Category Archives: culture

On the Critical Importance of Self-Care

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NaBloPoMo 2016, Letters to Patients, Day 6

To Patients Who Feel Overwhelmed:

Put your own mask on first!

In my spare time, I go around talking to other doctors about how to take care of ourselves.  You may or may not be aware of physician burnout.  It’s quite the trendy topic in medical circles these days, and not in a good way.  Over 50% of physicians report at least one symptom of burnout (emotional exhaustion, depersonalization, or low sense of personal accomplishment), higher than the general population.  Physicians also kill themselves at much higher rates than the general population.  I’m grateful for the opportunity to study and speak on physician health and well-being, because it informs my practice in ways I had not anticipated.

To be clear, physician burnout is not a problem of personal weakness on the part of doctors themselves.  The healthcare system in the United States has evolved to such a dysfunctional state that some of its best and brightest find themselves despondent, depressed, and ready to quit.  And yet, we are called to persevere in the system as it is, even as we strive to improve it.

I see the same pattern in American society generally.  Technology and other advances have created a world of 24/7 hyper-stimulation, global comparisons of productivity and innovation, and immense pressures to be perfect, or at least appear so.  Men and women live under constant scrutiny and competition.  Do I make enough money?  Is my work impressive enough (to others)?  Are my children in the right activities?  Am I doing enough?  I see, hear, and feel it from my patients every day—the anxiety, the uncertainty, the angst.  The suffering is real, if not totally tangible.

For those of you whose exercise routines hold you up, how quickly do you abandon your workouts when things get really busy?  What about quality time with your friends?  What about your painting, knitting, writing, reading, skating, volleyball, music, and sleep?  Everybody recharges a different way, but I see a common pattern of ignoring the low battery alerts and pushing ourselves to empty—physicians and patients alike.

Our systems need to change, no doubt.  Medicine, business, education, politics…  We need to get clear about what and whom we really serve.  In medicine, I believe physicians should lead the movement toward a more humane internal culture.  There is no way we can take excellent care of our patients if we are not well ourselves, and we cannot wait for corporate leaders and policy makers to advocate for us.  The same is true for you, our patients.  What do you need to be healthy?  What can you change in your habits, environment, and relationships to meet these needs?  And in making such changes, what positive ripple effects could you have on those around you?  Can you lead by example?

If we all put our own masks on first, like they say on airplanes, how many other people’s masks could we help with?

Holding the Space for Expectations Challenged

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Ray Great Wall 2016

Those of you who follow this blog know that I meet regularly with a group of insightful and engaging medical students. I have written about them here and here. At our meeting last month, one of them described his recent rotation in China, and I invited him to share his experience here. I’m so grateful for this continued connection to physicians in training—it keeps me grounded. It reminds me that no matter how old and wise I may consider myself, I always have much to learn from others.

Enjoy, everybody:

 

Expectations. In the United States, we have come to have certain expectations for how things should be. A meal at burger joint should include a burger, with a side of fries and a Coke. When we check into a hotel, there should at least be a TV and a coffee maker with complimentary coffee. These have become essential (American) assumptions, and because we are the “best in the world,” our way is the best way.

Similarly, when you go see a doctor, there are certain expectations, both good and bad. You expect that it may take a few days to get an appointment. You expect a reminder prior to your appointment. You expect to wait a certain amount of time to see the doctor and to fill out a ton of paperwork. You expect the staff to be courteous. You expect to see a nurse first, and to wait again in an exam room until your doctor arrives. You expect the doctor will listen to all of your health problems closely, and offer helpful suggestions regarding imaging and medications you can take. You expect those prescriptions to be sent to your pharmacy, and that you can to pick them up after your appointment. You expect to get better.

What if your reality ended up very different from these expectations?

Last month, I went abroad to see what the healthcare system is like in China, at an academic teaching hospital in the nation’s capital of Beijing. After spending a year deeply entrenched in the clinical wards of the United States as a third-year medical student, learning from the best of the best doctors, I thought I knew what it meant to provide good medical care. I expected that I could teach them better ways of delivering care based on what I learned in America. I soon found out that I was the one who had a lot to learn.

To provide some perspective on just how different the healthcare system is in China, imagine this scenario, based on an amalgamation of different patient experiences that I witnessed:

You are sick and want to see a doctor. You wake up the next day at 5 in the morning so that you have enough time to take the subway to get to the hospital by 6. When you arrive, there are already 30 people in line ahead of you, and the specialist you want to see only gives out appointments for 25 people for his morning clinic today. You don’t end up getting an appointment.

You go into the doctor’s office when he arrives at 8, bursting in the door with 10 other people who are sick but were unable to get appointments. You fight for the doctor’s attention during his first patient’s appointment, and, luckily, you get an add-on appointment, for after his 25 other morning appointments. You sit in the waiting room until 12:30PM, when you are finally called in.

You see the doctor. He only has 5 minutes to spend with you. As he is doing your physical exam, his next patient enters the room before being called, and watches everything. The doctor says you need imaging, which you need to pay for and schedule yourself. You then need to pick up hard copies of the images and bring them to your next appointment, so that he can make a diagnosis. You also need some medical equipment, and he suggests shopping for it online. He says you may need to be hospitalized, but it may take 2 weeks to get a hospital bed spot, so you should sign up for the waiting list now. You get the imaging and medical equipment, the doctor makes a diagnosis, and you get better.

Your total cost for everything was less than $50.

Your gut reaction to this story may be, “this is madness!” You may feel that your expectations of healthcare delivery, based on your experiences in the United States, are very different from the care provided in China–not only different, but almost certainly better. At least, that was my gut reaction. I was appalled on my first day of clinic; my mind raced with questions: How do patients put up with this disregard for their time and rights to privacy and respect? How are doctors able to treat patients adequately without hearing the patients’ stories? Can patients have a good understanding of their medical condition in this system of care? It made me feel grateful for what we have in our current healthcare system back home, with better customer service, shorter wait times in the doctor’s office, and more privacy during the appointment.

However, take a second to reflect: is our healthcare system universally better? In this compiled scenario in China, you got seen by a specialist on the same day you got sick, which happens on a regular basis for patients familiar with how the hospital system works (even those unfamiliar with the system can still be seen within one or two days). Your overall costs were low and did not involve convoluted paperwork from third and fourth parties. And, most importantly, you were still able to get better. These are all things that hospitals in the United States hope to improve on. By the end of my first week in China, I realized that my gut reaction on the first day was irrational, stemming from discomfort with things I was not accustomed to. As I distanced myself from my premature judgment on what I was seeing, I found that the differences were not bad, just different. China has the challenge of providing healthcare to the largest patient population in the world, and with that, factors like cost containment and short visit times are prioritized. In the United States, we have also had to prioritize certain factors, specifically patient satisfaction, due to our cultural values and our legal system. In both countries, though, positive patient health outcomes are the highest priority.

Dr. Cheng asked me what three things I learned primarily from doing a clinical rotation abroad. First, different does not equal bad. While China and the United States do not have the same priorities for or access to healthcare, both have well-functioning healthcare systems. Second, withhold judgment from your expectations. Your gut reaction may not always be correct and may limit you from fully understanding things unfamiliar to you. Third, be grateful for what you have. Though our own healthcare system has its problems, we should be grateful for everything that works well, and we should not take it for granted.

Holding the Space: Beyond ‘Agree to Disagree’, or, A Discussion of White Male Privilege

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I recently found myself engaged in another oppositional conversation on Facebook… and it was a very good thing.

It was the ‘Week of Brock Turner,’ the Stanford swimmer convicted of 3 felony counts of sexual assault of an unconscious woman behind a dumpster. He was sentenced to 6 months in the county jail, only 3 months of which he would likely serve.  Social media erupted more violently each day with outrage and revulsion.  I, like many others, concluded that this represented a stark case of white male privilege at play, and I stated as much on my page.

A friend quickly denied the concept. We agreed that the sentence for Brock Turner’s heinous crime was absurdly lenient.  I wrote that I might have been more accepting of the outcome if he had owned his wrongdoing, and conveyed a sincere apology to the woman for violating her so egregiously.  My friend replied, “You’re nicer than me, I think he should have his balls chopped off.  But I’m old school.”  We both saw the result as unacceptable, but explained it from totally different points of view: he attributed it to the Turner family’s high socioeconomic status, and not to privilege of race or gender.

I shared this article, which I thought explained the phenomenon, one of unconscious bias, with relevant scholarly references.  He shared this article, claiming that white male privilege is an idea promoted by the political left to retain power over minorities.  I posted a link to Michael Kimmel’s TED talk, explaining the essence of privilege—that it is invisible to those who have it.  My friend then posted this article, a logical refutation of white male privilege based on what the author describes as the fallacy of critical race theory.  We each followed the other’s links, and criticized the content thereof (with civility, of course).

Several screens into the thread I realized we were each trying to convince the other, to change the other’s mind. It wasn’t working, duh.  I found myself sucked, again, into a typical tit-for-tat, back and forth argument over positions.  It started to feel like an exercise in futility.  Finally I wrote to my friend that I will study more (I still don’t really understand critical race theory), and meanwhile we can agree to disagree.  I thanked him for engaging, and we concluded the conversation amicably.  It got me thinking though:  Once we agree to disagree, what then?  Where do we go from there?  I still believe strongly in the existence of white male privilege, and he still strongly does not.

Let’s assume that both he and I—indeed most of us—are, in fact, kind, decent, compassionate, and intelligent people. Let’s assume also that we all seek productive and positive relationships with others.  What, then, are the best and worst manifestations of our respective beliefs?  I think it’s an important question.  How could we Hold the Space for the answers?  Here is my attempt:

 

White Male Privilege Exists

Worst manifestations

  • “All white men are misogynist pigs, oblivious to their inherent, unearned privilege, who perpetuate the oppression of women and people of color.” This attitude oversimplifies, generalizes, and stereotypes.
  • “All institutions are insidiously and irrevocably driven by white male privilege, and the only way to overcome this oppression is to treat it/people aggressively. We need to shame them in public until they get it.” This militant attitude incites and provokes, further alienating the very population it seeks to convert.

Best manifestations

  • “We all cannot help our unconscious biases—they are indoctrinated from a very early age and operate beneath conscious awareness. It does not automatically make anyone an inherent racist, sexist, or otherwise a bad person.” I see this as a nonjudgmental, objective, and mindful framework. It recognizes things as they are, however much we dislike them, with patience. It does not pit one group against another, and allows us to approach one another with openness.
  • “We can do our best to call attention, with civility, to white male privilege when we see it playing out in the workplace, social settings, etc.” The goal here is to bring it from unconscious to conscious awareness, where it can be better managed by intellect and reason. This is exactly how we work to overcome stereotypes and other unconscious biases. The first step is awareness, which can come much more easily in settings of nonjudgement, curiosity, and shared humanity.
  • “I will monitor my own biases in all realms, and look for contradictions to my assumptions.” Because I believe white male privilege is so prevalent, I risk over-attributing. It is my responsibility to check my perceptions against reliable and objective truths, or at least seek others’ perspectives for balance.

 

White Male Privilege Does Not Exist

Worst manifestation

“The concept of white male privilege is colossal lie, confabulated by the political left to wield power over minorities. Anyone who ascribes to this fallacy is unworthy of intellectual discourse.”  This attitude dismisses not just the idea, but the people who believe it.  It leads easily to name-calling and accusations, defensiveness and contempt.

Best manifestation

“I don’t believe in white male privilege, but I recognize other important contributors to poverty and social disparities. I will reject attempts to shame my point of view, and refrain from slinging insults in kind.  I pledge to work with others to effect positive change though good-faith pursuit of shared values and common goals.”  This is what I wish for someone on ‘the other side’ to say.  It takes the conversation beyond ‘he said, she said,’ and allows both parties to stand side by side to tackle important issues from different, and possibly complementary perspectives.

 

I am grateful to my friend for engaging with me on this topic. If not for him, I would never have come across the articles he posted.  I would not have questioned my position, or thought to consider the origins and merits of an opposite one.  The conversation called on me to practice critical appraisal as well as openness.  And while my opinion remains unchanged, its application is now more nuanced and thoughtful.  I like this idea of getting beyond ‘agreeing to disagree.’ By identifying the best manifestations of our respective beliefs, we can all contribute to a more just future.