Everyday Power and Influence

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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?

*Hypothetical friends

Getting Past ‘You Suck’ as Dialogue

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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.

 

On Journeying Together

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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.

 

On You, Team Captain and Tribal Leader

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NaBloPoMo 2016, Letters to Patients, Day 29

To Patients Who Think What You Do Doesn’t Matter:

Think again.

Yesterday I described You, the Elite Athlete.  All great athletes know they do not succeed alone.  They also appreciate the unique contribution they make to their teams.  What teams do you serve?  How do you lead?  It doesn’t matter whether you have a title or designation.  One of my favorite ideas is that no matter our instrument in the orchestra, according to Ben Zander, we can lead from any chair.

For now, think of yourself as Team Captain, or Tribal Leader.  You have invested in yourself by fueling and training, resting and recovering, managing your stress, and cultivating excellent relationships.  Now you can take the returns and reinvest in those around you:

Appraise:  Prioritize self-care

  • Like on an airplane: “Put your own mask on first.” Tribal leaders know that to effectively care for others long term, they first need to be healthy themselves.
  • Practice awareness and management of your emotions, and prevent emotional hijacking, so as to be emotionally available to our teammates and tribe members.

Empathize:  Speak the team’s language(s)

  • Think of your favorite teachers and coaches—they were able to relate to learners at all stages of development and team morale—and lovingly lift us all up.
  • “People don’t care how much you know until they know how much you care.” –T. Roosevelt

Inspire:  Lead by example

  • Effective leaders reject victim mentality, take responsibility for our actions, and model accountability for fellow tribe members.
  • When we captains can take our own mistakes in stride, as learning opportunities rather than shameful horrors, we make it safe for our teammates to do the same.
  • Everybody is then free to take more risks, voice more ideas, offer more of their authentic selves as a contribution to the whole,
  • Because they see us, their leaders, the ones who set the tone for the group, doing it, too.
  • Key here also is leading out loud—excellent captains articulate and coach the methods of self-awareness and self-management that help us all succeed.
  • By inspiring individuals to pursue personal excellence, leaders create a supportive milieu for collaboration and collective achievement.

Motivate:  Empower team members

  • Effective captains (coaches, leaders) recognize team members’ strengths and potential, as well as areas for improvement.
  • Rather than shaming teammates for mistakes or deficiencies, good tribal leaders provide feedback and encouragement, and more opportunities for practice and development.
  • They take into account each team member’s personal goals, and help to align them with those of the collective—excellent captains connect individuals to the whole.

If your actions cause others to

Dream more, learn more,

Do more and become more,

You are a leader.

–John Quincy Adams

What would happen if you treated yourself like a true leader?

On You, the Elite Athlete

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NaBloPoMo 2016, Letters to Patients, Day 28

To All Patients:

What would happen if you thought of yourself as an elite athlete?

I present tonight the first phase of the presentations I have given this fall to physicians, corporate executives, and tomorrow, a corporate design team.  See how it applies to you:

***

What makes you exactly the same as Pat Summit, Martina Navratilova, Michael Jordan, Dana Torres, Peyton Manning, Serena Williams, Wayne Gretzky, and Walter Payton?  You are an elite athlete.  You have a specific skill set which you spent years training and honing.  You continue, through practice and discipline, to refine it.  It’s an upward striving, just like an Olympian—Higher, Faster, Stronger!  And, you’re part of a team.

So how should you take care of yourself—your very valuable, elite athlete self?

Fuel & Train

  • “Regular people diet and exercise. Athletes fuel and train.” –Melissa Orth-Fray
  • Our bodies are our vehicles. Elite athletes’ vehicles require premium fuel and meticulous maintenance.
  • We all struggle with the same challenges—time, motivation, discipline.
  • Each day we have an opportunity to walk the talk, and practice what we preach. Every good lifestyle choice, no matter how small (apple instead of candy, stand rather than sit), is a step of intention toward health.

Rest & Recover

  • Chronic sleep debt increases risks for diabetes, obesity, impaired immune function: GET MORE SLEEP.
  • Rest and recovery are integral for sustaining long term performance and injury prevention—ie burnout. This applies for both physical and mental exertion.
  • Take your allotted vacations and really disconnect.  The world will still function (temporarily) without you.
  • Broaden your methods: 15 minute walk, 10 minute meditation, 5 minutes of journaling—unwind, unload.

Manage your stress

  • How do you know when you are ‘stressed?’ How/where does stress manifest in your body?
  • What are your existing resilience practices? How quickly do you abandon them when things get busy?
  • Exercise mindfulness: Live in the moment; breathe deeply; speak and act intentionally, not incidentally.
  • We are no different from toddlers—easily emotionally hijacked when tired, hungry, over-extended.
  • Elite athletes use the disciplines above to manage their emotions and stay focused.

Cultivate positive relationships

  • Coaches, teammates, trainers, psychologists, equipment managers—no athlete succeeds alone.
  • We thrive when we feel seen, heard, understood, accepted, loved, and safe.
  • It is only when our relationships are strong and we feel connected, that we can truly care for ourselves and our teams.
  • Who is your support network, and how do they hold you up?
  • Who do you support, and why/how does this fulfill you?

 

What is your sport?  Who is your team?  How does caring for yourself benefit those around you?  And finally, what can you do today, tomorrow, next week, next month, and in the next year, that will elevate your own health and well-being, and that of your team?  Please share your ideas in the comments!

On the Full Body CT Scan: Don’t Do It.

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NaBloPoMo 2016, Letters to Patients, Day 27

To Patients Considering Full Body CT Scans:

Please reconsider.

Forgive me for putting on my preachy doctor hat for this post.  I will also break my NaBloPoMo 500 word limit for this one.

As we approach the end of the calendar year, many of you may have met your health insurance deductibles.  Maybe now would be a good time to get in some tests to ‘check under the hood,’ as some of you have said.  I share below some of my screening  recommendations, along with rationale.

Keep in mind that for this article, I define ‘screening’ as looking for a disease in a person with a) average risk for developing the disease and b) no symptoms.

Please also know that the opinions I express here are my own only and do not necessarily represent those of my colleagues, employer, or professional societies.

 

  1. Full body CT scan: This is not recommended by any clinical guideline or medical professional society as a screening test for anything.  As I will describe below, specific screening tests are recommended for specific diseases, and the best ones obtain actual cells or tissue, rather than imaging alone.  In addition, a full body CT exposes you to significant radiation, the long term consequences of which are still not fully understood.  Lastly, CT scans inevitably detect incidental abnormalities that have no clinical consequences, but that often lead to invasive tests that can cause real harm, such as bleeding, pain, infection, and anxiety.  This article from the FDA and this one by a radiologist at Harvard explain pretty clearly how the risks of this test far outweigh the benefits.
  2. Colonoscopy (colon cancer): This is the one test that nobody argues.  It is both diagnostic (can see signs of early disease) and therapeutic (can take it out).  Start at age 50, and repeat every 10 years if normal, barring new symptoms.  Read the full guideline from the US Preventive Services Task Force (USPSTF) here.  I know the prep is a pain, and I know you have to take a day off of work to have it.  But on the whole, the returns here are well worth the investment.
  3. PSA and digital rectal exam (prostate cancer): This is perhaps the most personal decision of all cancer screening. Population-wise, we have yet to show mortality benefit from screening of any kind, such that the USPSTF now recommends against screening until better tests become available.  But it’s not really that simple, because prostate cancer affects so many men, and is the second leading cause of cancer deaths in men in the US.  The most important thing here is to decide which risks you are more comfortable with: potential serious harm from screening and unnecessary treatment, or finding cancer at a later, potentially more high-risk stage.  This article from the New York Times may help, and this one from the National Cancer Institute.cancer-cases-and-death-2016
  4. Mammogram (breast cancer): It’s hard to walk back from more screening to less; people fear loss of security. When I started my training over 20 years ago, the recommendation was to screen every woman every year, starting at age 40.  Since then epidemiologists have kept track, and similar to prostate cancer screening, the mortality rate from breast cancer has not decreased proportionally to the amount of screening done.  Diagnosis has increased dramatically, due to early detection.  Again, screening increases the risk of certain harms:  anxiety (so much, for so many), pain, deformity, infection (from invasive biopsies), and then commitment to repeated testing (a vicious potential cycle of imaging, needling, more imaging, and more needling), while likely not saving your life.  Here is the USPSTF guideline, and a helpful infographic .  Like prostate cancer screening, this is one you have to decide for yourself, with the help of your doctor.mammo-infographic
  5. Pap smear (cervical cancer): Again, former guidelines called for annual screening. Today, if your test is repeatedly normal and your sex habits are low risk, the interval can be lengthened to 3 to 5 years, and can start later in life (over 21).  Cervical cancer is highly correlated to exposure to human papilloma virus, or HPV, which is sexually transmitted.  Positive pap results, which range from mild to severe, occur far more often in younger women, and of those, many will revert to normal without progression to cancer in a woman’s lifetime.  The main risk of over-screening, again, is unnecessary procedures when true disease not present.

In summary, these are the most common conversations I have with patients about screening.  You may rightly infer that my personal bias is minimalist:  Primum non nocere.  Unfortunately, we have no good screening tests for some diseases, such as pancreatic cancer, ovarian cancer, and liver cancer, and the screening guidelines in other countries (eg Taiwan screens adults regularly for liver cancer) do not apply here because prevalence rates differ so widely.

This is why I think it’s important to establish care with a primary care physician and get regular check-ups.  That fatigue you feel is likely just life and chronic sleep deprivation.  You’re probably constipated because you eat too few stems/stalks/leaves and don’t move enough.  You and your doctor can review your general health together, and if there is suspicion for some underlying health risk, it can be addressed personally and specifically.

To look up USPSTF guidelines yourself, I recommend searching Google for “USPSTF (disease) guidelines” and look for the hit that starts with “Final Recommendation Statement…”  I have no financial or professional interests in Google or the USPSTF.  Other respected sources for screening recommendations include the National Cancer Institute, the American Cancer Society, and the American Medical Association.  As an internist, I recommend the American College of Physicians.

I hope this piece has helped illuminate the complex decision-making behind screening and diagnostic testing.  I have only scratched the surface; the links contain the data and full rationale.  Please take the time to read through them and discuss them with your doctor.

On What Helps

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NaBloPoMo 2016, Letters to Patients, Day 22

To Patients Preparing for Uncomfortable Holidays:

Seek what helps.

What did I write recently about staying off of Facebook and minimizing my social media exchanges?  How fascinating, look what I just did—spent the last two hours on Facebook!  I also write about trying, falling down, and trying again…  So this is me both falling down (in my attempt to stay off) and trying again (to engage meaningfully).

The holidays are coming, yay!  …And, not so yay!  The conversations we have with friends and family in the next 6 weeks or so have enormous potential—for division as well as connection.  Personally, I feel optimistic.  I plan to evoke my core values of open-mindedness, empathy, and integrity.  I want to look back on the gatherings with gratitude and deeper connection.  So today I share with you all the things I have read (today—see?  I endure Facebook for your benefit! teeheehee) that have helped me.  These pieces validate, challenge, reassure, alarm, question and motivate me to Hold the Space, Stay on the Path, and Seek Love.  Please share yours, also!

A fellow physician’s acknowledgement of the humanness of bias, its potential for harm in caring for patients, and a reminder for self-awareness and –management.

Posts by Michelle at The Green Study, reminding us that internal conflict is normal in the face of world events such as ours, with concrete suggestions for actions that align with core values:  “We cannot strengthen our character unless it is tested. We cannot defend our freedoms unless they are threatened. We cannot become better writers or artists or humans unless we have obstacles to overcome.”

An article from The Guardian that points me to reputable sources of alternate points of view, so I may understand better.

A call out from the Wall Street Journal—to help me own my shit before I call out others on theirs.

A gentle message from fellow blogger John Pavlovitz: “Friend, however you choose to navigate these holidays, know that it’s the right way. Give yourself permission to pretend or confront or abstain as you need to, and forgive yourself later if you decide you chose poorly. You’re probably going to get it wrong or at least feel like you did.

“But remember too, to save a little of that mercy for those who sit across the table from you or those who choose not to. They’ll be doing the best they can too.”

And finally, the Prayer of Maimonides, the twelfth century physician and philosopher:

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These holidays, wish me persistence and ‘stubborn gladness,’ as Liz Gilbert calls it.  I wish you all the same!