Category Archives: physician

November 7:  Feedback Makes Me Better

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NaBloPoMo 2019

This post is about power.

Two friends provided important feedback on last night’s post, and I am, gratefully, much better for it.

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“You are a woman of color?”

My college friend commented on Facebook.  “Are you being serious?”  I asked him.  Yes, he replied.  He went on to point out that he sees the term being used more broadly, and that he thinks it’s been co-opted.  He made me think, which always makes me better.

In the original post, I described myself as a “petite, young, woman of color doctor,” standing up to an older white man. My friend wrote, “I think disadvantage is baked into the term, why else use it?”  Looking back, I admit I was exaggerating.  I had power on my mind, and I was trying to think of all the ways I should not have power in the situation, and yet I absolutely did, and I recognized it.  But labeling myself a person of color, I realize now, was at least somewhat inappropriate.  I have changed the text to “petite, young, Chinese woman doctor.”  I sincerely apologize if I insulted or offended anyone.

In medicine, East Asians are not considered a disadvantaged minority in the conventional sense (although while we are over-represented compared to the general population, we hold proportionally few leadership roles).  In general, however, I would argue that any non-white person in the US may still experience myriad disadvantages, in any field or situation, even if subtle.  At any point in an encounter, even with ‘MD’ and years of training and expertise behind my name, a white man can always hurl some racist, sexist remark to make me feel small.  He could just as easily attack a fellow white man on the basis of weight, sexual orientation, stature, or some other peculiar distinction, but somehow it feels like my white male colleagues just don’t have to think about this possibility as much as I do.  I feel self-conscious about my gender and race every day at work.  That is why this past spring, when I attended a negotiation skills presentation at the American College of Physicians (ACP) national meeting, I felt particularly gratified that the presenters were two East Asian women and one white man.

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“You may want to include physicians as victims in your blog.”

A colleague responded to my post by sharing her story of being verbally attacked by a patient.  She was alone, no witnesses, and he treated staff politely, unlike in my story.  She was ‘dumbstruck and said nothing.’  She wrote, “I think as physicians, we are targets for verbal abuse because we have a privileged profession and would look foolish or weak in defending ourselves.”  In other words, since doctors hold such high societal status (power), people think we should just accept being taken down a notch or two?  That if we express an expectation of respect we are lording our status over others and thus even more justifiably open to insult and ridicule?  I see now how this can make a physician feel like a victim of societal stereotypes and expectations.

That said, I think it doesn’t matter what we do for a living; every person has an absolute right to expect respect from anyone else.  Years ago, another older white male patient made a series of passive aggressive remarks in the space of several minutes at the end of a visit.  I felt they were unfair and uncalled for, as I had spent the entire visit doing my best to connect with and care for him.  After a moment of consideration, knowing it was a risk, I was respectfully direct with him.  I repeated his words and told him that they felt like digs.  He admitted that they were and apologized, and congratulated my courage to call him out.  He never came back to see me.  I feel good about how I handled it; was it a power struggle?  I would have been open to cultivating a mutually respectful and honest relationship, had he returned.

Feedback definitely makes me better.  I will never grow if I only attend to my own point of view.  I don’t have to abandon my own perspective when facing an opposing one, and I am not obligated to incorporate anyone else’s point of view.  But if I expect anyone to take my writing and message seriously, I am required to listen to and try to understand any feedback that is offered in good faith.

Thank you, my friends, for keeping me honest and grounded.

November 6:  Caring For the Team Makes Me Better

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NaBloPoMo 2019

“How does he treat you?”

I don’t only ask this question of women whom I suspect of being abused at home.  I also ask my medical assistants.  Not about their domestic partners, but about our patients.

In my first practice, I sat/stood to the left of my medical assistant every day for six years.  It was a cozy (cramped) little counter space stacked with charts from end to end, with a couple of high-wheeley chairs.  Each chart stack had a laminated cover on top:  “For Cheng to Review/Sign,” “For Rose,” “Labs,” and “Messages.”  Charts journeyed from my left to my right/Rose’s left, to the bin under the counter to be filed.  It was incredibly efficient, actually.  I had a handwritten emoji system for indicating (dis)satisfaction with cholesterol and diabetes results.  Rose knew all of my patients and how to communicate sentiments and instructions clearly and lovingly.  She had been an MA since I was a kid; she knew what she was doing.  If a patient had a question on the phone, she could put them on hold and clarify with me, or I could just get on the phone and speak to the patient myself.  We were busy and happy, a well-oiled team-machine.

One day as I came up to my spot at the counter, I noticed an unusual sound next to me, like a distant, scratchy loudspeaker.  I turned and saw Rose holding the phone receiver about an inch from her ear.  The sound was my patient, yelling profanities at her so loudly I could hear his words from two feet away.  I can’t remember what the issue was, but he was obviously upset, and taking it out on her.  It surprised me because I had only known him to be sweet, respectful, and grateful.  Maybe he was just having a bad day?  I looked at Rose, who rolled her eyes and exhaled heavily.  I asked her to put him on hold so she could catch me up.  Apparently this had been going on longer than I knew, and she had not told me.  Had I not come upon it in real time, she may never have told me.  She would have simply tolerated it.

I picked up the call and declared myself.  He was the usual, respectful and calm patient I had always known.  I answered his medical questions.  Then I told him firmly that he did not have the right to treat anyone in my office the way he had just treated Rose.  I think there may have been some excuses and then an apology.  I made it clear that if he abused my team again, he would be discharged from the practice.  He agreed and apologized again.

That was my first opportunity to stand up for my team as an attending.  I will forever remember it.  I was a petite, young, Chinese woman doctor, speaking to a white man decades older than myself.  I stood up for my medical assistant, a woman of color and a couple decades older than me.  She had felt powerless to stand up for herself to his verbally vomitous abuse.  All I had to do was pick up the phone and say, “Mr. Soandso, this is Dr. Cheng.”  He never yelled at Rose or anyone in the office again, to my knowledge.  How could I have this much power, and why had nobody asked me to wield it in their defense before?  It was just accepted that patients could yell and scream at our staff, with no consequences?

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We recently discussed abusive patients during our regular doctors’ meeting at my current practice.  Immediately I thought, HELL NO.  The good news was that our team members feel safe reporting incidents to our managers and physicians.  My partners and I have all had to call patients to clarify our expectations of respect.  We understand that illness is stressful.  We understand that our healthcare system, especially at a large, bureaucratic institution, causes frustration, even rage.  However, none of that ever justifies or entitles a patient, or anyone, to belittle, dehumanize, or otherwise degrade another person, and especially not a team member who is doing their best to help–ever.  At this meeting, gratifyingly, we all voiced definitive confirmation that we fully support our team, and we will, without hesitation, educate and/or discharge any patient who violates our team’s right to a collegial and non-threatening work environment.

Even as I write this, I shake a little with rage and outrage at these patients’ behavior.  I can feel tightness and tension in my chest and abdomen, my breath quicker and shallower than its usual resting state.  I wonder if this triggers me because my mom is a nurse and I have seen how patients in the hospital abuse nurses.  I also know how women physicians are mistaken for nurses and thus ignored or dismissed, even by female patients.  I have known racism and sexism first hand.  But as a physician, I’m in a position to not have to tolerate it.  By virtue of two letters after my name, I have the power to protect my team, with authority.  And I work with other physicians who also recognize both this power and its attendant responsibility.

I hope our team feels protected, defended, and loved by us docs.  We may be the default work unit leaders, but they do the lion’s share of work that allows our practice to run as smoothly and successfully as it does.  They are who let me do my work as well as I do.  I depend on them every day.  So caring for them absolutely makes me better, makes us all better.

 

NaBloPoMo 2019:  What Makes Me Better

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My friends, it starts again woohoooooo!

National Blog Posting Month occurs every November, a 30 day daily blogging challenge apparently founded in 2006, inspired by National Novel Writing Month, or NaNoWriMo.  I think this will be my fourth attempt, and it gets easier and more fun every year!

This year’s theme originates from a sense of both gratitude and anticipation.  Increasingly I feel compelled to do more, contribute more, help more.  When I look around I am consistently humbled by those who go before me, on whose broad and strong shoulders I stand.  So I dedicate this month to all of you.

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November 1:  Role Play Makes Me Better.

I was converted to the Church of the Necessity of Role Play in 2003.  I had previously belonged to Tribe of Full-Socket Eye Roll at Role Play.  That year I had the privilege of attending a Stanford Faculty Development Program series.  It was a 7 week clinical teaching program for physicians.  Every week we practiced a specific teaching skill, on camera, then had to watch ourselves and critique our own and one another’s performance.  Even though each ‘encounter’ was only a few minutes, and we were all pretending, it felt real enough to translate into concrete behavior changes in real life—for all of us.

Since then I have always employed role play when teaching motivational interviewing (MI) to medical students.  At first I played the noncompliant or resistant patient, and had students take turns trying MI skils on me.  When I noticed myself feeling defensive and belittled in that role, I realized what the students were missing, and how it could enhance their empathy.  So I started having them take turns playing both patient and physician.  That was an epiphany for us all.  When I attended the Harvard Lifestyle Medicine Conference MI session in 2015, I experienced yet another layer of important experiential learning.  In dyads, we not only took turns playing patient and physician, but we practiced both directive and MI styles of counseling.  The contrast on both sides of each of those interactions solidified in both my cognitive and limbic brains why MI is a superior counseling method for behavior change.

This week at ICCH I innocently volunteered to play the physician in yet another role play.  Little did I know what I was in for.  I should have seen it coming, as the workshop title was “Teaching Medical Students How to Deal with Challenging Patient-Physician Encounters.”  I, unknowingly, stepped into a scenario of recurrent asthma exacerbation brought on by stress, due to domestic violence.  I felt anxious with a circle of international colleagues watching, and also confident that I could enter the play encounter the same as I aspire to enter a real one—present, open, grounded, kind, loving, and smart.  The physician teacher who played my patient stayed solidly in character and immediately drew me in with her slumped posture, dejected facial expression, and barely perceptible voice.  And she, like so many victims of violence, was not giving it up easily.

I had to conduct a medical interview as well as a psychological one, at times alternating between them.  I wanted to get at what I suspected (first generalized stress, and then clearly violence at home), but we had just met, and she really wanted to get out of the hospital.  Her fear was obvious; but she held its cause close to her chest, like the rest of her, until she could trust me.  I approached with general words at first, “Anything else going on lately?”  I kept my questioning as open ended as possible, and tried to leave space for her to answer.  Nothing.  Then I confessed my own inner dissonance:  “I feel like there’s something else…”  When that didn’t work, I continued with the general history.  No other chronic medical problems, no surgeries; allergies that can trigger her asthma, but no recent exposures.  You have 4 young kids, a full time job, a house to take care of.  Are you partnered?  Yes, married, to Bob.  Pause; a breath.  Then, “How does Bob treat you?”  Pause.  Why do you ask me that?  “I’m asking about abuse.”  And then it opened.  How did you know?  “I’ve been doing this a long time…  And someone close to me was abused.”  Do I look like her?  “You remind me of her.”

She was mortified that I would tell anyone.  How could I possibly help, then?  There were longer silences as I, frantic on the inside and slow breathing on the outside, racked my brain for solutions.  The harsh reality eventually settled on us both:  Neither of us could do much about her situation in that moment, her asthma attack was resolved, and the longer I kept her away from her family the worse I might make everything for her in the near term.  We agreed that I would look for ‘stress management’ resources, and I would give her my phone number.  And I would discharge her later that day, back to her violent husband, who had promised he would never hit her again.

It was so real.  I was almost able to forget about the audience.  I was personally invested in the health and well-being of this one person in front of me.  I imagined if she were a real patient.  Would I actually give her my phone number in this moment?  Absolutely I would.  We had to start somewhere, and I was the only person who knew, who could connect her to resources for help.

After it ended, I felt pretty drained.  We had both been tearful at times.  I also felt proud to have gotten through—both the exercise and to my patient.  I connected.  And even though I had no immediate solutions, I had established a relationship that had hope for helping a person who really needed it.

I have not encountered this scenario in real life in a while—that I know of.

I hope I’m not missing something, somewhere, for somebody who needs me.  Yikes.

Role play makes me better.  It reminds me to always beware my blind spots, to keep practicing, and to remember the deep humanity of every person I meet.