare social media), one realizes – like the old Oldsmobile commercials – that this is not your father’s medical system anymore.

There is a long lead-in period to becoming a doctor. If you decide at 18 (when one is expected to somehow definitively know what career will make one happy until retirement) to be a doctor, you still have at least 11 years before you practice independently in your field. Perspective: The students who are entering college this year determined to be a doctor will complete residency training in 2023 or later. Where will you be in 2023?

My hope is that future generations of doctors have or create opportunities to think outside of the box as they are training. The end point is not the medical degree. Regardless of all the time and money put into it, the degree might even be the beginning… because everything can change by the time these students get out.

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Never Let Them See You Sweat

One workday a few years ago, I had to be at a semi-formal family function by a certain time. Of course, of all clinic days, this one was even more hectic: multiple consultant phone calls, phone messages marked with “red flags,” letters that – for some reason – needed to be written on the day requested, and not one, but two people needed to go to the ER (one via ambulance). I drove as fast as legally possible to get to my relative’s house. Without having had a break to even go to the bathroom, it was difficult to sit in traffic. 

I got there eventually and was greeted with a slight reprimand for being late. OK. I expected that. But I didn’t expect the comment that followed. “What do doctors do, anyway? They spend just a few minutes with patients. Otherwise, all I see them do is talk to each other in the hallway.”

Leave it to family or close friends to push you off of your high horse (irrespective of whether you are on one or not). Not too long before this, there was a suggestion by an administrator of our clinic that we should increase the number of patients we see since recent changes in our EMR should have improved our efficiency. These two events made me wonder: Exactly how much time do I actually spend involved in patient care outside of seeing them? 

So, for the next few weeks, I used an online stopwatch and closely monitored my daily activities, recording how much time I spent on “indirect care,” including, but not limited to:
– refills
– patient questions on the phone
– phone messages
– reviewing consultant notes
– talking to consultants on the phone
– documenting/charting
– reviewing outside records
– filling out forms, including insurance authorizations and nursing home documents

(all of these tasks can require research into the respective patient’s chart)

Before you read on, if you are a patient, can you guess how much time this adds up to? If you are a physician, do you know exactly how much time this takes you? Have you ever tried to measure it? 

The answer for me:

4 to 4.5 hours a day. 

To clarify, I was the second most “efficient” physician in that moderate-sized practice, if not THE most efficient. And I was shocked by this number. I imagine that it would take 5-6 hours for docs who were not as efficient.

I do it despite the lack of reimbursement for the majority of these tasks. After all, it’s part of the overall care of my patients. You might not see such generosity, however, from other productivity-based-paper-pen-and-brain careers that lack fancy tools or equipment (accounting, law). What’s more, when nurses were phased out of primary care clinics, we lost some of the help with administrative tasks and some of the minor, more straightforward clinical work. Instead, primary care doctors were asked to “do more, in less time, with less help, and with less reimbursement.” It’s a part of medicine we often try to hide – rather than fix – and the part that medical students tend to avoid. That being said, I continue to practice in primary care because I still strongly believe in its purpose and I believe I am helping others… at least until a candid remark about physician “laziness” shocks me into the reality of a completely different perception out there.

While I work diligently to take care of other patients in between actual patient visits, I also work hard to give each person I physically see the amount of time needed to have him/her be heard and to be thorough. Though it sounds pseudo-therapeutic on some days, there is no such thing as a three-martini lunch, only a three-minute lunch. So, if I do happen to have the time to talk to a colleague, it is a nice reprieve. But twiddling my thumbs I most certainly am not. And, quite often, I think and worry about some of my sicker patients long after the clinic has closed….

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….

Focus on the Mission, Not the Score: Healing the Doctor-Patient Relationship

I recently read a post entitled “Patient Satisfaction and Doctor Requests – What’s the Score?” The post addressed the patient perception that doctors are not empathic and the physician perception that patients want to get what they want in order to be happy with their care. The content of the blog post notwithstanding, the phrase “What’s the Score?” is really what stuck with me.

What is the score?

0-0

If this is a fight, it is an unfair one with unfair rules. The doctor-patient relationship in its current state is like a marriage fraught with miscommunication, assumptions, and unspoken expectations. And let us not forget third- and fourth-party intruders (including insurance companies and administrators who push for productivity). The encroachment of these groups has put a strain on the original partnership.

One of the reasons I started this blog was to get back to the things about medicine that inspired me during my early years of training. I have had a relatively short career, so I am almost embarrassed to admit that there was a point shortly after residency that I felt I lost the meaning of being a physician. This was a time where I was seeing a large number of patients a day, not to mention all the other non-clinical –but just as crucial- work that was not built into the schedule and some life stressors that were going on at the time. There was no breathing room or bathroom breaks (and I am being literal about the latter, not the former). I believed that I was an empathic and capable physician, but I also knew that my interaction with patients was far from ideal during this time despite my best ability to stay afloat. Luckily, circumstances around scheduling patients changed in my office for unrelated reasons and things improved just enough for me to say to a clinic administrator “I am finally feeling like the doctor I have wanted to be.” Don’t get me wrong. I was still ridiculously busy, but not stressed to the point of physical, mental, and emotional exhaustion.

In some ways, physicians are functioning as skeletons of what they intended to be in our current healthcare system. I was a good example of this. I do not know any doctor who would not prefer to spend more time with their patients and be able to tap into their own empathic side. But the truth is that things like LDL goals, weekly visit numbers, and CPT codes are the measures that are valued because they are tangible and because practicing medicine in this country is still a business, after all, not a charity. So physicians working in cognitive specialties (like primary care) are trying to keep up with demand, working faster and smarter, pushing their neurons to the limits. How is this not going to translate into the interaction with patients?

Receiving sympathy from the general public is not my point here. What would be better is an understanding from both sides. So I cringe at comments and posts that pit doctors against patients. Patients do this. Doctors do this, too. And when doctors make certain negative comments online (mostly anonymously), I find it embarrassing to my profession. But I also know they do not do this out of malice. There is something seriously wrong with a system that turns a bright, well-intentioned, caring, and naively optimistic group into one that finger-points at the very people they aimed to heal.

I unknowingly embarked on a mini-mission to repair the doctor-patient relationship when I started to write this blog. My hope is to educate and inspire and to collaborate with others who have the same goals. As part of this mission, I am also hosting a movie event that is open to the public. It addresses some of the lesser-known aspects of practicing medicine that contribute to a physician’s burnout and will open your eyes to why some well-intentioned doctors are leaving the field. 

Remember, what both sides are really lamenting in our current healthcare system is the relationship that they hoped they would have. Ultimately, patients and doctors want the same things. We also both want this “marriage” to work and to have a long-lasting and mutually fulfilling partnership. With the right perspective from both sides and emphasis on the most important aspects of care -not the codes, visit numbers, or provision of unnecessary treatments and evaluations – it can be a win-win for both.

A Letter to my Readers: An Inspiring Story

 

Dear readers,

At a time when there is so much bad news in the media, I came across this touching story. It speaks for itself, but for doctors, it is a humbling and rejuvenating reminder of exactly what role we play in the lives of others. For patients, it is a great story about giving back and gratefulness. There is much to inspire all of us. Because positive stories and optimism should be more infectious than the opposite, please share this story with others.

Thank you.

 -Linda

Certainty, Uncertainty, and How Patients Respond to Both

The Harvard Business Review recently presented an interview with Zakary Tomala, the author of a Stanford Business School study regarding certainty and uncertainty. The surprising finding? Experts are more persuasive when they’re less certain.

“The phenomenon at work here is what we call expectancy violations. People expect experts to be confident. Violations of that expectation surprise them. We see that in our data. Subjects reported being more surprised by the uncertain experts and the confident amateurs. A surprise draws you in and makes you pay more attention. It gives the review more impact.”

Tomala says that his study is one of the first to focus on “how one person’s certainty affects others.“ Although the study involved opinions about a restaurant, I started to wonder how the findings might apply to healthcare.

“When I went to the doctor, he said I was going to die in 3 months, and that was 2 years ago.” How many times have we heard this type of comment, one that seems to gloat at the failures of medical science? Growing up around religious people, I heard this a lot. At the time, I had feelings of relief and gratefulness when people I knew were able to beat the odds of their illnesses. But in the back of my mind, I wondered how a doctor would be able to claim such certainty. Or perhaps the patient misunderstood the doctor?

Medical training – mine, anyways – taught me that medicine is a lot grayer than we think. This was most clear in residency, and even more so when practicing. There are odds to everything. Expressing uncertainty as a physician can be difficult because patients today want to know things definitively. Most of the time, they come to us for answers, not opinions (even though a medical opinion is just that, albeit a very educated one, and often involves trial and error). Sometimes, we are pressed to answer questions that are impossible to answer with certainty. “How much longer do I have, doc?”

Perhaps part of the problem is that we shot ourselves in the foot when we had rapid advances in medical technology, which helped us diagnose and treat and make more of an impact on a person’s health. The perception of patients towards physicians and the self-perception of physicians themselves changed with the advances, as well. The we’ll-just-have-to-wait-and-see approach has been replaced by the let’s-get-to-the-bottom-of-this-ASAP approach. There is nothing wrong with this. We have benefitted more from these advances than the numbers can really tell us (think about loves ones treated for diseases that had dismal prognoses in the past).

Did American Healthcare get cocky? Did/do doctors presume that they had/have everything they needed to have the utmost certainty when treating a patient? In certain scenarios, if doctors project a particularly high level of confidence in a diagnosis or treatment and they are wrong, it can lead to distrust, doctor-shopping, and disjointed (read: expensive) care. There will always be cases where a patient found the diagnosis was in error and subsequently held that probably proficient doctor in lower regard.

I honestly do not know what goes on behind the closed doors of other doctor-patient evaluations. However, I do know that in my exam room words like “possibly,” “probably,” “I think”, “maybe,” “likely,” and “good chance” abound. I hope that’s what the patient hears, because that is the truth. Does that mean I am a bad doctor? Probably not.