A couple of weeks ago I met my new medical students. These 10-12 trainees will be my small group for the next two years. We will meet monthly to discuss the soft stuff of medical training—hierarchy, tribalism, death and dying, medical errors, difficult patients, etc. Some call it “third year medical student support group.” This is my 6th year of the pleasure and privilege (I inherited my first group halfway through, when their previous preceptor moved out of state).
With each successive group I am ever more amazed at the students’ level of insight. They articulate compassion, humility, and maturity that I don’t think I had at their level of training. Or maybe it’s because we did not have classes like this to explore such things when I came up (or maybe I don’t remember?). More and I more I see my role as facilitator more than teacher. I am not here to impart medical knowledge. Rather, it is my job to stimulate exploration, conversation, and meaning. It’s so freeing, really—there is no standardized test to teach to. And yet I see it as my responsibility to help prepare these gifted young people to face the greatest challenge and reward of the profession: human relationships.
I feel no fear or trepidation. We cannot ‘fail’ at this class, any of us. Because the point of it is simply for everybody to participate, contribute, consider, and learn—myself included. Each month the students are given questions to answer in the form of a blog post. For example, “Recall an example of inspiring or regrettable behavior that you witnessed by a physician. Describe the situation, and its impact on you, the team, and/or the patient.” I read them all and facilitate discussion, tying together common themes and asking probing questions. My primary objective is to help them maintain the thoughtfulness and humanity that led them to medicine in the first place. Medical training has evolved in the past 20 years, for the better in some ways, not so much in others. One way we do much better nowadays is recognizing the hidden curriculum, and shining light on its effects, both positive and negative, through classes like this.
We all have those teachers who made a difference in our lives—or at least I hope we all do. I have multiple: Mrs. Cobb, 4th grade; Mr. Alt, 7th grade math; Ms. Townsend (now Ms. Anna), 7th grade English; Ms. Sanborn, 7th grade social studies; Mrs. Stahlhut, 9th grade geometry; Mrs. Summers, 10th grade English; Coach Knafelc, varsity volleyball; Dr. Woodruff, primary care preceptor; Dr. Roach, intern clinic preceptor; Dr. Tynus, chief resident program director. My mom is one of these teachers, also. She leads nursing students in their clinical rotations. I have seen her student feedback forms—they love her. And it wasn’t until I heard her talk about her students that I realized why they love her and what makes her so effective—she loves them first. Teaching is often compared to parenting. Our parents, at their best, see our potential and love us into our best selves. They cheer us, support us, redirect us, and admonish us. They show us the potential rewards of our highest aspirations. If we’re lucky, they role model their best selves for us to emulate.
All of my best teachers did (do) this for me. I’m friends with many of them to this day, and I still learn from them in almost every encounter. I love them because I feel loved by them. They held space for my ignorance and imperfections. I always knew that they knew that my best self was more than the last paper I wrote, the last test I aced, or the last patient encounter I botched. To them, my peers and I were not simply students. We were fellow humans on a journey of mutual discovery, and they were simply a little farther along on the path.
This is my aspiration as a teacher, to live up to the example of all those who loved me into the best version of myself today. This kind of love allows for growth and evolution, from student to colleague, to friend, and fellow educator. This is not something attending physicians typically express to medical students, positive evolution of medical education notwithstanding. But when I met this new group, I was overcome by love for them. So I told them. “If you take away nothing else from our two years together, I want you to have felt loved by me. I wish to love you into the best doctors you can be. That is my only job here.” Or something like that. It was impulsive and possibly high risk. But it was the most honest thing I could say in that moment, my most authentic expression of my highest goal for my time with them. I only get to see them once a month, and I want them to be crystal clear about what I am here to do. We have lots to cover these two years, so much to learn and apply. And love is the best thing I can offer to hold us all up through it.
The Journey and the Struggle
18 months ago I wrote about my plan for maximizing menopause preparedness. As with so many missions, this one has experienced both successes and failures. Since January 2016, I have grooved my exercise routine in the most awesome way. I am all over the TRX, doing Spiderman push-ups, incline presses, pistols and more. I get my cardio intervals and I’m foam rolling. I feel stronger now than at any time since high school, and I’m proud of this accomplishment.
The eating, on the other hand, continues to be a challenge. Earlier this year a patient looked at me without expression, and stated bluntly that I had gained 8.7 pounds since the last time he saw me. Right after that’s kind of inappropriate, I thought, well, he’s right, I have been gaining weight. Last March I wrote about weight loss strategy, thinking mainly about my exercise habit formation. Sadly, my own weight has gone opposite to the desired direction, despite an honest attempt at adherence to my own advice. Evidence suggests that weight loss really is about 80% diet and 20% exercise. But sometimes you can only focus on one thing at a time.
Back in 2008, when I finished nursing, I thought, I can get my body back! I knew I was not going to exercise, and I had no energy to police my food choices. But I also knew I was eating too much, so I decided to just cut my portions in half. It felt easy, decisive, and empowering. I lost 25 pounds in 9 months, and got down to my wedding weight. But eventually I acknowledged that though I was thin, I was squishy. So I connected with my trainer in 2014, the primary goal being to get moving without injuring myself. Right now I’m up 17# since my nadir in 2009, though I’m much more fit than the last time I lived at this weight.
Talking the Walk
I’ve always had a love-love relationship with food, and it shows in my weight/habitus. I notice also that my own state of mind and body has influenced the advice I offer to patients. Before I exercised regularly I spoke to patients a lot more about diet; now it’s more balanced. One patient brought it up recently. He asked, “What about the doctors who smoke, or the obese ones, how can they advise anybody about healthy habits?” I’ve thought a lot about it, so I was ready to answer. To me, there are three main options, all of which I have tried.
Disclaim. We doctors can rely on our authority to tell people what to do to get healthier. They notice our fat rolls, or smell cigarette smoke on us. They see the dark circles under our eyes and surmise that we don’t sleep enough. Maybe they can tell we don’t exercise. But we admonish them to eat less and move more. We say (subconsciously) to ourselves, “Do what I say, not what I do.”
Avoid. Rather than give lifestyle advice at all, we can focus on prescriptions and referrals. We feel we have no place instructing patients to eat more leaves, go to the gym, or quit smoking, when we don’t even do so ourselves. So we don’t even bother, feeling like hypocrites.
I think both of these responses are rooted in shame and perfectionism. And I think we should not fault physicians for choosing them—that would be meta-shaming–never helpful. These are normal, human responses to our professional training and expectations. Physicians have long held positions of authority and expertise. Until very recently, our relationships with patients were mostly paternalistic. But with burgeoning access to information, a culture evolving (rightly) toward patient autonomy, and physicians experiencing historically high levels of burnout and suicide, we cannot afford to burden ourselves with the illusion that we must be perfect in order to be credible.
Connect. I think the healthiest response, for both patients and physicians, is for us doctors to acknowledge our own struggles; to empathize with the difficulty, the conflict, and the utter disappointment of not being able to control our actions and choices as we would like. I think patients don’t expect us to be perfect. But they do want us to be human and relatable. I often find myself saying, “I know that feeling,” or, “Yep, that’s my weakness, too,” or, “Oh, and what about x-y-z? That’s my problem!” Only once has a patient said to me, “Shame on you!” He was a perfectionist himself; I didn’t take it personally.
I stress eat. I eat when I’m bored. I eat late at night, and I love sugar, starch, salt, and fat. The struggle is real, and I know it all too well. So when I ask you, “What small changes can you commit to in the next month?” believe me, I’m asking myself also. And if you tell me something that has worked for you, I’ll probably try it. I still think my ‘4 A’s of goal setting’ apply: Assessable, Actionable, Attainable, and Accountable. I just haven’t found my 4A formula for eating yet. But lately I have taken a more lighthearted approach to healthy eating trials. Nothing is life or death, and I know iterative changes are best. If one thing doesn’t work, hopefully I can learn something and move on to the next. No dessert on weekdays. Vegetarian on days I work. No eating after 8pm. No starch at dinner… Meh, none of it seems to stick yet. Even my cut-it-in-half strategy doesn’t appeal to me these days. It’s so frustrating! And it’s also okay, because I know I’m doing my best, just like my patients are. We can all just take it a little more lightly, one step at a time.
So by the time menopause actually hits, I’m confident that I will be prepared to meet it, with grace and maybe a little irreverence. I’m learning to judge myself (and thus others) a little more gently. I’m learning to love my body, whatever shape it’s in. After all, it’s the only one I’ll have this time around, and I need to maintain it for the long haul. Turns out, my patients have been my best companions and consultants on the journey.
My high school friend went tubing with her kids, and her body let her know the next day, it was not happy. As so many of us do when we realize life milestones, she posted to Facebook, “I must remember that I am closer to 40 than 20.” Before I could type my, “Amen, sister!” another friend astutely pointed out, “Might I remind you that you are closer to 50 than 20.” OUCH! And, true. We were 38 at the time.
This year I turn 44. Sigh. And wooo hoooooooo!! Aging kinda sucks, and it also freaking rocks.
Recently our babysitter invited me to volleyball night at her church. I played in high school and college; it’s how the hubs and I got together. We relived those days briefly in 2015 when some local people organized a loose pick-up group. Like many such groups, the level of play varied, and we had fun, but weren’t challenged much. I expected the same last week, but nope. I walked into a small gym filled with people averaging, by appearance and vernacular, about half my age. I watched wide-eyed as they leapt Michael Jordan high, serving, hitting, blocking, and digging better than any team I had ever played for or against. AWESOME!!! I finally get to play, after all these years! And yikes. I got a little nervous. These people were intense, skilled, and young. “Take a seat, Grandma,” I imagined them saying. But I was a guest of a regular, so I had a little street cred. And, everybody was very welcoming and friendly.
I stretched discreetly on the narrow sidelines, something we old people must do to prevent injury. I reminded myself to take it easy, no need to go all out and pull something. A few more full circle arm wheels and test jumps, and I was ready to go. I felt my heart pounding a little as I stepped onto the court. I was one of two women on my team, and my sitter-friend (the other woman) was very encouraging. I served underhand, as I can no longer rocket it overhand like I could 30 years ago (working on this). Two thirds of the way through the night my right knee started to get a bit wobbly, and I sometimes felt a strange zinging sensation up and down my lateral thigh. Grandma, I thought. It’s usually my left knee that aches. This was a new pain, with no attributable trigger.
I had so much fun. The general skill level ranged wider than I had initially observed, though it still skewed high. I estimate that I ranked in the upper half, maybe upper 40%, rustiness not withstanding. Everybody was mindful to make sure we all touched the ball, a very egalitarian league. As such, I got to pass, set, dig, and even hit a few. I held my own, and it felt good. One young man gave me the compliment of my month when he said I seemed ‘not that old’ and ‘nimble.’ I could have hugged him. I went home a little sore, and more than a little high.
I credit the last three years of fitness training for my utter lack of pain the next day. After all, I’m doing things on the TRX that I could not have done at 16, and I’ve exercised 5 days a week, most weeks for the last 18 months. I’ve relearned how to ride a bike, I can run 5K as a casual jog, and I’m as strong as I’ve ever been in my adult life. I just need slightly more maintenance nowadays.
But the best part of the night was mental. 25 years ago my worry over what people thought of me loomed over my consciousness in a way that robbed my fun. Back then every mistake I made on the court chipped away at my confidence, and more mistakes inevitably ensued. Sometimes I’d have an “on” night, and I always had enough fun to keep me coming back, but too often I’d go home wondering if my teammates regretted my presence.
No more. I no longer have anything to prove to anyone but myself. I’m just here to have fun and maybe make myself better—and I can only do that if I’m with people who play better than I do. I’ll own my mistakes and not beat myself over them—we all mess up sometimes. I know what I can and cannot do. I own all of me, and I’m okay. Looking back, my self-defeating attitude was probably worse for team morale and performance than any dig I missed. Not anymore!
Maybe some people already had this kind of self-efficacy in adolescence. I can recall a few peers in my youth who had that calm, collected aura about them. It wasn’t arrogance or superiority. Rather, it was an unassuming and authentic self-assuredness, which often translated into a generosity that attracted others to their orbit. That’s how I feel now, and I think this manner of self-confidence comes most organically with age. It’s the same confidence I see even more in my older, wiser friends. I might have run faster, jumped higher, and hit stronger in my teens and twenties, but I would never go back. Life is too good now, with decades of accumulated experience and integrated learning.
My kids were there last week. They watched me participate with enthusiasm, mistakes and all. When I commented that I might not have helped my team much (we lost all our games), my daughter sounded surprised. “But you’re good!” she said. Like I said, I left more than a little high.
If you wonder how physicians think and feel, about anything and everything related to medicine, healthcare, economics, parenting, relationships, and life in general, check out KevinMD, an expertly curated blog by physicians all around the world. I recently read a heartening and important piece on gender equality in medicine. A pediatrician husband wrote about the stark differences in assumptions about work-life balance for men and women, in “What Does Your Husband Think of You Being a Surgeon?” Then I came across another article by a male cardiologist, whose wife is also a physician, entitled, “The Gender Gap in Cardiology Is Embarrassing.” Both men’s wives delayed their medical training, and these husbands bore witness to our culture’s implicit gender bias against their life partners. I strongly encourage you to read both pieces; they are short and poignant.
—- Please click on the links and at least skim the articles, before continuing here. —-
Now, consider how much more weight and influence these pieces carry, simply because they are written by men. If you find this difficult, imagine your internal response if they had been written from the women’s perspectives. Which position is more likely to evoke, “Hmm, interesting,” as opposed to, “What are these women whining about?”
When we consider advocacy, it’s fair think of it as those with more power and influence using these advantages to champion those who have less. Sure, the less powerful and influential can and do advocate for themselves, but without allies among the advantaged, the message and movement stall and stutter. Consider slavery and the Civil Rights Movement. If it were only ever black people advocating for themselves, what would the American racial landscape would look like today? Think about women’s rights. There is a reason the United Nations launched the HeforShe campaign. Self-advocacy is required, but sorely inadequate, to lift people out of oppression. And let’s be clear: oppression takes many forms, which we often fail recognize or acknowledge.
I have a fantasy about patients advocating for physicians.
I imagine Sally and John*, two friends communing at their favorite coffee shop, one of their regular meetings of mind and soul. The conversation veers toward healthcare, and Sally starts ranting about how physicians don’t care about patients anymore. They’re only in it for the money, having sold out to pharma and industry, and they think of themselves as second only to God him(her)self, exercising control over patients’ lives with little regard or actual caring. In this coffee shop scenario, I as physician have no power or influence. If I sat there with them, trying to explain how ‘the system’ drives wedges between us doctors and our patients, about how on average doctors spend twice as much time on administrative activities as patient care activities, how 50% of us report burnout, and how our suicide rate is up to 4 times that of the general public, I estimate that I’d likely be seen as whining and making excuses. In this scenario, facing a (rightfully) prejudiced audience, my voice counts for very little.
Although physicians still enjoy a fair amount of respect and deference in society, our struggles, personal and professional, are still poorly understood by the general public. I think people are even less cognizant of the insidious and profound detriment that physician burnout and depression have on patient care and the economy at large. But when doctors describe our adversities to patients, I think we still come across as whining. Knowing that I write this as a physician, what is your reaction? Is it closer to, “You live at the top of the food chain, what are you complaining about?” Or rather, “Wow, what’s going on that so many doctors feel so badly, and how could we all help one another?”
Lucky for doctors everywhere, John is my patient and we have a longstanding, collaborative relationship. He empathizes with Sally’s perspective, as he knows what she has been through medically. He has also inquired about my work, and understands the systemic frustrations that physicians face in all fields. Because they are such good friends, John feels comfortable challenging Sally’s skewed assertions. He describes what he has learned from me, and explains earnestly that all doctors are not, in fact, swine. Because he is her trusted confidant, she believes him. Her attitude opens ever so slightly, and she is more likely to acknowledge how physicians and patients alike suffer from our overall healthcare structure. John is, in this case, the strongest advocate for me and my ilk.
Whenever one of us stands up as a member of a group, and speaks up to our peers on behalf of another group—white people for black people, men for women, Christians, Jews, and Muslims for Muslims, Christians, and Jews, liberals for conservatives, physicians for patients, and vice versa in each case—we are all elevated. Our mutual compassion and humanity are called forth to heal our divisions. This is how personal advocacy, how everyday power and influence, works.
As a patient, you have more power than you may realize. I bet most people don’t necessarily feel adversarial toward doctors. But they probably don’t necessarily feel allied, either. What can you, as a patient, do to bridge this gap? How else could we all, physicians and patients alike, create that essentially healing inter-tribal connection?
Hello again friends, and Happy New Year! It feels good to be back. Diving right in with long form again…
This recent article from Wired got me thinking (again), there are so many layers and moving parts to healthcare reform, that no one player stands to lose all or benefit all from any changes. And yet so much of what we read and hear has an, ‘it’s so simple, they just don’t care about you, but I do’ tone. The piece describes why insurance companies, who may have advocated most fervently against implementing ACA regulations, actually have a stake in maintaining its current status. Nothing in our healthcare system is black or white, all good or all bad.
So when I see politicians (and friends) speaking and writing in oversimplified sound bites, and vilifying a whole group (all liberals, all Republicans) over one aspect of their point of view, it really frustrates me. That is exactly the opposite of productive dialogue. It just makes people stop listening, because they don’t feel heard or understood. So they have no incentive to hear or understand you.
Many use the car insurance analogy to explain health insurance. It’s not exactly parallel, but it makes some sense. The law requires every car to be insured. (Drivers of) cars that don’t violate traffic law get lower premiums, the longer they stay ‘safe.’ The more traffic law violations, the higher the risk, the higher the premium. I have an actuary friend, who works for a health insurance company, who advocates, in part, for higher premiums for those who ‘use’ the healthcare system more—like the higher risk cars (drivers). I understand this logic. But this idea of making older and sicker people, and women pay more, just because they ‘use’ the system more (and thus financially speaking cost more), does not sit well with me. People are not cars. Not everybody maintains their cars well. But poorly maintained cars do not necessarily lead to increased accidents and traffic law violations. Poorly maintained health often leads to a human body’s multi-car highway pile-up equivalents.
My friend advocates for insurance coverage for catastrophic care (also aligned with the car insurance model), but not necessarily for preventive or primary care. There are different ways of ‘using’ the system. If you get preventive care, like recommended cancer screening and annual exams, it may cost more at the time. If you seek help for your back pain early, from your PCP, chiropractor, and physical therapy, that costs money. But if these early interventions prevent future, more catastrophic and costly outcomes, should we really penalize those who make them? Illness and infirmity come with age. So, often, do fixed incomes. Is it right to make our elderly pay more for their care?
There are costs and benefits to care other than money, which is where health insurance and car insurance diverge sharply, in my view. I know they are harder to quantify and assign, but they matter. That secure feeling that I can get care when/if I need it, that my children and I have access to professionals dedicated to my health and well-being, a sense that in our society, I matter just as much as the next person, regardless of my net worth—these things all matter. Each individual’s health or illness contributes synergistically to the health or illness of a society. A mother’s depression, untreated and uncontrolled because her health plan does not cover mental health services, can negatively affect every aspect of her and her children’s lives, emotionally, physically, financially, and socially. We cannot only look at healthcare on dollar spreadsheets of ‘use.’
Maybe it’s about priorities and philosophy—ideology? Do we feel all people have an equal right to equal care, or do we differentiate what people deserve based on particular group memberships or other characteristics? Do we feel we should only be responsible for ourselves, or are we called to look out for one another? I personally believe in equal access to care and ‘look out for others as yourself.’
I also believe that people need to understand–personally and concretely–that everything does cost money, we all pay for one another’s use (and disuse, and misuse) eventually, and more care is not necessarily better. So I understand and partially agree with my friend’s argument that people need to have ‘skin in the game’ to control overuse of services for no benefit. One great example is end of life care. I like this article from Fobres, which describes the conundrum succinctly:
According to one study (Banarto, McClellan, Kagy and Garber, 2004), 30% of all Medicare expenditures are attributed to the 5% of beneficiaries that die each year, with 1/3 of that cost occurring in the last month of life. I know there are other studies out there that say slightly different things, but the reality is simple: we spend an incredible amount of money on that last year and month.
Dr. Susan Dale Block, Chair and Director of Psychosocial Oncology and Palliative Care at the Dana Farber Cancer Institute and Brigham and Women’s Health Care, recently shared some data with her colleagues. In the Archives of Internal Medicine, a study asked if a better quality of death takes place when per capital cost rise. In lay terms … the study found that the less money spent in this time period, the better the death experience is for the patient.
Cost, longevity, quality of life, quality of care, value, perceptions, public health—these and other aspects of health and medicine are all inextricably enmeshed, though definitely not integrated. Any decisions about one must be made in the context of all the others, carefully, transparently, and honestly. Whenever we hear, ‘if we just do this, everything will be better,’ red flags should fly.
I wrote the first draft of the paragraphs above on my Facebook page. I ended the post with, “So let’s each educate ourselves on the facts, as well as we can, and try to look at the big picture. It’s so messy. And it’s what we’ve got, so let’s deal with it–with maturity, patience, professionalism, and equanimity.”
Another friend, a fellow liberal, commented, “This has nothing to do with healthcare. It’s about reducing taxes on the wealthy, reducing benefits for the poor, and denying the democrats credit for anything good. If they actually cared about healthcare, they would fix the obvious problems with the ACA. And because the ACA was the republican plan, they will continue to tie themselves up into pretzels to disown it and put something else in place. That being said, I hope the American people continue to demand access to affordable healthcare for all. It’s a right, not a privilege.”
I had to reply: “(My friend,) I understand your point of view, and I share your passion for equality. But your statement exemplifies exactly the broad brush, ‘you suck’ attitude that I see holding us all back. I refuse to believe that all Republicans are only motivated by making the rich richer, and that none of them care anything about the poor, as so many of us on the left say. We must extricate ourselves from this destructive narrative and learn to hold space for everybody’s complex views and experiences.”
My point here is that nothing is as simple as we’d like. It’s so much easier to blame those who disagree with us for being stubborn, selfish, or evil, than to cope with the discomfort that our system is deeply flawed, there are no easy answers, and our fundamental philosophical differences make it that much harder to agree on the best way forward. And yet, this is what we are called to do. It’s up to each and every one of us to change our language. Each of us has, I believe, the opportunity and the responsibility to create an environment in which open, respectful discussion and debate are the norm, rather than echo chambers and verbal warring.
I am only one person. I have no designated leadership titles or widely visible platform. But my words have power. So do yours. Please use them wisely.
NaBloPoMo 2016, Letters to Patients, Day 30
To Patients Who Journey With Me:
It is my privilege and my honor.
Well here we are, my friends, we made it! 30 posts in 30 days, woooo hoooooooooo!!
I had 30 topics all lined up on Halloween, and I think I used 6 of them. How fascinating! Looking back, I’m pretty proud of the content this month. It all came from places of true feeling and contemplation, and I tried my best to make it relevant to the physician-patient relationship. I meant to write more cogently about policy and operations, maybe illuminate more of the physician’s experience, to help patients understand our perspectives. I wonder if that is more appropriate for long form writing, or even not writing at all, more like panel discussion or podcast?
Some of you have followed, liked, and commented all the way through—thank you so much. After all, what is a blog if nobody reads it? The feedback has held me up and kept me going. It’s not so different from my relationships with actual patients. Some are superficial and short-lived. But most have a true human connection, and potential for integrative growth over time. My heart is warmed whenever you inquire about my children with genuine caring. When you remember my extracurricular projects and congratulate my successes, I feel respected. Heck when you just notice that my hair is longer, I know you see me!
Believe me, I’m not in this just for the science, or the money, or the prestige, or the teaching. I’m in this to know you, my patient—and for you to know me. I know there are some who see me as expendable, exchangeable. Their interactions with me feel purely transactional. And that’s okay; everybody needs something different. But I could not long survive a practice of only such relationships. No, that would kill my soul for sure. I live for the connections, I say. I learn from every one of you, and you make me better.
So thank you for journeying with me. It’s a long, strange trip, eh? The path winds, the weather shifts, and times change. But as long as we go together, I’m all in.