Author: Maria Yang, MD

Categories
Blogosphere Medicine Observations

Fear and the Online Physician.

To follow up on my last post I had intended to write something that follows the style of an FAQ:

  • What if your patients read your blog?
  • What if your boss reads your blog?
  • What if your patients ask you for medical advice through your blog?

Fear underlies all of those questions, though, and it seemed to make more sense to address that fear.

If you are a physician and you are concerned about the vulnerability of having an online presence, what do you worry about? Do you worry that patients will learn to hate you? That your boss will find a reason to fire you? That random patients will “bother” you?[1. Why do some physicians worry that patients will find them online and “bother” them? What low opinions we must have of patients if we automatically assume that they will “bother” us! And what little faith we must have in ourselves to establish and maintain boundaries should that happen! And how grandiose we must be to believe that patients want to expend the time and energy to “bother” us!]

Would you do something on the internet that you wouldn’t do “in real life” as a physician?

All the people you interact with as a physician—your patients, your colleagues, that person who works in the system, but you see him only every few months—already have opinions about you. You build your reputation with the little things you do every day.

If you think patients are lazy, your behavior will reveal that belief. If you tell someone (a colleague! a friend! another patient!) that you think patients are lazy, that will eventually become common knowledge. If someone confronts you about that, you’ll manage it the way you manage it… and people will observe that, too.

Recording your belief on the internet that patients are lazy seems like a bad idea (because it is). Stuff stays online for a long time and people will find it. If that scares you, it should. But if you’re not doing things like that “in real life” now, why would you suddenly start doing that on the internet?

You might think that the lack of an online presence (or having an anonymous presence[2. It may be true that physicians, under cloaks of ostensible anonymity, can report and discuss problems in medicine with greater candor. Whistle-blowing can be a good and necessary thing. However, anonymity is ultimately short-sighted: It is difficult to maintain true anonymity on the internet. More importantly, if people know who you are, you have greater power and credibility to identify and solve problems.]) will protect you because if they can’t find you, they won’t talk about who you are, what you think, and what you do.

That’s not true. People already talk about you.[3. Yes, people are talking about you, but let’s be realistic: They don’t talk about you all the time. Or even all that often.]

And these are people who know what you look like, know where you work, and have experience interacting with you. Patients who don’t like you will continue to dislike you. They’ve probably told someone why they don’t like you. Who knows: They might’ve even shared their opinions about you on the internet. (As I have noted elsewhere: Having an online presence gives you the opportunity to shape your reputation on the internet. You already take active steps to shape your reputation “in real life”: Maybe you make a point of greeting everyone at work with a smile. Or overtly washing your hands in front of patients.)

The internet may be different medium, but the messages we send are the same. It’s also a place to learn and exchange ideas: What are other medical professionals learning? What do patients want? What problems are we trying to solve? How can we make things better? We’d like you to join the conversation.

As a physician you’re trained to discuss risks, benefits, and alternatives about interventions with patients. Having a presence online has its own risks and benefits. If you do decide to step into the online arena, know that you aren’t alone: There are many physicians who write on the internet. Join us.

Categories
Blogosphere Nonfiction Reflection

My Brief History on the Internet.

The first time I posted my writing on the internet was in 1997. I created a website about The Evolution of Mickey Mouse. It was based on a report I wrote in high school about the small mammal. My research for this report entailed several visits to the library to scroll through multiple rolls of microfilm (do kids these days even know what microfilm is?) to find articles that described the mouse during his heyday. I decided to put my findings on the internet so other people wouldn’t have to dig through canisters of microfilm. That Mickey Mouse website did well: For a short period of time, back when the Yahoo! search engine reigned supreme and Google was new, the site was ranked #2 with the search terms “Mickey Mouse”.[1. Disney.com, of course, came up first if you searched for “Mickey Mouse”.] Children from the world over sent me e-mails with instructions to “say hi” to Mickey Mouse. The internet was a sweet and innocent place.

My first blog was hosted on Open Diary. It was late 2000 and I was a medical student. I used a nom de plume that now causes me some mild embarrassment. I wanted to record my experiences in medical training. This was not a new practice for me: In junior high, high school, and college, I filled the college-ruled pages of dozens of spiral-bound notebooks with my thoughts. To my knowledge, there weren’t many medical students blogging at that time. Other Open Diary users read my writing, seemed to enjoy it, and expressed interest in what happens in medical school. Writing for an audience was fun. The internet was a social and friendly place.

Open Diary used fixed templates. While I knew that the substance of the writing was paramount, I wanted more style on the screen. That’s when I moved my writing to Blogger (still owned by Pyra Labs at that time) and adopted the title “intueri: to contemplate”. That would remain the name of my blog for six to seven years. I dropped my nom de plume and started using my first name. No one could figure out who I am with just my first name, right? And even if they do, who’s gonna care?

I wrote about my experiences in medical school… and then about my experiences in residency. My blog moved off of Blogger and I bought my own domain. I used MovableType for a few years. I then tried WordPress and have used it since. I read Instapundit and he posted an e-mail I sent to him. Ezra Klein, before he became Ezra Klein, called me “one of the web’s most graceful prose stylists“. I hosted Grand Rounds a few times.[2. If you know what Grand Rounds is, that shows your blogging age.] I started meeting people who read my writing online. The internet was a dynamic and exciting place.

I started feeling ambivalent about writing online. I closed down comments because anonymous people left statements like, “ALL PSYCHIATRISTS SHOULD DIE” and “YOU’RE A PSYCHIATRIST, YOU KILL CHILDREN”. A physician who wrote a blog under a pseudonym was revealed in court. I worried that my writing wasn’t fictitious enough, that maybe my stories weren’t purely coincidental. My mind generated catastrophes: Someone might read a story and think I was talking about them! They would sue me and I would lose my license! Other doctors would judge me! I would never recover! Even if I did, one of those commenters who hate psychiatrists would then kill me!

So I shut down that blog. The internet was a scary and dangerous place.

I moved to New York City. A man who was living there had been reading my blog for a few years. He suggested that we meet. We dated. We eventually got married in Central Park.

I couldn’t not write. Nearly two years had passed since I had posted any of my writing online. I decided to start another blog, though I did not want to write in fear. In White Ink revealed my full name. (Nothing bad happened.) The first post appeared there in 2010. The internet was not dangerous place, though not an innocent place, either. The internet was a place to learn.

I purchased this domain name, mariayang.org, that same year. Would you believe that it took nearly four years for me to build the courage to finally occupy the space?

Next time: Occasionally asked questions about blogging as a physician.

Categories
Nonfiction Observations Reflection

Sea Lions.

The sun was beginning its ascent into the sky, though it had yet to peek over the horizon. An occasional harbor seal poked its round head through the surface of the dark water in the marina. The twinkling stars overhead were starting to fade.

Dozens of sea lions were piled on top of the rocky pier. The males, some weighing close to 700 pounds, barked and snarled at each other. A loud splash occasionally cut through the din when, during a quarrel, one of them fell into the water.

My friend and I walked along the platform. The wood planks creaked under our weight as we followed the path back to the shore. We spied a sea otter, curled up and snoozing, at one end of the dock.

My friend stopped walking.

“What?” I asked.

He pointed. My gaze followed his finger through the purple darkness.

Not six feet away from us on the pier was a heap of eight or nine sea lions. The smaller ones were farther away from the main walkway. A blubbery male, teeth showing and head raised, was seated on the platform. He was looking at us.

“What if he attacks us?” my friend whispered.

Some of the other sea lions turned their heads and cast a wary eye upon us. The corpulent male guarding his tribe barked. My friend leaned back into me.

“He won’t attack us. They eat fish,” I reasoned.

“That thing weighs like 700 pounds,” he said. “He could crush us.”

The distance between the fleshy sea lion and the other edge of the platform was about three feet. There was no other way back to the shore.

“Just don’t make eye contact and keep walking,” I said.

He didn’t move. Shrugging, I slipped around my friend, kept my eyes down, and walked past the bulky creatures. My fingers could have patted their heads; their flippers could have smacked me into the water.

When I was about eight feet past the sea lions, I heard hasty footfalls behind me. My friend, unscathed by the animals, appeared by my side.

“That was scary,” he murmured.

“They could have eaten us!” he exclaimed once we were on shore. “They weigh a lot! Did you know that sea lions can run on land faster than humans can? Can you imagine a 700-pound sea lion tackling you? Into the water?”

“But they don’t eat humans. And we weren’t going to fight him for that dock or his clan.”

After a few moments of silence, he said, “You’re brave. You walked by them as if they weren’t there.”

I wondered about this later. My friend is not timid, nor is he nervous. Why did the sea lions rattle him so much?

The construction workers across the street shouted at me.

“Hey baby! Wanna gimme some sugar tonight?”

He was sitting on the stoop when I walked by.

“Konichiwa. An nyoung. Ni hao,” he called. “You speak one of those, right, honey? How do you say ‘I love you’?”

While I was waiting to cross the street, he came up to me and said, “You’re pretty. You’re pretty. You’re really pretty. Asian woman, you’re pretty.”

He waved at me from across the room. “Hey, doc! Do you do sex therapy? I want to learn more about that… from you.”

Of course. I am a woman, he is a man. What have I done in the past when I got attention I didn’t want, when I wanted to disappear?

“Just don’t make eye contact and keep walking.”

Categories
Nonfiction Observations Reflection

Michael.

Everyone noticed him before we boarded the plane. He asked the airline representative at least three times to confirm that he had a seat. He looked like an adult, but the tone of his voice was that of a child.

“Yes, you have a seat, Michael. It’s 7B.”

Grey cargo pants covered his short legs. The sleeves of his striped polo shirt collected below his elbows, making his arms look even shorter and his hands even smaller. His neck hid inside his collar. His fingers were short and thick. His glasses magnified the creases in his eyelids. Because his nose was flat, it made his mouth look wide.

The elderly man in the aisle seat had asked the flight attendant to stow his cane. Wrinkles burrowed into his forehead and surrounded his eyes. They revealed a lifelong habit of frowning. The elderly man heaved a sigh of resignation when Michael took the seat between him and me.

Michael sat down with conviction, then stood up and adjusted the nozzle so more air blew into his face. After sitting down again with resolve, he picked up the seat belt.

“What is this?” he asked, his fingers poking the thick padding. When no one responded, he turned to me and said, “This isn’t a normal seat belt. It’s weird.”

As other passengers filed past us, he greeted every third or fourth person.

“Hi! Hi!” He thrusted his arm forward across the lap of the elderly man. Without realizing what they were doing, many people found themselves shaking his hand.

“Hello! My name is Michael! Who are you going to see? I’m going to see my dad. He bought my plane ticket for me.”

“Oh… that’s nice.”

The elderly man sat back, leaned away from Michael, and sighed.

Michael turned off his cell phone. Turning to me, he saw me send a text message.

“You’re supposed to turn off your phone, like this, see?” He waved his phone at me like it was a baby rattle.

Shortly after the plane took flight, Michael reached his hand in front of my face and pulled down the window shade.

“Too bright,” he said as he looked back at the television.

The flight was about two and half hours long. Twice, Michael announced to the elderly man, “I need to use the bathroom.” The elderly man said nothing, pushed himself out of his seat with his arms, and stood in the aisle with sorrow on his face as Michael ambled his way to the lavatory.

When the pilot announced that we were approaching our destination, Michael reached over, grunted, and pulled the shade up halfway. Through the double-paned window we saw the Pacific ocean, its waves rolling towards the coast in a never-ending parade. A squadron of pelicans glided over the water. Small boats left frothing white wakes atop the blue-green swells.

Michael reached over again and pulled the shade up a little more. We both continued to look out the window.

When the plane arrived at the gate, Michael bolted out of his seat, reached over the elderly man, popped open the overhead bin, and pulled down his backpack.

“I’m going to see my dad!” he announced.

An airport attendant boarded the plane and called Michael’s name. He raised his hand with the enthusiasm of a child who wants to answer a question first.

“I’m Michael!” he said. “Are you going to walk with me off the plane?”

I saw Michael a few minutes later outside the terminal and witnessed his reunion with his father. His father did not share physical characteristics with Michael; Down syndrome is not heritable.

They hugged each other and both smiled with joy. The extra copy of chromosome 21 did not diminish the love father had for son.

“How was your flight?”

“It was great,” Michael said. They began to walk away together, his father’s arm holding Michael close to him.

We judge ourselves by our intentions, but we judge others by their actions.[1. This quote is attributed to several different people, including Andy Andrews, Stephen Covey, and Ian Percy.] For people with overt disabilities or deformities, we are more forgiving of their behaviors because we are more charitable about their intentions.

Why do we not do the same for those people whose deformities or disabilities are not visible?

Categories
Consult-Liaison Education Lessons Medicine Systems

Have You Thanked Your Nurse Today?

As I noted earlier, hospitals permit around-the-clock observation of patients. If you don’t need around-the-clock monitoring, you don’t need to be in the hospital.[1. “But what about ‘social admits’?” you may cry. “They don’t need to be in the hospital, but we admit them anyway.” True. “Social admits” reflect the intersections of social policy, politics, health, economics, and the lack of resources. That topic is beyond the scope of this post.]

Who is doing this around-the-clock monitoring? Nurses.

Therefore, whether you are a patient or a physician, one of the best things you can do is get on the good side of the nurses.

If you are a patient, a nurse watches over you and your care. Nurses make sure that you won’t fall. They make sure they give the right dose of the right medication in the right route to the right person at the right time (which can be easier said than done). Nurses provide education about medicines, tests, and health conditions. They make sure you know what day it is, where you are, and who you are. (Also easier said than done.) They monitor your progress and try to ensure that your health only improves. Nurses can also page the doctor for you or your family. They can find out when you are scheduled to go through a procedure. They can find out what you are waiting for. Nurses advocate for you.

Sometimes it may seem like they’re not “doing” anything. They are. They’re keeping an eye on what is happening with your health.

If you are a physician, you must already recognize the value of nurses. (If you are a medical student or resident and have fantasies that, one day, you will be “running the show”, don’t be a fool: There is no way you could do your work in the hospital without the help of nurses.) Nurses serve as our eyes and ears. They tell us information about patients that patients themselves cannot or will not tell us. They do triage with us when we have multiple patients who are not doing well simultaneously. They tell us if someone is starting to look a lot worse… or a lot better.

While it is true that nurses provide around-the-clock observation of patients in hospitals, it is also true that nurses provide around-the-clock monitoring of doctors in hospitals.

Nurses know when doctors typically meet with patients. They know which doctors are more likely to spend time with patients and answer questions. They know which doctors work in collaboration with nurses and which ones treat them like second-class citizens. They know which doctors return pages promptly. Nurses quickly learn how to alter their approaches with various doctors to get work done.

This is yet another reason why, as a patient, you want to get on the good side of nurses. Nurses manage doctors. Skilled nurses will know how to work with different doctors to help you get what you want (e.g., answers to your questions, a meeting with your family, better pain control).

(Patients, you should also know that nurses also manage you. Nurses tell doctors which patients yell at nurses, which family members are berating them, which patients are trying hard to follow recommendations, and which family members left cookies and treats for them.)

Physicians, thank your nurses for helping you do your job better. Positive reinforcement and good manners go a long way. The more you acknowledge the skills and efforts of your nurses, the more they will want to work with you and make your job easier.

Patients, thank your nurses for watching over you. Nurses play an essential role in your care in the hospital. Be kind to them. The more you acknowledge the skills and efforts of your nurses, the more they will want to work with you to get you back to health as soon as possible.