Category: Observations

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Education Informal-curriculum Lessons Medicine Observations Reflection

Guiding Principles for Medical School.

Dear Jane:

Thank you for asking me about my perspectives on medical school. Here are some general principles that you might find useful in your own training:

View everyone as your teacher.

Everyone you encounter will teach you something. Be open to what they have to offer.

Yes, your professors and attendings, the “official” teachers, will educate you. Patients, however, will often be your best teachers. Listen to what they say, watch how they react to what you do, and acknowledge and accept the feedback they give to you. Their teachings are often the most useful and valuable.

You might see a physician condescending to a patient and decide that you never want to do that. You might see a nurse offer quiet comfort to a patient and decide that you want to mimic that manner. You might witness a technician help a patient feel less anxious before a procedure and decide that you will steal that technique. You might talk to a physician on the phone and decide that you will adopt that professional and kind manner when you talk to other physicians.

In this way you can be a student for life.

Reflect on your experiences every day.

This can take many forms: You can keep a journal. You can talk with friends. You can meditate. You can go for a ten-minute walk around your neighborhood. You can sit in a chair and stare out the window. It doesn’t have to be a big thing.

Reflecting on your experiences will help consolidate what you learn so you can apply that knowledge in the future. This applies to “book” knowledge (physiology, pharmacology, etc.) and “non-book knowledge” (how to redirect a patient or your colleague, how to manage your emotions in the face of disease and death, etc.).

There will be times when you will feel overwhelmed and cannot or choose not to reflect. That’s okay. It happens.

You will see terrible things.

You will see people suffer. You will see people die. You will hear hospital staff say derogatory things about patients. You will see your colleagues lie about things they should not lie about. You will see everyone—the patient, nurses, doctors, technicians, family members—work as hard as they can and none of it will help the patient. You will see people who need help, but don’t want it.

Remember the discomfort you feel when you see things you don’t like. These experiences are your teachers, too. They will help you stay human and humane. Medical training can steal that from us.

You will do terrible things.

You yourself will do things you will not like. (Hopefully infrequently.) You will snap at patients. You will be snarky to staff. You will bend the truth, if not lie, because you won’t know what else to do.

You must reflect on these events so they don’t become habits.

Connect with physicians who do not work in academic centers.

Some physicians in the community will have practice patterns and work in systems that will appall you. Some will inspire you. While academic medicine does happen in the “real world”, it’s often different from what is in the community.

Exposing yourself to the non-academic world will help you learn about a greater variety of patients, creative and innovative developments in health care, and provide more context about medical care in the world. Even if you end up working in an academic center, these experiences will shape your practice.

After you decide what kind of doctor you want to be, take rotations in every other specialty.

Medicine is compartmentalized, but people are not. Your patient with high blood pressure may become pregnant… develop a painless red eye… fracture a bone… have her gall bladder taken out… or develop an alcohol problem. Learning about a variety of conditions will help you take care of people, not just diseases.

The most useful guiding principle for me during my training (and now) is to remember that your work is to take care of the patient. It’s not about the letters after your name, long titles, or how big your salary is. Medicine isn’t about you. It’s about the patient. That attitude will keep you humble, curious, and grateful.

Congratulations on your admission to medical school! May you find the work rewarding and meaningful.

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Lessons Observations Reflection

Length of Day.

The long, glorious days have arrived in Seattle. The sun rises shortly after 5am and sets after 9pm. We’ve savored the warmth of the sun on our faces; the sky has been more blue than grey in the past few weeks.

The tradeoff is that, in the winter, the days are short. The sun rises close to 8am and sets before 4:30pm. Furthermore, the pewter clouds and rain blot out the light of the sun. The days are dark.

These cycles, though, are predictable. We celebrate what light we have during those winter days as we step through puddles and under naked trees. During the summer, we relish the long days as we witness the alpenglow of the sleeping volcano, hike the verdant mountains, and squint at the sparkling waters of the sound.

Life is not predictable. We do not know if our lives will be like a day in December or June in Seattle. We only know the length of day after the sun sets, after someone dies.

When his mother died, my father followed the custom and wore a black braid around his left bicep.

“How long did you wear it for?”

“Ninety days.”

He gave me four pieces of black yarn. While on the plane I created an uneven braid with the yarn and wrapped it around a black armband. I will wear it until August 20th.

The thing about death and dying is that, even though you know it will happen, it’s still abrupt.

This is why it is vital that you say what you need to say and do what you need to do while you still can.

You don’t know when someone you love or care about will die. If you have stuff you need to tell someone—your apologies, your love, your hopes, your affection—tell them now.

We regret those things that we could have done, but, for whatever reason, chose not to. Regret sucks.

And even if you do say everything you need to say and do everything you need to do, know that it may still not be enough. For those that we love, we can never tell or show them enough how much we love them, how grateful we are for them, how much we want them to have happiness and peace. When they die, that ache of regret may still persist: You wish you could express your love to them one last time.

It will be too late.

I told my mother everything I wanted to say in the six months between the time of her diagnosis of cancer and her death. She took advantage of the time, too, and shared her hopes, fears, dreams, and wishes with me.

I thank her. And I miss her.

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Blogosphere Medicine Observations Policy Systems

Why I Work at the Fringe.

This article is making the rounds among physicians on Twitter. Much of the information in the article, unfortunately, is accurate.

For some of the reasons stated there, I left the “traditional” health care system and pursued work at the “fringe”.

Part of this is due to my clinical interests: I like working at the intersections of different fields. For example, I like the intersection of psychiatry and hospital medicine, which is called psychosomatic medicine. Another example is my interest in public psychiatry, which focuses on the intersection of social factors and mental health (e.g., individuals with psychiatric and substance use conditions in the context of homelessness and poverty).[1. Really, though, all of medicine could be “psychosomatic medicine” or “public psychiatry”; the divisions between mind, body, and environment are arbitrary.]

Part of this, though, was my sense that the system would not let me be the kind of doctor I want to be.

For a brief period I worked in a clinic where I had slots for four new intakes a day (60 minutes each) and 15-minute follow-up appointments for the rest of the day. If my schedule was completely filled with follow-up appointments, I could have seen up to 34 patients a day. (I never got to this point because I quit well before my panel got full.)

In reality, the 15-minute appointments were 12-minute appointments. I needed about three minutes to type out some notes to myself for clinical documentation.[2. I don’t like typing my note while I am seeing a patient. I’m not fully attending to either one when I do that.]

Because I was building a new practice, people with a wide variety of conditions and concerns came to see me. I was advised to refer patients out of the medical center who were “too sick”. This included individuals who were frequently in and out of psychiatric hospitals, had significant psychiatric symptoms, or otherwise had other stressors in their lives that made them “difficult“.

In other words, they told me to refer out the people who needed specialist care the most.

The reality, too, was that no psychiatrist could provide quality care to these individuals in 12 minutes. Imagine someone with depression so severe that he lacks the energy or interest to share his current distress with you. Or someone who is psychotic and insists that her ex-husband is tracking her through all the electronics in her home. Or someone who is so anxious about leaving his house that his attendance to the clinic is worthy of celebration.

Obtaining an accurate history guides diagnosis, which then guides treatment. An insufficient history can thus lead to haphazard interventions. You can see how the 15-minute appointment model results in heavy reliance upon (potentially unnecessary) medications. If someone says he feels depressed, it’s difficult to validate his emotional experience, provide education about his condition and non-pharmacological ways to manage it (e.g., behavioral activation, sleep hygiene, etc.), and have a discussion about medications, which should always include risks, benefits, and alternatives, in 12 minutes.

It is much easier to write a script and ask someone to return in a month. (This inspired my post about the Automated Psychiatrist Machine.)

Furthermore, this clinic was in a medical center with a group of primary care physicians. Primary care doctors referred their patients with diagnoses of schizophrenia and bipolar disorder to the psychiatry clinic (as they should). These individuals, however, were “too sick”. Never mind that, unlike the primary care physicians, we psychiatrists had the training to diagnose, treat, and manage these individuals with significant psychiatric conditions.

Thus, these patients often returned to their poor primary care physicians, who tried to care for them the best they could… which often entailed medication regimens that were unnecessary. (Primary care physicians deserve no blame for this: How are they supposed to know?)

This clinic also “rewarded” psychiatrists for “productivity”. The more patients a psychiatrist saw, the more money the psychiatrist would earn. This led to “cherry-picking” patients. Psychiatrists would keep patients who either had minor conditions or symptoms that had resolved, because those are the patients you can adequately see in 12 minutes. As a consequence, patients with more debilitating symptoms could not access the clinic. The psychiatrists had no incentives in either time or money to send these “cherry-picked” patients back to their primary care doctors.

My frustration and disillusionment compelled me to leave the job. I returned to positions at the “fringe” to work with patients who often are also not part of the system or patients that the system had failed. Consider the man who has been homeless for the past ten years and is too paranoid to access any health care service. Or the woman who was beaten and molested as a child, sent to foster care and group homes, never completed high school, “aged out” of youth care, and now has no resources or support.

I couldn’t wait for the system to change, so I sought out settings where both my skills would be useful and I could be the kind of doctor I want to be. There may not be many physician jobs at the “fringe” and certainly not all physicians want to work there. When we physicians vote with our feet, though, we show what we value, the kind of care patients deserve, and how the system must change.

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Homelessness Observations

All Four Seasons.

Green leaves are budding from the trees lining the city streets. The branches sway from the weight of small birds, their throats full of song. The chill in the morning air melts away as the Spring sun warms the ground, beckoning the flowers to push through the damp earth. Pedestrians carry their umbrellas and weave around the puddles on the sidewalk.

Some of them do not see the soiled sneakers poking out from under the bundle of blankets heaped in the shop doorway. Some people cast a sideways glance and say nothing. They have places to go.

People turn the calendar pages and begin to wear white again as Summer breezes into the city. The air is thick with moisture and the asphalt radiates the heat of the sun. When shop doors open and the cool conditioned air whooshes outside, people wearing strappy sandals, twill shorts, and thin tank tops sigh with relief. Fireworks light up the sky, people have picnics in the park, and the kids catch fireflies at night.

The bundles of blankets have moved underneath the bridges and along the banks of the river. The shop owners, taking advantage of the longer hours of the season, throw away the flattened cardboard boxes they find near their doorways. These are entryways, not platforms for beds.

The arc of the sun shortens and fog begins to drift into the city. The once verdant trees now don red, orange, and yellow leaves. The Autumn rain begins to fall. Kids pile into school buses and adults board the train, all daydreaming about their summer adventures.

The bundle of blankets appear downtown again. The blankets get wet from the frost in the woods. Rectangles of cardboard, piles of blankets, and rolling suitcases collect under the awnings of buildings.

Old man Winter hobbles into town. Freezing rain and snow fall from the pewter sky. People hurry to the store to stock up on toilet paper, bread, milk, and canned food. Their breath turns to white mist as they mutter about the cold and prepare for several feet of snow. Smoke floats out of chimneys, readers snuggle with books, and the kettles whistle when the water boils.

The bundles of blankets poke out of cardboard forts dressed with tarps or garbage bags. The snow is already collecting on the corrugated roofs, which sag from the wet weight.

“If you see someone in need during the storm,” the newscasters say, “if you see someone who is homeless, call this phone number.”

The homeless are there all the time. They are there all four seasons.

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.