The Pursuit of Mastery in the Worlds of Medicine and Wine

SOMM movieMedical 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):

Cour of Master Sommeliers

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.)

Posted in Film, Medical Education, Medicine and the Arts, Not Medical...Or Is It?, On the Lighter Side | Tagged , , , , , | Leave a comment

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. 

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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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Posted in Medical Education, Social Media | 4 Comments

A Marriage Made in #HCSM Heaven

Priscilla Chan probably knows that she is going to be watched. What she may not know is that it won’t be the paparazzi alone who will be watching her closely.

No sooner did Chan get married to the most famous social media icon and gain an “M.D.” after her name than did Twitter go abuzz with anticipatory murmuring. (Read here and here). While the tabloids and major “news” outlets pondered the presence of a prenup, physicians on Twitter – an already selectively progressive sort – have been pinning high hopes and expectations on this new graduate.

It would seem – by reading the tweets – that with the Chan-Zuckerberg marriage announcement, a new potentiality was born. Doctors who currently utilize social media (myself included) have been trying to change the face of medicine and doctoring to something more human, more “social,” and more impactful. Unsurprising, then, is this sense of excitement among them regarding the joining of the human embodiments of the very two fields they themselves have been trying to marry – medicine and social media.

(A marriage made in #hcsm heaven, perhaps.)

The news that “tech’s newest first lady” received her medical degree, should be a reality check. One that reminds us that if there ever was a time think outside of the box during medical education, it is now. With “reasonable” residency work hours and access to more avenues of communication – including social media – than ever before, it is an enviably exciting time to be training to be doctor. How can there not be a rapid pace of innovation coming from the next few generations of physicians? The time seems ripe for it. (No pressure, Class of 2012.)

The potentiality of innovation is also a present reality and does not require marriage or a legal document (except in the form of HIPAA paperwork, at the moment) to exist. The etched portrait of the traditional physician, though on a steadfast rock, is weathering with the winds of time and the tides of social change. And with this transformation, creative medical minds have discovered more freedom to innovate and collaborate. This can be observed when following the work of forward thinkers (like Bryan Vartabedian or Eric Topol), bright minds (Mike Moore or recent med school grad, Aaron Stupple), innovative practitioners (Wendy Sue Swanson and Howard Luks), and dedicated academic clinicians (Vinny Arora, Ryan Madanick, and Katherine Chretien).

What we hope from the newly married, newly minted Dr. Priscilla Chan and her generation of doctors should be no more than what we hope to aspire as physicians currently practicing in the medical field. Hard as it may be, we need to keep our eyes and minds open and complacency out. Admittedly, I, too, am curious what further contributions Chan will make to the fields of social media and medicine. But I don’t want to pressure her just yet. As I remember it, internship is hard enough.


See Kevin Pho, MD’s well-written commentary here:

I commented on his post in order to clarify my quote:

Great post, Kevin.

The particular quote in my blog, which could be differently worded in retrospect as I see it in this context, was referencing a hope that all of us – current physicians and medical trainees – would think big and outside of the box about the impact we can make with the resources we have. We should expect just as much out of our own abilities as we do from her. We may not be able to deliver on quite the scale she can, but I think we – as busy physicians – underestimate our ability to innovate and influence. I am quite sure, in fact, that Dr. Chan will be influential in the coming years. And it will be exciting to see.

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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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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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